Citation Nr: 1318987 Decision Date: 06/11/13 Archive Date: 06/21/13 DOCKET NO. 08-33 832 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include bipolar disorder and paranoid schizophrenia. REPRESENTATION Appellant represented by: Virginia Department of Veterans Services ATTORNEY FOR THE BOARD S. Mishalanie, Counsel INTRODUCTION The Veteran served on active duty from October 11, 1983 to January 9, 1984. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision promulgated by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. Previously, in a May 1997 decision, the Board denied entitlement to service connection for an acquired psychiatric disorder, diagnosed as bipolar disorder. That decision is final. 38 U.S.C.A. § 7104 (West 2002). In December 2007, the Veteran filed claims of entitlement to service connection for paranoid schizophrenia and bipolar disorder. In a July 2008 rating decision, the RO declined to reopen the claim of entitlement to service connection for bipolar disorder and denied entitlement to service connection for schizophrenia. In May 2011, the Board remanded the issues for additional development. In November 2012, the Board reopened the claim of entitlement to service connection for bipolar disorder and remanded the matter for additional development. In addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claim. The Virtual VA file has been reviewed in conjunction with the disposition of the issue on appeal. FINDING OF FACT An acquired psychiatric disorder, including paranoid schizophrenia and bipolar disorder, was not demonstrated in-service or within one year of discharge from active duty, and there is no competent and credible evidence of a nexus between a current psychiatric disorder and service. CONCLUSION OF LAW An acquired psychiatric disorder, to include paranoid schizophrenia and bipolar disorder, was not incurred in or aggravated by service; psychoses may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist The requirements of 38 U.S.C.A. § 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or the completeness of the application. VA notified the Veteran in March 2008 of the information and evidence needed to substantiate and complete the claim, to include notice of what part of that evidence is to be provided by the claimant, and what part VA will attempt to obtain, and how disability ratings and effective dates are determined. VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate the claim, and as warranted by law, affording a VA examination. In this case, the Veteran was afforded a VA examination in July 2012. In November 2012, the Board determined that the VA medical opinion was inadequate and remanded the issue to obtain a supplemental opinion from the examiner. In December 2012, the examiner reviewed the claims file, noted the pertinent medical history, and provided the requested medical opinion with supporting rationale. For these reasons, the Board finds that all questions necessary to render the determination made herein have been answered. The medical examination, along with the supplemental medical opinion, is therefore adequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (defining adequacy with respect to medical examinations and opinions as those providing sufficient detail so that the Board can perform a fully informed evaluation). In sum, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. 38 C.F.R. § 3.159(c). Legal Criteria Service connection is established where a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). 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); Caluza v. Brown, 7 Vet. App. 498 (1995). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). For veterans who served for 90 days or more during a war period or after December 31, 1946, service connection may be presumed for certain chronic diseases, such as a psychosis, if manifest to a compensable degree within one year after discharge from active duty. 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309(a). In the present case, the appellant served exactly 90 days; hence, this presumption applies. Where there is a chronic disease shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). When a condition noted during service is not shown to be chronic, or the fact of chronicity in service is not adequately supported, then a showing of continuity of symptomatology after discharge is required to support the claim. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed. Cir. 2013) (noting that the continuity of symptomatology provisions apply only to the chronic disorders as listed in 38 C.F.R. § 3.309(a)). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). Analysis In this case, the Veteran asserts that his current psychiatric disorder is related to the stress he experienced during his military service. The Veteran's service treatment records are unremarkable for complaints, findings, or diagnoses related to a psychiatric disorder. At his June 1983 enlistment examination, his psychiatric evaluation was normal and he denied depression or excessive worry and nervous trouble of any sort. A separation examination is not of record. The Veteran's military personnel records include a November 1983 General Counseling record, which indicates that he appeared in good physical condition and was ready and willing to start training. Two days later, it was noted that he did not "want to be here." Shortly thereafter, he was brought up on Article 15 charges for willfully disobeying a lawful order from a staff sergeant. A hearing was conducted and he was ordered to forfeit $100 of his pay per month for 2 months and to serve 30 days in a correctional custody facility. A General Counseling record indicates that he refused to do push-ups, showed a lack of motivation in everything he did, and disobeyed a lawful order. In December 1983, he showed disrespect to a noncommissioned officer and was counseled about his poor attitude. Shortly thereafter, he was once again disciplined for disobeying a lawful order. A hearing was conducted and he was ordered to forfeit $250 in pay for one month and a restriction was imposed. His commanding officer recommended that he be discharged immediately, noting that the appellant had a very poor attitude and his potential for advancement did not exist. He was involuntarily discharged in January 1984. Private treatment records from Southwestern Virginia Mental Health Institute reflect that the Veteran, age 19, was involuntarily committed in March 1985 for treatment of disorientation, flight of ideas, poor short and long-term memory, and a history of drug and alcohol abuse. It was noted that he had no previous confinements, and a four-year history of drug and alcohol abuse. It was felt that he was in a state of delirium, most likely due to substance abuse. He was discharged in June 1985 with diagnoses on Axis I of episodic alcohol abuse, continuous cannabis abuse, and schizophreniform disorder. Thereafter, the Veteran was hospitalized numerous times for psychiatric complaints. He was hospitalized from January to March 1986 for treatment of psychoses. The final diagnoses were bipolar disorder, characterized as manic with psychotic features, and episodic cannabis abuse. He was involuntarily committed from October to December 1986 for delusional and disorganized thinking; the final diagnoses were schizophrenic disorder, characterized as chronic paranoid type, and continuous alcohol abuse. An August 1987 private treatment record from Mount Rogers Mental Health Center reflects a diagnosis of bipolar disorder, characterized as manic. In February 1991, the Veteran reported that he wanted back into the military so he could get benefits. An October 1991 private treatment record from Mental Health Services of Roanoke Valley reflects that the Veteran reported that he lasted about eight days in the military before decompensating and requiring hospitalization. He said he was given a training discharge and was hospitalized at age 18 at Southwestern Virginia Mental Health Institute. In November 1991, a history of treatment for schizophrenia beginning in 1986 or 1987 was noted. He was diagnosed with a bipolar disorder, and rule out schizophrenia. A history of cannabis abuse was also noted. Private treatment record from Twin Brook Regional Hospital reflect that the Veteran was diagnosed with schizo-affective disorder in October 1994. A note was made to rule out schizophrenia and bipolar disorder. The Veteran was hospitalized from April to June 1999. It was noted that he was first treated around age 19 shortly after he had been in the Army; the diagnoses was schizophrenia, characterized and episodic and paranoid type. The Veteran's Social Security Administration records reflect that he was determined disabled from July 1987 with a primary diagnosis of "affective disorders" and a secondary diagnosis of "substance addiction disorders." In January 1995, disability benefits continued with a primary diagnosis of schizophrenia and a secondary diagnosis of substance abuse disorder. An August 1996 treatment record from Catawba Hospital notes that the Veteran was not fully reliable due to some grandiosity and paranoia, but that he appeared oriented and was able to give some basic information. The report of a July 2012 VA examination reflects the Veteran's history of paranoid delusions and auditory and visual hallucinations. The examiner noted that treatment records also showed thought disorder and idiosyncratic use of language. It was noted that the Veteran had been diagnosed with bipolar disorder in the past, but did not exhibit any of those symptoms at the time of the examination. The examiner interviewed the Veteran and reviewed his claims file. The appellant reported that he did not believe he had signs of symptoms of bipolar disorder or schizophrenia while in basic training, but said that it was very stressful. The appellant stated that he believed it was a chemical imbalance or blood disorder, and did not know if the military was involved or not. The diagnosis was chronic schizophrenia, characterized as paranoid type. The examiner opined that it was impossible, with any degree of certainty, to ascertain whether the Veteran had an acquired psychiatric disorder due to service. The examiner indicated that it was impossible to determine the extent to which genetic versus environmental (i.e., military) factors contributed to the Veteran's difficulties without resorting to mere speculation. Furthermore, the examiner stated that it was impossible to pinpoint when the Veteran may have started exhibiting prodromal signs and symptoms of schizophrenia, if he ever did. The examiner noted that it was conceivable that the events that led to his entry level separation may have been prodromal signs and symptoms of schizophrenia, but that it was equally conceivable that his difficulties in basic training reflected longstanding premorbid personality traits. The examiner noted that there was no suggestion that he exhibited overt psychotic symptoms or unusual/bizarre behaviors at the time. In November 2012, the Board remanded the issue to obtain a supplemental opinion from the July 2012 VA examiner. Specifically, the examiner was instructed that a veteran is presumed to be in sound condition at enlistment except for defects, infirmities or disorders noted when examined or where clear and unmistakable evidence established that an injury or disease existed prior to service and was note aggravated by service. 38 U.S.C.A. § 1132 (2002). Since the Veteran's entrance examination was normal, he was presumed to have been in sound psychiatric condition. In December 2012, the VA examiner provided a supplemental opinion. The examiner opined that it was less likely than not that the claimed condition (paranoid schizophrenia/bipolar disorder) was incurred in or caused by service. The examiner noted that there was no evidence of referral for psychiatric evaluation or treatment during service and that the Veteran's behaviors, as described in the personnel records by his superiors, "in no way clearly and unmistakably" reflected prodromal signs and symptoms of any acquired psychiatric disorder. It was also noted that prodromal signs and symptoms of schizophrenia are often very difficult to definitively identify and diagnose. The examiner did note that there was "clear and unmistakable" medical evidence that the Veteran was abusing alcohol, marijuana, and Benzedrine inhalers prior to his first psychiatric hospitalization for psychosis, some 14 months after his military discharge. It was also noted that the delirium most likely was due to substance abuse. The examiner noted that while substance abuse does not directly cause schizophrenia, there was ample scientific evidence consistent with the view that certain drugs such as cannabis can trigger psychosis and the risk is increased in individuals vulnerable to mental health problems. At the outset, the Veteran is competent to report that which he personally experiences, including the stress he experienced during basic training and his subsequent psychiatric problems. See 38 C.F.R. § 3.159(a)(2); Layno v. Brown, 6 Vet. App. 465, 470 (1994). To the extent his statements are consistent with the underlying record, the Board finds him credible. Here, the evidence reflects that the Veteran had disciplinary problems during service and was hospitalized for psychotic symptoms thirteen months after he was discharged. To the extent the Veteran reported that he was hospitalized for psychiatric problems during service, however, the underlying record does not reflect this to be the case and he has been inconsistent in these contentions. Hence, the Board finds such statements lack credibility and that the military service treatment and personnel records are much more probative. The preponderance of the evidence reflects that the Veteran's psychiatric disorder was not demonstrated in-service, and it was not compensably disabling within one year of discharge from active duty. Rather, the first indication of a psychiatric disorder occurred in March 1985 when he was involuntarily committed for psychotic symptoms and substance abuse problems. Therefore, the only remaining question is whether there is a nexus between the Veteran's service and any current psychiatric disorder. See 38 C.F.R. § 3.303(d). In this case, the most probative and competent evidence preponderates against finding a nexus between the Veteran's current psychiatric disorder and service. In this regard, the Board finds the July 2012 VA examiner's opinion that his psychiatric disorder was not incurred in or caused by military service highly probative. As the VA examiner explained the reasons for his conclusion, which was based on an in-depth interview and mental status evaluation, the Veteran's assertions, and review of the claims file, this opinion is adequate for the adjudication of this claim and is 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). Although the examiner's usage of the "clear and unmistakable" language was unnecessary and arguably confusing, the Board finds this immaterial in light of the overall definite and unequivocal conclusion that it was the Veteran's psychiatric disorder was not incurred in or caused by service. The Board considered the Veteran's lay contentions that his current psychiatric disorder is related to service. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), as to the specific issue in this case, the etiology of his psychiatric disorder, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer)." The question of etiology in this case goes beyond a simple and immediately observable cause-and-effect relationship. Even assuming the Veteran's lay assertions regarding etiology were competent, the Board finds the VA examiner's opinion discussed in detail above is more probative. For the foregoing reasons, the Board finds that the preponderance of the evidence is against the claim of entitlement to service connection for an acquired psychiatric disorder. The benefit of the doubt doctrine is not for application, and the claim is denied. See 38 C.F.R. § 3.102. ORDER Entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia and bipolar disorder, is denied. ____________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs