Citation Nr: 1313189 Decision Date: 04/19/13 Archive Date: 05/02/13 DOCKET NO. 04-09 324 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUE Entitlement to service connection for paranoid schizophrenia. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Hager, Counsel INTRODUCTION The Veteran served on active duty from April 1978 to May 1982. This matter initially came before the Board of Veterans' Appeals (Board) from a February 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut. In that decision, the RO denied entitlement to service connection for paranoid schizophrenia and depression. The Board has recharacterized the issue based on its grant of service connection for paranoid schizophrenia in the decision below. In May 2005 the Veteran testified at a videoconference hearing before the undersigned. The Board subsequently remanded the claim multiple times, as discussed below. FINDING OF FACT The most probative evidence of record reflects that the Veteran's paranoid schizophrenia is related to the psychiatric symptoms he experienced in service. CONCLUSION OF LAW Paranoid schizophrenia was incurred in service. 38 U.S.C.A. § 1131 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Clams Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012). As the Board is granting entitlement to service connection for paranoid schizophrenia, further discussion of the VCAA is unnecessary. Wensch v. Principi, 15 Vet. App. 362, 367-368 (2001). Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service connection is warranted for a disease first diagnosed after separation from service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). There are other ways of establishing entitlement to service connection, which will be discussed below. In this case, however, there is uncontradicted evidence that the Veteran currently, and has for some time, suffered from paranoid schizophrenia, and that he had psychiatric symptoms in service. Specifically, service treatment records show the veteran's complaints and/or treatment for personnel problems beginning in March 1982 with diagnoses of personal problems with depressive features and marital and family problems, as well as personal problems with chronic depressive features. Post service records show the Veteran's complaints and/or treatment for a delusional disorder since 1999 with a diagnosis of paranoid schizophrenia beginning in 2000. In 2000, the Veteran was committed to the jurisdiction of a Psychiatric Security Review Board after being found not guilty of attempted murder and manufacturing a bomb by reason of insanity. The dispositive question on this appeal is therefore whether the current paranoid schizophrenia is related to the in-service psychiatric symptoms. The only medical opinion offered on this question was by a psychologist who conducted the June 2009 VA examination. The psychologist recounted his thorough review of the claims file, including the positive evaluations that the Veteran received at the beginning of his period of service, and the Veteran's mental health evaluations beginning in March 1982 with diagnoses noted above. The psychologist also noted the Veteran's statements indicating that he began having delusions during service in 1979. After his review of the claims file and examination of the Veteran, the psychologist diagnosed paranoid schizophrenia and responded to multiple questions that had been posed by the Board in its September 2005 remand. As to whether paranoid schizophrenia was related to service, he wrote, that, based on review of the claims file, "it is at least as likely as not that the Veteran's observed depressive symptoms, identified during his active duty service in the Air Force, was the prodromal stage of his psychotic disorder which later blossomed into more observable and significant symptoms presentation." The psychologist's rationale was that the Veteran's age at the time of onset of depressive symptoms, his noted stressors, and his consistent report of his experiences over time "make this a plausible conclusion." In response to the question whether paranoid schizophrenia was incurred in or aggravated by service, the psychologist wrote, "The Veteran is currently diagnosed with paranoid schizophrenia. It is less likely than not that the Veteran's currently diagnosed condition was clearly established during his time in the Air Force," because while the reported symptoms could plausibly develop into a more significant psychiatric disorder, "there appears to be no indication in the record that the Veteran suffered from a psychotic disorder while on active duty." As to whether it was at least as likely as not that any currently diagnosed psychosis was compensably disabling within the first year following service, the psychologist wrote that it was less likely than not that paranoid schizophrenia caused compensable disability within the one year period, as reinforced by the Veteran's statement that symptoms improved following discharge from service. In conclusion, the psychologist indicated that it was extremely difficult to identify the onset of a psychiatric disorder without substantive supporting evidence, but it was his opinion that the Veteran experienced mood-related disturbance with the possibility of more severe psychiatric symptomatology during service and "a link can be established between these military experiences and his later diagnosed schizophrenia." He noted, however, that review of the evidence by another provider could indicate a different opinion. In its August 2009 remand, the Board found this opinion to contain conflicting responses and instructed that the AMC/RO obtain clarification. In his responses, the psychologist essentially adhered to his opinions, explaining that depressive symptomatology may be part of a larger prodromal stage for the later development of a psychotic disorder, but there is no conclusive evidence from the interview or the file that could definitively link the Veteran's current schizophrenia to his in-service symptoms. He added that such a connection was plausible, but he could not specify the degree or percentage of likelihood, as that would be mere speculation. As to his final statement, indicating that a link could be established between current schizophrenia and service was a statement of plausibility and "the evidence to clearly establish this link is not fully supported by information obtained from the Veteran's claims file or the interview. In subsequent March and July 2010 and June 2012 remands, the Board indicated its intention of obtaining an opinion from the from the Veterans Health Administration (VHA) or an independent medical expert (IME), but first instructed that additional evidence be obtained, including the transcript of the Veteran's commitment proceedings to include the testimony of Dr. Zeman. In the interim, however, the Court has emphasize that medical reports must be read as a whole and in the context of the evidence of record. Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012). In light of this principle and on re-review of the June 2009 VA opinion and November 2009 clarification and the other evidence of record, the Board finds that the opinions are adequate and the evidence sufficient to render a decision on the claim. Reading the VA psychologist's opinions as a whole and in the context of the evidence of record, he stated with sufficient certainty that the Veteran's current schizophrenia is related to his in-service psychiatric symptoms. The psychologist stated in two different ways that the Veteran's current paranoid schizophrenia was related to his in-service psychiatric symptoms, first writing that the in-service depressive symptoms were the prodromal stage of the subsequently diagnosed schizophrenia, and second that there was a "link" between schizophrenia and symptoms in service. The psychologist explained the reasons for his conclusion, in particular the Veteran's age at the time of onset of depressive symptoms, his noted stressors, and his consistent report of his experiences over time. The psychologist's opinion is therefore entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). On re-review of the evidence, there is no conflict between this conclusion and the others rendered by the psychologist. The other questions were whether the paranoid schizophrenia was incurred in service or manifested within the one year presumptive period. These are alternative bases for establishing service connection. See 38 C.F.R. § 3.303(b) (with chronic disease shown as such in service, subsequent manifestations of the same chronic disease are service connected); 38 C.F.R. §§ 3.307(a), 3.309(a) (service connection warranted for chronic diseases including schizophrenia that manifest within a year after separation from service). The psychologist's negative answers to these questions were not relevant to his earlier nexus opinion, which was based on a different method of establishing entitlement to service connection as described above and did not conflict with the earlier opinion. The psychologist explained that he could not state that schizophrenia was incurred in service because the evidence did not reflect that he suffered from a psychosis while in service (as opposed to symptoms developing into a psychosis) and that, similarly, he could not find that schizophrenia manifested within the one year presumptive period because the evidence including the Veteran's statements indicated that his symptoms had improved when he left service. As it is possible for a disease not to manifest in service or during the one year presumptive period, but to manifest after service and still be related thereto, the psychologist's multiple answers conflicted neither with each other nor with VA law and regulations, which anticipate precisely the situation described by the psychologist, where a disease manifests years after service but the evidence including symptoms that could have been precursors (prodromal) in service indicate that the disease is related thereto. The only remaining question is whether the VA psychologist stated his opinion of a relationship between schizophrenia and service with sufficient certainty. Initially, the Board notes that, even if flawed because stated uncertainly, an opinion from a psychologist regarding the etiology of a claimant's psychological disorder must be considered as "evidence" of whether the disorder was incurred in service. Hogan v. Peake, 544 F.3d 1295, 1297-98 (Fed. Cir. 2008). Here, however, the psychologist's opinion was not the equivalent of the "may or may not" terminology that the courts have found insufficient to establish entitlement to service connection. Winsett v. West, 11 Vet. App. 420, 424 (1998) (terminology equivalent to "may or may not" is an insufficient basis for an award of service connection). The psychologist initially stated that it was at least as likely as not that the schizophrenia was related to service and that this was a plausible conclusion. This statement is sufficiently definitive to support a finding of entitlement to service connection because it indicates that there is at least a 50 percent probability of the sated relationship. While the psychologist was somewhat less certain when asked for clarification, he continued to maintain that it was a plausible, but "speculative" conclusion. In the context of his remarks, however, the use of the word speculative indicated that the psychologist did not feel he could render a definitive opinion on the question. As pointed out by the representative in the March 2013 brief, "Speculation is innately intertwined in the examiner's line of work. That is why there are graduated levels of certainty. Few things in this life, particularly where VA claims are concerned, are perfectly clear." The Board agrees. The psychologist's statements, taken as a whole, indicate that he believed it was at least as likely as not that the Veteran's paranoid schizophrenia was related to his in-service psychiatric symptoms, even if he used terminology such as "plausible" and "speculative" that was not a model of clarity, something that was understandable in light of the Board's request for clarification of an initial opinion that on review was not internally contradictory. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (stating that although clarity is preferred, it cannot be demanded in every instance or "finality would forever be delayed pending perfection in draftsmanship"). The psychologist's opinion is also supported by the other evidence in the case, including that obtained pursuant to the Board's remands such as that of Dr. Zemin, who indicated in 2000, based on the Veteran's credible statements, that the Veteran had been having delusions of one kind or another for at least 22 or 23 years, i.e., since service. See Coburn v. Nicholson, 19 Vet. App. 427, 432-433 (2006) (reliance on history provided by a veteran only warrants the discounting of a medical opinion in certain circumstances, such as when the opinion is contradicted by other evidence in the record or when the Board rejects the statements of the veteran). Finally, there is no contrary medical opinion in the evidence of record. For the foregoing reasons, the weight of the evidence supports a relationship between the Veteran's paranoid schizophrenia and his in-service psychiatric symptoms. Entitlement to service connection for this disability is therefore warranted. In reaching this decision the Board offers no opinion as to the rating warranted for paranoid schizophrenia, the appellant's competency to receive monetary benefits, or whether any VA compensation paid is subject to Connecticut laws governing an injured victims compensation fund. ORDER Entitlement to service connection for paranoid schizophrenia is granted. ____________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs