Citation Nr: 1329438 Decision Date: 09/13/13 Archive Date: 09/20/13 DOCKET NO. 07-32 023 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for a gastrointestinal disorder, to include as secondary to service-connected paranoid schizophrenia, or secondary to medications prescribed for service-connected paranoid schizophrenia. 2. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected paranoid schizophrenia, or secondary to medications prescribed for service-connected paranoid schizophrenia. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Sara Schinnerer, Counsel INTRODUCTION The Veteran had active service from April 1967 to July 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2007 rating action of the Department of Veterans Affairs (VA), Regional Office (RO) in Lincoln, Nebraska that, in pertinent part, denied service connection for a gastrointestinal disorder and denied service connection for erectile dysfunction, both to include as secondary to service-connected paranoid schizophrenia. In an April 2009 decision, the Board in pertinent part, denied the Veteran's claims for entitlement to service connection for a gastrointestinal disorder and for erectile dysfunction, both to include as secondary to service- connected paranoid schizophrenia. The Veteran then appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In a February 2011 Memorandum Decision, the Court vacated and remanded the Board's April 2009 decision as to the issues of entitlement to service connection for a gastrointestinal disorder and for erectile dysfunction, both to include as secondary to service-connected paranoid schizophrenia. In a September 2011 decision, the Board remanded the Veteran's claims for additional development. In January 2013 and March 2013, the Board referred the Veteran's claims for advisory medical opinions. The record before the Board consists of the Veteran's paper claims files and an electronic file known as Virtual VA. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required. REMAND Additional development is required before the issues on appeal can be adjudicated. Specifically, examinations are necessary, for the reasons discussed below. Further, the Veteran's VA outpatient treatment records should be obtained, and associated with the claims file. The Veteran contends that his current gastrointestinal disorder and erectile dysfunction are related to service, to include his service-connected paranoid schizophrenia disorder. Specifically, he alleges that the medications that have been prescribed for his paranoid schizophrenia have caused his current gastrointestinal disorder and erectile dysfunction. The Veteran's service treatment records do not specifically show complaints of, findings, or diagnoses of gastrointestinal problems or erectile dysfunction. Post-service treatment records show treatment for variously diagnosed gastrointestinal problems and for erectile dysfunction. Records also demonstrate that the during the appeal period, the Veteran has been prescribed several medications for his service-connected paranoid schizophrenia, to include, Risperidone, Citalopram, Alprazolam, and Xanax. A March 2007 VA gastrointestinal examination report notes a diagnosis of lower gastrointestinal bleeding of an undetermined source. The examiner noted that the Veteran's medications included Citalopram or Risperidone. The examiner commented that the Veteran's gastrointestinal disease (gas, explosive diarrhea, and bleeding) was not caused by or a result of medication used for his service- connected schizophrenia. The examiner stated that the Physician's Desk Reference (PDR) did not list any such conditions as side effects of Citalopram or Risperidone. An April 2007 VA genitourinary examination report notes a diagnosis of impotence. The examiner noted, as to history, that the most likely cause of the Veteran's erectile dysfunction was his psychiatric disorder. An April 2007 VA psychiatric examination report notes a diagnosis of schizophrenia, residual type. The examiner indicated that the Veteran's gastrointestinal disorder and erectile dysfunction were not caused by his service- connected schizophrenia. The examiner commented that there was no medical literature that showed that schizophrenia caused gastrointestinal disorders or erectile dysfunction. In a May 2007 addendum to the March 2007 VA gastrointestinal examination report, the examiner indicated that the Veteran's gastrointestinal symptoms could be irritable bowel syndrome. The examiner remarked that since the Veteran's diarrhea was intermittent, in spite of his chronic use of medications, the medications did not aggravate his irritable bowel syndrome. In a November 2008 addendum to the April 2007 VA psychiatric examination report, the examiner indicated that his opinion was based on a review of the April 2007 VA psychiatric examination report, recent VA treatment records, and a medical treatise which indicated that there was no indication that erectile dysfunction was a side effect of Risperidone. The examiner commented that based on his clinical experience treating individuals with schizophrenia, it was his opinion that erectile dysfunction was not aggravated by the Veteran's service-connected schizophrenia. An October 2011 VA examination report notes diagnoses of erectile dysfunction and irritable bowel syndrome. The examiner noted that erectile dysfunction was diagnosed in October 2007; however, explained that the Veteran was unable to precisely state when his erectile dysfunction began as he had not had intercourse for over 20 to 25 years. The examiner noted that the Veteran currently only took Risperidone for his schizophrenia, but also took other medications for his non-service connected conditions, including heart and blood pressure medications such as Metroprolol, which was a well known cause of problems with erections. The examiner commented that there was no evidence that the Veteran's current erectile dysfunction was due to or a result of Risperidone taken for his service- connected schizophrenia. He further stated, that paranoid schizophrenia less likely, in and of itself results in erectile dysfunction. The examiner also commented that it was less likely than not that the Veteran's current gastrointestinal disorder was due to or aggravated by the service-connected paranoid schizophrenia, or medications taken for the paranoid schizophrenia. In providing this opinion, the examiner noted that with regard to Risperidone, although the PDR or other medical sources may list gastrointestinal condition as a potential side-effect of such medication, it was not necessarily the case that Risperidone caused the Veteran a chronic or ongoing gastrointestinal disorder, as the Veteran had taken medication on a daily basis for a number of years; however, only described periodic symptoms of once per week. The examiner further noted the Veteran's report, that changes in his diet helped him to greatly reduce, and control his gastrointestinal symptomatology. In a January 2013 VA opinion, B.H., a gastroenterologist opined that while it was always possible that a medication could cause side effects, there was not a preponderance of evidence to support that the Veteran's gastrointestinal symptoms were likely the result of Citalopram or Risperidone. In a February 2013 addendum opinion to the January 2013 VA opinion, B.H. opined that while it was always possible that a medication could cause side effects, there was no evidence to support the claim that the Veteran's gastrointestinal symptoms were more likely than not related to Citalopram, Risperidone, or Alprazolam. In providing the opinion, B.H. noted that with respect to Citalopram, three percent of patients increased diarrhea over placebo, which means that only one in 33 additional patients developed drug induced diarrhea. He further noted that Citalopram had been studied as a possible treatment for irritable bowel syndrome, and had thereafter been used by physicians to treat such disease. Regarding Risperidone, B.H. commented that gastrointestinal side effects appeared to be even smaller, and that upon examining patient self-reporting websites, he could not find evidence that more than two percent of patients self-reported that Risperidone caused irritable bowel syndrome or diarrhea issues. Regarding Alprazolam, B.H. noted that according to the package insert, patients taking such medication had less diarrhea and abdominal distress, which was consist with his 21 years of clinical practice, as he could not recall any patients who reported gastrointestinal symptoms attributable to Alprazolam. In an April 2013 VA opinion, P.B., Chief of Urology opined that it was not at least as likely as not that the Veteran's erectile dysfunction was due to or aggravated by medications taken for his service-connected paranoid schizophrenia. In providing the opinion, P.B. noted that it was quite difficult to disentangle sexual dysfunction related to drugs from sexual dysfunction related to the illness itself. P.B. further stated that sexual dysfunction affected many patients with paranoid schizophrenia, and that antipsychotic medications (mostly Citalopram and Risperidone, not Xanax), were known to be associated with sexual dysfunction, which included erectile dysfunction. P.B. commented that in reviewing the literature, it was difficult to know the precise risk of specifically erectile dysfunction associated with Citalopram and Risperidone, as Xanax had minimal to no adverse effect on erectile dysfunction. To date, the VA opinions of record addressing the etiology of the Veteran's current gastrointestinal disorder and erectile dysfunction are inadequate for rating purposes. In this regard, the March 2007, May 2007, April 2007, and the November 2008 opinions were essentially found inadequate by the Court pursuant to the February 2011 Memorandum Decision. Specifically, in such Decision, it was noted that the PDR listed a variety of gastrointestinal and sexual performance problems as side effects of Citalopram, a medication that the Veteran was taking during the course of the appeal. The Court further noted other medical research of record which indicates that sexual performance problems were a possible side effect of Risperidone, another medication that the Veteran was taking during the course of the appeal. Similarly, the October 2011 VA examiner failed to address the relationship between gastrointestinal disorder and erectile dysfunction and the other medications that the Veteran was taking during the appeal period for his service- connected paranoid schizophrenia, aside from Risperidone. The January 2013 and February 2013 opinions from Dr. B.H. are likewise inadequate, as B.H. did not address whether the medications taken for schizophrenia aggravated the Veteran's gastrointestinal disorder, nor did he comment on the medication Xanax, as per the Board's directive. Finally, the April 2013 opinion offered by Dr. P.B. regarding the etiology of the Veteran's current erectile dysfunction is merely a conclusion, and is not supported by any medical analysis or explanation. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 204 (2008) (a medical opinion that contains only data and conclusions is not entitled to any weight). Accordingly, once VA undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Accordingly, new medical examinations and opinions are necessary to make a determination in this case. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Prior to the examinations, any outstanding records of pertinent medical treatment should be obtained and associated with the record. See 38 C.F.R. § 3.159 (2012). Accordingly, the case is REMANDED for the following actions: 1. Contact the Veteran and ask him to identify all medical providers who have treated him for gastrointestinal disorders and erectile dysfunction since August 2011. After receiving this information and any necessary releases, contact the named medical providers and obtain copies of the related medical records which are not already in the claims folder. Specifically, VA outpatient treatment records since August 2011 to the present, should be obtained. If any requested records are unavailable, or the search for such records otherwise yields negative results, that fact should clearly be documented in the claims file, and the Veteran so notified. 2. Schedule the Veteran for an appropriate VA examination in order to determine the current nature and likely etiology of any gastrointestinal disorder that may be present. The entire claims file (i.e. the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE) must be reviewed by the examiner in conjunction with the examination. If the examiner does not have access to Virtual VA, any relevant treatment records contained in Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. All tests deemed necessary must be performed. Based on the examination and review of the record, the examiner must answer the following questions: (i) Is it at least as likely as not (50 percent or greater probability) that the Veteran's current gastrointestinal disorder had its onset during service, or is otherwise related to service? (ii) If the answer to (i) is no, is it at least as likely as not (50 percent or greater probability) that the Veteran's gastrointestinal disorder has been caused or aggravated (worsened) by the service- connected paranoid schizophrenia disorder? If the Veteran's gastrointestinal disorder is aggravated by his service-connected paranoid schizophrenia disorder, to the extent possible, the examiner is requested to provide an opinion as to the approximate baseline level of severity of the gastrointestinal disorder before the onset of aggravation. (iii) If the answer to (ii) is no, is it at least as likely as not (50 percent or greater probability) that the Veteran's gastrointestinal disorder is caused or aggravated (worsened) by medications prescribed for his service-connected paranoid schizophrenia disorder? If the Veteran's gastrointestinal disorder is aggravated by medications prescribed for his service-connected paranoid schizophrenia disorder, to the extent possible, the examiner is requested to provide an opinion as to the approximate baseline level of severity of the gastrointestinal disorder before the onset of aggravation. In rendering such opinion(s), the examiner must consider and comment on: * The following medications are taken by the Veteran for his service- connected paranoid schizophrenia: Citalopram, Risperidone, Alprazolam, and Xanax. * The October 2011 VA opinion, which includes the examiner's comment, that although the Physician's Desk Reference or other medical sources may list gastrointestinal condition as a potential side-effect Risperidone, it was not necessarily the case that Risperidone caused the Veteran to have a chronic or ongoing gastrointestinal disorder, as the Veteran had taken medication on a daily basis for a number of years; however, only described periodic symptoms of once per week. The examiner further noted the Veteran's report that changes in his diet helped him to greatly reduce and control his gastrointestinal symptomatology. The examiner is advised that "aggravation" is defined for legal purposes as a chronic worsening of the underlying condition versus a temporary flare-up of symptoms, beyond its natural progression. The examination report must include a complete rationale for all opinions expressed. If the examiner is not able to provide an opinion, he or she must explain why. 3. Schedule the Veteran for an appropriate VA examination in order to determine the current nature and likely etiology of his erectile function disorder. The entire claims file (i.e. the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE) must be reviewed by the examiner in conjunction with the examination. If the examiner does not have access to Virtual VA, any relevant treatment records contained in Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. All tests deemed necessary must be performed. Based on the examination and review of the record, the examiner must answer the following questions: (i) Is it at least as likely as not (50 percent or greater probability) that the Veteran's current erectile function disorder had its onset during service, or is otherwise related to service? (ii) If the answer to (i) is no, is it at least as likely as not (50 percent or greater probability) that the Veteran's erectile function disorder has been caused or aggravated (worsened) by the service- connected paranoid schizophrenia disorder? If the Veteran's erectile function disorder is aggravated by his service- connected paranoid schizophrenia disorder, to the extent possible, the examiner is requested to provide an opinion as to the approximate baseline level of severity of the erectile function disorder before the onset of aggravation. In rendering such opinion(s), the examiner must consider and comment on: * The April 2013 VA opinion from P.B., which includes P.B.'s comment, that it was quite difficult to disentangle sexual dysfunction related to drugs from sexual dysfunction related to the illness itself. (iii) If the answer to (ii) is no, is it at least as likely as not (50 percent or greater probability) that the Veteran's erectile function disorder is caused or aggravated (worsened) by medications prescribed for his service-connected paranoid schizophrenia disorder? If the Veteran's erectile function disorder is aggravated by medications prescribed for his service-connected paranoid schizophrenia disorder, to the extent possible, the examiner is requested to provide an opinion as to the approximate baseline level of severity of the erectile function disorder before the onset of aggravation. In rendering such opinion(s), the examiner must consider and comment on: * The following medications are taken by the Veteran for his service- connected paranoid schizophrenia: Citalopram, Risperidone, Alprazolam, and Xanax. * The April 2013 VA opinion from P.B., which includes P.B.'s comment, that sexual dysfunction affects many patients with paranoid schizophrenia, and that antipsychotic medications (mostly Citalopram and Risperidone, not Xanax), were known to be associated with sexual dysfunction, which includes erectile dysfunction. P.B. further commented, that in reviewing the literature, it was difficult to know the precise risk of specifically erectile dysfunction associated with Citalopram and Risperidone. The examiner is advised that "aggravation" is defined for legal purposes as a chronic worsening of the underlying condition versus a temporary flare-up of symptoms, beyond its natural progression. The examination report must include a complete rationale for all opinions expressed. If the examiner is not able to provide an opinion, he or she must explain why. 4. The examination reports must be reviewed by the RO/AMC to ensure that they are in complete compliance with the directives of this remand. If the reports are deficient in any manner, the RO/AMC must implement corrective procedures. 5. Thereafter, readjudicate the Veteran's claims, with application of all appropriate law and regulations, including consideration of any additional information obtained as a result of this remand. If the decision with respect to either claim remains adverse to the Veteran, he and his representative must be furnished a supplemental statement of the case and afforded a reasonable period of time to respond. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ DENNIS F. CHIAPPETTA Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).