Citation Nr: 1035581 Decision Date: 09/20/10 Archive Date: 09/28/10 DOCKET NO. 06-23 195 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California THE ISSUE Entitlement to service connection for a chronic acquired psychiatric disability, variously classified. REPRESENTATION Appellant represented by: California Department of Veterans Affairs ATTORNEY FOR THE BOARD Robert E. O'Brien, Counsel INTRODUCTION The Veteran had active service from February 1971 to February 1973. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the VARO in Oakland, California, that denied entitlement to the benefit sought. The case was previously before the Board in September 2009 at which time it was remanded for further development. The requested actions have been accomplished and the case has been returned to the Board for appellate review. FINDINGS OF FACT 1. The evidence of record reveals varying psychiatric diagnoses. 2. The Veteran is shown as likely as not to have a chronic acquired psychiatric disorder attributable to his active service. CONCLUSION OF LAW The criteria for service connection for a chronic acquired psychiatric disability are reasonably met. 38 U.S.C.A. §§ 1110, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist In view of the allowance of the claim, compliance with the Veterans Claims Assistance Act of 2000 (VCAA) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009)) need not be discussed. The Board notes that there has been essential compliance with the mandates of the VCAA throughout the course of the appeal. Pertinent Legal Criteria In general, service connection will be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Regulations also provide that service connection may be established when all the evidence of record, including that pertinent to service, demonstrates that the Veteran has a current disability that was incurred in service. 38 C.F.R. § 3.303(d). The United States Court of Appeals for Veterans Claims (Court) has held that for service connection to be awarded, there must be: (1) Medical evidence of a current disability; (2) medical evidence, or in certain circumstances, lay evidence of a service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed inservice disease or injury and the present disease or injury. Coburn v. Nicholson, 19 Vet. App. 427, 431 (2006); Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Each of the elements above must be met or denial of service connection will result. Factual Background and Analysis The Board notes that it has thoroughly reviewed all the evidence in the claims folder. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss in detail all the evidence submitted by the Veteran or in his behalf. See Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The Board's analysis below focuses on the most salient and relevant evidence, and on what this evidence shows, or fails to show, on the claim. The Veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). A review of the service treatment records reflects that at the time of separation examination in November 1972, it was indicated the Veteran was in good health. There were no complaints or abnormal findings with regard to the Veteran's psychiatric status. In January 1973 the Veteran was air evacuated as opiate user. It was noted his separation date was only about two weeks away. He gave a history of about two months of daily usage of heroin. He was given a diagnosis of improper use of drugs. He was evacuated by air to the United States and discharged from the service and "transferred to VA hospital." In a claim for disability benefits received in October 2003, the Veteran stated that he had received for depression in July 1973 at the VA Outpatient Clinic in Oakland, California. In a communication received in February 2005, the Veteran reported that he had received treatment for depression between 1973 and 1977 at the Quincy VA Mental Health facility. He reported he was prescribed various psychotropic medications "for an ongoing depression and schizophrenia. The records were destroyed after seven years." Of record is a March 2005 communication from a Plumas County Mental Health facility in Quincy, California, indicating that the Veteran's notation that records of any contact with him would have been destroyed because he exceeded the seven-year limit was correct. The director of the facility indicated that if the Veteran was seen, there was currently no record of the contacts. Also of record is a communication from the VA Medical Center in Mather, California, indicating that there were no mental health records available for the Veteran pertaining to July 1973. It was indicated the Veteran started with the Northern California Health Care System in March 1988. Also of record is a March 2006 communication from the Martinez VA Outpatient Clinic in Martinez, California. It was indicated that there are no medical records pertaining to the Veteran for 1973 or 1974. Of record are communications from an ex-wife and the Veteran's mother that were received in November 2006. The Veteran's mother referred to psychiatric problems the Veteran had ever since service discharge. She recalled that before he went into the service, he did not outwardly display any tendencies, "but was a typical boy, with some neurosis." The Veteran's ex-wife stated that they were married for 13 years between 1980 and 1996 and the Veteran told her many stories of his childhood focused on verbalized physical abuse of the Veteran by his father. She believed that the Veteran's problems came from his "abuse of home life and his abusive experiences in the Army." She stated that in going to counseling with him, she learned that the Veteran's "depression and anger had been with him since childhood and that his experiences in the Army seemed to make them worse." Of record is a November 2006 communication from a social worker at the Northern California VA Health Care System. She indicated that paperwork pertaining to the Veteran at that facility dated from 1996. She was not able to find any information prior to 1996. The 1996 records referred to include a May 1996 report from an Oakland Mental Health Clinic visit at which time the recorded history of the Veteran's treatment there included a notation that he had been hospitalized at the facility in Martinez for 23 days in 1976. It was reported that he had seen a health care professional and had been medicated with Librium until 1976 when the medication was changed to Valium. Further notation was made that the Veteran had been seen at the Mental Health Clinic in Berkeley, California, and was started on an antidepressant for three months. Of record is a letter dated in December 2008 from the Veteran's sister. She recalled that the Veteran was a completely changed person on his return home from his Army service. Also of record is an undated communication from an individual who grew up with the Veteran. He also stated that on his return from the military in 1973, the Veteran was a different person. Additional pertinent evidence includes the report of a June 2009 communication from health care professionals at the VA Oakland Outpatient Mental Health Clinic. It was reported the Veteran had been in treatment at that facility since November 2003. They stated that the Veteran had a schizo-affective disorder "the symptoms of which first became noticeable during his military service and for which he was first hospitalized immediately after discharge." Reference was made to a "somewhat traumatic childhood," but they reported the Veteran did not have any severe mental health symptoms until he was drafted into the military in 1971. It was stated the Veteran became increasingly paranoid and isolated while in service. The Veteran told them that his problems first became apparent shortly after he contracted German measles during basic training. After this episode his mental health status took a severe turn for the worse. He had become increasingly anxious, depressed, and isolated through the course of his training. They stated that the Veteran reported "within months of his discharge, he had began to get care for his mental health symptoms through the VA in Oakland where he was diagnosed with schizophrenia and prescribed Thorazine and Librium, with a change to Valium and Stelazine. The veteran was hospitalized several times during the early-mid 1970's for mental health issues. He has since been treated on an outpatient basis consistently for the last 40 years." The Veteran was accorded a mental disorders examination by VA in December 2009. The claims file was reviewed by the examiner prior to the examination. It was noted the Veteran had problems in service with substance abuse. He first reported experiencing psychotic symptoms in 1973 soon after discharge. It was indicated that in 1976 the Veteran received inpatient substance abuse treatment for two weeks. It was further added that in 2004 he was hospitalized by VA for three weeks for psychiatric purposes. He had been in outpatient treatment through the Oakland VA since 1994. The Veteran was given Axis I diagnoses of: Psychosis not otherwise specified; depression, not otherwise specified; and history of polysubstance abuse, and sustained partial recovery. There was no Axis II diagnosis. The examining psychologist opined that "it is likely that this Veteran suffers from a complex psychiatric condition with a history of depression, thought disorder and polysubstance dependence." He added that it was not possible to determine beyond mere speculation whether the Veteran's substance abuse had impacted on his current cognition and mood. A written statement was added to the typewritten reported of the examination. In that statement, the psychologist indicated "it is at least as likely as not that psychotic symptoms began in the military." The claims file also contains a statement from the Appeals Management Center in Washington, D.C., that reflect that treatment records for the Martinez VA Medical Center between January 1976 and December 1977 are not available for review. It was indicated all procedures to obtain the records had been correctly followed and it was related that further attempts to locate any records would be futile. The Board is therefore constrained to rely on the evidence that is of record. After a longitudinal review of the record, the Board finds, particularly with resolution of all reasonable doubt and benefit of the doubt in favor of the Veteran, that service connection for a chronic acquired psychiatric disorder is reasonably warranted. The Veteran has provided statements from family members who recalled psychiatric difficulties the Veteran has had ever since his return home from the military. Additionally, a VA psychologist reviewed the entire claims file in conjunction with examination of the Veteran in late 2009. That health care professional opined that the Veteran's psychiatric disorder was "at least as likely as not" related to his military service. There is no contrary medical opinion of record. The Board sees no reason to disagree with the VA psychologist, particularly in view of the fact that he reviewed the entire claims file. Accordingly, the Board finds the claim should be granted. ORDER Service connection for a chronic acquired psychiatric disability is allowed. ____________________________________________ V. L. JORDAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs