Citation Nr: 1753880 Decision Date: 11/24/17 Archive Date: 12/01/17 DOCKET NO. 00-00 115A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include bipolar disorder. 2. Entitlement to service connection for Hepatitis A vaccination residuals. REPRESENTATION Veteran represented by: New York State Division of Veterans' Affairs ATTORNEY FOR THE BOARD G. Morales, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from May 1996 to February 1998. This case is before the Board of Veterans' Appeals (Board) on appeal from an April 1999 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In August 2004, July 2009, and September 2016 decision, the Board remanded the Veteran's claim for additional development. The matter has now been returned to the Board for appellate consideration. The Board finds there has been substantial compliance with its prior remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand.) Specifically, additional clinical records were added to the file and medical opinions were obtained that adequately address the questions posed in the prior remand. FINDINGS OF FACT 1. The weight of the competent and probative evidence is against finding that the Veteran's acquired psychiatric disorder, to include bipolar disorder, had its onset in or is otherwise related to his period of active service. 2. The weight of the competent and probative evidence is against finding that the Veteran experiences residual symptoms related to his in-service Hepatitis A vaccinations. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder, to include bipolar disorder, have not been met. 38 U.S.C. §§ 101, 1101, 1110, 1113, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307(d) (2017). 2. The criteria for service connection for Hepatitis A vaccination residuals have not been met. 38 U.S.C. §§ 101, 1101, 1110, 1113, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.04, 3.159, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA will assist a claimant in obtaining evidence necessary to substantiate a claim, but it is not required to provide assistance to a claimant if there is not a reasonable possibility that assistance would aid in substantiating the claim. VA must notify the claimant of any information, and any medical or lay evidence, not previously provided to VA, that is necessary to substantiate the claim. 38 U.S.C. §§ 5103, 5013A (2012); 38 C.F.R. § 3.159 (2017). The Veteran and his representative have not alleged any deficiency in VA's duties to notify and assist. It will not be discussed further. As such, the Board will proceed with consideration of the Veteran's appeal. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Legal Criteria and Analysis In order to establish entitlement to service connection, there must be 1) evidence of a current disability; 2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and 3) causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990). Bipolar Disorder The Veteran contends that his bipolar disorder developed in service. Following a review of the record, the Board finds that the criteria for service connection for an acquired psychiatric disorder, to include bipolar disorder, have not been met. See 38 C.F.R. § 3.303. The record reflects diagnoses of bipolar disorder and substance induced bipolar disorder. See VBMS 3/17/1999, MTR at p. 9 (diagnoses of "polysubstance abuse, questionable bipolar dx."); VBMS 10/23/2001, MTR - Government Facility at p. 15 ("history of bipolar disorder without observed symptoms at this time."). The Veteran's medical records generally state that bipolar disorder was diagnosed in the latter part of 1998. See VBMS 12/18/1998, VA Examination at p. 2; VBMS 12/28/1998, MTR at p. 6-7. However, there are records explaining that the Veteran's bipolar disorder is due to his substance abuse. As there is evidence to support both positions, the Board resolves doubt and finds that the Veteran has an acquired psychiatric disorder diagnosis of bipolar disorder. The Board does not find that there was an in-service event leading to the Veteran's bipolar disorder. The Veteran himself believes that his bipolar disorder is related to his service, as do his parents. See VBMS 6/10/1999, VA 21-4138; VBMS 8/27/1999, Buddy/Lay Statement. However, in reviewing the medical records, the Board finds many of the medical treatment records to be of little probative value. These records largely rely on the Veteran stating he was diagnosed with bipolar disorder, but cannot remember by whom. Additionally, the records indicate under Axis I that the Veteran had bipolar affective disorder, but do not indicate any symptoms in the mental status examination or discuss the Veteran's mental health. See VBMS 3/11/2004, Medical Treatment Records A, at p. 3; VBMS 9/4/2009, MTR at p. 8, 10, 14; cf. VBMS 12/20/2004 - VA 10-1000 A, Progress Notes at p. 135 ("Patient has been previously diagnosed with Narcissistic Personality Disorder and Bipolar Disorder, however, patient's extensive substance abuse precludes accurate diagnosis."). The service treatment records are also silent for mental health diagnoses. See generally, VBMS 2/8/2016, STR - Medical A. The Veteran indicated on his entrance examination that he had never been treated for mental health conditions. Id. at p. 4. On the discharge examination, the Veteran listed that he had multiple problems, including frequent colds, asthma, chronic cough, arthritis, and back pain among others. Id. at p. 6. Notably, he did not indicate he had depression or that he had been treated for a mental health condition. Id. at p. 6, 7. His clinical evaluations were also normal for psychiatric problems at enlistment and separation. Id. at p. 8, 12. His service treatment records indicate respiratory problems but are silent as to mental health conditions/disabilities. See generally, id. The Board finds the two most competent, credible, and probative evidentiary documents to be against a determination that the Veteran had an in-service event or injury leading to his bipolar disorder. The first is the Report of Psychological Examination on July 6 and 9, 1999, in the Veteran's medical records. See VBMS 9/27/1999, MTR at p. 65-70. In the examination, the examiners stated that the Veteran denied experiencing additional depressive symptoms and symptoms isolated to manic episodes. The examiners determined that he did not meet the full criteria for a diagnosis of Bipolar Disorder, and that his mood symptoms appeared to be due to his use of substances and characterological immaturity. Id. at 69. Importantly, the examiners noted that his use of substances precedes his mood symptoms, and "he has not experienced mood symptoms outside of use of substances. His substance use, rather than mood disturbance, appears to predominate in the clinical picture." Id. (emphasis added). The examiners concluded that on the Axis I, he had alcohol dependence, cannabis abuse, cocaine dependence, and early full remission. Id. at 70. Notably, he did not have bipolar disorder listed on Axis I. The Board finds this examination competent and credible and to be extremely probative as the examiners went into great detail concerning the Veteran's history. The second highly probative piece of medical evidence is a disability benefits questionnaire opinion dated in July 19, 2017. VBMS 7/19/2017, C&P Exam. Similar to the 1999 examination, in this opinion, the physician thoroughly reviewed all of the relevant medical information. She noted the problems with Veteran's bipolar diagnoses - "[t]he examiner diagnosed Bipolar I disorder (without supporting criteria documented AND despite the behavioral problems occurring in the context of polysubstance abuse) . . . also diagnosed (historically, based on [the Veteran's] report) with Bipolar disorder and Narcissistic Personality disorder as well as cannabis abuse." Id. at 1-2. The physician also explained the inconsistencies in the Veteran's reporting of his medical history, and how such inconsistencies are common in substance abuse cases. Id. at 1. The physician concluded that the Veteran has substance induced bipolar and related disorder, but that it was not incurred in or caused by his military service. She explained the Veteran had a history of cannabis use prior to military service, that he was discharged from service because of substance abuse, and finally, that his ongoing and increasing use of illicit substances ultimately led to his current mental health condition after his discharge. Id. Importantly, she stated that "[i]n order to have a pure diagnosis of Bipolar disorder, it must occur in the context of the individual being clean and sober," which did not happen in the Veteran's situation. The Board finds this examination competent and credible and to be extremely probative as it went into detail concerning the Veteran's history. The Board concludes that while the Veteran has a current diagnosis of bipolar disorder, the preponderance of the evidence is against a finding that such bipolar disorder is related to his active service. Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). Hepatitis A Vaccination Residuals The Veteran also seeks service connection for residuals of several Hepatitis A vaccinations he received during service in 1996 and 1997, to include: asthma, right shoulder arthritis, cervical spine degenerative arthritis, Churg Strauss syndrome, Demyelination, leg cramps, recurrent respiratory infections and susceptibility to infections, cerebral vasculitis, gastroenteritis, and pneumonia. The Veteran is competent to report his symptoms, but is not competent to opine as to whether said symptoms are related to his in-service Hepatitis A vaccinations. While he submitted medical documentation, such documentation is general and lists potential side effects. See VBMS 12/28/1998, Correspondence. This documentation does not relate specifically to the Veteran's medical history and so it is of minimal probative value. Additionally, the Veteran submitted medical webpages concerning Demyelination and Churg Strauss Syndrome, but there is no evidence that he has or had a diagnosis of these conditions. See VBMS 2/11/2004, MTR, at p. 14, 40. The Board finds that the Veteran satisfied the requirement as to current diagnosis with respect to his asthma, right shoulder arthritis, cervical spine degenerative arthritis, cerebral vasculitis, and pneumonia and related respiratory infections during the pendency of this appeal. See VBMS 12/10/1998, VA Examination at p. 2; VBMS 12/28/1998, Correspondence; VBMS 1/20/1999, Correspondence at p. 2; VBMS 2/4/1999, Correspondence; VBMS 7/1/1999, MTR at p. 5, 7, 18; see generally, VBMS 1/7/2002, MTR A. Indeed, the Veteran's medical treatment records indicate a diagnosis during the period on appeal of asthma, right shoulder arthritis, cervical spine arthritis, cerebral vasculitis, and pneumonia, and the Board finds he had or has the above listed disabilities. However, the record fails to establish current diagnoses of Churg Strauss syndrome or Demyelination, and the Veteran denied gastrointestinal symptoms in February 1999 and has not alleged such symptoms further. See VBMS 2/9/1999, MTR at p. 3. The Veteran has not presented any evidence or medical diagnoses relating to Churg Strauss Syndrome or Demyelination; instead, he submitted medical pages indicating he thought he had symptoms of the disabilities. Id. However, there is no evidence that the Veteran currently has a diagnosis of Churg Strauss Syndrome, Demyelination, or a chronic gastrointestinal disorder, and as such, those disabilities cannot be residuals of his Hepatitis A vaccinations. It is conceded that the Veteran received two Hepatitis A vaccinations - one in 1996, and the second, six months later in 1997. See VBMS 2/8/2016, STR-Medical A, Immunization Record at p. 11. Thus, an in-service event is established here. With respect to the disorders that have been diagnosed during the pendency of this appeal, as identified above, the evidence is against a finding of a nexus to the Hepatitis A vaccinations in service, or to any other incident of service. While the Veteran and his parents are competent to report symptoms, they are not competent to opine as to whether they are connected to the Veteran's Hepatitis A vaccinations, as such a causal relationship requires medical expertise. Layno v. Brown, 6 Vet. App. 465 (1994). In a June 2017 examination, the examiner found that the Veteran's asthma, leg cramps, pneumonia, and cerebral vasculitis are not related to the in service vaccinations. See VBMS 6/26/2017, C&P Exam at 1-2. The Veteran's asthma (onset of reactive airway disease) did not occur within 14 days after he was vaccinated, which, if his asthma had been a side effect of the vaccination, it would have occurred immediately or up to 14 days after, not two months later. Id. Further, the Veteran's leg cramps were also not noted within 14 days of the vaccination, and are not related to the vaccinations. Id. Additionally, the examiner explained that the Veteran's pneumonia occurred at least six months after the 1997 vaccine, which is beyond the period during which respiratory reaction or adverse respiratory side effects of the vaccine are expected. Id. Concerning the Veteran's cerebral vasculitis, the examiner noted that if the vaccinations caused reactions or side effects that would result in vasculitis, it would have been recorded in the Veteran's service treatment records. Id.; see also, VBMS 2/08/2016, STR-Medical A, Separation Examination at p. 6-7. The physician also explained that the Veteran's right shoulder arthritis and cervical spine degenerative arthritis were not caused by the Hepatitis A vaccinations. Although arthritis is a chronic disease under 38 C.F.R. § 3.309(a), in this case there is no showing that it manifest within the first post-service year. Furthermore, service connection on a nonpresumptive basis is also not for application here. Indeed, addressing the Veteran's arthritis, the physician stated that the Veteran's arthritis is degenerative in nature. If the vaccination had caused the arthritis, it would have been inflammatory and not degenerative. Thus, the weight of the evidence indicates that the Veteran's arthritis is not related to the Hepatitis A vaccinations he received while in service. Additionally, the physician stated the Veteran's recurrent respiratory infections existed prior to the Hepatitis A vaccination. The physician explained that there is not medical knowledge available to determine the natural progression of a worsening of susceptibility to respiratory infections, and therefore, there is no evidence to support worsening beyond natural progression. The Board concludes that while the Veteran has or had current diagnoses for some of his claimed disabilities, the preponderance of the evidence is against a finding that there is a nexus or connection between the diagnosed disabilities and his in-service Hepatitis A vaccinations. The Board acknowledges the Veteran's sincere belief that his bipolar disorder and Hepatitis A vaccination residuals are related to his service and notes that lay persons are competent to provide opinions on some medical issues. However, in this case, the question of whether the Veteran's bipolar disorder and residuals of Hepatitis A vaccinations are related to his active service are outside the realm of common knowledge of a layperson. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The intricacies in diagnosing bipolar disorder and vaccination residuals and opining regarding the etiology of such disabilities are issues that require the expertise of a medical professional, as they involve complex body systems. While the Veteran and his parents can report symptoms that he experiences, they are not competent to make medical opinions. In sum, regarding both issues on appeal, the Board finds the preponderance of the evidence is against the Veteran's claims in light of the negative competent medical evidence, the little probative value of the general and conclusory nature of the articles, and the Veteran's lay statements. In reaching this decision, the Board considered the doctrine of reasonable doubt, but it is not applicable. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). ORDER Service connection for an acquired psychiatric disorder, to include bipolar disorder, is denied. Service connection for residuals from Hepatitis A vaccinations is denied. ____________________________________________ Eric S. Leboff Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs