Citation Nr: 18131234
Decision Date: 08/31/18	Archive Date: 08/31/18

DOCKET NO. 15-29 633
DATE:	August 31, 2018
REMANDED
The claim of entitlement to service connection for an acquired psychiatric disability, including a bipolar disorder, is remanded.
The claim of entitlement to service connection for double vision, including as secondary to an acquired psychiatric disability, is remanded.
The claim of entitlement to service connection for ulcers, including as secondary to an acquired psychiatric disability, is remanded.
The claim of entitlement to service connection for renal disorder, including as secondary to an acquired psychiatric disability, is remanded.
The claim of entitlement to service connection for memory problems, including as secondary to an acquired psychiatric disability, is remanded.
The claim of entitlement to service connection for Parkinson's disease, including as secondary to an acquired psychiatric disability, is remanded.
The claim of entitlement to service connection for a partial finger amputation, including as secondary to Parkinson’s disease, is remanded.
REASONS FOR REMAND
The Veteran served on active duty from November 1969 to November 1973, and from July 1975 to April 1976.  He also served for many years in the Air National Guard.  
These claims come before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (AOJ) in Wichita, Kansas.  
Entitlement to service connection for an acquired psychiatric disability, including a bipolar disorder 
After performing active duty service the appellant, through 1990, served in the Air National Guard.  He now has a bipolar disorder, which was diagnosed in 1988 as manic-depressive disorder, which he believes first manifested in the early 1970s, during active duty, as irritability, a temper, and stress-induced headaches and sleeping difficulties.  
Service treatment records note that the Veteran reported experiencing “migraine headaches” in childhood, which persisted during his first period of active duty.  He also experienced anger and irritability, as alleged.  In February 1971, while seeking treatment for two months of daily headaches, the claimant reported that, for the last six months, when chastised or corrected, he was quick tempered with superiors and peers.  He also reported that, once, while sitting alone in a room, he kicked a hole in the wall without apparent reason for doing so.  No doctor rendered a psychiatric diagnosis during this visit, instead focusing on the headaches and suggesting they were due to the Veteran’s exposure to solvents.
In April 1988, while working in the Air National Guard, the Veteran acted inappropriately, resulting in a psychiatric referral.  In April 1988 the appellant was diagnosed with “other interpersonal problems,” and possible cyclothymia on Axis I.  The appellant was noted to refuse further help.
In January 1989, the appellant was scheduled for a fitness for duty examination.  The Board notes that this examination was addressed to the appellant in his position as a civil servant, not as an active duty airman.  The summary ordering this referral states that the appellant denied having problems that day, but that he had been having difficulty controlling his temper and stress levels.  The appellant explained that these episodes did not occur at regular intervals, but rather, manifested every six months.  The appellant did not elaborate regarding how long these episodes had been happening, but it was noted that he was on medication for depression.   
In July 1989 the appellant was found to have an affective psychoneurosis (bipolar affective disorder).  That same report noted that other providers had diagnosed interpersonal problems.
Since then, the Veteran has received regular psychiatric treatment, including medication for bipolar disorder and, as alleged, medical professionals have attributed other medical conditions to the disorder and/or medication.  To date, however, none has addressed whether, as alleged, the bipolar disorder or any other psychiatric disability initially manifested during active service as the documented temper, irritability and headaches.  Given the foregoing, an examination is in order.  
Entitlement to service connection for double vision, ulcers, a renal disorder, memory problems, Parkinson’s disease including as secondary to an acquired psychiatric disability; entitlement to service connection for residuals of a partial finger amputation, including as secondary to Parkinson’s disease
The Veteran claims that Parkinson’s disease, double vision, ulcers, memory problems, and renal disorder developed secondary to his bipolar disorder and/or the medications he takes to control that disorder.  He also claims that a partial finger amputation results from his Parkinson’s disease.  Given the Veteran’s assertions, the Board defers decisions on these issues until it is clear whether the Veteran’s psychiatric disability is related to, or initially manifested during, active service.  
The matters are REMANDED for the following action:
1. Schedule the Veteran for a VA examination to obtain a medical opinion addressing the etiology of his psychiatric disability.  The examiner is to review all records in the appellant’s VBMS and Virtual VA/Legacy files.  This specifically includes, but is not limited to: 
•	the Veteran’s statements claiming continuous problems with headaches, sleeping difficulties, anger and irritability since service; 
•	lay statements from JW and LM indicating that, as early as 1975, the Veteran was “high strung” with nervous energy, exhibiting strange behavior, a loss of control and violent temper tantrums; 
•	service treatment records dated since February 1971, which confirm longstanding headaches, anger issues and irritability; 
•	records from the Air National Guard, dated 1988 and 1989, which include psychiatric diagnoses, which show the Veteran was being treated for depression, and, which show that twice yearly he reported experiencing episodes during which he lost control of his temper and stress levels; 
•	post-service treatment records showing continued psychiatric treatment for, in part, bipolar disorder; 
•	medical professionals’ comments linking other medical conditions to the bipolar disorder and/or medication used for that condition; and 
•	letters from TJ, M.D., and GF, M.D., dated December 2012, and DS, O.D., dated October 2017.  
Based on a review of these documents, the examiner must diagnose all psychiatric disabilities found on examination or which were diagnosed over the course of this appeal.  Accepting as true all reports of lay-observable mental health symptoms (including those provided by the Veteran, JW and LM), offer an opinion addressing in detail whether it is at least as likely as not that any diagnosed acquired psychiatric disability, to include a bipolar disorder, is related to the Veteran’s active service, i.e., the periods from November 1969 to November 1973, and from July 1975 to April 1976.
The examiner must specifically note the problems documented in February 1971 while the appellant was on active duty, or initially manifested during service as anger, irritability and stress-induced headaches.  
A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training.
2. If a relationship between an acquired psychiatric disorder and active duty service is found, an appropriate VA physician must identify all medical conditions related to the psychiatric disability, including, if appropriate, Parkinson’s disease, double vision, a renal disorder, memory problems, and ulcers.  The examiner must also indicate whether it is at least as likely as not that residuals of a finger amputation are related to Parkinson’s disease. 
A complete, well-reasoned rationale must be provided for any opinion offered. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training.

 
DEREK R. BROWN
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	L. N., Counsel

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