Citation Nr: 1417346 Decision Date: 04/17/14 Archive Date: 05/02/14 DOCKET NO. 10-39 844 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUE Entitlement to service connection for acquired psychiatric disability. ATTORNEY FOR THE BOARD J. Chapman, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1975 to April 1979. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2009 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In February 2013, this matter was reopened and remanded for additional development. FINDING OF FACT A psychosis, specifically borderline schizophrenia, was manifested within one year of the Veteran's discharge from active duty service. CONCLUSION OF LAW A psychosis, currently diagnosed as schizoaffective disorder, bipolar type, is presumed to have been incurred in the Veteran's active duty service. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.384 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Because the benefit sought is being granted discussion of the impact of the Veterans Claims Assistance Act of 2000 (VCAA) on this matter is not necessary. Legal Criteria and Analysis Service connection may be granted for disability due to disease or injury incurred in or aggravated by military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Service connection may also 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). To substantiate a claim of service connection, there must be evidence of a current claimed disability; evidence of incurrence or aggravation of a disease or injury in service; and evidence of a nexus between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1153, 1166-1167 (Fed. Cir. 2004). 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). Additionally, certain chronic disabilities, such as psychoses, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Likewise, certain chronic diseases, including psychoses, may be service connected if shown to be of a chronic nature in service, or if not chronic, then seen in service with continuity of symptomatology demonstrated after discharge. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Pursuant to 38 C.F.R. § 3.384, the term "psychosis" means any of the following disorders listed in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, of the American Psychiatric Association (DSM-IV- TR): (a) Brief Psychotic Disorder; (b) Delusional Disorder; (c) Psychotic Disorder Due to General Medical Condition; (d) Psychotic Disorder Not Otherwise Specified; (e) Schizoaffective Disorder; (f) Schizophrenia; (g) Schizophreniform Disorder; (h) Shared Psychotic Disorder; and (i) Substance-Induced Psychotic Disorder. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board notes that it has reviewed all of the evidence in the Veteran's claims file, in the Veterans Benefits Management System, and in "Virtual VA," with an emphasis on the evidence relevant to the matter on appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. The Veteran contends that he developed a psychiatric disability due to his time in service. The STRs show no evidence of psychiatric problems. Both the Veteran's reports of medical history and the examinations provided to him at entrance to service and separation from service report that he was in good health, and was not experiencing nervous trouble, depression, excessive worry, or frequent trouble sleeping, among other symptoms. In May 1979, one month after discharge from service, the Veteran was seen for a psychological assessment. He complained of having fears of people and stated that he has a lot of tension which is difficult to control. The impression was borderline schizophrenia. A February 1996 VA treatment record notes Axis I diagnoses to include depressive disorder not otherwise specified and alcohol and cocaine dependence. He was treated at a VA facility for one month before discharge where he was instructed to attend outpatient therapy sessions. The Veteran continued seeking treatment for his psychiatric symptoms and a psychiatry note from August 2004 noted Axis I diagnoses of cocaine dependence continuous, alcohol abuse, depression, bipolar disorder, and nicotine dependence. A January 2005 private psychiatric evaluation noted an Axis I diagnosis of schizoaffective disorder, bipolar type. In March 2009, a clinic outpatient record noted an Axis I diagnosis of schizoaffective disorder bipolar type MRE manic. In April 2009, the reported that his stress began when he was in service, escalating after his release, and continuing until he became disabled and could no longer work. He further stated that being discharged from service increased his stress level and that he then became mentally sick. He said that at the time he did not realize that he was actually sick so he did not seek medical treatment, until his symptoms became unbearable at which time he went to the hospital in 1981 or 1982. He stated that he became completely disabled in 2005 or 2006. The Veteran also submitted a mental disorder questionnaire which showed diagnoses of schizoaffective disorder and anxiety disorder. In addition, the Veteran also submitted a notice of disagreement in March 2010 and a VA Form 9 in September 2010. In both, the Veteran stated that his symptoms began in service, but that he did not report them while on active duty for fear of being discharged with less than honorable conditions. A Social Security Administration (SSA) disability determination indicates that the Veteran has been considered disabled since May 1, 2004 due to schizophrenic, paranoid, and other functional psychotic disorders, and secondarily due to affective/mood disorders. On March 2013 VA mental disorders examination, the examiner diagnosed schizoaffective disorder, bipolar type and stated that the etiology is unknown. The examiner noted that the Veteran was discharged from service in 1979 and that his discharge examination did not indicate any mental health diagnoses. Further, the examiner noted that the Veteran was not "properly" diagnosed with schizoaffective disorder until 2004 and that his earliest psychiatric treatment records were in 1996. The examiner concluded that "based on the available evidence, it is difficult for this examiner to substantiate that this Veteran's mental disorder dates back to his military service." In light of the objective medical findings of a psychosis, specifically schizophrenia diagnosed in May 1979, within a year of the Veteran's separation from service in April 1979, and the objective medical evidence that he continues to be treated for a psychosis, currently diagnosed as schizoaffective disorder, the Board has determined that service connection is warranted for his psychotic disability. The Board acknowledges that the evidence is not overwhelmingly persuasive in favor of the Veteran's claim, however, affording the Veteran the benefit of the doubt, the Board finds that service connection is warranted. ORDER Entitlement to service connection for a psychosis, currently diagnosed as schizoaffective disorder, is warranted. The appeal is granted. ____________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs