Citation Nr: 1306407 Decision Date: 02/25/13 Archive Date: 03/01/13 DOCKET NO. 07-09 869 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina THE ISSUE Entitlement to service connection for an acquired psychiatric disability. REPRESENTATION Appellant represented by: Robert V. Chisholm, Attorney ATTORNEY FOR THE BOARD Mary C. Suffoletta, Counsel INTRODUCTION The Veteran served on active duty from March 1976 to June 1976. This matter initially came to the Board of Veterans' Appeals (Board) on appeal from a May 2006 rating decision that declined to reopen a claim for service connection for an acquired psychiatric disability on the basis that new and material evidence had not been received. The Veteran timely appealed. In January 2010, the Board found new and material evidence to reopen the Veteran's claim, and remanded the reopened claim for additional development. In a September 2011 decision, the Board denied service connection for an acquired psychiatric disability. The Veteran appealed the September 2011 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a March 2012 Joint Motion for Remand, the parties moved to vacate the Board decision and remand the case to the Board. The Court granted the motion. Thereafter, the case was returned to the Board. Lastly, in addition to reviewing the Veteran's paper claims file, the Board has surveyed the contents of his Virtual VA file. The issue of entitlement to a total disability rating based on individual unemployability (TDIU) has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDING OF FACT Resolving all doubt in the Veteran's favor, schizophrenia had its onset in service. CONCLUSION OF LAW Schizophrenia was incurred in service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. 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 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The Veterans Claims Assistance Act of 2000 (VCAA) is not applicable where further assistance would not aid the Veteran in substantiating his claim. Wensch v. Principi, 15 Vet App 362 (2001); see 38 U.S.C.A. § 5103A(a)(2) (Secretary not required to provide assistance "if no reasonable possibility exists that such assistance would aid in substantiating the claim"); see also VAOPGCPREC 5-2004; 69 Fed. Reg. 59989 (2004) (holding that the notice and duty to assist provisions of the VCAA do not apply to claims that could not be substantiated through such notice and assistance). In view of the Board's favorable decision in this appeal, further assistance is unnecessary to aid the Veteran in substantiating his claim. II. Analysis Service connection is awarded for disability that is the result of a disease or injury in active service. 38 U.S.C.A. §§ 1110, 1131. Service connection requires competent evidence showing: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time. 38 U.S.C.A. § 1111. Here, the Veteran's enlistment examination is not of record. There is a clinical notation, dated in May 1976, revealing that the Veteran had no prior psychiatric treatment or behavior problem. With respect to the showing of chronic disease, there must be a combination of sufficient manifestations to identify the disease entity and sufficient observation at the time, as distinguished from isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303 (2012). The Veteran contends that the onset of his acquired psychiatric disability was during active service with the Marines on Parris Island in 1976, and that his symptoms have been ongoing since then. It appears that the Veteran was hospitalized in May and in June 1976 for a situational stress reaction with psychotic features, although records also reveal no evidence of a psychosis at the time. The Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). Service treatment records show that the Veteran was admitted to a hospital by his mother, aunt, and cousin after serving two months of active duty at Parris Island. The Veteran allegedly was absent-without-leave, and complained that Parris Island was making him nervous and that he could stand it no longer. The Veteran described becoming progressively more anxious and disorganized while at Parris Island, and reportedly hallucinated for about four weeks that his drill instructor's voice was yelling at him; he then ran away and came home. When his family suggested that he might go back, the Veteran jumped out the window. A notation from the Veteran's private physician at the time reflects that the Veteran ran and hid all night, and talked of suicide and became completely unmanageable. He was given a sedative. Mental status examination in May 1976 shows that the Veteran's affect was blunted; his mood was depressed. He had hallucinated for the past four weeks that his drill instructor's voice was yelling at him. The Veteran was confused and disorganized, and unable to subtract 7 from 100 when evaluated upon admission. His stupor and disorganization were the result of his having been given a sedative by his private physician prior to hospitalization. The diagnosis was acute situational reaction, severe, manifested by hallucinations and anxiety of panic proportion; moderate stress of basic training; unknown predisposition. It was recommended that the Veteran transfer to the naval hospital for further treatment. Service treatment records, dated in June 1976, show that the Veteran reported a history of numerous problems with dealing with authority or a structured situation. He related civilian episodes of time in jail due to impulsive behavior. The impression at that time was personality disorder, chronic. Post-service VA records, dated in November 2003, include findings of anxiety and depression, and a diagnosis of bipolar disorder. Records received from the Social Security Administration in December 2003 include a psychological evaluation, indicating that the Veteran's mood was both anxious and depressed. While there was no evidence of an overt psychosis at the time, the psychologist noted that the Veteran had been psychotic in the past. The Veteran reported having a psychotic break after about ten weeks in the Marines, and that he spent the last two weeks in a mental hospital. He reportedly never fully recovered from the psychotic break. The Veteran also reported psychiatric admissions in the 1980s and 1990s, and that he had been hospitalized four times. He currently took medication, and reported that probably anxiety was his biggest problem. Mental status examination in December 2003 revealed that the Veteran was oriented; his speech was relevant and coherent, and there was a little looseness of thought content. He sometimes heard voices, often calling his name. The Veteran gave a vague description, and the psychologist doubted that these hallucinations would be a major hurdle for him working. The psychologist opined that the Veteran was more of an anxious, tense, and fearful individual. He slept poorly, and his energy was low. He did not enjoy life, and felt useless. Psychomotor movements were slowed, and affect was blunted. The psychologist found that the Veteran was withdrawn and isolated, and had some mild hallucinatory-type experiences. The Axis I diagnoses were generalized anxiety disorder, moderately severe; major depression, moderate. VA treatment records, dated in May 2004, show assessments of mood disorder and PTSD. During a January 2007 VA examination, the Veteran reported that he was stressed on active duty because he was sent to "the ditch" on Parris Island, which was a place to break up rocks and make sand piles. This was supposed to be a form of punishment, although the Veteran denied knowing the reason that he was being punished. He reportedly relived this experience on a daily basis, and felt depressed and withdrawn from others. The Veteran isolated himself, and reported that he did not like to be around a crowd of people. He continued to take medication for anxiety. The Veteran denied a history of psychiatric illness prior to active service; and there have been no recent psychiatric hospitalizations. He denied suicidal and homicidal ideation or plan. The Veteran denied significant remissions in his symptoms, and noted that they have been ongoing since 1976. He also denied significant post-military stressors. Following mental status examination in January 2007, an Axis I diagnosis was deferred by the examiner. The examiner noted both the inconsistencies in the record, and the poor effort put forth by the Veteran in his mental status examination. For example, the Veteran recently had been diagnosed with PTSD due to Gulf War experiences, but he had never served in combat nor served during the Gulf War. The examiner also noted that the Veteran described symptoms of PTSD during this examination, based on his training experiences at Parris Island; however, the symptoms did not meet criteria for a diagnosis of PTSD. In February 2007 the Veteran underwent an evaluation by a board of two psychologists. Following a review of the record, the examiners noted that the Veteran had been diagnosed with various illnesses-including bipolar disorder, PTSD, anxiety, and depression. Following mental status evaluation, the examiners provided no Axis I diagnosis. While acknowledging that the Veteran had been diagnosed with numerous psychiatric illnesses, the examiners found that the symptoms he currently presented did not fit and were not consistent with any of those categories. In essence, when the Veteran was asked, 'what was the worst thing that happened [to him],' he did not report being harassed by a drill instructor. Due to the lack of effort on the Veteran's part, no diagnosis was rendered. In July 2012 and in August 2012, VA received statements from the Veteran's nephew and from his mother, respectively, indicating that the Veteran spent most of his time after returning from active service alone in his room; and that he was withdrawn and secluded. The Veteran's nephew also noted that the Veteran's behavior became more erratic over the years and more aggressive toward others. The Veteran's mother also indicated that the Veteran was a complete nervous wreck when he returned from active service, and that the littlest of things would make him jump. She indicated that the Veteran talked to himself, and that it was hard to understand what he was saying because it sounded jumbled. The Veteran spent the first couple of years post-service going in and out of mental institutions, and trying to get correctly medicated. The Veteran lived with his mother until about 11 years ago, and she still supported him financially. In December 2012, VA received a psychological evaluation of the Veteran from Jonathan Mangold, PhD. Dr. Mangold's evaluation was based upon a complete review of the record, including recent statements submitted by the Veteran's nephew and his mother. Following a complete review of the record, Dr. Mangold opined that the Veteran's appropriate diagnosis was schizophrenia, undifferentiated type, chronic; and that the Veteran certainly experienced limitations of functioning and psychoses related to his schizophrenia to a degree of 10 percent or more during active service. Dr. Mangold also opined that the Veteran's functioning due to schizophrenia had been severely limited since 2003, and had rendered the Veteran unemployable. Significantly, Dr. Mangold provided several citations to the record to demonstrate schizophrenia, and noted reports by patients of having lost control of one's mind is common among schizophrenics. The memory loss described by the Veteran, and his being nervous since active service and not remembering being depressed prior to active service, also was highlighted by Dr. Mangold. Likewise, the Veteran's reports of continuing auditory hallucinations, flat affect, odd and unusual characteristics, and crippling anxiety-all signs, Dr. Mangold thought, as schizophrenia. Moreover, the Veteran's claim that he was in the Gulf War was clearly delusional; and he reported profound dissociative phenomena, which seemed more consistent with psychosis than PTSD. Dr. Mangold also noted the Veteran's report of continuing memories of his experiences at Parris Island in January 2007, and that his symptoms have been ongoing since 1976. At the time the Veteran admitted to hallucinations, and that he had problems relating to people. The Veteran's nephew, in a July 2012 statement, described the Veteran as profoundly changed from pre-service to post-service; and indicated that the Veteran was now severely limited. The Veteran's mother, in an August 2012 statement, described the Veteran as becoming schizophrenic in service, and that he was now dependent upon others. Lastly, Dr. Mangold noted that patients who sit for boards of two or three are never as forthcoming as they are when sitting with a familiar and trusted provider; and opined that the February 2007 evaluation was not representative of the Veteran's actual status. When assessing the probative value of a medical opinion, the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). A medical opinion that contains only data and conclusions is not entitled to any weight. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Here, the Veteran's entrance examination is not of record; therefore, he is presumed sound at entry in March 1976. Service treatment records reflect further that he received treatment during service in June 1976 by a psychologist due to confusion, disorganization, and hallucination; and after examination, a diagnosis of acute situational reaction, severe, manifested by hallucinations and anxiety of panic proportion, was rendered. He was discharged later that same month. Thus, the overall evidence reflects treatment for an acquired psychiatric disability in active service. The Veteran has reported that he never fully recovered from the psychotic break in service, and that he had four psychiatric admissions over the years. He reported that his symptoms have been ongoing since 1976. Both the Veteran's nephew and his mother have confirmed ongoing symptoms since active service. The available medical evidence demonstrates several gaps of decades in time from when the Veteran separated from service and when he became disabled for Social Security purposes in 2003. In Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006), the Federal Circuit Court indicated that, where lay evidence provided is competent and credible, the absence of contemporaneous medical documentation during service or since, such as in treatment records, does not preclude further evaluation as to the etiology of the claimed disorder. In this case, the Veteran is competent to report what has occurred since service because his statements are regarding his first-hand knowledge of factual matters-that is, the symptoms that the Veteran experienced from the time of his separation forward. Furthermore, the Board finds that the Veteran is credible in this regard. The available treatment records indicate a longstanding history of symptomatology. Also, the Veteran's statements are consistent with findings of anxiety, depression, and bipolar disorder since 2003. The Veteran's statements are not expressly contradicted by the record. While the January 2007 and February 2007 examiners provided no Axis I diagnosis, these examiners did acknowledge that the Veteran had been diagnosed with various illnesses-including bipolar disorder, PTSD, anxiety, and depression. Because no psychiatric diagnosis had been rendered, each of these examination reports lacks probative value. Accordingly, the Board finds that the lay statements of record support a finding of continuity of symptomatology since active service. When considering the service treatment records, the competent and credible lay statements, and the post-service medical evidence substantiating the Veteran's claim, and resolving all reasonable doubt in his favor, the Board finds that an acquired psychiatric disability had its onset in active service. See 38 C.F.R. § 3.102 (2012). Schizophrenia Moreover, the Board finds that the December 2012 opinion by Dr. Mangold is the most probative evidence for resolving the matter on appeal. The opinion is fully supported by the objective evidence of record and lay statements, and is factually accurate and contains sound reasoning. Certainly then, when considering the Veteran's competent and credible lay statements with the medical evidence substantiating his claim, as well as Dr. Mangold's favorable opinion; and resolving all reasonable doubt in his favor, the Board finds that the Veteran's schizophrenia had its onset in active service. See 38 C.F.R. § 3.102 (2012). (Continued on next page.) ORDER Entitlement to service connection for schizophrenia is granted. ____________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs