Citation Nr: 1136819 Decision Date: 09/29/11 Archive Date: 10/11/11 DOCKET NO. 03-07 435 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, including schizophrenia and posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Virginia Girard-Brady, Attorney WITNESSES AT HEARING ON APPEAL Appellant, his brother, his mother ATTORNEY FOR THE BOARD M. Turner, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1973 to December 1976. This matter initially came before the Board of Veterans' Appeals (Board) on an appeal from a rating decision that was issued by the Regional Office (RO) in Winston-Salem, North Carolina. The Veteran and his family members testified at a hearing before the undersigned Veterans Law Judge in March 2005. This matter was remanded to the Board by the United States Court of Appeals for Veterans Claims (Court) in April 2008, upon Joint Motion of the parties. In July 2008, the Board remanded this claim to the RO to complete the additional development required by the Court. In April 2009 the case was again remanded by the Board for additional development. It has now been returned to the Board for appellate disposition. FINDINGS OF FACT 1. The evidence does not show that it is at least as likely as not that the Veteran's currently diagnosed schizophrenia began during the Veteran's service or within a year of his service or that it was otherwise caused by his service. 2. The Veteran was not shown to have PTSD that is related to his military service. CONCLUSION OF LAW An acquired psychiatric disorder was not incurred or aggravated by service, nor may a psychosis be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist The Veterans Claims and Assistance Act of 2000 (VCAA) describes VA's duties to notify and assist claimants with substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. § 3.102, 3.156(a), 3.159. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant of any information, and any medical or lay evidence, that is necessary to substantiate his or her claim. 38 U.S.C.A. § 5103(a), 38 C.F.R § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183, 186-187 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. The Board notes that 38 C.F.R. § 3.159 was revised in part, effective May 30, 2008. See 73 Fed. Reg. 23,353-23,356. The third sentence of 38 C.F.R. § 3.159(b)(1), which stated that "VA will also request that the claimant provide any evidence in the claimant's possession that pertains to the claim," was removed. This amendment applies to all applications pending on, or filed after, the regulation's effective date. VCAA notice should be provided to a claimant before the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Pelegrini v. Principi, 18 Vet. App. 112, 115 (2004). However, the VCAA notice requirements may be satisfied notwithstanding errors in the timing or content of the notice if such errors are not prejudicial to the claimant. Id at 121. Further, a defect in the timing of the notice may be cured by sending proper notice prior to a re-adjudication of the claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333-1334 (Fed. Cir. 2006). The VA General Counsel issued a precedential opinion interpreting Pelegrini as requiring the Board to ensure that proper notice is provided unless it makes findings regarding the completeness of the record or other facts that would permit the conclusion that the notice error was harmless. See VAOGCPREC 7-2004. The United States Court of Appeals for the Federal Circuit reaffirmed the importance of proper VCAA notice in Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Mayfield and its progeny instruct that a comprehensive VCAA letter, as opposed to a patchwork of other post-decisional documents, is required to meet the VCAA's notification requirements. Id at 1320. However, VCAA notification does not require a pre-adjudicatory analysis of the evidence already contained in the record. See, e.g. Mayfield v. Nicholson, 20 Vet. App. 537, 541 (2006). During the pendency of this claim, the United States Court of Appeals for Veterans Claims (Court) decided Dingess v. Nicholson, 19 Vet. App. 473 (2006), aff'd sum nom Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), in which it held that VCAA notice requirements are applicable to all five elements of a service connection claim. Thus, the Veteran must be notified that a disability rating and effective date for the award of benefits will be assigned if service connection for a claimed disability is awarded. Id at 486. In this case, the Veteran was sent a notice in July 2002 that explained what the evidence needed to show in order to establish service connection for a claimed disability. It also informed the Veteran of what evidence VA had already received and what type of evidence the Veteran still needed to submit in order to prevail on his claim. In February 2003 the RO sent the Veteran a statement of the case (SOC) which included the text of 38 C.F.R. § 3.159, describing VA's duty to assist him with developing evidence in support of his claims. This information was also provided in an April 2004 supplemental statement of the case (SSOC) as well as subsequent SSOCs. The Veteran was sent another letter in August 2008 which explained VA's duty to assist the Veteran with developing evidence in support of his claim. The August 2008 letter also explained what the evidence needed to show in order to establish service connection for a claimed disability, as well as explained the general manner whereby VA assigns ratings and effective dates for service connected disabilities. The Veteran's claim was subsequently readjudicated, most recently in a June 2011 SSOC, thereby curing any pre-decisional notice errors. In addition to its duty to provide the claimant with various notices, VA also must make reasonable efforts to assist the claimant with obtaining the evidence that is necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the current appeal, VA has of record evidence including service treatment records, VA treatment records, private treatment records, lay statements, and a transcript of the testimony of the Veteran and his family members at the March 2005 hearing. In accordance with the terms of a Joint Motion in this case, efforts were made to obtain Social Security Administration (SSA) disability records pertaining to the Veteran; however, the Veteran was not granted benefits by SSA and no such records exist according to that agency. The Veteran was also afforded a VA examination; such examination was comprehensive and adequately addressed the nature and etiology of the Veteran's psychiatric problems. Prior Remand This case was remanded by the Board, most recently in April 2009. A Veteran has a right to substantial compliance with the instructions that are set forth in a Board remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998); See also Dyment v. West 13 Vet. App. 141, aff'd sub nom Dyment v. Principi, 287 F.3d 1377, 147 (2002) (remand not required under Stegall where Board's remand instructions were substantially complied with). The remand instructed that the following steps should be taken (1) attempt to obtain more complete records from the Veteran's treatment at VA in the 1980s, and should attempt to obtain private treatment records from the Veteran's admission to a private hospital in July 1985; (2) attempt to obtain the Veteran's complete service personnel records; (3) afford the Veteran a VA psychiatric examination to determine the nature and etiology of any current mental disorders. VA treatment records from a hospital stay in 1984 at the VAMC in Richmond, Virginia were obtained. VA attempted to obtain treatment records from the private hospital which treated the Veteran, but the hospital declined to release the records without a release that was signed by the Veteran. In September 2009 the RO notified the Veteran's attorney that the private hospital would not release the records without the Veteran's signature, but no release signed by the Veteran was received by VA so these records could not be obtained. The Veteran's complete personnel file was requested and received; however, it did not contain records such as enlisted performance reports (EPRs) that could be used to verify the Veteran's performance in service. Given that the entire personnel file was sent to VA, these records either do not exist or the custodian does not have them, and further attempts to obtain this evidence would be futile. The VA examination specified in the remand was accomplished in March 2011. The examination was complete and fully addressed the questions which were set forth in the remand instructions. For the reasons set forth above, the Board finds that VA substantially complied with the instructions that were set forth in the April 2009 remand. Service connection The Veteran alleges that he has a psychiatric disorder that was incurred in, or caused by, his military service. Service connection may be granted for a disability resulting from disease or injury that was incurred in, or aggravated by, service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection for some chronic diseases, including schizophrenia, may be granted if manifest to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for any disease diagnosed after discharge if all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish a right to compensation for a present disability, a Veteran must show: "(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"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The requirement that a current disability exist is satisfied if the claimant had a disability at the time his claim for VA disability compensation was filed or during the pendency of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Service treatment records do not show any complaints of, or treatment for, any type of psychiatric disorder in service. The Veteran's psychiatric condition was assessed as normal on his separation examination which was dated in October 1976. Service personnel records reflect that the Veteran's military occupational specialty (MOS) was bridge specialist. All of the Veteran's military service took place at Fort Bragg, North Carolina. He was released from active duty in St. Louis, Missouri. The Veteran did not have any overseas service. He did not receive any combat awards or decorations. He did not receive any specialized training. The Veteran received terminal leave because he planned to be married and needed the leave to assist with the relocation of his domicile and to obtain civilian employment. Upon separation, his service was characterized as honorable and he was considered eligible for immediate reenlistment. There is no record of any psychiatric treatment until 1984, approximately 8 years after the Veteran's service. He received a month of outpatient treatment in January 1984. He was brought by his mother, aunt, and uncle for treatment in May 1984. They stated that the Veteran had not been right since he got out of the service. The Veteran was admitted for polysubstance abuse. His last drug use was the night before admission which consisted of wine and marijuana. The Veteran reported that he used hallucinogens on a regular basis. The Veteran was unable to hold a job. It was difficult for the Veteran's family to tell whether his hallucinations were always accompanied by drug use. He had frequent nightmares and would wake up screaming. He also became more quiet and withdrawn over time, seeming nervous and extremely anxious at home. The Veteran gave a somewhat variable history, but he did give a history of having drug and alcohol related seizures. He reported having a long history, 10 years, of intermittent auditory and visual hallucinations. The Veteran reported that the voices, hallucinations, and drug use all started in basic training. The Veteran's reported 10 year history of bizarre behavior, hallucinations, thought insertion, thought withdrawal, even in the presence of drug abuse, was thought to be consistent with an underlying schizophrenia. The Veteran's baseline mental status in the first several days of admission was very, very withdrawn, and anxious with multiple somatic complaints. He had poor eye contact with poverty of speech. Thought was generally goal directed, admitting to auditory hallucinations that were sometimes friendly, sometimes telling him to leave the hospital or harm himself. After several days he was sent to radiology for a head CT scan where he became forwardly psychotic and was hallucinating. Immediately after refusing the CT he was essentially catatonic. Over a couple of hours, with medication, he gradually improved but remained extremely anxious. He did have a head CT which was within normal limits. Psychological testing showed borderline intellectual functioning. The Veteran was very guarded and the highest level of adjustment was felt to be schizoid or schizophrenic. Test data were felt to be consistent with schizophrenia. With medication the Veteran greatly improved. His affect became broader, he was much less anxious, and was interactive with the staff. He also had no further auditory or visual hallucinations. It was felt that the etiology of his acute psychotic episode could have been drug related because he had used drugs just up until admission and this had occurred only several days after admission. However, he was felt to have a diagnosis of schizophrenia. Notes from this hospitalization reflect that the Veteran reported using a variety of illegal substances including marijuana, cocaine, heroin, and angel dust since age 18. The Veteran dated both his hallucinations and his drug use to his time in the service. When he was using drugs and alcohol his family noticed a personality change, he became violent under drugs. His family wanted him to seek help because of personality changes. The Veteran's uncle reported that the Veteran was depressed, had a blank expression, had difficulty holding conversations, and that the Veteran reported to him having nightmares and hallucinations. The Veteran's uncle said that the Veteran had been withdrawing from social activities. An outpatient record from November 1984 reflected that the Veteran reported being hospitalized for nerves and drugs. He denied current drug usage. In July 1985 he reported that he had been on cocaine for 2 months. He was also using marijuana. He felt that he could not control his drug habit. The Veteran was again hospitalized in September 1985. He reported that at present he takes about $200 worth of cocaine at one time. He drank alcohol in large quantities multiple times per week. In the past he also took LSD, PCP, speed, Phenobarbital, valium, Quaaludes, and other street drugs. In the past he had withdrawal symptoms and seizures but he had not had one since 1984. He denied visual or auditory hallucinations. He denied delusions, depression, and suicidal or homicidal ideas. Upon examination he appeared about his stated age. He dressed and groomed himself appropriately. He was alert, oriented, verbal, coherent, and goal directed. His statement regarding his drug habit was not consistent and appeared to be exaggerated. Generally he was pleasant and friendly but he could be quite demanding when his requests were not immediately met. He was not depressed or suicidal. There was no evidence of a thought disorder. He had average intelligence and intact memory. His insight and judgment were fair. He was diagnosed with alcohol and cocaine abuse and passive-aggressive personality disorder. In August 1986 the Veteran reported that he becomes very depressed and withdrawn. The Veteran was examined, but he gave very little information about his medical and psychiatric history although the information that he supplied corresponded with the information available in his records. He was vague about his substance abuse. He was diagnosed with schizophrenia, undifferentiated type, and substance abuse by history. In a letter dated in September 1986 the Veteran contended that his "head sick" happened when he was in Fort Jackson, South Carolina, Fort Leonwood, Missouri, and Fort Bragg, North Carolina. He was not over it yet. The Veteran was again hospitalized in late September to early October 1986, this time at a private hospital, complaining of severe headaches and mental illness. He reported a history of hearing voices. He was not medication compliant. He associated with undesirable characters and was unable to manage his VA pension check. His treating psychiatrist recommended that a custodian be appointed to manage the Veteran's VA benefits. A few days later an outpatient records reflects that the Veteran had several somatic complaints. There was some improvement in stability of mood and he was living with his mother. The Veteran reported that he had been drinking prior to his hospitalization but claimed sobriety since coming home. In July 1987 the Veteran complained that his psychotropic medication was making him ill. He denied any visions or voices and was focused solely on physical discomforts. He denied any recent alcohol abuse. He also denied any IV drug history although he in the past acknowledged shooting cocaine and heroin. In September 1988 the Veteran had mostly financial complaints. He denied auditory or visual hallucinations and denied current or recent alcohol and drug abuse. The diagnostic impression was paranoid schizophrenia, in remission. He refused to discuss his alcohol problem. The Veteran was hospitalized in 1992 and again in 1996. In 1992 he was hospitalized to rule out cocaine psychosis. In 1996 he was hospitalized to help address his substance abuse. The Veteran reported using $20 to $25 worth of cocaine per day as well as increasing amounts of alcohol. The Veteran was continued on his same medications until discharge. In the beginning he had difficulty adjusting to the group, but at the end of his stay he got along better with others. The Veteran left on a "positive note" and was to follow up with Alcoholics Anonymous. The Veteran was again admitted to the hospital in March 1998. At that time, he reported that he could not sleep for 2 or 3 days and had been dreaming about smoking drugs. He reported that he had been clean since his last admissions 2 years prior. The Veteran was fully oriented, verbal, and vague. He was hostile, but there was no evidence of a thought disorder. Throughout his hospitalization the Veteran remained alert, angry, and argumentative. He was diagnosed with an adjustment disorder with depressed mood and personality disorder NOS during this admission. In May 2002 the Veteran asserted that his depression began while he was on active duty because working around explosives was traumatizing. The Veteran was admitted to a VA psychiatric hospital in June 2002 with a diagnosis of psychotic disorder not otherwise specified (NOS). It was noted that when the Veteran was scheduled to be discharged he claimed that the bombs and voices were still bothering him, he brought up the voices only that day or recently which made his claims suspicious. The Veteran at times expressed paranoia about others, but acted normally when out on smoke breaks with his peers. He claimed the presence of hearing bombs, today more clearly used the word voices, but only after being asked what else needs to improve. There was no external evidence for response to hallucinations, especially when in a less structured environment. It was noted that the Veteran spent more time dictating how the unit will be managed to accommodate his desire to have a single room, rather than taking advantage of therapeutic activities. His claims were suspect. His symptoms had been vague all along and he would not cooperate with psychological testing. He was diagnosed with psychotic disorder NOS, rule out (r/o) malingering, and antisocial, dependant, and narcissistic personality traits. The author of the note planned staffing with other psychiatrists regarding placing malingering as a formal diagnosis. The primary gain would be having a patient role, with a secondary financial gain. The Veteran was discharged at his request. It was at this admission when the Veteran first related that he heard the sound of bombs going off. It was noted that the Veteran denied actual traumatic events or injuries, or even near accidents, except that being placed in basic training was anxiety-producing. It was noted that the Veteran had been very uncooperative, entitled, and provides minimal to no details about his military experience or current symptoms. It was stated in notes from this admission that the Veteran's most significant psychiatric problem is a personality disorder. Holding him in the inpatient unit would be a disservice to him because it would only behaviorally reinforce his maladaptive personality style. Moreover his symptoms were suspicious in nature in that the improvements and exacerbations coincide with his admission and discharge. His behavior at this discharge is consistent with his behavior at his most recent discharge, especially vague threats of hurting others. He had not been noted previously to impulsively act out his feelings of aggression due to his perception of being mistreated. Diagnoses were depressive disorder NOS, psychotic disorder NOS, r/o malingering, and personality disorder NOS with prominent antisocial and narcissistic personality traits. In an undated letter the Veteran recounted various circumstances which he believed led him to develop a psychiatric disorder. He related that during a training session he became too terrified to move when he was instructed to throw a live hand grenade. His instructor had to grab the grenade from him and throw it. His instructor jumped on top of him because he was supposed to take cover behind a bunker. Since that time he has been afraid of explosives. Second, he related that he had to learn about setting bombs and mines. The unit was supposed to look for mines, disarm them, and set their own mines. Learning about this was frightening to the Veteran, as was the thought that he could be sent to Vietnam. Third, he was trained "how to kill people" while at Fort Bragg, North Carolina, and this was very upsetting to the Veteran. A treatment record from March 2003 reflects that the Veteran was seen for the treatment of psychotic disorder NOS, history of polysubstance abuse in remission, and cognitive disorder NOS (borderline intellectual functioning versus mild substance induced persisting dementia). The Veteran complained of frequently hearing explosions and gunfire. He complained of dysphoric mood and feeling tense like he will have to take cover. He related that while he was stationed at an Army base in Missouri he received training with explosives, mines, and bombs in preparation for going to Vietnam and that this frightened him. He also admitted that he was regularly using drugs like marijuana, cocaine, and alcohol during this period. The Veteran was alert, irritable, and had intimidating posture and clothing. He appeared angry and depressed. It was difficult for the Veteran to stop repeating his chief complaint and give a more detailed history. There were no overt psychotic features, although the Veteran reported frequent hallucinations of explosions. He was fully oriented. Assessment of the Veteran was that he was depressed and the examiner suspected some degree of manipulation to establish a PTSD diagnosis. In September 2003 the Veteran was admitted to the Salisbury VA Medical Center where he was diagnosed with PTSD, r/o schizophrenia, and history of polysubstance abuse- alcohol, marijuana, and crack cocaine, reportedly in remission since 1996. He was admitted on a holding order after reportedly being paranoid and expressing homicidal ideations. He had stated that he was a guerilla and was going to kill someone. He looked around the clinic for bombs and firearms. The Veteran reported that he was just trying to express his usual feelings but his new doctor did not understand this. He reported that his military training was traumatizing for him. It was noted that the Veteran's thought process was at times disorganized. He stated that he did not hear voices, but would hear other noises at times. He stated on several occasions, "I am a gorilla, I kill people." His mood was depressed and nervous. His affect was mildly agitated but tearful at the end of session. He denied suicidal and homicidal ideations. He appeared to be fully oriented. He could not remember his current medication but his history was otherwise intact. During his stay, the Veteran displayed no behavioral problems and consistently denied and suicidal or homicidal ideations. He reported that he was a little paranoid but stated that he had always felt like that. He denied any auditory or visual hallucinations. At the time of his discharge the Veteran denied hallucinations but continued to report mild paranoid thinking, In a statement dated in April 2004 the Veteran related that he was so frightened by his training as a combat engineer that he had to turn to illegal drugs to tolerate his own fears. A letter from the Veteran's psychiatric nurse practitioner dated in August 2004 indicated that the Veteran was chronically mentally ill with no possibility of improvement. The Veteran was again admitted to the hospital in April 2005. At that time the Veteran reported hearing voices. The Veteran told his psychiatrist, Dr. R.D.R. that he became paranoid in his thinking in basic training after throwing a hand grenade, He reported that his symptoms progressed since that time to where he is now essentially unable to function in life. The Veteran expressed difficulty eating with other patients because crowds made him nervous. During this admission, the Veteran was diagnosed with PTSD, paranoid schizophrenia, dysthymic disorder, and a history of polysubstance abuse. In a letter dated in April 2005 the Veteran's psychiatrist, Dr. R.D.R., wrote that the Veteran reported that he became paranoid in service. He began to believe that he was not safe and that others were out to harm him. He reported that he remembered throwing a grenade in basic training and then having an overwhelming fear that he was in danger. He reported that his feelings intensified throughout his time in the military and he would often hide from others for fear of being harmed. By the time of his discharge, the Veteran reported that he was debilitated with fear and paranoia to such a degree where he was unable to function in society and unable to maintain employment. He reported having nightmares about his military training, flashbacks, and was irritable and tends to feel more comfortable when he isolates himself from others. He first sought psychiatric care from VA in 1983 and has been given many psychiatric diagnoses since then as well as been placed on many different psychiatric medications. He had at least 7 prior hospitalizations at VA facilities. During his most recent hospitalization he was diagnosed with paranoid schizophrenia, PTSD, dysthymic disorder, history of polysubstance abuse, and nicotine dependence. Dr. R.D.R. opined that he believed that the Veteran's psychiatric symptoms onset while he was in the military and progressively worsened since that time. He noted that it was very common for symptoms of schizophrenia to begin in a person's late teens and early 20s. He also opined that the Veteran was unable to work due to his psychiatric disorders. A lay statement from an acquaintance of the Veteran dated in August 2005 related that he served with the Veteran in the Army. The Veteran began to express various fears while in service. He was afraid of explosives. During his time in the Army he grew more nervous and fearful of his duties. He saw the Veteran change from a quiet, awkward person to talking, laughing sometimes out of control at the wrong times. He expressed fears of maybe having to kill someone even though he made a choice to join the Army. The writer believed that the Army "changed" the Veteran and that he had not recovered. A lay statement from another acquaintance of the Veteran indicated that he knew the Veteran since childhood and they grew up in the same town. In service, sometimes he would drive the Veteran home on the weekends. One weekend when heading back to camp the Veteran did not seem like himself. He did not want to return to base but was afraid of the consequences if he did not return. The Veteran said he did not like his job in the military. The Veteran said that working around explosives caused him to be nervous. The Veteran seemed as if he had gone from being a happy and secure young man to a nervous wreck and scared out of his skin that every day of his life might be his last. This was very traumatic for the Veteran. A lay statement from one of the Veteran's high school teachers related that in high school the Veteran was a very cooperative student who got along well with his classmates and teachers. After he enlisted in the military, she had occasions to see him when he returned home on leave and was concerned about his changed demeanor. He seemed very nervous and disturbed about his military experiences. He talked excessively about his fear of bombs. He talked about his dread of returning to the military because he was so frightened. Treatment records from 2004 reflect that the Veteran was diagnosed with schizophrenia and, at times, PTSD or depression. He continued to relate that he was very scared in service and that he used drugs to cope with his fear. The Veteran testified at a videoconference hearing in March 2005. The Veteran testified that he was traumatized by being ordered to throw a live grenade during training. Ever since that time he was frightened by explosives. He was also frightened by being issued a pistol with 5 bullets when guarding an air field. He was unable to hold a job after leaving the military. The Veteran's brother testified that after the Veteran's service he was more withdrawn and did not want to go out. The Veteran's mother testified that the Veteran was very nervous after he came home from service. She felt that something happened to change the Veteran in service. The Veteran was admitted to a psychiatric hospital again in April 2005. The discharge summary shows diagnoses of PTSD, paranoid schizophrenia, dysthymic disorder, history of polysubstance abuse in remission since 1996, and nicotine dependence. He was admitted after reportedly being seen in an outpatient clinic and found to be significantly delusional. The Veteran related that he had been having significant depressive and PTSD related symptoms. He reported difficulty sleeping and sadness but denied any suicidal or homicidal ideations. The Veteran reported auditory hallucinations but he would not elaborate on these. He denied visual hallucinations. He reported feeling like others were "after me and I have to be on guard." The Veteran reported that he had nightmares and flashbacks related to combat training. He reported that he was trained as a "guerilla" and that any loud noise causes flashbacks. He reported that he was constantly on guard and felt that he was in danger. He reported a history of marijuana, crack cocaine, and alcohol use but with no use since 1996. The Veteran's drug screen at the time of admission was negative. The Veteran was alert and oriented but appeared very paranoid and anxious. His speech was appropriate in rate and volume. His mood appeared moderately depressed. His affect was moderately anxious. His judgment and insight were poor. From the Veteran's report, he had been followed by VA for mental health treatment for 22 years. The Veteran had at least 5 past psychiatric admissions to the Fayetteville VA Medical Center since 1992 and 1 past admission to the Salisbury VA Medical Center in September 2003. The Veteran reported that he became paranoid in his thinking during basic training. He stated that he threw a grenade and since that time his paranoia has been problematic for him. He thinks now that he is essentially unable to function in life. The Veteran reported that he was uncomfortable around other people and did not want to eat with other patients. A few days after his admission he reported that he felt better and wanted to go home away from other people. At the time of discharge, the Veteran was ambulatory and alert and oriented times 3. He reported moderate feelings of sadness, anhedonia, or depressed mood, but denied suicidal or homicidal ideation. The Veteran denied visual hallucinations and reported improvement in his auditory hallucinations and paranoid delusions. He denied any medication related side effects or other concerns prior to discharge and agreed to comply with recommendations. The Veteran continued to receive outpatient thereafter. He continued to be psychotic and paranoid. An undated letter from the Veteran's psychiatrist, Dr. W.K., indicated that the Veteran was diagnosed with schizophrenia and PTSD for the last 5 years. The Veteran reported that he was trained in demolition and defusing bombs in service and was "trained to kill." The Veteran was unable to handle this stress. He became increasingly withdrawn and paranoid and starting believing that there were trip wires and bombs set everywhere. This belief seemed real to him so he did not seek psychiatric treatment, even though he started hearing voices telling him that bombs were everywhere. After service, he could not hold a job due to severe paranoia. He was easily started and was hyper alert looking for trip wires everywhere. This has continued to be a severe problem for the Veteran. He looks for trip wires and bombs before each session. He has nightmares about explosions. He is afraid to be out in public and afraid to leave his home. An undated written statement from the Veteran related several experiences that he felt were stressful. He reported that when he was instructed to throw a hand grenade during basic training he became so frightened that he could not move. He reported that when he was transferred to a combat engineer unit he had to learn about bombs and demolition and this frightened him. Although the Veteran's records clearly show he was not in combat, the Veteran also reported that he had to search and find land mines, disarm them, and set new mines, which was frightening. The Veteran contended that he underwent "guerrilla training" about "how to kill people" and that this was very distressing. He was assigned to build bridges and hurt his back. He trained in communications and played a loudspeaker in the woods to deceive the enemy. Although the Veteran did not go overseas and was not in combat, he indicated that he was frightened because the enemy could come and destroy the communications equipment and he was not well armed. In an undated statement the Veteran wrote that in service he was taught how to blow up bridges and people and how to kill people and that this was distressing. He copied portions of Dr. W.K.'s letter. Two VA psychologists evaluated the Veteran in March 2011. At the time of the examination the Veteran reported that he had a normal, happy childhood. The examiner was unable to get any information about the Veteran's relationships and adjustment due to the Veteran's disorganized thinking and behavior. The Veteran denied any disciplinary problems in the military, but the examiners noted that documents in the claims file indicated that the Veteran abused drugs when he was in the military. However, the Veteran denied this. The Veteran reported that in service he was trained to be a "professional killer." He did not go to Vietnam. He felt that he might have gotten frostbite in his feet from training in the snow. The Veteran lived with his mother and was very concerned about what would happen to him when she died. He talked to one brother but did not have a relationship with his other brother, who was not in the military. The examiner was unable to get an information about the Veteran's social relationships due to his disorganized thinking and behavior. The examiners concluded that the Veteran's current psychosocial functioning was severely impaired by his current positive schizophrenia symptoms (paranoid delusions, auditory hallucinations, disorganized behavior/thinking). The Veteran denied any drug use, but the examiners noted that his records showed that the Veteran had tested positive for cocaine in March 2007 and in February 2009. It was noted that cocaine use would exacerbate the Veteran's symptoms. The examiners noted that the Veteran was seeing Dr. W.K. for treatment and that the most recent diagnoses were paranoid schizophrenia and possible cocaine abuse. They noted that the Veteran's record showed approximately 7 hospitalizations, including approximately 5 between the Fayetteville VAMC and the Salisbury VAMC. They noted that the Veteran was given a variety of different diagnoses. At the interview the Veteran continued to have severe paranoid delusions, but appeared to have a good rapport with his psychiatrist. Paranoid delusions were observed throughout the clinical interview. The Veteran looked for trip wires all down the hallway prior to going into the office, and suspiciously looked into medical rooms while walking down the hall. He reported that he was concerned that if the interviewer used her computer a bomb would go off. He looked out the window the entire interview and never sat down. He took a long time to open the office door after the interview due to his reported concern that a trip wire was placed outside while the interview was being conducted. The Veteran indicated that the trip wires are so thin only he could detect them. At the interview the Veteran reported that he heard weapons and guns going off and he appeared to be responding to some internal stimuli during the clinical interview. The interviewer had a difficult time obtaining information from the Veteran during the interview because of his thought disorder. At times the Veteran was incoherent and he was frequently derailed in his responses to questions. The Veteran's functioning during the interview seemed consistent with the most recent notes from his psychiatrist. The Veteran's delusional thinking was clearly military based. Throughout the interview he talked continuously about his training as a "professional killer." He described his training with weapons and how he feels that he is "still in training." He reported that he began feeling scared during the military and had remained scared since that time. He indicated that he wanted to get out of the military right away. However, despite his report of feeling scared, the Veteran was not admitted psychiatrically until 1984, which was years after his military service. The Veteran did not appear to have a military stressor that would meet criterion A for PTSD. He indicated that he pulled a live grenade and that his instructor took it from him. This was consistent with what was documented in the C-file. PTSD was not diagnosed because there was no criterion A stressor. The Board notes that there is a typographical error in this portion of the report, in that the examiner left out the word "not" and wrote "PTSD is diagnosed because there is not a report of a criterion A stressor." While this initially seems favorable to the Veteran, it is clear from the context that the examiner intended to give a negative opinion. In the same paragraph she made clear that the Veteran did not appear to have a military stressor that would meet criterion A, one of the necessary criteria, for PTSD. Also, in the multiaxial diagnosis included in her report, she did not diagnose PTSD. The Board concludes that the sentence was intended to read, "PTSD is not diagnosed because there is not a report of a criterion A stressor," which sentence is consistent with the conclusions expressed in the remainder of the report. At the interview the Veteran was in military attire. He never sat down during the interview. He watched out the window and commented on people walking by. He was very restless. His speech was illogical at times and pressured throughout the interview. His attitude toward the examiner was hostile, suspicious, irritable, and guarded. He appeared to get frustrated with the interviewer, particularly when discussing his role while in the military as a "professional killer." He reported that the "blinders are off" all the time and that he lived in fear and that the examiner would have no idea what that felt like. His affect was inappropriate. His mood was anxious and fearful. He had a short attention span, likely due to his thought disorder. He was fully oriented. His thought process was characterized by rambling, preservation, and tangentially. His disorganized thinking made it difficult to obtain information from him. He was preoccupied with describing his experiences in the military. He had persistent paranoid delusions. He did not understand the outcome of his behavior. His intelligence was below average. He did not understand that he had a problem. The Veteran reported that he did not get a lot of sleep. He had auditory hallucinations. He had paranoid ideation, and felt that there could be trip wires going to the interview room and that a bomb could go off the interviewer used her computer, and indicated that trip wires could have been placed in the hall during the interview. He stood up during the whole interview, watching out the window, and commenting on people walking by. When complaining about his foot pain he started to take off his shoes, but when the interviewer told him that this was unnecessary he stopped. He did not interpret proverbs appropriately. He did not have obsessive or ritualistic behavior, panic attacks, homicidal or suicidal thoughts. He had poor impulse control but there were no episodes of violence. It was noted that the Veteran's thought disorder would likely make problems with his activities of daily living difficult at times. His memory was mildly impaired, but that examiner noted that it was difficult to assess due to the Veteran's disorganized thinking and speech. The Veteran was not competent to manage his financial affairs. He was unemployed due to his mental disorder. The examiner diagnosed paranoid schizophrenia. She assigned a global assessment of functioning (GAF) score of 30. She noted that the Veteran met the criteria for paranoid schizophrenia and that his paranoid delusions cause serious impairment in both his functioning and judgment. He was unable to function in most areas due to his thought disorder. There was total occupational and social impairment due to his mental disorder. The psychologists opined that the Veteran currently met the criteria for schizophrenia, paranoid type. His behaviors observed during the assessment were consistent with this diagnosis and also supported by his medical records. However, the Veteran did not appear to have any treatment for psychiatric symptoms until 1984 at the Richmond VAMC. The Veteran's military service ended in 1979 (actually, 1976). Although the Veteran's delusional thinking is military based, his psychotic symptoms are less likely than not manifested during his military service or the year thereafter. There was a substantial time period between his discharge from military service and his first psychiatric admission in 1984. Additionally, the Veteran's illicit drug use during his military service and after he was discharged makes it difficult to determine whether there were any underlying psychotic symptoms present during his military service or one year thereafter. The examiners concluded that based on the amount of time between the Veteran's discharge from military service and his first treatment for a psychiatric disorder, it was their opinion that his current diagnosis of paranoid schizophrenia was less likely than not manifested during his military service or the year thereafter. The overwhelming weight of the competent evidence does not show that it is at least as likely as not that the Veteran's schizophrenia onset during service or within a year from service or that he has PTSD that is related to his military service. While the Veteran contended that his fearfulness, paranoia, and hallucinations started in service, his service records contradict his claim. Given the severity of the symptoms that the Veteran claims he experienced in service and later demonstrated, it is not credible that he would not have exhibited overt signs of his mental disorder in service if it had in fact existed at that time. His service treatment records show that he was never assessed for the presence of any type of psychiatric disorder, indicating that he did not display behavior of the type that would call his psychiatric state into question by his supervisors. Furthermore, despite his claimed fear of bombs, feelings that trip wires were everywhere, and hiding from people, he was nonetheless able to perform his duties as a bridge specialist until the time of his discharge, which is inconsistent with his current claim that he was essentially debilitated since his discharge from military service. The Veteran was discharged in order to prepare for his upcoming marriage at the time, which again is inconsistent with his claim that he was practically completely debilitated as records show that the Veteran conscientiously requested terminal leave in order to look for housing and civilian employment. It is also noted that the reenlistment code assigned to the Veteran enabled immediate reenlistment; had the Veteran displayed behavioral problems consistent with his later actions, or if he in fact had been unable to perform his duties, he would not have been considered eligible for immediate reenlistment. Moreover, while the Veteran's current paranoia and delusions related to military subjects, records of outpatient treatment and inpatient hospitalizations prior to 2002 do not show this, which is also inconsistent with the Veteran's story that he feared bombs and trip wires since he was in the service. The Veteran did not report paranoia or hallucinations related to bombs or trip wires at the time of his hospitalizations in 1984, 1986, 1996, and 1998. This was also not a subject of discussion shown in his outpatient treatment records during this period. The first mention of auditory hallucinations of bombs was in or around 2002, more than 25 years after the Veteran's service. The Veteran's fear of trip wires appears to have onset even more recently. While the Veteran's family members and some friends indicated that they observed a change in the Veteran's personality during and after service, there is no indication that these personality changes were indicative of schizophrenia. Friends testified that the Veteran did not like his military duties, expressed reservations about wartime service, and was nervous about some of his duties involving explosives. This does not demonstrate anything more than disenchantment with military service and some apprehension about certain military duties that the Veteran was required to perform. It is also significant that the Veteran was abusing a variety of drugs at this time, which could possibly have caused him to alter his behavior. The Veteran's family members noted that the Veteran was nervous and withdrawn after his service. These factors alone do not show that the Veteran met the diagnostic criteria for schizophrenia at that time. This was recognized by the VA psychologists who performed the March 2011 examination; after reviewing all of the evidence in the claims file, which included the lay statements and testimony about the Veteran's behavior, they opined that it was less likely than not that the Veteran's schizophrenia was present in service or within one year thereafter. They also noted that the Veteran's drug usage at that time, which included hallucinogens and various other drugs, made it difficult to determine when psychotic symptoms first onset. Also, while the Veteran's family members testified to a personality change after service, it is notable that they did not seek treatment for the Veteran until approximately 8 years after his service. While they then reported that the Veteran "hasn't been right" since service, heavy drug use was suspected at that time. In 1984, family members noted personality changes brought on by substance abuse, and while they noted the Veteran then complained of hallucinations and nightmares, there is no indication that these symptoms were present within 1 year of the Veteran's service or that they existed apart from the Veteran's drug use. Notably, at that time the Veteran's family members attributed his changed personality, hallucinations, and nightmares to substance abuse and were unable to state whether these symptoms existed at times other than when the Veteran was using drugs. It is also notable that while medical personnel believed that the Veteran had an underlying schizophrenia at this point, the diagnosis was somewhat uncertain in that they also entertained the possibility that his symptoms were caused by drug use. The Board acknowledges that the Veteran's treating psychiatrist, Dr. R.D.R., opined that the Veteran's symptoms began in service. However, his opinion is based on a faulty factual foundation insofar as it is based on an inaccurate history that was provided by the Veteran. Dr. R.D.R. indicated that the Veteran dated his paranoia to service, stated that he would hide from others in service, and that he was totally debilitated by fear and paranoia by the time of his discharge. As noted above, this is inconsistent with contemporaneous records which indicate that the Veteran was able to satisfactorily perform his duties prior to his separation, consciously chose to go on terminal leave to seek civilian employment and accommodations prior to a planned marriage, and never displayed behavior that was so out of the ordinary as to require psychiatric evaluation in service. While Dr. R.D.R. also indicated that it was common for symptoms of schizophrenia to start in a person's late teens or early 20's, this is a generalized statement that does not demonstrate when this Veteran's symptoms actually onset. It is also notable that the Veteran was discharged from the Army when he was 21 years old and thus a common onset date of the early 20's would also encompass a period of time after the Veteran's service ended. Significantly, the Veteran was only 29 at the time of his first psychiatric admission in 1984. While in 1984 the Veteran dated his hallucinations to his time in the service, he also dated his drug use to that time, which included hallucinogenic drugs. The frequency of his drug use after service also makes his ability to recall when his symptoms actually onset questionable. For example, he now dates his symptoms to an incident when he had to throw a hand grenade in training, but there is no mention of this alleged incident in the Veteran's early treatment records from the 1980s and 1990s. Furthermore, there is no indication the Veteran's hallucinations were of a military character at that time. Similarly, while Dr. W.K. also recounted a history of symptoms beginning in the service, this was likewise based on the Veteran's inaccurate report. For example, Dr. W.K.'s letter indicated that the Veteran was easily hyper alert looking for trip wires everywhere since service. However, the Veteran's treatment records do not show that he developed a fear about trip wires until more than 25 years after his service. His paranoia and delusions are documented to have a military character starting around 2002. In contrast, the Board finds that the opinion of the examiners who conducted the March 2011 examination of the Veteran is highly probative. The examiners were able to review documentation of the Veteran's treatment back to 1984 to get a picture of how his symptoms developed over time. Based on their review of his history, they were unable to identify a manifestation of schizophrenia prior to the Veteran's first hospitalization in 1984. They noted that there was a substantial lag time between the Veteran's service and his first hospitalization, which was inconsistent with a history of schizophrenia during or shortly after service. The examiners also noted that the Veteran's illicit drug use during his military service and after he was discharged made it difficult to determine whether there were any underlying psychotic symptoms present during his military service or within one year thereafter. They concluded that based on the lag time between the Veteran's military service and his first treatment for schizophrenia, it was less likely than not that this disorder manifested during the Veteran's military service. For these reasons, the Board concludes that the evidence does not show that it is at least as likely as not that schizophrenia was present in service or within 1 year of service. Similarly, the Board does not find that the Veteran has PTSD that is related to his service. While certain treatment records indicate that the Veteran was diagnosed with PTSD, use of this diagnosis is inconsistent. The Board acknowledges that Dr. W.K. diagnosed the Veteran with PTSD. He indicated that the Veteran reported symptoms of severe PTSD that started during training. However, again this is based on an inaccurate history given by the Veteran, who reported that he became increasingly withdrawn and paranoid in the service, thinking trip wires were everywhere, hearing voices, and having nightmares about killing and blowing up people. As previously discussed, the Veteran did not display overt psychiatric symptoms in service as demonstrated by his service records, his symptoms were not focused on military subjects such as bombs until approximately 2002, and his fear of trip wires onset even later than this. Additionally, the Board notes that Dr. W.K. did not identify a stressor upon which his diagnosis of PTSD was based, stating only that the Veteran reported being distressed about his training and guilty about not being sent to Vietnam. The Board finds the opinion of the psychologists who evaluated the Veteran in March 2011 to be more probative on the subject of whether the Veteran has PTSD related to service. They noted that the Veteran did not appear to have a military stressor that would meet criterion A for PTSD. He indicated that he pulled a live grenade and an instructor took it from him. This was consistent with the stressor documented in the claims file. The examiners did not diagnose PTSD. Given that the examiners reviewed the Veteran's psychiatric history back to 1984 as well as interviewed the Veteran, and fully explained their conclusion that PTSD could not be diagnosed because there was no criterion A stressor, and diagnosed only paranoid schizophrenia, their opinion that the Veteran does not have PTSD is more probative than the opinion of Dr. W.K. which does not identify the Veteran's stressor, does not provide a rationale for the diagnosis, and is based on an inaccurate history by the Veteran. However, even if the Veteran has PTSD, it is not shown to be related to the Veteran's service. The Veteran primarily predicates his alleged PTSD on an incident when he allegedly pulled a live grenade and in instructor took it from him. The only evidence that this occurred is the Veteran's statement, which is of doubtful credibility. He did not identify this incident until decades after his service. The Veteran specifically denied actual traumatic events or injuries, or even near accidents, in service during his June 2002 hospital admission. His story about the grenade appears to have been generated at some point after this, which coincides with when he began experiencing increasingly militaristic delusions and hallucinations. The Veteran's submissions can also be read to indicate that he considered his military training as a whole to have been his stressor because he was allegedly trained to kill people and as a guerrilla. The VA examiners did not diagnose PTSD based on this history, which does not identify any particular incident. While arguably Dr. W.K's letter may be read to indicate that he diagnosed PTSD based on the Veteran's military experiences as a whole rather than a particular incident, the VA examiners explained that for a diagnosis of PTSD to be valid there has to be a particular criterion A stressor. Moreover, the Veteran's recollection of his training is of questionable credibility. He did not provide any specifics other than the incident with the grenade, just claiming that he was trained to kill people and that this distressed him. He never described what this training allegedly entailed or how it placed him or anyone else in danger. His reported recollections of his training are very vague and they reportedly did not onset until decades after his service, which is inconsistent with an event that caused significant distress at the time and thereafter. The Veteran also identified as distressful having to guard an airfield and having to play messages for enemies in the woods. There is no evidence that anyone diagnosed the Veteran with PTSD based on these incidents. Furthermore, the Veteran's recollection of these incidents appears to be confused. While he acknowledges that all his service was stateside, he reported being afraid that the airfield would be attacked and that he would not be able to defend himself. Similarly, he reported playing messages for enemies in the woods who would want to find and destroy the communications equipment, although there were no enemies at a base within the continental United States to either hear messages or attack communications equipment. The evidence does not show that the Veteran has PTSD based on these, or any other, military experiences. The Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine is inapplicable in the instant case because the preponderance of the evidence is against the Veteran's claim. See, e.g., Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C.A. § 5107(b). Accordingly, the appeal is denied. ORDER Service connection for an acquired psychiatric disorder, including schizophrenia and PTSD, is denied. ____________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs