Citation Nr: 1421815 Decision Date: 05/14/14 Archive Date: 05/21/14 DOCKET NO. 01-01 563 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUE Entitlement to service connection for a psychiatric disability and Gilles de la Tourette Syndrome (GTS). REPRESENTATION Appellant represented by: Daniel G. Krasnegor, Attorney WITNESSES AT HEARING ON APPEAL Veteran and his spouse ATTORNEY FOR THE BOARD J. Connolly, Attorney INTRODUCTION The Veteran had active service from December 1972 to November 1973. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from an October 2000 decision by the RO which found that new and material evidence had not been received to reopen a service connection claim for a psychiatric disability. In July 2002, a hearing was held at the RO before the undersigned Veterans Law Judge. In January 2003, the Board reopened the claim and undertook additional development by returning the file to the RO for additional development. The Board remanded the appeal for Veterans Claims Assistance Act of 2000 (VCAA) compliance in July 2003. In September 2005, the Board promulgated a decision which denied service connection for an acquired psychiatric disability, and the Veteran appealed to the United States Court of Appeals for Veterans Claims (hereinafter, "the Court"). In November 2006, the Court granted the Secretary of Veterans Affairs motion to vacate and remand the September 2005 Board decision. The Board remanded the appeal for additional development in March 2007. Thereafter, the Board in a September 2008 decision denied the Veteran's service connection claim for a psychiatric disability, and the Veteran again appealed the Board's decision to the Court. In a January 2011 Memorandum Decision, the Court vacated the Board's September 2008 decision and remanded the claim for additional consideration. In April 2012, the Board remanded this case again. In November 2012, the RO confirmed and continued the prior denial of service connection for GTS. However, this issue is inextricably intertwined with the matter on appeal and is granted herein, per below. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT The Veteran's GTS with associated obsessive compulsive disorder (OCD) and dysthymia is attributable to service. CONCLUSION OF LAW GTS with associated obsessive compulsive disorder and dysthymia was incurred in active service. 38 U.S.C.A. §§ 1101, 1131 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION VCAA There has been a significant change in the law with the enactment of the VCAA. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. The Veteran's claim is being granted. As such, any deficiencies with regard to VCAA are harmless and nonprejudicial. Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1153; 38 C.F.R. §§ 3.303, 3.304, 3.306. Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Reasonable doubt concerning any matter material to the determination is resolved in the Veteran's favor. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. The Veteran contends, in essence, that he did not have any psychiatric or physical problems when he entered service in December 1972, and that he was able to complete basic and advanced training without incident. He argues that he was exposed to infectious diseases while working as a medical assistant at a military hospital, and subsequently developed chronic fatigue. He claims that he had a "little jerk" of his head, but rather than treating his fatigue, military doctors focused on his spasm and started him on Haldol, which worsened his fatigue and caused additional body movements. The Veteran maintains that his current psychiatric problems are related to his exposure to infectious diseases or, in the alternative, due to the medications prescribed for his tic. The service treatment records show that he was initially seen for a nervous tic in January 1973, less than one month after service enlistment. The records reflect that he was started on a low dose of Haldol at that time. He was seen for neck pain and a nervous tic manifested by twitching of his head in February 1973. In June 1973, the Veteran was referred for additional work-up by psychiatric and neurologic services for his nervous tic and neck pain. At that time, the Veteran provided a more detailed history of his childhood and pre-service medical problems, and reported that he had psychological problems since childhood. He said that he was placed in a state institution when he was five years old after his parents divorced, and that he was in several homes over a ten to twelve year period. He reported a jerking or shaking motion in his head since 1967, after he was thrown from his bicycle and landed on his back and neck. He said that his symptoms had progressively worsened over the past six to seven years and that they were more acute when he was anxious or under stress. The impression on neurological evaluation was dyskinesia of the neck and facial muscles, possibly a familial disorder or a tic. In September 1973, he reported that he had a "nervous breakdown" the previous weekend and noted an increase in his nervous tic. The records did not reflect any specific abnormalities and the Veteran was referred to psychiatric services. He was provided a psychiatric evaluation in September 1973 and was then referred to a Medical Evaluation Board for possible separation from service. The diagnosis was musculoskeletal disorder of presumably psychogenic origin (psychogenic torticollis). On a Report of Medical History for administrative discharge from service in September 1973, the Veteran reported depression and worry since going home on leave and learning about a "family problem." He also reported a history of nervous twitch, frequent headaches, right scapular and low back pain, and nervousness since a childhood bicycle accident. The Medical Evaluation Board found that the Veteran's musculoskeletal disorder of presumably psychogenic origin existed prior to service and was not permanently aggravated by service, and recommended separation from service. The Veteran was separated from service in November 1973. Subsequent to service, the Veteran was treated by VA in September 1975 for a facial and neck tic which was noted to be a muscular physiological reaction. The Veteran was again examined by VA in November 1975. The diagnosis was conversion reaction manifested by musculoskeletal disorder (twitching). The examiner indicated under the diagnosis portion that stress was service-aggravated. A private medical report, dated in September 1978, showed that the Veteran was evaluated for a movement disorder. The diagnosis was GTS. An October 1978 private report indicated that the Veteran's GTS was being treated with Haldol. Subsequent multiple private evaluations continued to reflect a diagnosis of GTS, which began in childhood. The Veteran was also diagnosed as having a personality disorder as well as other psychiatric impairment, including a chronic affective disorder or bipolar disorder A VA examination was conducted in May 2003. In an addendum report, dated in June 2003, the examiner noted that ADHD, OCD and Tourette's (also referred to as GTS) were entities that begin in childhood, existed prior to service, and that his history of symptoms and manifestations were consistent with the natural progress of the disease process. When examined by VA in April 2008, the diagnoses also included dysthymic disorder and OCD which were not related to service, and that the Veteran's medications prescribed for Tourette's syndrome in service did not play any role in initiating or intensifying his dysthymia. A medical opinion was subsequently provided by a VA psychiatrist in August 2011 who stated that at this time, it was felt that the Veteran had Tourette's syndrome, a neuropsychiatric condition that was noted for tics/movement disorder. He indicated that the Veteran's condition developed while in the military and was aggravated by his service in the military. In October 2012, the Veteran was afforded another VA examination by a VA psychologist, which yielded diagnoses of Tourette's, OCD, and dysthymia. The examiner stated that it was not likely that the Veteran's psychiatric disabilities were incurred in or related to his military service. The examiner indicated that the record showed that records from as early as 1978 and 1982 showed that the Veteran began to display tics in early childhood, common for this disorder. The examiner indicated that the Veteran reported some increase in the frequency/severity of his tics while in the military necessitating the use of haloperidol. However, the examiner stated that such an increase in symptoms over time is not an unknown phenomenon with this disease. The examiner went on to indicate that Tourette's syndrome is primarily a neurological versus a psychiatric disorder, with both motor and psychiatric manifestations, but the examiner indicated that he did not profess to be an expert in this particular disorder and additional opinions may be desired. With regard to psychiatric diagnoses, it was the opinion of this examiner the primary source of his dysthymic mood at present has been the problems within his family, and not primarily due to his tic disorder at this time. The examiner also indicated that the Veteran had asserted that the use of haloperidol for treating his tic disorder while in the military caused his condition to worsen, in particular that it made his tics worse and caused excessive drowsiness. The examiner said that haloperidol can result in various dyskinesias, but it would be relatively rare for it to have a prolonged effect after only 6-months of use and should not exacerbate the Tourette's symptoms per se. The examiner then stated again that the Board might want to seek the opinion of someone who is considered an expert in movement disorder and neuroleptics. Thereafter, the Board obtained a medical expert opinion to resolve if the Veteran's GTS preexisted service or was incurred initially during service. This opinion was completed in February 2014. The medical expert concluded that the Veteran had GTS with associated psychiatric disorder which did not preexist service, but was rather incurred during service. He explained that while GTS often occurs during childhood, it was likely in this case that the Veteran's GTS had its onset during service. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors: whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case; whether the medical expert provided a fully articulated opinion; and whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ( "[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). In this case, a medical expert opinion was obtained to resolve differing opinions in the record. The medical expert had the benefit of reviewing all the prior opinions. The Board finds this opinion the most probative of record. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). Accordingly, as the most probative evidence establishes that GTS with associated psychiatric disability began during service, service connection is warranted. ORDER Service connection for GTS with associated OCD and dysthymia is granted. ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs