Citation Nr: 1752022 Decision Date: 11/14/17 Archive Date: 11/22/17 DOCKET NO. 07-32 291 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include bipolar disorder. REPRESENTATION Veteran represented by: T. Hammond, Attorney at Law WITNESSES AT HEARING ON APPEAL The Veteran and S.B. ATTORNEY FOR THE BOARD B. Garcia, Associate Counsel INTRODUCTION The Veteran served in the U.S. Army Reserves from November 1979 to November 1985. She had periods of active duty for training from November 1979 to February 1980, April 1980 to July 1980, and June 13 to June 27, 1981. This appeal originally came before the Board of Veterans' Appeals (Board) from a September 2006 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2008, the Veteran appeared before a Veterans Law Judge (VLJ) at a Travel Board hearing. A transcript of the proceeding is contained in the claims file. In March 2009, the Board reopened the Veteran's previously-denied claim and remanded it for further development. The Board remanded the Veteran's claim again in November 2009 for additional development. Of note, the Board denied the Veteran's claim in an April 2012 decision. The Veteran subsequently appealed the Board's April 2012 decision to the Court of Appeals for Veterans Claims (Court). In a December 2013 memorandum decision, the Court vacated the Board's April 2012 decision and remanded the matter for adjudication consistent with its memorandum decision. The Board remanded the Veteran's claim for development consistent with the Court's memorandum decision in June 2014. In July 2016, the Board remanded the claim to schedule the Veteran for a Travel Board hearing based on a request received in April 2016. In February 2017, the Veteran appeared before the undersigned VLJ at a Travel Board hearing. A transcript of the proceeding is associated with the claims file. As the Veteran's claim is being granted in full, to the extent that any errors were committed with respect to VA's duties to notify or to assist, or the Board's duty to ensure compliance with prior remand directives, any such errors are not prejudicial to the Veteran and will not be discussed further herein. See 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015); Stegall v. West, 11 Vet. App. 268, 271 (1998). FINDING OF FACT There is at least an approximate balance of positive and negative evidence as to whether the Veteran's acquired psychiatric disorder, diagnosed as bipolar disorder, initially manifested in service or is otherwise etiologically related to the Veteran's active military service. CONCLUSION OF LAW Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for the Veteran's acquired psychiatric disorder, diagnosed as bipolar disorder, have been met. 38 U.S.C. §§ 101, 1110, 5107 (2012); 38 C.F.R. §§ 3.6, 3.102, 3.303 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Entitlement to Service Connection: Legal Criteria A veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered, or disease contracted, in the line of duty, or for aggravation of a preexisting injury or disease incurred in the line of duty during active service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Active service includes active duty and any period of active duty for training (ACDUTRA) during which the veteran was disabled or died from a disease or injury incurred or aggravated in the line of duty. See 38 U.S.C. § 101(22), (24); 38 C.F.R. § 3.6(a), (c). To establish a right to compensation for a present disability, a veteran must generally show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Determinations regarding service connection are based on a review of all of the evidence of record, including pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a). To deny a claim for benefits on its merits, the preponderance of the evidence must be against the claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990) ("A veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' to prevail."). Factual Background and Legal Analysis The Veteran contends that she is entitled to service connection for an acquired psychiatric disorder that manifested during training at Fort Benning in June 1981. The Veteran's personnel records indicate that this training constituted ACDUTRA. See 38 U.S.C. § 101(22), (24); 38 C.F.R. § 3.6(c). As reflected in multiple statements from the Veteran and Board hearing testimony from April 2005, September 2008, and February 2017, the Veteran essentially maintains that during swamp training exercises at Fort Benning, she was terrified and believed she was going to die on account of the swamp being infested with poisonous water moccasins and dotted with sinkholes. The Veteran asserts that the water was sludge-like and that every time a twig snapped against her body, she thought she had been bit. According to the Veteran, the only way she could explain why the Army would expose her and other service members to such conditions was that extraterrestrials had infiltrated and taken control of the Army in efforts to kill them and invade the planet. She also maintains that during this period, she was unable to sleep at night and would watch blinking lights on top of a jump tower, as she believed the blinking lights reflected communication between extraterrestrials and the infiltrated military. The Veteran contends that she did not seek medical treatment while she was at Fort Benning, or after returning home, because she believed that medical treatment providers were part of the extraterrestrial conspiracy or that extraterrestrials would learn about her reports and kill her. The Veteran maintains that while she initially believed the infiltration was limited to the military, when she returned home, she began to believe that everyone was an extraterrestrial except for her. She began to drink heavily, and her spouse made her leave their home. The Veteran then attended a 30-day inpatient alcohol treatment program, and during this time, she was served with divorce papers. As a result of the divorce proceedings, she lost custody of her three children. The Veteran contends that prior to her period of training at Fort Benning, she had an accomplished civilian career and was successful in her military occupational specialty as a journalist. However, following her training at Fort Benning, her military and civilian work began to decline. She maintains that she was no longer able to write stories for the military newspaper and was placed on an "inactive Reserves" list. She also asserts that she eventually lost her job due to poor performance. She subsequently attempted suicide by ingesting 200 aspirin but was unsuccessful in her attempt. Believing that she had been kidnapped by extraterrestrials and was no longer on Earth, in April 1983, the Veteran robbed a local restaurant in hopes that she would be "deported as an undesirable alien" or killed by a responding police officer. A review of available service treatment records shows that in a June 1981 annual training statement of physical condition, the Veteran affirmed that during her June 1981 ACDUTRA, there was no change in her physical condition, and she was not suffering from any disability, defects, or illnesses which had not present at the beginning of her tour. The Veteran's personnel records include a performance evaluation for the period from May to August 1981. For her overall performance assessment, she was noted to "rank[] with the very best." The Veteran's personnel records also indicate that in August 1982, she was reassigned from the 104th Training Command to the U.S. Army Reserves Control Group Reserve Component Personnel and Administration Center due to an "employment conflict." Treatment records from a private hospital indicate that the Veteran was admitted for a period of observation, evaluation, and treatment concerning competency to stand trial on charges of second degree robbery following the restaurant incident. During her evaluation, the Veteran was convinced that she had been kidnapped from Earth and was on another planet, and she robbed a restaurant in an effort to be caught and transported back to Earth. The Veteran's mental status was noted as being "obviously delusional." It was noted that although she had been sober for approximately one-and-a-half years, she had a long history of alcohol abuse and lost custody of three children during divorce proceedings on account of her history of excessive drinking. According to the evaluating psychiatrist and psychologist, it appeared that the Veteran had become increasingly psychotic over the last several months to the point where she was no longer able to work and finally became convinced that she was on another planet. The Veteran had been unemployed for approximately four months at the time of her admission. She indicated that she was afraid that treating providers would think she was "crazy" and might not believe that they were on a planet other than Earth. The discharge diagnosis was schizophrenia, chronic disorganized type, in partial remission. A December 1996 letter from the County Clerk's Office indicates that the Veteran was acquitted of the robbery charge by reason of insanity. In a September 1986 response to request for information, presumably for purposes of the Veteran's application for Social Security Disability benefits, her psychiatrist of approximately two years wrote that the Veteran's chief indicators were for a severe affective disorder of a bipolar type that became apparent when she was institutionalized at a private hospital and was later determined to be a manic episode. However, the psychiatrist also wrote that prior to this time, the Veteran had suffered from a gradually increasing period of disorganization that was characterized by flight of ideas, disorganization, and both mood incongruent and congruent delusions. It was noted that there had been an increased alcoholic intake to the point of addiction, agitation, and increasing problems with impulse control, and that these symptoms were in contrast to her previously organized lifestyle. The psychiatrist's diagnostic impression was bipolar manic depressive illness, mania. The record shows continued treatment for bipolar affective disorder, in addition to other involuntary admissions on account of the Veteran's disorder. It also includes an April 2005 letter from D.W., a retired U.S. Army Reserves Sergeant First Class. As set forth in the letter, she met the Veteran in 1980 when the Veteran was assigned to D.W.'s unit at the 1st Brigade, 104th Division. D.W. noted that she had "special" memories of the Veteran given the Veteran's talents and performance. According to the letter, D.W. was present during the annual training at Fort Benning in June 1981. She recalled the fact that the Veteran only brought two left boots with her to training. She also wrote that during the training, the Veteran became "very unstable, unbelievable, and very unproductive." She "withdrew and was not able to write anything," which was in contrast to the Veteran's prior performance. D.W. discussed the swamp training and noted that drill instructors kept reminding them that there were many water moccasins in the swamp and to be careful and alert, which was "frightening at best" and affected the Veteran in "ways [she] will never know." D.W. wrote that following the training, she was able to transfer the Veteran to the "Irregular Ready Reserve" and that many months later, she recalled seeing an article in the local newspaper about the Veteran robbing a restaurant. Here, the Board finds that that first Shedden element of a current disability is met given the Veteran's noted diagnosis of bipolar disorder throughout the appeal period. E.g., Shedden, 381 F.3d at 1167. With respect to the Veteran's current diagnosis, the Board notes that although a September 2005 report from psychologist L. M. includes a diagnosis of PTSD, the evidence of record is against a finding that the Veteran has had a diagnosis of PTSD during the course of the appeal. As detailed in a September 2007 report from Dr. N., which will be detailed further below, there was no evidence of PTSD in his assessment of the Veteran, and the Veteran's symptoms were much more consistent with a diagnosis of bipolar disorder with psychotic features. Dr. N. also stressed that the diagnosis of bipolar was consistent with other diagnostic findings of record, including those of the Veteran's current treating psychiatrist. A diagnosis of bipolar disorder was also confirmed in a September 2014 VA examination report, which will also be addressed below. The Board also acknowledges that in a September 2015 report, psychologist S. B. gave a diagnosis of schizoaffective disorder, bipolar type. However, at the Veteran's February 2017 Board hearing, she clarified that this was, in essence, bipolar disorder. In light of this background, the issues of PTSD and schizoaffective disorder will not be further addressed, and the Board finds no reason to obtain clarification regarding pertinent diagnoses. For the reasons below, the record supports a finding that the Veteran's bipolar disorder was incurred during ACDUTRA, particularly when relying on private opinions from licensed psychologists D. Northway and S. B. As set forth in a September 2007 comprehensive psychological evaluation from Dr. N., based on careful review of the Veteran's history, corroborative sources, relevant medical records, and research literature, it was clear that the Veteran's bipolar disorder was directly caused by her June 1981 training at Fort Benning. Dr. N. detailed the nature of the Veteran's fear during the swamp training, in addition to the conditions of the training, and provided that the Veteran's constant fear, along with sleep deprivation and a somewhat fragile psychological makeup, triggered a psychotic decompensation. As stressed by Dr. N., after the Veteran returned from the training at Fort Benning, she was "never again the same." Specifically, prior to her training, she had a healthy marriage and successful employment and academic pursuits. Subsequent to the training, she deteriorated rapidly across a number of areas. For instance, she was put on the "inactive list, her drinking increased significantly, and her marriage fell apart. She became increasingly paranoid and delusional, and she felt that the same extraterrestrial sources that had invaded the military had also begun to permeate the rest of her life. She eventually lost her job, attempted suicide, and robbed a restaurant. In rendering his opinion, Dr. N. interviewed several corroborative sources, including the Veteran's adult son who recalled the Veteran behaving increasingly strange after returning from Fort Benning. She would make comments about people on television being "aliens," and he recalled her engaging in activities that Dr. N. characterized as "manic," such as purchasing 50 stuffed animals for his sister, even though the family had no money. He remembered the Veteran drinking more heavily and noted that the family would sometimes have to pick her up at a bar. He recalled the Veteran talking about how her children were not really her children, and were instead of a "parallel world." He recalled that after his parents' separation and divorce in the fall of 1981, she acted even more bizarre. She would not go out with him in public, and he would have to go out to get food for himself and his siblings. Retired Sergeant D.W., who wrote the above-noted letter, reported to Dr. N. that she knew the Veteran for approximately three years and that the Veteran was an outstanding soldier and extremely good writer. D.W. recalled changes in the Veteran's personality, thinking, and behavior following the swamp exercises. Specifically, the Veteran "never wrote stories again" despite the fact that she had been a "prolific writer" prior to the training. The Veteran's writing, in general, declined rapidly, and "something was really bothering her." D.W. added that many service members who did the training were anxious, and that the observed changes in the Veteran occurred immediately after the training at Fort Benning. Architect L.S., who was involved in the County Jail project, where the Veteran had previously been employed, recalled the Veteran being a "very capable justice services planner" and a "very pleasant person prior to her decline." He recalled that things "seemed to build up" in late 1981 and early 1982, but prior to that time, she did everything that was required, and more. D.C., a consultant who worked closely with the Veteran on the County Justice Center project, was noted to have "quite clear" memories of the Veteran. He remembered the Veteran functioning "quite well" early on in the project. Her ability to present information on their plans to various State agencies and commissions was "quite good," and she was "quite knowledgeable" about the subject matter. However, she rapidly began to go downhill. It was "as if someone switched a light switch," as she "became a different woman." He recalled the Veteran being in a Reserves unit and maintained that this change occurred after a training exercise, specifically, in 1981 or very early 1982, as this was around the time that he retired from the State Department of Transportation, went into the consulting business, and was retained to manage the County Jail Project. K.M., an attorney who worked for the County, trained the Veteran to replace her as a justice planner, and they became friends in the process. K.M. noted a decline in 1981 with an increase in unusual behaviors. K.M. left the county employ late in 1981, but remained friends with the Veteran, who reportedly continued to decline. Specifically, she had conflicts at work and demonstrated inappropriate decision-making, eventually leading to the Veteran and another supervisor losing their jobs. Dr. N. also cited to various peer-reviewed medical literature suggesting that stressful life events triggering an onset of bipolar disorder is a relatively common occurrence. According to Dr. N., the Veteran presented in an honest and straightforward manner, and even though various records have suggested that she did not seek treatment for the onset of her symptoms until 1983, there was substantial evidence that her symptoms began during the swamp exercises at Fort Benning. For instance, her alcohol use exploded, her marriage imploded, and her employment declined. Dr. N. also noted that the Veteran entered a treatment program for alcoholism in August 1981, which removed one of the external methods she had been using to treat her psychiatric symptoms. According to Dr. N., the Veteran's personality, intelligence, and memory testing indicated above-average intelligence and superior memory, indicating that it was unlikely she was misremembering these events. Moreover, personality testing did not indicate any exaggeration of psychological problems. Instead, it was more indicative of a tendency to minimize problems. In a May 2014 letter, Dr. N. wrote that his opinion continued to be that the Veteran's bipolar disorder was caused by her experiences at Fort Benning. Given that Dr. N. evaluated the Veteran over the course of two days, in addition to the fact that his opinion reflects review of pertinent medical records, the Veteran's contentions, interviews with individuals who observed the Veteran's behavior and work practices both before and shortly after her training at Fort Benning, and his expertise as a licensed psychologist, the Board affords the opinion probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301-04 (2008). Dr. N.'s opinion is supported by a September 2015 psychological evaluation and February 2017 testimony from psychologist S. B., who also opined that the onset of the Veteran's disorder was during the June 1981 training at Fort Benning. In her report, Dr. S. B. maintained that the first time the Veteran experienced a manic episode was during this training and noted symptoms such as an inability to sleep, a sensation of "trembling" throughout the body despite having steady hands, and thoughts that were "spinning and racing" out of control, including delusions that her drill sergeants were extraterrestrials and that the lights on the jump towers were a means of communicating with the "alien mothership." Similar to Dr. N., Dr. S. B. stressed that the Veteran was a high-functioning and goal-oriented individual who succeeded in every aspect of her life until she attended training at Fort Benning, where she was exposed to a highly stressful, threatening event unlike any other she had previously experienced. Dr. S. B. maintained that in response to the stress, the Veteran suffered a psychotic break in the presence of a manic episode. At the February 2017 Board hearing, Dr. S. B. provided that even though there is no diagnosis of bipolar disorder that is contemporaneous with the June 1981 psychotic break, her opinion remained that the onset of the Veteran's condition was during the training at Fort Benning in June 1981. According to Dr. S. B., the lack of earlier medical documentation was consistent with the Veteran's report that she was trying hard not to discuss her delusions because she feared that extraterrestrials would kill her if she did. As such, that was "part and parcel of her psychosis and her delusions," and it is not uncommon for people who experience such delusions to not discuss them with others. Dr. S. B. added that instead of seeking medical help, the Veteran self-medicated with alcohol, which is not uncommon, and also served as a marker of her psychological decline following her training at Fort Benning. The Board also finds Dr. S.B.'s opinion to be probative given that she conducted a three-hour in-person clinical interview of the Veteran and formal psychological testing, considered relevant medical records, and utilized her expertise as a licensed psychologist. See id. The Board also observes that the record includes a negative etiology opinion from a September 2014 VA examiner. The record also includes an August 2006 VA examination report, but as the Court deemed this report "unclear," and therefore inadequate, in its December 2013 memorandum decision, its probative value is limited. Nevertheless, the Board finds significant that the August 2006 examiner wrote that the Veteran provided a credible report of emerging psychotic symptoms during the Fort Benning training, which were most likely early symptoms of her serious psychiatric disorder. She also found that the Veteran's reports were validated by the April 2005 letter from D.W., which provided observations of the Veteran's "disorganized behavior" at the time. As such, the examiner opined that even though the Veteran did not receive treatment for psychiatric symptoms until an acute episode in 1983, it was more likely than not that the symptoms she described during training in 1981 were early symptoms associated with her bipolar disorder. As such, the report appears to lend some support to the positive etiology opinions noted above. Thus, the evidence of record is at least in relative equipoise with respect to the question of whether the Veteran's bipolar disorder was incurred during ACDUTRA. See Gilbert, 1 Vet. App. at 54. As the positive and negative medical evidence of record is at least in relative equipoise, the benefit-of-the-doubt rule applies, and service connection for bipolar disorder is warranted. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Entitlement to service connection for bipolar disorder is granted. ____________________________________________ S. HENEKS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs