Citation Nr: 18123955
Decision Date: 08/03/18	Archive Date: 08/03/18

DOCKET NO. 14-29 341
DATE:	August 3, 2018
ORDER
New and material evidence having not been received, the claim to reopen entitlement to service connection for a traumatic brain injury (TBI) is denied.
New and material evidence having been received, the claim to reopen entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) is granted.
REMANDED
Entitlement to service connection for a compressed pituitary gland, secondary to head trauma, is remanded. 
Whether new and material evidence has been received to reopen a claim of entitlement to service connection for headaches is remanded.
Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded. 
FINDINGS OF FACT
1. In a November 2009 rating decision, the RO reopened and denied service connection for an acquired psychiatric disorder, to include PTSD, and denied reopening a claim of service connection for a TBI; the Veteran did not appeal the decision and it became final.
2. The evidence received subsequent to the November 2009 rating decision is cumulative of the evidence previously of record; it does not relate to an unestablished fact necessary to substantiate the claim and does not raise a reasonable possibility of substantiating the claim of entitlement to service connection for a TBI.
3. The evidence received subsequent to the November 2009 rating decision is not cumulative of the evidence previously of record; it relates to an unestablished fact necessary to substantiate the claim and raises a reasonable possibility of substantiating the claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD.
CONCLUSIONS OF LAW
1. New and material evidence has not been received to reopen the claim of entitlement to service connection for a TBI.  38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156(a) (2017).
2. New and material evidence has been received to reopen the claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD.  38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156(a) (2017).
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran served on active duty from March 1971 to December 1971.
This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2010 rating decision denying service connection for a compressed pituitary gland and a June 2012 rating decision denying claims to reopen claims of entitlement to service connection for a TBI, an acquired psychiatric disorder, to include PTSD, and headaches.  Both rating decisions were issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia.  The issue of service connection for a compressed pituitary gland has been recharacterized to better reflect the evidence of record.
The Board notes that despite an RO’s decision on whether to reopen a previously denied claim, the Board must make its own determination as to whether the Veteran has submitted new and material evidence to reopen the claim.  See Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996).
With regard to the issue of a TBI, the Board acknowledges that additional VA treatment records were associated with the claims file after the most recent statement of the case (SOC) was issued in July 2014.  However, because these records reflect ongoing treatment and do contain new and material evidence, the records are cumulative in substance of treatment records previously considered by the Agency of Original Jurisdiction (AOJ).  Therefore, the Board finds that the records are not pertinent to the appeal and, thus, referral to the AOJ for consideration in the first instance is not required.  38 C.F.R. §§ 19.31, 20.1304(c).  With regard to the issues of a compressed pituitary gland, an acquired psychiatric disorder, to include PTSD, and headaches, the Board notes that these records will be considered by the AOJ on remand.
New and Material Evidence 
Generally, when a claim is disallowed, it may not be reopened and allowed, and a claim based on the same factual basis may not be considered.  38 U.S.C. § 7105(c).  A claim on which there is a final decision may be reopened if new and material evidence is submitted.  38 U.S.C. § 5108.  “New” evidence means existing evidence not previously submitted to agency decision makers.  “Material” evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim.  38 C.F.R. § 3.156(a).  New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim.  Id.  
The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.”  See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010).  Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA Secretary’s duty to assist or through consideration of an alternative theory of entitlement.  Id. at 118.  
Reopening a claim for service connection which has been previously and finally disallowed requires that new and material evidence be presented or secured since the last final disallowance of the claim.  38 U.S.C. § 5108; Evans v. Brown, 9 Vet. App. 273, 285 (1996); see also Graves v. Brown, 8 Vet. App. 522, 524 (1996).  The evidence submitted to reopen a claim is presumed to be true for the purpose of determining whether new and material evidence has been received.  Duran v. Brown, 7 Vet. App. 216, 220 (1994); Justus v. Principi, 3 Vet. App. 510, 513 (1992).
1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for a TBI is denied.
The Veteran seeks to reopen a previously denied claim of entitlement to service connection for a TBI.
In December 1971, the Veteran submitted a claim of entitlement to service connection for a head injury.  He asserted that he had been hit in the head with a rifle by a drill instructor and had experienced head pain since.
The Veteran was afforded a VA examination for a head injury in February 1972.  On examination, the VA examiner noted that the Veteran’s head, face, and neck were normal.  Imaging studies of the skull did not reveal definite fractures, calcified pineal, abnormal intracranial calcification, or evidence of prolonged increased intracranial pressure.  The study was normal and no head injury was found.
The Veteran’s claim was denied in a February 1972 rating decision.  The RO determined there was no valid basis for a grant of service connection, as no head injury was found and no head condition had been documented on his 1971 separation examination.  Although the Veteran filed a timely notice of disagreement (NOD) in March 1972, the Veteran failed to perfect his appeal after the RO issued a SOC in April 1972.  Therefore, the decision became final.
The evidence of record at the time of the February 1972 rating decision consisted of partial service treatment records, post-service treatment records, and a February 1972 VA examination. 
The Veteran’s October 1970 Report of Medical Examination on entry did not note any skull fractures or head injuries.  He denied ever having a head injury on his corresponding October 1970 Report of Medical Examination.  The Veteran was also found to have no skull fractures or head injuries on his October 1971 Report of Medical Examination upon separation from service. 
In November 1981, the Veteran filed a claim to reopen his previous claim of entitlement to service connection for a head injury.  In May 1984, the RO sent the Veteran notification that he would need to submit new and material evidence in order to reopen his service connection claim.  The Veteran failed to respond with any additional evidence.
In March 1985, the Veteran again filed a claim to reopen his claim of service connection for a head injury.  An October 1985 notification letter stated that new evidence was considered, but there was no change in the disposition.  The Veteran filed a timely NOD in February 1986, a SOC was issued in March 1986, and the decision became final when the Veteran failed to perfect his appeal.
At the time of the October 1985 rating decision, the new evidence of record consisted of additional military personnel and service treatment records, which revealed multiple complaints of headache pain, but no evidence that the Veteran ever visited sick call for a head injury or with complaints of trauma to the head. 
New evidence also consisted of an August 1985 transcript of a Decision Review Officer (DRO) hearing.  At the hearing, the Veteran described the circumstances that led to a drill instructor striking him on the head with the butt of a rifle.  The Veteran reported he was wearing a helmet when he was hit and did not seek immediate medical treatment.  He denied swelling, bleeding, or an open wound to the head. 
Additional treatment records were added to the evidentiary record and while they contained reports of headache pain, there was no pertinent treatment related to a head injury.
In January 2009, the Veteran submitted a claim of entitlement to service connection for a TBI.  In May 2009, the Veteran was notified that his claim had previously been denied as entitlement to service connection for a head injury and new and material evidence was required to reopen the claim.  The Veteran’s claim to reopen was denied in a November 2009 rating decision.  The RO determined that no new and material evidence had been submitted, as there was still no evidence that a TBI occurred in service.  A timely NOD was submitted in November 2009 and the RO issued a SOC in May 2010.  The Veteran failed to perfect his appeal and the decision became final.  
Evidence received subsequent to the October 1985 rating decision included updated treatment records, Social Security Administration (SSA) records, and a lay statement from the Veteran.  
A March 1989 VA treatment record noted that the Veteran had been in six motor vehicle accidents from 1971 to 1986 and had suffered a right facial fracture in one accident.  In a March 1989 statement, following the Veteran’s inaccurate report of an in-service concussion, Dr. J. O. opined that the Veteran had some residual traumatic brain disease that was manifested by some behavior which he would loosely label as eccentric personality syndrome.  In a January 1990 VA treatment record, the Veteran reported that he had broken the windshield with his head in a car accident.  On neurological examination in February 1990, the Veteran’s cranial nerves were noted to be intact.  A March 1992 computed tomography (CT) scan of the brain failed to find acute intracranial hemorrhage, abnormal extra-cranial fluid collection, mass lesions, or mass effects.  Gray and white matter differentiation was normal and examination of the brain was within normal limits.  A September 2005 VA treatment record noted that a 1997 magnetic resonance imaging (MRI) of the Veteran’s brain had revealed a partially empty sella.  An MRI ordered that month showed an empty sella with compressed pituitary tissue and an old right lacunar infarction versus Virchow-Robin space.  
In June 2006, the Veteran submitted a statement recounting the in-service events which he believed led to his TBI.
A February 2007 VA treatment record indicated the etiology of the compressed pituitary gland was unknown.  A March 2009 neuropsychic testing consult summarized the Veteran’s reported history of head trauma, but failed to note any indication of a TBI.  In June 2009, Dr. R. B., a private physician, indicated that the Veteran suffered a TBI after being hit in the head with a rifle during active duty.  Dr. R. B. stated that the TBI resulted in a compressed pituitary gland and left him with a lacunar infarction. 
In March 2011, the Veteran again submitted a claim to reopen his previous claim of entitlement to service connection for a TBI.  The RO denied reopening the claim in a June 2012 rating decision, finding that the new evidence submitted failed to show that a TBI was incurred in service, that there was a diagnosis of TBI, or that the Veteran suffered a head injury related to service.  The Veteran filed a timely NOD in August 2012 and the RO issued a SOC in July 2014.  He perfected his appeal in August 2014 and the issue is now before the Board.
Evidence submitted since the November 2009 rating decision consists of a March 2010 DRO hearing in which the Veteran stated he was hit in the head with a rifle by a drill instructor.  He began experiencing headaches following the incident.  In an October 2011 VA treatment record, the Veteran stated his in-service injury to the head caused his pituitary gland to collapse.  In February 2014, a MRI of the Veteran’s brain was conducted in response to his forgetfulness.  The MRI revealed prior lacunar infarcts in the deep gray nuclei of both hemispheres with no acute process identified.  Nonspecific foci of T2 signal abnormality in the white matter of both frontal and parietal lobes was noted to be seen in patients with hypertension, diabetes, chronic microvascular ischemic change, migraine headaches or demyelination.  The Veteran was noted to most likely have chronic small vessel disease.  A subsequent February 2014 treatment record indicated that the MRI of the Veteran’s brain was abnormal and revealed old strokes and a hardening of the arteries.  In October 2017, Veteran asserted he had suffered a stroke and another MRI of his brain was conducted, which failed to note a history of a TBI.
The Board notes that the electronic claims file reflects that the Veteran’s service treatment records were added to his file in October 2014; however, it appears that these records were available in the claims file long before this.  See, e.g., September 1972 Statement of the Case, June 1977 Statement of the Case, and June 2010 Rating Decision.  As such, these service treatment records are not considered new evidence.
The treatment records received subsequent to the November 2009 rating decision were not a part of the record at the time of the prior final denial, but they are not material to this claim.  The records do not indicate, in any way, that the Veteran incurred a TBI or head injury in service or that the Veteran currently suffers from a TBI or head injury that was incurred in service.  Although numerous MRIs conducted between 1997 and 2017 have noted a partially empty sella, an empty sella, compressed pituitary tissue, and an old right lacunar infarction, no physician, with the exception of Dr. R. B., has etiologically linked these findings to the Veteran’s service or any incident therein.  The Board would like to note that while Dr. R. B. provided a positive opinion linking the MRI findings to the Veteran’s in-service head injury, he failed to provide a rationale for his opinion or address evidence of post-service trauma to the head from multiple motor vehicle accidents. 
Accordingly, having determined that new, but not material, evidence has been submitted, the Veteran’s claim of entitlement to service connection for a TBI is not reopened.
2. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is granted. 
The Veteran seeks to reopen a previously denied claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD.
Given the lengthy procedural history and the favorable disposition herein, the Board will discuss the procedural history of the claim followed by a summary of the total evidence of record prior to the November 2009 rating decision.
By way of history, an August 1976 rating decision denied service connection for schizophrenia, hebephrenic type.  The RO determined that there was no in-service evidence of schizophrenia and the Veteran was diagnosed too remotely from service for the diagnosis to be associated with active duty.  The Veteran filed a timely NOD in April 1977 and an SOC was issued in June 1977.  In February 1978, the Veteran explicitly withdrew his claim and the decision became final. 
In October 1985, a notification letter denied reopening the Veteran’s claim of service connection for a nervous condition.  The Veteran filed an NOD in February 1986 and a SOC was issued in March 1986.  The Veteran failed to perfect his appeal and the decision became final.
In January 1996, the Veteran again filed to reopen his claim of service connection for a nervous condition.  An April 1996 rating decision denied reopening the claim, as no new and material evidence had been submitted.  Although new evidence was found to be submitted, it was considered duplicative and merely cumulative of the evidence already of record.  The Veteran did not respond with a timely NOD and the rating decision became final. 
In April 2001, the Veteran filed to reopen his claim of service connection for an acquired psychiatric disorder, to include schizophrenic process.  In September 2002, the RO denied reopening the claim, determining that newly added evidence failed to relate the Veteran’s post-service psychiatric disorder to service.  The Veteran filed a timely NOD in September 2002 and was issued a SOC in February 2003.  The Veteran perfected his appeal in February 2003.  In February 2004, the Board reopened and remanded the Veteran’s claim of service connection for a psychiatric disability, to include schizophrenia.  The Board again remanded the issue in January 2006 and in March 2007, the Board denied the Veteran’s claim, finding there was no nexus between his psychiatric disorder and service. 
In January 2009, the Veteran filed a claim of service connection for a psychiatric disorder, to include PTSD.  A November 2009 rating decision denied the claim, finding that the Veteran’s stressor could not be corroborated and a chronic psychiatric condition, to include PTSD, could not be linked to service.  The Veteran filed a timely NOD in November 2009 and a SOC was issued in May 2010.  The Veteran failed to perfect his appeal and the rating decision became final.
In March 2011, the Veteran filed to reopen his claim of service connection for an acquired psychiatric disorder, to include PTSD.  In a June 2012 notification letter, the RO denied reopening the Veteran’s claim, as the evidence did not show that the Veteran experienced a stressor in service or had a diagnosed condition related to service.  The Veteran file a timely NOD in August 2012 and was issued a SOC in July 2014.  The Veteran perfected his appeal in August 2014 and the issue is now before the Board.
At the time of the November 2009 rating decision, the evidence consisted of military personnel and service treatment records, post-service private and VA treatment records, medical records provided by the SSA, DRO and Board hearing transcripts, and lay statements.
Service treatment records show the Veteran underwent a psychological evaluation in October 1971.  He had been in the Army for approximately six months before he was referred to the Mental Hygiene Consultation Service from the troop dispensary physician.  The Veteran had numerous complaints of low back pain and headaches and claimed he was struck several times on several occasions by the drill instructor for his inability to march well.  The Veteran’s history revealed that he quit school in the eighth grade because of poor grades and difficulty with teachers.  In service, after basic training, the Veteran was assigned to “cooks school.”  He flunked out and was sent to the Field Wiremans Course.  The Veteran was noted to be marginally functioning, spending most of his time being recycled and going to sick call.  The Veteran received an Article 15 in the past for threatening a noncommissioned officer (NCO).  The psychology specialist noted that the Veteran did not exhibit symptomatology of a psychiatric disease and his main features included immaturity, impulsivity, and poor judgement.  He did not have insight into the causative agents involved with his head and back pain, nor did he have the sophistication to deal with them.  The psychology specialist determined that if the Veteran were retained on active duty, he would continue to be marginally effective, as well as a burden on medical facilities.  His separation was recommended.
A November 1971 military personnel record indicated that the Veteran had been diagnosed with borderline mental retardation.  The Veteran was noted to have a history of marked social inadaptability prior to and during his active duty service.  The Veteran had a character and behavior disorder due to deficiencies in emotional and personality development.  In November 1971, the Veteran was officially recommended for discharge from service due to character and behavior disorders.  The Veteran displayed fair to poor conduct and efficiency throughout his career and his inefficiency was attributed to his borderline intelligence with a minimal ability to grasp basic instruction.  His intellectual inadequacy compounded his character problems in the areas of self-esteem and confidence, leading to immature and impulsive behavior and poor judgement. 
The Veteran’s October 1971 Report of Medical Examination upon separation noted that the Veteran was evaluated as psychiatrically clinically normal. 
A September 1975 VA treatment record noted that the Veteran was dull and mental retardation should be considered. 
An October 1975 VA treatment record noted a diagnosis of schizophrenia, simple type.  The Veteran had a past history of psychiatric problems and had been admitted to a psychiatric ward in California prior to his discharge from service.  The Veteran reported suicidal and homicidal ideations, particularly during periods of headaches.  It was noted that he had previously tried to hang himself with a shoelace, but the shoelace had broken.  The Veteran presented with psychopathic ideas during the interview and was noted to be a little mentally slow in all aspects, exhibiting grins and laughter at inappropriate times. 
A February 1976 VA treatment record diagnosed the Veteran with schizophrenia, hebephrenic type.  The Veteran presented with vague medical complaints and suicidal ideation.  The record noted that the Veteran was frequently referred to the hospital for evaluation.  Mental status examination revealed mild impairment of intellectual functioning, suicidal ideation coupled with inappropriate giggling, auditory hallucinations, and flat and inappropriate emotional responses.  The Veteran was noted to have been tested in the past, obtaining scores in the borderline mentally retarded range. 
In an August 1985 DRO hearing, the Veteran stated that he was sent to Mental Hygiene in service when sick call could not determine what was causing his headaches.  He also stated he was sent to Mental Hygiene because he looked depressed after he cussed at a drill sergeant and was sent to the stockade.  The Veteran reported he was given a shot to make him sleep and the next morning, he went in front of the colonel and could not express himself because of the effects of the shot from the night before.  He was discharged that evening. 
The Veteran was afforded a psychiatric VA examination in February 1989.  The VA examiner diagnosed the Veteran with mild mental retardation, degree unmeasured, with associated personality disorder not otherwise specified (NOS).  The examiner noted that the Veteran suffered from markedly limited intellectual endowment, as well as significant arrest in psychological development.  His condition was not severe enough to warrant a diagnosis of schizoid personality or simple schizophrenia.  The examiner noted personality particularities, which he determined were just as likely to have resulted from the Veteran’s life experiences throughout his development.  These personality particularities did not call for a more serious diagnosis. 
In March 1989, Dr. J. O. noted that he had never observed any psychoses in the Veteran, but believed he had some residual TBI manifested by eccentric personality syndrome.
The Veteran underwent a psychiatric evaluation in August 1989 for SSA disability purposes.  The Veteran was noted to be an unreliable historian, as he did not like to discuss his mental illness.  He was diagnosed with chronic paranoid schizophrenia with residual symptoms of paranoia. 
The Veteran was afforded another psychiatric VA examination in April 1991 with the same VA examiner who conducted the February 1989 examination.  The examiner confirmed his original diagnosis of borderline mental retardation.  He noted that the Veteran had difficulty adapting, meeting performance requirements, or getting along with others.  The Veteran’s adaption had been marginal at best and he had flunked out of various training schools, rationalizing each occurrence.  The examiner again discounted the diagnosis of schizophrenia and noted that with an unreliable historian such as the Veteran, access to his claims file was necessary to in order to provide an accurate evaluation.  He explained that individuals with mental retardation often have inadequate coinciding personality resources.
In a July 1998 VA treatment record, the Veteran presented with depression.  He was diagnosed with cognitive disorder, NOS with borderline intellectual functioning and reversible dementia; sexual disorder NOS; and gender identity disorder, NOS.
In a May 2003 Board hearing, the Veteran testified he had schizophrenia but that he tried not to claim it due to his religion and background.  He had not been seen by a mental health physician in eight years.  He denied experiencing hallucinations or needing medication to treat his mental conditions.  The Veteran testified that he could not recall a diagnosis of schizophrenia being discussed during his in-service psychiatric evaluation. 
In May 2005, a lay statement was submitted by Mr. R. P., stating he had known the Veteran since grade school and had noticed a change in him after service.  A lay statement was also submitted in April 2006 by Mr. H. E., indicating he had known the Veteran since he was a teenager and never knew him to have had a mental condition. 
A May 2006 VA treatment record noted diagnoses of depressive illness and gender identity disorder. 
The Veteran was afforded a psychiatric VA examination in June 2006.  On examination, the Veteran reported no stressor events he found particularly traumatic.  The VA examiner noted that the Veteran’s self-report and medical record were not consistent with a diagnosis of PTSD, as there was no evidence of trauma.  The examiner diagnosed the Veteran with mild mental retardation and noted that the Veteran’s psychosocial functioning was consistent with what would be expected of an individual who faced the challenges of mild mental retardation with little to no history of a positive support system that would assist him in developing positive skills for independent living and socializing.  The examiner further explained that mild mental retardation would appear in childhood and not young adulthood.  The etiology of mental retardation may be a combination of biological factors and early childhood environment.
A June 2006 VA treatment record noted a positive PTSD screening. 
In an April 2008 VA treatment record, the Veteran reported experiencing depression since service.  He was diagnosed with depression, NOS. 
In July 2008, the Veteran was evaluated by a private physician, Dr. R. B. and was diagnosed with PTSD resulting from being hit on the head with a rifle in service.  Dr. R. B. noted that the Veteran’s PTSD was chronic and progressive in nature.  The Veteran was withdrawn from society and had many anger and control issues.  He suffered from chronic insomnia, memory loss, night terrors/flashbacks, panic attacks, anxiety, and depression.  Dr. R. B. explained that following the strike with a rifle, the Veteran was left with overwhelming isolation issues, guilt, nervousness, anxiety, panic attacks, and anger issues due to the traumatic nature of the situation he experienced. 
In a December 2008 VA treatment record, the Veteran reported he had been diagnosed with PTSD by a family physician. 
A March 2009 VA treatment record revealed a negative PTSD screening. 
An April 2009 VA treatment record noted a diagnosis of depression, NOS.  The Veteran was noted to have mild schizotypal traits. 
In a June 2009 neuropsychic testing consult, the Veteran endorsed mild to moderate anxiety and depression. 
In October 2009, VA issued a Formal Finding on a lack of information required to verify stressors in connection with the Veteran’s claim of PTSD.
Since the November 2009 rating decision, the evidence received into the record includes VA treatment records and a DRO hearing transcript.  The Board finds that this evidence is new and material and warrants a reopening of the Veteran’s claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD.  
At a March 2010 DRO hearing, the Veteran described symptoms resulting from an in-service rifle attack.  He reported that he suffered from reoccurring thoughts, dreams, fatigue, and infrequent audio hallucinations. 
An October 2011 VA treatment record revealed a negative PTSD screening. 
In December 2011, the Veteran presented with poor attention, unique thought content, and insight and judgement subject to impulsivity.  He presented as hypomanic due to thought and affect.  The Veteran was diagnosed with a mood disorder, NOS, possibly bipolar mixed, possibly schizoaffective.
An October 2016 VA treatment record revealed a negative PTSD screening. 
The Board finds that the evidence received subsequent to the November 2009 rating decision which denied reopening a claim of service connection for an acquired psychiatric disorder, to include PTSD, satisfies the definition of new and material evidence, as it raises a reasonable possibility of substantiating the claim.  These documents were not of record at the time of the prior final denial and they provide evidence that the Veteran suffers from symptoms of an acquired psychiatric disorder that may be linked to service.
Accordingly, the Board finds that new and material evidence has been received to reopen the Veteran’s previously denied claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD.  However, as will be explained below, the Board is of the opinion that further development is necessary before the merits of the Veteran’s claim can be addressed.  
REASONS FOR REMAND
3. Entitlement to service connection for a compressed pituitary gland, secondary to head trauma, is remanded.
The Veteran is seeking service connection for a compressed pituitary gland.  Specifically, he contends that his compressed pituitary gland is secondary to head trauma he received in service when a drill instructor struck him on the head with the butt of a rifle. 
VA treatment records indicate that the Veteran had an MRI conducted in 1997 which showed empty sella surrounding the pituitary gland.  In a subsequent May 2005 MRI, ordered in response to the Veteran’s hypogonadism, findings revealed a compressed pituitary in the inferior portion of the sella.  The impression was empty sella, which the interpreting physician suggested could explain the Veteran’s headaches and hypogonadism from compression of the pituitary tissue.  An old right lacunar infarction versus Virchow-Robin space was noted.  
The Board notes that the Veteran has not been provided with a VA examination to determine if his compressed pituitary gland is etiologically linked to active duty service.  VA is obliged to provide an examination or obtain a medical opinion in a claim of service connection when the record contains competent evidence that the Veteran has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim.  38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006).  The threshold for finding a link between current disability and service is low.  Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon, 20 Vet. App. at 83.
Although the Board has found that there is no basis to warrant reopening the Veteran’s claim of entitlement to service connection for a TBI, as there is no evidence that the Veteran has ever suffered a TBI, the Veteran has consistently held that he was hit on the head with the butt of a rifle in service.  Further, the Veteran’s service treatment records contain many documented complaints of headaches, a symptom which could be linked to compressed pituitary tissue, according to the 2005 interpreting physician.
The Board also notes that the Veteran’s evidentiary record indicates that the Veteran has been in multiple motor vehicle accidents.  Specifically, in a March 1989 VA treatment record, the Veteran reported involvement in six car accidents beween 1971 to 1989.  In the second accident, the Veteran noted he had hit his head against the windshield.  In a January 1990 VA treatment record, the Veteran elaborated that he had broken the windshield with his head in a car accident.  In a July 1998 VA treatment record, the Veteran reported a motor vehicle accident in 1994 in which he lost consciousness. 
As there is evidence of a current disability and some evidence that the Veteran suffered head trauma in service, along with a post-service history of head trauma, the Board finds that the Veteran should be afforded a VA examination to determine if his compressed pituitary gland is etiologically linked to active duty.  
4. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for headaches is remanded.
With regard to whether the claim of service connection for headaches should be reopened, the Board finds that this matter is inextricably intertwined with the claim of service connection for a compressed pituitary gland.  The findings from the VA examination, which will be afforded to the Veteran on remand, may contain findings which impact whether the Veteran’s claim of entitlement to service connection for headaches should be reopened and potentially granted.  Thus, the Board finds it appropriate to defer adjudication of the new and material evidence issue at this junction and remand the matter to be decided after the intertwined issue of service connection for a compressed pituitary gland has been adjudicated.  Harris v. Derwinski, 1 Vet. App. 180 (1991).
5. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD is remanded.
The Veteran is seeking service connection for an acquired psychiatric disorder, to include PTSD.  Specifically, he contends that he suffers from a psychiatric disorder stemming from an assault he suffered in service when he was struck over the head with a rifle butt.  The Board accepts this stressor as true, as the Veteran has consistently reported the rifle assault for more than 30 years. 
The Veteran underwent a private psychiatric evaluation in July 2008, in which the Veteran was diagnosed by Dr. R. B. with PTSD resulting from being hit on the head with a rifle in service.  Dr. R. B. noted that the Veteran’s PTSD was chronic and progressive in nature.  Although he listed the Veteran’s symptoms associated with PTSD, Dr. R B. failed to discuss how the Veteran met the diagnostic criteria under the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) required for a diagnosis of PTSD.  While this evaluation is probative evidence, it is inadequate as a basis upon which to grant service connection for PTSD.  
Further, the Board notes that while the Veteran has been afforded VA examinations in the past for acquired psychiatric disorders, the Veteran has yet to be afforded a psychiatric VA examination since he filed his claim for PTSD.  The evidence of record also reveals psychiatric disorders that were not diagnosed at the time of the Veteran’s previous psychiatric VA examinations.  Therefore, remand is warranted to afford the Veteran a VA examination to determine whether he has a diagnosed psychiatric disorder, to include PTSD, which is related to active duty service.  
The matters are REMANDED for the following action:
1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his compressed pituitary gland.  The electronic claims folder, including a copy of this remand, should be made available to the examiner, and the examiner must review the entire claims file in conjunction with the examination.  The examiner should determine whether it is at least as likely as not (at least a 50 percent probability) that the Veteran’s compressed pituitary gland is caused by or etiologically related to active duty service.  In forming this opinion, the examiner is asked to address the following:

(a) the Veteran’s consistent reports of being struck in the head with the butt of a rifle while in service;

(b) multiple complaints of headaches documented in the Veteran’s service treatment records;

(c) the August 1985 DRO hearing in which the Veteran reported he was wearing a helmet when struck and did not notice any immediate effects, such as bleeding, swelling, or an open wound; 

(d) the March 1989 VA treatment record noting that the Veteran had been in six motor vehicle accidents between 1971 and 1989, the January 1990 VA treatment record indicating that the Veteran had broken a windshield, and the July 1998 VA treatment record noting the Veteran lost consciousness in a 1994 motor vehicle accident; and
(e) the May 2005 MRI which indicated that the Veteran’s compressed pituitary gland could be the cause of his headaches.

The examination report must include a complete rationale for all opinions expressed.  If the examiner feels that a 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. Schedule the Veteran for a psychiatric examination to determine the nature and etiology of any diagnosed psychiatric disorder, to include PTSD.  The electronic claims folder, including a copy of this remand, should be made available to the examiner, and the examiner must review the entire claims file in conjunction with the examination.  The examiner is asked to address the following:
(a) With regard to PTSD, the examiner should explain how the diagnostic criteria for PTSD are met and opine whether it is at least as likely as not (at least a 50 percent probability) related to the Veteran’s in-service stressor of being struck over the head with a rifle by a drill instructor.  The examiner should acknowledge that the Board accepts this stressor as true. 
(b) For each diagnosed psychiatric disorder, the examiner should determine whether it is at least as likely as not (at least a 50 percent probability) that the Veteran’s disorder is caused by or etiologically related to active duty service.  
The examination report must include a complete rationale for all opinions expressed.  If the examiner feels that a 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).
(Continued on the next page)
 
3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran’s claims should be readjudicated based on the entirety of the evidence.  If any benefit sought remains denied, furnish the Veteran and his representative a supplemental statement of the case (SSOC) which considers all evidence added since the July 2014 SOC and return the case to the Board.
 
KRISTI L. GUNN
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	L. Silverblatt, Associate Counsel 

For A Complete Guide To VA Disability Claims and to find out more about your potential VA disability case and how to obtain favorable VA Rating Decision! Visit: VA-Claims.org

For More Information on Veterans Disability Compensation Benefits! Visit: DisableVeteran.org ~ A Non-Profit Non Governmental Agency


Advertisements

Leave a Reply

Please log in using one of these methods to post your comment:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.