Citation Nr: 21031334 Decision Date: 05/21/21 Archive Date: 05/21/21 DOCKET NO. 16-40 625 DATE: May 21, 2021 ORDER Entitlement to service connection for bipolar disorder, to include as secondary to service-connected posttraumatic stress disorder (PTSD), is granted. FINDING OF FACT Resolving all reasonable doubt in the Veteran's favor, his currently diagnosed bipolar disorder is aggravated by his service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for bipolar disorder as secondary to service-connected PTSD are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1969 to February 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded this case in December 2018 for further development. Pursuant to the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159. Given the Board's favorable disposition of the service connection claim for bipolar disorder, the Board finds that all notification and development action needed to fairly adjudicate the appeal has been accomplished. 1. Entitlement to service connection for bipolar disorder, to include as secondary to service-connected PTSD, is granted. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Generally, service connection requires: (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. See Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). In addition, service connection may be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). Service treatment records do not show complaints of, treatment for, or a diagnosis of a psychiatric disorder, to include bipolar disorder. Military personnel records showed that the Veteran served in the Republic of Vietnam from February 1970 to February 1971. From February 1970 to December 1970, he served as a deck seaman on a mine sweeping boat, which operated in enemy infested waters in Vietnam. He made daily combat mine sweeping missions on the "always dangerous" Long Tau River. In an October 2007 VA examination, the examiner diagnosed the Veteran with bipolar disorder. The Veteran reported that he had received outpatient mental health treatment since the mid-1980's. He stated that he had been diagnosed with PTSD in the 1980's and with bipolar disorder in 1992. The Veteran's identical twin brother had also been diagnosed with bipolar disorder, his older brother was described as an alcoholic, and two of his sons had significant mental health problems including schizoaffective disorder, depression, and suicidal ideation. The Veteran believed that his mother had "undetected" bipolar disorder. The Veteran's first marriage lasted from 1971 to 1988 and his first wife got him into Jehovah's Witnesses, which he described as a cult. After twelve years, he left Jehovah's Witnesses. Thereafter, he was shunned by the community and his wife divorced him. His wife had also been cheating on him. He married his current wife in 1989 and he described their marriage as tough. They argued a lot and called each other names. The Veteran had not been in any significant combat. He was a seaman on a mine sweeper and a gunman on a bat. He had vague recollections of ducking to avoid a couple of isolated bullets and another incident in which someone threw a rock in his vehicle which frightened him. The examiner opined that based on the Veteran's self-report alone, it appeared at least as likely as not that his bipolar disorder had been exacerbated by his military experiences. In a December 2007 lay statement, the Veteran reported that he watched tracer bullets in the distance and realized that the war was so close that it could be "right on us." He reported that he was a mess inside even though on the outside, he looked like he "had it all." In a private April 2015 examination by Dr. J. R. Tuorila, the Veteran was diagnosed with PTSD and bipolar disorder. He reported that his mother probably had undiagnosed bipolar disorder and that one of his sons had bipolar disorder and another had schizoaffective disorder. The Veteran stated that he spent his first four months in Vietnam on river patrols and then later became a driver for a division that went into Saigon and other locations to pick up supplies. He was scared and watched firefights at night from the base. He described other in-service traumatic events, to include when a Vietnamese child threw a rock into the back of a truck he was driving and he believed that it had been a hand grenade and that he was going to die. He also reported that he had to throw a hand grenade into the water when he heard a Viet Cong swimmer near the boat even though it was against his spiritual belief to kill someone. He felt guilty afterwards. Dr. Tuorila noted the Veteran's report of in-service traumatic events and opined that his bipolar disorder was less likely than not secondary to his military experiences. In a May 2015 lay statement, the Veteran reported that he had not shot, but could have been many times. He also described a number of in-service traumatic events, to include: (1) being "sitting ducks" when on the mine sweeping boat; (2) sniper fire directed at the boat; (3) having to throw grenades in the water even though he was morally opposed to taking a life; (4) the incident in which a boy threw a rock into his truck; (5) general fear of attack during mine sweeps and hypervigilance during runs to Saigon; (6) when a fellow serviceman attempted to pull down his pants in front of women and being shamed by his fellow servicemen; and (7) disillusionment that Americans were the "good guys" when he saw servicemen doing drugs and consuming excessive alcohol, having prostitutes bussed in from Saigon, and disrespecting the Vietnamese. In a July 2015 VA examination, the Veteran was diagnosed with bipolar disorder, but not PTSD. His oldest brother had passed away the day before the examination. It was noted that the Veteran had been diagnosed with bipolar disorder in 1992. The examiner opined that it was unlikely that the Veteran's bipolar disorder was related to or caused by his reported military service or experiences. In a November 2017 statement, D. Oosten, a VA therapist stated that the Veteran experienced clinically significant mental health issues after service in Vietnam, specifically a haunting state of inner conflict and turmoil. D. Oosten suspected that the Veteran's presentation of symptoms at the most recent VA examination may have been askew and minimized by the Veteran. The Veteran reported that he had been clearly overwhelmed with anxiety and numbness due to his older brother's passing the day before the examination. D. Oosten opined that the Veteran experienced clinically significant mental health issues that interfered with daily functioning and relationships that was more likely than not secondary to his military service in Vietnam. In a May 2018 VA examination, the Veteran was diagnosed with PTSD and bipolar disorder. The Veteran reported no clear or disabling mental health difficulties while in the military, but did clearly describe how he was offended, humiliated at times, and shocked at the behavior of his peers who he felt were often engaging in immoral, if not illegal, activities. He felt that he was a pacifist, but in a situation that called for killing at times, which was a tremendous conflict for him. The examiner found that the Veteran had been diagnosed with bipolar disorder approximately 21 years after separation from service. The examiner further found that the Veteran's bipolar disorder began subsequent to his PTSD, but was not related to his PTSD either as a means of coping with the condition or as a psychological reaction to the condition. Rather, his bipolar disorder was a separate entity entirely from the Veteran's PTSD and unrelated to it. As such, there was no nexus between his service-connected PTSD and bipolar disorder. In an October 2019 VA examination, the Veteran was diagnosed with bipolar disorder, which had first been diagnosed in 1992, and PTSD. The examiner found that while there was some overlap in the symptoms from these two conditions, several of them, by definition, could be attributed to one condition versus the other. Insomnia overlapped with both conditions, such that at times, his sleep apprehension was due to chronic nightmares associated with PTSD and long periods of lack of sleep due to increased energy from hypomania. The examiner also found that it was not possible differentiate which impairment was caused by each mental disorder. The Veteran's bipolar disorder and PTSD appeared to interact in complex ways and would be difficult, if not impossible, to differentiate the relative impacts on his social and occupational functioning from each other. The examiner opined that it was less likely than not that the Veteran's bipolar disorder was due to his military service as there was minimal evidence in the record to support this. By his own report, the Veteran did not develop symptoms while in service and denied immediate need for it at the time. Based on the Veteran's reports as to the development of his symptoms, none of those that he experienced that day and were attributed to bipolar disorder (i.e., flight of ideas, lack of sleep, increased energy, goal-directed behavior, etc.) were evidence when he was in service. The Veteran developed his first hypomanic episode in 1991, seemingly sporadically, 20 years after separation from service. Further, the examiner noted that the Veteran did not see how his bipolar disorder was caused by his service. The examiner opined that it was less likely than not that the Veteran's bipolar disorder was the result of his service-connected PTSD. The assertion that bipolar disorder could be directly caused by or the result of PTSD was not scientifically supported. The examiner stated that it would go beyond the current state of knowledge in clinical psychology and require mere speculation to opine whether the Veteran's history of trauma may have somehow changed the chemistry of his brain or changed the psychosocial circumstances that would make him more vulnerable to the development of bipolar disorder. Bipolar disorder was noted to be a separate class of psychiatric diagnosis with very complex genetic and etiological inputs. The examiner noted that the Veteran's genetic history included his twin brother who developed bipolar disorder in the 1970's (without a history of PTSD) and his mother who may also have had bipolar disorder. The examiner acknowledged that in some instances, those with genetic predisposition may first manifest symptoms of bipolar disorder following significant trauma or psychosocial stressors. However, the Veteran had not been diagnosed with bipolar disorder until after his first episode onset in 1991. It did not appear that his bipolar went undiagnosed or misdiagnosed as his change in symptoms (manic episode) was obvious at the time and he had previously functioned relatively well. The Veteran did not have a pre-history of hypomanic behaviors leading up to this point either. As such, it seemed unlikely that the Veteran's PTSD would incite the development of hypomanic episodes two decades after his initial trauma. The examiner found that two decades' worth of intervening interpersonal stressors and difficulties could have also as likely as not influenced development of his first symptoms unrelated to or independent of PTSD. The examiner opined that it was as likely as not that the Veteran's bipolar disorder had been aggravated by his service-connected PTSD. The examiner found that there was evidence for aggravation in terms of increased manifestations. The Veteran endorsed symptoms of hypervigilance, exaggerated startle response, and anxiety. The Veteran and his wife believed that his PTSD symptoms may exacerbate his hypomanic episodes, which were already marked by increased irritability as he was already on edge. It seemed to take less frustration or stimulus before he had an angry outburst when he was also having increased PTSD symptoms. The Veteran's wife complained about his irritability, particularly when something suddenly happened (i.e., a car speeding by or hearing a loud sound). Additionally, during the depressive phase of his bipolar disorder, in addition to the vegetative symptoms often observed in bipolar disorder (i.e., appetite, energy, and sleep problems), he also developed significant ruminations about his military experiences to include things he should have done or not done and expressing a great degree of guilt. It also appeared that his periods of bipolar depression were made worse by his belief that he had a moral or spiritual injury due to his experiences in Vietnam. The examiner found that the reports from the Veteran and his wife sounded plausible and reasonable from a clinical standpoint. Given his understanding of the reports from the Veteran and his wife and that there was no medical basis to doubt the history they provided, the examiner opined that it was as likely as not that the Veteran's assertion regarding aggravation was plausible. However, the examiner also found that he could not ascertain the baseline manifestations of the Veteran's bipolar disorder prior to aggravation by his PTSD considering that the Veteran had developed PTSD before his bipolar disorder and changes in his medication dosage. According to post-service treatment records, the Veteran had been consistently diagnosed with and treated for bipolar disorder. His family history showed that his older brother had alcoholism, his identical twin brother had bipolar disorder, his mother may have had untreated bipolar disorder, and his sons had schizoaffective disorder and bipolar disorder. It was noted that he had been diagnosed with bipolar disorder in 1992 and PTSD in 1993. In a February 1992 record, it was noted that the Veteran had probable PTSD and bipolar disorder. In January 1993, he was diagnosed with chronic PTSD and bipolar disorder. It was noted that in the summer of 1991, he had an episode lasting several months of hyper irritability, early waking, voluminous writing, and spending hours of the early morning mentally meditating "conversations with God." In August 1992, he woke at 1:00 or 2:00 AM and felt "high, wrote hundreds of pages documenting his thoughts and ideas, actively "walk[ed] with God" in the early morning, felt himself to be racing inside himself, engaged in many worthwhile projects, and felt that there were not enough hours in the day to do all he wanted. Resolving all reasonable doubt in favor of the Veteran, the Board finds that the criteria for service connection for bipolar disorder based on secondary service connection have been met. As noted above, the Board finds that the evidence of record is at least in equipoise that the Veteran's bipolar disorder was aggravated by his service-connected PTSD. The Board finds the October 2019 VA opinion highly probative to the issue of whether the Veteran's bipolar disorder was aggravated by his service-connected PTSD. The examiner possessed the necessary education, training, and expertise to provide the requested opinion. Grottveit, 5 Vet. App. at 93 (1993). In summary, resolving all reasonable doubt in favor of the Veteran, the evidence is at least in equipoise that his bipolar disorder was aggravated by his service-connected PTSD. Accordingly, the Veteran's service connection claim for bipolar disorder must be granted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Ko, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.