Citation Nr: 1237755 Decision Date: 11/05/12 Archive Date: 11/09/12 DOCKET NO. 10-26 213 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to service connection for an acquired psychiatric disorder. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD W.H. Donnelly, Counsel INTRODUCTION The Veteran served on active duty with the United States Army from February 1983 to March 1983. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision by the Chicago, Illinois, Regional Office (RO) of the United States Department of Veterans Affairs (VA), which denied entitlement to the benefit sought. In perfecting her appeal in April 2010, the Veteran requested a personal hearing before a Veterans law Judge, to be held at the RO; she withdrew this request in January 2011 correspondence. FINDINGS OF FACT 1. An acquired psychiatric disorder did not clearly and unmistakably exist prior to the Veteran's entry onto active duty. 2. The currently diagnosed acquired psychiatric disorder was first manifested during active military service. CONCLUSION OF LAW The criteria for service connection of an acquired psychiatric disorder are met. 38 U.S.C.A. §§ 1111, 1131, 1137 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA's Duties to Notify and Assist 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; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). The Board is granting in full the benefit sought on appeal. Accordingly, any error committed with respect to either the duty to notify or the duty to assist was harmless and will not be further discussed. Analysis 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. When no pre-existing injury or disease is noted at examination for entry into service, the Veteran is presumed to have been sound upon entry. The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the Veteran's injury or disease was both pre-existing and not aggravated by service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b); Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Clear and unmistakable evidence is a more formidable evidentiary burden than the preponderance of the evidence standard. See Vanerson v. West, 12 Vet. App. 254, 258 (1999). It is an onerous evidentiary standard, requiring that the result be undebatable. Cotant v. West, 17 Vet. App. 116, 131 (2003). If the government fails to rebut the presumption of soundness, the Veteran's claim is one for service connection and the claim is granted. No deduction for the degree of disability existing at the time of entrance will be made. See 38 C.F.R. § 3.322. The Veteran underwent examination in connection with her enlistment in December 1982. She made no subjective complaints of any current psychiatric problems, nor did she report any history of mental health problems. The objective medical assessment noted no psychiatric problems; that system was reported to be "normal." Service records show that the Veteran entered onto active duty on February 22, 1983. Service treatment records include March 15, 1983, report by the Entrance Physical Standards Board (EPSBD); the examining doctors reported that the Veteran had been admitted to the hospital three days after arriving at the recruit reception station; MPs had observed her "bizarre behavior" for three days before bringing her in for assessment. The Veteran stated that she began having problems as soon as she stepped off the bus, including hallucinations and paranoia. The examiner felt, however, that based on some of her statements regarding her problems "being part of life" and "probably won't change over a few days period of time," her problems were actually chronic and longstanding. The EPSBD determined that the Veteran was not fit for induction, and should be separated from service due to diagnosed pre-existing schizophrenia, which had not been aggravated by service. Post service medical records reveal that at discharge, the Veteran was immediately hospitalized at several private facilities, which confirmed a diagnosis of schizophrenia, and stated that the Veteran had suffered an "acute" or "initial" psychotic break during service. Although the Veteran was somewhat confused and uncooperative with her initial treatment, she consistently reported that she had no history of prior psychiatric treatment or problems. Relatives who were questioned by doctors stated the same, and no doctor, relative, care provider, or the Veteran has at any time indicated any treatment for or complaints of mental health problems before her arrival for active duty service. The Veteran has more recently indicated that her problems began immediately after receiving a mandated vaccination upon arrival at thee recruit depot, still after entry onto active duty. A September 2008 VA examiner reviewed the claims file and opined that the condition diagnosed during active duty and treated immediately following separation is the same condition which is present currently. The sole evidence of pre-existence of a psychiatric disorder is the opinion of the EPSBD examiner who, based on characterization of the Veteran's statements regarding her situation at the time of examination. The examiner inferred that problems were likely long-standing. However, at every opportunity, the Veteran and her relatives have stated that there was no treatment for mental health problems prior to service, and no behaviors or complaints suggestive of such. The Veteran had attended two years of college, and was working productively at the time of her enlistment. The direct statements regarding her pre-service status far outweigh the EPSBD examiner's inference. There is no clear and unmistakable evidence of pre-existence, and hence the presumption of soundness is not rebutted. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). Therefore, the evidence establishes that the Veteran's currently diagnosed acquired psychiatric disorder, identified as a form of schizophrenia, was first manifested on active duty service. It is not relevant that the condition manifested, apparently, within minutes or hours of being exposed to the heightened stress of arrival at the recruit depot. The Veteran was on active duty when she suffered her break, and service connection for the acquired psychiatric condition is accordingly warranted. ORDER Service connection for an acquired psychiatric disorder is granted. ____________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs