Citation Nr: 18155075 Decision Date: 12/04/18 Archive Date: 12/03/18 DOCKET NO. 17-33 911 DATE: December 4, 2018 REMANDED The service connection claim for hair loss/scalp dermatology (scalp dermatology) is remanded. The service connection claim for an acquired psychiatric disability, to include post-traumatic stress disorder (PTSD), intermittent explosive disorder, and bipolar disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1983 to November 1983; and from June 1991 to December 1991, with additional, unconfirmed periods of service in the Army Reserve. This appeal comes before the Board of Veterans’ Appeals (Board) from a September 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In the September 2013 rating decision, the RO denied the service connection claim for scalp dermatology (also claimed as hair loss), on the basis that material evidence submitted was not new and material; and the service connection claims for an intermittent explosive disorder (claimed as depression and anxiety) and PTSD. Given that the service connection claims for an intermittent explosive disorder and PTSD, as well as other psychiatric diagnoses, of record, are all mental disabilities that are ratable using the same criteria under the General Rating Formula for Mental Disorders, these claims encompass one another and therefore, have been merged as one disability, referred to as an acquired psychiatric disability. See Clemons v. Shinseki, 23 Vet. App. 1, 5 – 6 (2009) (holding that the scope of a claim includes any disorder that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and other information of record). The Board regrets further delay but finds that additional development is necessary before a decision can be rendered on the issues on appeal. 1. Service Connection Claim for Head Scalp Dermatology The claim for service connection for scalp dermatology was previously denied in a November 1992 rating decision. In the present appeal, this issue has been characterized as a claim to reopen based on new and material evidence. However, relevant official service treatment and personnel records that existed and had not been associated with the claims file when VA initially decided the claim have now been added to the file. On this basis, the claim is reconsidered. See 38 C.F.R. § 3.156(c) (2017). At a May 2017 VA examination for skin diseases, the Veteran reported that the hair loss and scalp condition had its onset during active duty in 1990. She reported that she noticed the scalp condition after wearing a helmet during flight school and that later she noticed hair loss. She explained that this condition has remained the same, with a quarter size area of hair loss, and itching at the site of the hair loss. A December 1991 clinical record from her service treatment records (STRs) reflects that the Veteran requested a referral to a dermatology clinic and that she complained that she had been having dandruff and itching of the scalp over the past year. She was diagnosed with seborrheic dermatitis. However, her June 1991 report of medical examination for re-enlistment reflected no abnormalities of the scalp and/or skin, and she was deemed qualified for duty. Therefore, the Board finds that the Veteran was in sound condition when examined, accepted and enrolled into active service. 38 U.S.C. § 1111 (West 2012); 38 C.F.R. § 3.304(b) (2017). In April 1992, the Veteran underwent a VA examination, in which she complained of hair loss on the top of her head. She explained that the hair on the top of her head appeared to fall out and that she occasionally had some itching in the scalp. On physical examination, the VA examiner noted that her scalp revealed an area of approximately 2.5cm in diameter at the top of her head, where the hairs were about 1 inch long, compared to the rest of the scalp, “as though someone had snipped out a bunch of hair at the top of her head.” Although this made it apparent that the Veteran had hair loss, the VA examiner, however, determined that the scalp was normal, and the rest of her hair “appear[ed] normal, with no bald spots.” Nonetheless, at the time of this VA examination, the Veteran’s STRs were not available to enable the VA examiner to evaluate and determine whether the Veteran’s hair loss and/or scalp condition had any correlation to her in-service treatment and diagnosis of dandruff, itching, and seborrheic dermatitis. Furthermore, despite a determination that the Veteran did not have a scalp condition, the VA examiner failed to render a nexus opinion on the Veteran’s hair loss and her active service. Thus, the opinion is inadequate for lack of sufficient rationale. In a May 2017 VA examination for skin diseases, the VA examiner, a nurse practitioner, indicated that the Veteran does not “now have” or has not “ever had a skin condition. He documented the Veteran’s statements and complaints that the onset of her symptoms was in 1990 when the condition began while in flight school, and that she was wearing a helmet when she noticed hair loss. He additionally noted that the Veteran’s skin conditions did not cause scarring or disfigurement of the head. He opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness. As the rationale for his opinion, he explained that a review of the record did not reveal a diagnosis of hair loss during service or other dermatologic disease, and that there was no diagnosis of a skin condition or hair loss at this examination because there was no pathology to render a diagnosis. However, the Board finds that this opinion is inadequate for determining this claim for numerous reasons. First, the VA examiner failed to undertake a physical examination of the Veteran’s scalp. He explained that he was unable to complete the physical examination because the Veteran was wearing a ‘weave cap”, which is “attached to the scalp” and unable to be removed. However, to the contrary, this very VA examination report reflects that the “weave cap” is removable because the VA examiner noted that the Veteran explained that she goes to the salon for “cap and braiding to cover [the] area” of the “quarter sized area of [her] hair loss.” Nonetheless, even though the VA examiner did not undertake to examine the scalp, he speculated and presumed that that the Veteran did not have a scalp condition. Additionally, the troubling findings in this VA examination are contrary to the medical evidence of record. Specifically, the VA examiner determined that the Veteran has not ever had a skin condition. Additionally, he indicated that a “review of record does not reveal a diagnosis of hair loss during service or other dermatologic disease.” However, as noted above, the claims file consists of evidence of in-service complaints and treatment for dandruff and an itchy scalp, as well as a diagnosis of seborrheic dermatitis. Therefore, this opinion is based on an inaccurate factual premise. Therefore, based on the foregoing, a remand is required for a new VA examination and opinion on the etiology of the Veteran’s hair loss and scalp condition. 2. Service Connection Claim for An Acquired Psychiatric Disorder The medical evidence of record reflects that the Veteran has been diagnosed with various mental disorders. However, none of the VA examinations and opinions for mental disabilities are adequate for determining this claim. Specifically, an August 2013 VA examination for mental disorders reflects that the Veteran has a diagnosis of intermittent explosive disorder, and that the Veteran does not have more than one mental disorder diagnosed. The VA examiner opined that the Veteran’s claimed depression and anxiety is not caused by or a result of complaints that occurred in September 1991 and August 1991. As a rationale for this opinion, the VA examiner stated that the Veteran’s current diagnosis is better represented as intermittent explosive disorder. He further expounded that any depression and anxiety experienced appears to be in reaction to the consequences of her impulse control problem, interpersonally; her service medical records that are dated September 1991 and August 1991 are not mental records, and that the records indicate fatigue, in association with medical problems of back problem and UTI. Accordingly, he concluded that there was no evidence of a psychiatric diagnosis. However, this opinion is inadequate because the VA examiner did not render a nexus opinion on the correlation between her current mental disability and her active service. Additionally, given that only some STRs were associated with the claims file prior to this examination, the VA examiner did not undertake a complete review of all of the Veteran’s STRs. Pertinently, STRs that were apparently associated with the claims file in November 2016 suggest that the Veteran sought mental health treatment while she was on active duty, as they reflect, for example, complaints of depressive symptomatology, anxiety and difficulty with coping in November 1991. Additionally, in addition to documentation that the Veteran experienced stress since being assigned to Fort Rucker, with symptoms of anxiousness and withdrawal, the Veteran was also diagnosed with an adjustment disorder, with mixed emotional features in November 1991. An April 2017 VA examination for mental disorders reflects that the Veteran has mental diagnoses of bipolar disorder and borderline personality disorder. A VA examiner opined that the Veteran was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness. As the rationale for her opinion, the VA examiner explained that the Veteran reported significant emotional difficulties related to childhood trauma, prior to entering the military, no specific military related trauma was reported, and that “rather, the claimant indicated that she felt more stable in the military due to the structure of the environment.” However, the Board finds that the VA examiner provided an insufficient rationale for this opinion because he did not discuss or account for the Veteran’s in-service complaints, treatment and diagnosis of a mental disability. His explanation that the Veteran indicated that “she felt more stable in the military due to the structure of the environment” is contrary to treatment records in the STRS, in which at least one documentation indicated that she was experiencing stress, since being assigned to her post at Fort Rucker.” Additionally, the VA examination report predominantly discussed the mental symptoms and issues the Veteran had prior to and post-service, and doing so, failed to discuss whether any of the Veteran’s in-service symptoms of a mental disorder aggravated and/or was a contributing factor to her current mental disability. Consequently, the VA examiner failed to address and discuss the Veteran’s in-service diagnosis of an adjustment disorder, as well as discrepancies with other post-service mental diagnoses, including and not limited to, a February 2012 psychological evaluation, which diagnosed the Veteran with an adjustment disorder, ruling out intermittent explosive disorder and PTSD; and the August 2013 VA opinion, which diagnosed the Veteran with an intermittent explosive disorder. Therefore, based on the foregoing deficiencies discussed, a remand is required for a new VA examination and opinion on the nature and etiology of the Veteran’s mental disabilities. 3. Outstanding Service Records The evidence of record indicates that the Veteran served in the Army Reserves from approximately December 1982 to December 1991. However, there are no documents in the claims file to confirm all of the Veteran’s period of active duty, and if any, active duty for training (ACTDUTRA) and inactive duty for training (INACTDUTRA). Therefore, it is apparent that there are outstanding service personnel records, which may provide additional information about the Veteran’s periods of active service, and additionally, pertinent information about possible additional complaints, treatment and or diagnoses relating to the claims on appeal. Therefore, on remand, the RO must obtain an enumerated list of the Veteran’s period of service, indicating for each period, whether the service was active duty, ACTDUTRA, INACTDUTRA, or unverified, prior to scheduling new VA examinations. The matters are REMANDED for the following action: 1. Make as many requests as are necessary to obtain all outstanding service personnel records for the Veteran’s period of service in the Army Reserves, from approximately December 1982 to December 1991, including and not limited to, undertaking a request with the Army Reserves; submitting a personnel information exchange system (PIES) request; submitting a request for records from Record Management Center (RMC); and if necessary, submitting a request to Defense Finance and Accounting Service (DFAS). 2. Then, provide a clearly enumerated list of the Veteran’s periods of service in the Army Reserves, which should indicate for each period, whether the service was active duty, ACTDUTRA, INACTDUTRA or unverified. 3. Then, after obtaining all outstanding information and records and associating them with the claims file, schedule the Veteran for a VA examination with a physician (VA examiner) that has not yet evaluated the Veteran, to assess the nature and etiology of her hair loss and scalp condition. The VA examiner must review the claims file and must note that review in the report. All necessary tests and studies should be accomplished and all clinical findings reported in detail. A copy of this REMAND should be made available to the VA examiner. The VA examiner must undertake the following: a. Opine whether it is at least as likely as not (50 percent probability or greater), the Veteran’s hair loss and/or scalp condition was incurred in, a result of, or related to an injury, illness, disease, or event in service. b. In rendering an opinion, please consider all pertinent lay statement from the Veteran about onset and symptomatology. A detailed rationale is requested for all opinions provided. If an opinion cannot be provided without resort to speculation, provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 4. Also, after obtaining all outstanding information and records and associating them with the claims file, schedule the Veteran for a VA examination with a psychologist or psychiatrist, who has not yet evaluated the Veteran, to determine the nature and etiology of her psychiatric disabilities. The VA examiner must review the claims file and must note that review in the report. The VA examiner must undertake the following: a. Opine whether it is at least ast likely as not (50 percent probability or greater), the Veteran’s current mental disabilities are due to or a result of her active service. b. If it is determined that the Veteran manifested symptoms of a mental disability prior to service, opine whether it is at least as likely as not (50 percent probability or greater), that an in-service diagnosis of a mental disability is a contributing factor of her current mental disabilities. c. If it is determined that the Veteran manifested symptoms of a mental disability prior to service, opine whether it is at least as likely as not (50 percent probability or greater), the Veteran’s in-service diagnosis of a mental disability was aggravated by her active service. “Aggravation” means an increase in severity of the disorder beyond any medically established baseline. The appropriate section of the Disability Benefits Questionnaire pertaining to aggravation opinions should be filled out for this purpose, if possible. d. Consider all lay statements from the Veteran about onset and symptomatology. e. Discuss all discrepancies in diagnoses for mental disabilities, of record, if any. (Continued on the next page)   A detailed rationale is requested for all opinions provided. If an opinion cannot be provided without resort to speculation, provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. M. TENNER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD V-N. Pratt, Associate Counsel