Citation Nr: 1016745	
Decision Date: 05/05/10    Archive Date: 05/19/10

DOCKET NO.  03-21 658A	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in 
Philadelphia, Pennsylvania


THE ISSUE

Entitlement to service connection for an acquired psychiatric 
disorder, claimed as paranoid schizophrenia.


REPRESENTATION

Appellant represented by:	Disabled American Veterans


ATTORNEY FOR THE BOARD

Siobhan Brogdon, Counsel



INTRODUCTION

The Veteran served on active duty from May 1987 to April 
1990.  

This appeal comes before the Department of Veterans Affairs 
(VA) Board of Veterans Appeals (Board) from a September 2002 
rating decision of the VA Regional Office in San Diego, 
California that denied service connection for paranoid 
schizophrenia.  The Veteran subsequently relocated to within 
the jurisdiction of the Philadelphia, Pennsylvania RO.

This case was remanded by decisions of the Board in May 2006 
for further development, and in March 2008 for scheduling of 
a Board hearing.  Although a hearing was scheduled to be held 
via videoconference from the RO in January 2010, and the 
Veteran notified at his current address of record, he failed 
to report for the hearing.  His request is therefore 
considered withdrawn.

This appeal has been advanced on the Board's docket pursuant 
to 38 C.F.R. § 20.900(c) (2009). 38 U.S.C.A. § 7107(a)(2) 
(West 2002).


FINDING OF FACT

An acquired psychiatric disorder, to include paranoid 
schizophrenia, was not shown in service or within one year of 
discharge from active duty, and the preponderance of the 
competent evidence of record is against a finding that the 
current disability is related to service.


CONCLUSION OF LAW

The criteria for service connection of an acquired 
psychiatric disorder, to include paranoid schizophrenia, have 
not been met.  38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1153, 
5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 
3.303, 3.304, 3.306, 3.307, 3.309 (2009).


REASONS AND BASES FOR FINDING AND CONCLUSION

Preliminary Considerations - VA's Duty to Assist the Veteran

As provided for by the Veterans Claims Assistance Act of 2000 
(VCAA), the United States Department of Veterans Affairs (VA) 
has a duty to notify and assist claimants in substantiating a 
claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 
5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R. 
§§ 3.102, 3.156(a), 3.159 and 3.326(a) (2009).  Upon receipt 
of a complete or substantially complete application for 
benefits, VA is required to notify the claimant and his or 
her representative, if any, of any information, and any 
medical or lay evidence, that is necessary to substantiate 
the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); 
Quartuccio v. Principi, 16 Vet. App. 183 (2002).

The notice requirements of the VCAA apply to all elements of 
a service-connection claim, including: (1) veteran status; 
(2) existence of a disability; (3) a connection between the 
veteran's service and the disability; (4) degree of 
disability; and (5) effective date of the disability. See 
Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006).  
Further, this notice must include information that a 
disability rating and an effective date for the award of 
benefits will be assigned if service connection is awarded. 
Id. at 486.  

Here, the Veteran was sent a letter in April 2002 prior to 
the initial unfavorable decision on the claim.  This was 
supplemented by additional duty-to-assist letters in March 
2005, July 2006, November 2006 and July 2009.  The letters 
informed the appellant of what evidence was required to 
substantiate the claim and of the appellant's and VA's 
respective duties for obtaining evidence.  Notification that 
included information pertaining to a disability rating and an 
effective date for the award if service connection has also 
been sent to the appellant.  The Veteran's claim has been 
readjudicated in multiple supplemental statements of the case 
following provision of legally adequate notice.

The Board finds that all necessary development has been 
accomplished and that appellate review may proceed without 
prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 
384 (1993).  Extensive VA clinical records have been received 
and associated with the claims folder.  The Veteran has had 
the benefit of a number of psychiatric and neurological 
examinations during the appeal period, which have included 
medical opinions.  The case was remanded on two prior 
occasions for further development.  The whole of the record, 
including his multiple personal statements, have been read 
and carefully considered. 

In a February 2010 Informal Hearing Presentation, the 
Veteran's representative questions the adequacy of the most 
recent VA compensation and pension examination in 2006 and 
requests that the case be remanded for another to be 
performed.  The Board finds, however, that the 
representative's concerns are unfounded.  It is determined 
that the 2006 VA examination is adequate for adjudication 
purposes.  The examiner reviewed the complete file as it 
existed at the time, and provided a medical opinion on 
etiology with a detailed rationale.  Moreover, it appears 
that the Veteran is itinerant and does not have a stable 
residence, and has not kept VA thoroughly apprised of his 
whereabouts.  A Report of Contact dated in October 2009 
indicated that an attempt was made to contact the appellant 
by phone to schedule a VA examination but that he was unable 
to be reached at the numbers he had previously provided.  The 
"duty to assist is not always a one-way street." Wood v. 
Derwinski, 1 Vet. App. 190, 193 (1991). It is the burden of 
the Veteran to apprise VA of his whereabouts, and if he does 
not do so, there is no burden on the part of VA to "turn up 
heaven and earth" to find him. Hyson v. Brown, 5 Vet. App. 
262, 265 (1993).

Under the circumstances, the Board finds that no further 
notice or assistance to the appellant is required to fulfill 
VA's duty to assist in the development of the claim. See 38 
U.S.C.A. § 5103A (a) (2); Dela Cruz v. Principi, 15 Vet. App. 
143 (2001); Smith v. Gober, 14 Vet. App. 227 (2000); aff'd 
281 F.3d 1384 (Fed. Cir. 2002); see also Quartuccio v. 
Principi, 16 Vet. App. 183; Soyini v. Derwinski, 1 Vet. App. 
540, 546 (1991) (2002).  The claim is ready to be considered 
on the merits.  



Factual Background

Service treatment records reflect that the Veteran was a 
passenger in an automobile in April 1988 and struck his head 
against the dashboard when the vehicle hit a pole.  When 
treated, he was noted to have a superficial laceration under 
the left eyebrow and complaints of a headache.  No 
neurological abnormality was noted.  He returned with 
complaints of headaches when seen the following day.  An 
assessment of head injury was noted.  On examination in 
January 1990 prior to discharge from active duty, psychiatric 
and neurologic status was evaluated as normal and no 
pertinent defects were noted.  On the Report of Medical 
History, the Veteran denied nervous trouble of any sort.  No 
voices or other auditory hallucinations were reported in 
service.

Post service, the Veteran filed a claim in May 1990 and did 
not indicate any problem with psychiatric symptoms.  He was 
afforded a VA examination in July 1990 and no complaints 
referable to psychiatric status were recorded.  The appellant 
filed another claim for a condition not pertinent to this 
appeal in 1993 and no reference to a mental disorder was 
shown.  The Veteran made no reference to hearing voices.  A 
claim for an acquired psychiatric disorder was received in 
February 2002.  

Subsequently received were VA outpatient records dating from 
December 2001 indicating that the Veteran was new to that VA 
and seeking treatment for increasing headaches.  The 
inservice history of head trauma was elaborated upon.  The 
appellant related in January 2002 that he drank "as much as 
I can get for 10 years now" and stated that he had been 
hearing voices for nine years.  He admitted to becoming 
violent when he drank and said he had blackouts.  Upon 
ensuing initial screening evaluation, he related that he was 
homeless and unemployed and had come in that day because he 
wanted to stop drinking and smoking crack cocaine which he 
had not been able to do on his own.  On this occasion, the 
Veteran reported a 15-year history of alcohol abuse and use 
of cocaine for five years.  He denied a previous history of 
psychiatric treatment.  He was admitted into inpatient 
treatment for alcohol and cocaine dependence.  

Subsequently, in January 2002, the Veteran was admitted 
psychiatrically and related that he had heard voices in his 
head since 1989 but had mainly attributed it to the drinking 
and drugs "because I was always high."  It was noted at 
that time that he had been sober for approximately two weeks 
and that his voices had intensified and were telling him to 
do negative things, including hurting himself.  The appellant 
stated that the voices were unrelenting and interfered with 
his ability to concentrate.  History obtained from the 
Veteran indicated that the only previous contact he had had 
with a psychiatrist had been at the age of nine after being 
molested by family members.  He admitted to a suicide attempt 
three to four years before when he had tried to overdose on 
Valium.  Following evaluation, diagnoses were rendered of 
cocaine dependence, continuous, alcohol dependence, 
continuous, psychosis, not otherwise specified, and rule out 
substance induced versus schizophrenia.  The attending 
resident in psychiatry noted that it was unclear as to 
whether the Veteran's psychiatric issues were related to his 
history of alcohol/cocaine use, or whether his substance use 
had been masking an underlying psychotic disorder.  It was 
felt that it was most likely related to cocaine use.

The Veteran continued in long-term VA treatment for substance 
abuse and psychiatric disability with some abatement of 
symptoms.  In March 2002, it was recorded that he was feeling 
some relief from his voices since starting Risperiodol.  
Following evaluation, assessments of alcohol dependence, 
cocaine dependence-early remission, and rule out psychotic 
disorder due to head injury were rendered.  In May 2002, an 
Axis I diagnosis of paranoid schizophrenia, rule out 
psychotic disorder due to general medical condition (head 
trauma) was recorded.  

The Veteran underwent VA neurological examination in August 
2002 and presented complaining of head injury in 1988 or 1989 
and reported loss of consciousness for 20 minutes when his 
head went "through a windshield'.  The examiner indicated 
that the claims folder was reviewed, stating that the Veteran 
was a poor historian because "I could not find any of his 
service records to back this up."  It was noted that in any 
case, the appellant said that he had lost consciousness for 
20 minutes and that after that he starting hearing voices and 
having headaches.  The examiner noted that when talking about 
hearing voices, the Veteran had had a big drug and drinking 
problem.  A physical examination was performed.  A diagnosis 
of cerebral concussion with head injury and post-traumatic 
headaches, by history, was rendered.  The examiner stated 
that "At this point, I do not think his psychiatric 
disability has anything [to do] with his head injury.  It may 
have something to do with some of his drug use but even then 
I do not think there is a direct causal connection."  

The Veteran was afforded a psychiatric examination by a VA 
physician in August 2002.  It was noted that the record was 
reviewed.  Biographical information and history pertaining to 
alcohol and cocaine abuse were recited.  The appellant 
related that he had been clean and sober for eight months.  
He said that he had a 10-year history of hearing intrusive 
derogatory voices on a daily basis.  It was noted that he 
claimed his symptoms had been present since head trauma in 
service with loss of consciousness but no hospitalization.  
In addition to hearing voices, the appellant described 
feeling uncomfortable around people and feared that they were 
'out to get me'.  He related that he sometimes heard the 
television saying things he had been thinking, and that he 
could sometimes read other peoples' minds.  Following 
objective assessment and mental status testing revealing very 
poor cognitive functioning, diagnoses on Axis I were cocaine 
dependence in early remission, alcohol dependence in early 
remission and chronic paranoid schizophrenia.  The examiner 
commented that although the Veteran's psychosis was probably 
aggravated by drug and alcohol abuse in the past, "today's 
examination suggests that there is an independent psychotic 
illness, schizophrenia, that continues to manifest despite 
the Veteran's reported abstinence from drugs and alcohol."

In April 2004, the Veteran's attending physician noted that 
he had returned from California in May 2002 and had come in 
because staff at vocational rehabilitation thought that he 
should have counselling.  The Veteran reported hearing 
whispered voices chronically.  During the course of the 
evaluation, the examiner noted "[p]sychosis secondary to 
brain injury." 

The Veteran underwent VA psychological evaluation in March 
2005.  It was noted that he began the interview by telling 
the examiner about a car accident and head injury he had had 
since in the military and said that his thinking had been 
'off' since that time.  The Veteran related that he had 
struggled with paranoia and problem drinking, was bothered by 
auditory and visual hallucinations, had cut his wrists with 
the intent to kill himself on one occasion, and was seriously 
depressed and homeless.  He stated that antipsychotic 
medication had had a positive impact on the quality of his 
life.  The appellant related that he had been sober for three 
years.  Following evaluation, diagnoses of paranoid 
schizophrenia and alcohol dependence, in remission, were 
rendered.  

Statements were received from the Veteran's friend and his 
uncle in May and June 2005, respectively, attending to their 
knowledge of his paranoia, erratic behavior and lack of 
mental clarity.  

The Veteran underwent VA neurology examination in January 
2006 by the same examiner who had evaluated him previously.  
The examiner stated that almost all of the appellant's record 
dealt with his mental health, including the diagnosis of 
paranoid schizophrenia and substance abuse disorder which 
included alcohol and cocaine.  It was noted that records did 
show he had a motor vehicle accident in 1988 but that there 
was no mention of syncope at that time.  

The Veteran was afforded a VA compensation and pension 
examination in December 2006 and stated that he was his 
normal self until about 1988 at which time he was involved in 
a motor vehicle accident, sustaining injuries to his head and 
knees.  He related that he was unconscious for up to half an 
hour.  He said that in the five-year period after discharge 
from active duty, he began to drink excessively and snort 
cocaine, and that these were new behaviors for him.  He noted 
that his family thought he was not acting his usual self.  
The Veteran related that he believed he initially made 
contact with the San Diego VA Medical Center in 1993 or 
possibly later, and that over the next five years, received 
sporadic treatment for alcoholism.  He stated that it was 
during this time frame that he made a suicide attempt while 
drinking by cutting his wrists.  He said that sometime after 
that, he first began hearing voices and became very 
suspicious.  The examiner noted that in essence, the Veteran 
ascribed his alcoholism, cocaine dependence, and mental 
illness to sequela of the motor vehicle accident that 
occurred when he was in the military.  

The examiner stated that upon careful review of the record, 
the Veteran had sustained a head injury in a motor vehicle 
accident in April 1988, but that immediate reports indicated 
that there had been no evidence of any neurological deficits.  
It was reported that the next significant entry in the claims 
folder was in 2002 when he was admitted to the San Diego VA 
Medical Center with the chief complaint of hearing voices.  
Medical reports from previous providers were reviewed, to 
include opinions in August 2002 and 2006 that the Veteran's 
psychiatric symptoms had nothing to do with his head injury.  
A comprehensive mental status examination was performed and a 
summary of the clinical evidence was provided.  The examiner 
stated that based on all the available information and the 
interview, the Veteran suffered from paranoid schizophrenia, 
and that as far as could be determined, there was no 
relationship between schizophrenia and military service.  The 
examiner stated that as to whether the appellant's 
psychiatric symptoms were related to his head injury, the 
most meaningful information from the record came from the VA 
neurology examiner who had seen the appellant in 2002 and 
again in January 2006 and had the same diagnosis each time; 
that psychiatric symptoms might have been related to the 
Veteran's then substance abuse.  The examiner stated that 
this was very important historical information because it was 
an evaluation performed close to the time the Veteran was 
diagnosed as having paranoid schizophrenia, and was the same 
person who had evaluated him on two separate occasions.  The 
examiner went on to say that "Consequently, it is my 
opinion...that the [Veteran's] psychiatric symptoms are not 
related to [his] head injury, especially given the report by 
the [VA] neurologist..."  The examiner added that it more 
likely than not that the Veteran's schizophrenia was not 
related to his military service because as far as it could be 
determined, he did not have psychiatric symptoms during 
military service, and that in fact, "his initial diagnosis 
of schizophrenia was not made until several years after the 
patient had been discharged from the military."  It was 
reiterated that "it is my opinion that it is more likely 
than not that the [Veteran's] psychiatric symptoms are not 
related to ...head injury that he had suffered in a motor 
vehicle accident while in the military."  Following 
examination, diagnoses of chronic paranoid schizophrenia, 
alcohol dependence, in remission, and cocaine dependence, in 
remission, were rendered.  

VA outpatient records dating through May 2009 indicate that 
the Veteran continued to seek treatment for psychiatric 
symptoms diagnosed as schizophrenia, but that he was a "no 
show" for all appointments from the latter part of March 
2009.

Legal Analysis

The Veteran asserts that he has been hearing voices since a 
motor vehicle accident in service and used alcohol in an 
attempt to self medicate.  It is maintained that he now has 
paranoid schizophrenia for which service connection should be 
granted.  The Veteran contends that he was a normal fully 
functioning person before entering the military and never had 
any problems with hearing voices, bad dreams or paranoia, and 
that it was only after a motor vehicle accident and head 
injury during service that he developed psychiatric 
disability.

Service connection will be granted if it is shown that the 
veteran suffers from a disability resulting from personal 
injury suffered or disease contracted in the line of duty, or 
for aggravation of a preexisting injury suffered or disease 
contracted in the line of duty, during active military 
service.  38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303.  
Disorders diagnosed after discharge will still be service 
connected if all the evidence, including that pertinent to 
service, establishes that the disease was incurred in 
service.  38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 
F.3d 1039, 1043 (Fed. Cir. 1994).  

Some chronic diseases may be presumed to have been incurred 
in service, if they become manifest to a degree of ten 
percent or more within the applicable presumptive period.  
Psychoses are listed presumptive conditions.  38 U.S.C.A. 
§§ 1101(3), 1112(a); 38 C.F.R. §§ 3.307(a), 3.309(a).  The 
applicable presumptive period is one year following 
separation from service.  38 C.F.R. § 3.307(a)(3).

To establish service connection, there must be a competent 
diagnosis of a current disability; medical or, in certain 
cases, lay evidence of in-service occurrence or aggravation 
of a disease or injury; and competent evidence of a nexus 
between an in-service injury or disease and the current 
disability.  Hickson v. West, 12 Vet. App. 247, 252 (1999); 
see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).

Competent medical evidence is evidence provided by a person 
who is qualified through education, training, or experience 
to offer medical diagnoses, statements, or opinions.  
Competent medical evidence may also include statements 
conveying sound medical principles found in medical 
treatises.  It also includes statements contained in 
authoritative writings, such as medical and scientific 
articles and research reports or analyses.  38 C.F.R. 
§ 3.159(a)(1).  Competent lay evidence is any evidence not 
requiring that the proponent have specialized education, 
training, or experience.  Lay evidence is competent if it is 
provided by a person who has knowledge of facts or 
circumstances and conveys matters that can be observed and 
described by a lay person.  38 C.F.R. § 3.159(a)(2).  This 
may include some medical matters, such as describing symptoms 
or relating a contemporaneous medical diagnosis.  Jandreau v. 
Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).

In determining whether service connection is warranted for a 
disability, VA is responsible for determining whether the 
evidence supports the claim or is in relative equipoise, with 
the veteran prevailing in either event, or whether a 
preponderance of the evidence is against the claim, in which 
case the claim is denied.  38 U.S.C.A. § 5107; Gilbert 
v. Derwinski, 1 Vet. App. 49 (1990).  When there is an 
approximate balance of positive and negative evidence 
regarding any issue material to the determination, the 
benefit of the doubt is afforded the claimant.

Service clinical records do indeed indicate that the Veteran 
sustained a head injury when he struck it on a windshield in 
a motor vehicle accident in 1988.  The record reflects that 
although he complained of headaches and dizziness at the 
time, there was no indication of loss of consciousness.  The 
service treatment records do not disclose further treatment 
for head injury past the first initial days, or that he was 
seen for psychiatric symptoms during the remainder of his 
service.  He denied a nervous disorder on separation 
examination in 1990.  The record reflects that the appellant 
filed claims at least two times after service discharge for 
conditions not pertinent to this appeal and did not refer to 
any psychiatric symptoms.  No complaints or findings 
referable to psychiatric status were noted on post service VA 
examination in 1990.  The Board thus finds that the records 
contemporaneous to service, the Veteran's denial of a 
psychiatric disorder at service discharge, the lack of a 
reference to any disability of this nature on initial post 
service VA examination or in claims filed in 1990 and 1993 
are highly probative of whether there was continuing 
psychiatric symptomatology deriving from service.  

Records do show that the Veteran was involved in a car 
accident in service, and do confirm a current psychiatric 
disability.  However, the preponderance of the evidence is 
against a finding that such are related in any way.  No 
medical professional has opined, based on examination, 
clinical findings, and medical knowledge, that the Veteran's 
current psychiatric disability is related to the in-service 
injury.  At most, a VA treating doctor has repeated the 
Veteran's assertion that his psychosis was "secondary to 
brain injury."

Even if the April 2004 VA doctor's statement were considered 
a medical opinion, it is far outweighed by the other 
competent evidence of record.  The December 2006 examiner 
reviewed the entire claims file and did not rely solely upon 
the Veteran's reported history in opining that the current 
condition was not likely related to the head injury, and two 
August 2002 VA examiners opined that drug use was the 
causative factor.

The evidence of record indicates that no psychiatric 
disability was extant until 2002, well past the one year 
period for presumptive service connection of a psychoses.  
The veteran made no report of signs or symptoms of a mental 
disorder when claiming benefits in 1990 or 1993, and there 
are no treatment records from that period corroborating his 
current allegations of symptoms during that time.  The sole 
evidence of psychiatric symptoms since service is the lay 
statements of the Veteran.  While he is competent to report 
subjectively experienced symptoms, in this case the Board 
must find those reports not credible.  The Veteran has not 
consistently reported the circumstances of his accident and 
medical history.  His accounts are contradicted by 
contemporaneous medical records.

Even if the Veteran's statements were considered credible, 
they are outweighed by the reasoned medical opinions of 
record.  The weight of the competent and credible evidence of 
record establishes that no mental disorder existed or was 
diagnosed for many years after service, and no psychiatric 
disorder was caused by any disease or injury in service.


ORDER

Service connection for an acquired psychiatric disorder, to 
include paranoid schizophrenia, is denied.  



____________________________________________
WILLIAM H. DONNELLY
Acting Veterans Law Judge, Board of Veterans' Appeals


 Department of Veterans Affairs