Citation Nr: 1604659 Decision Date: 02/08/16 Archive Date: 02/18/16 DOCKET NO. 08-16 303A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for an acquired psychiatric disorder other than posttraumatic stress disorder (PTSD), to include schizophrenia and depression, and to include as secondary to service-connected hepatitis. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Gallagher, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1973 to January 1976. This appeal is before the Board of Veterans' Appeals (Board) from a June 2004 rating decision of the abovementioned Department of Veterans Affairs (VA) Regional Office (RO). The Veteran originally requested a local hearing before a Veterans Law Judge in connection with the issues on appeal. In July 2009, he withdrew his request. In a February 2013 statement, the Veteran requested a Central Office hearing. The hearing was scheduled for April 2014. An April 2014 memorandum from the Veteran's representative explained that the Veteran's hearing was cancelled and no further action was needed. The representative requested that the Board proceed with the final disposition on the case. Thus, the Board found that the Veteran's request for a hearing is withdrawn. 38 C.F.R. § 20.704(e). The issue was first before the Board in January 2012, at which point the Board reopened the Veteran's claim and remanded it for further development. The Board remanded the claim a second time in July 2014, finding that the opinion of the VA examiner was inadequate and instructing that a new opinion should be obtained. A new opinion was obtained in August 2014. The Board is therefore satisfied that the instructions in its remands of January 2012 and July 2014 have been complied with to the extent necessary to decide this appeal. See Stegall v. West, 11 Vet. App. 268 (1998). FINDING OF FACT Any acquired psychiatric disorder is neither related to service nor related to service-connected heptatitis, and psychosis did not manifest within one year of separation. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disorder other than PTSD, to include schizophrenia and depression, and to include as secondary to service-connected hepatitis, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). In the present case, required notice was provided by letters dated March 2004 and October 2006. See Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). As to VA's duty to assist, all necessary development has been accomplished. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Veteran's service treatment records, VA medical records, and relevant Social Security Administration records have been obtained, as have relevant private medical records identified by the Veteran. The Veteran was provided VA examinations of his mental health in February 2012 and August 2014. The Board finds that these examinations and their associated reports, taken together, were adequate. Along with the other evidence of record, they provided sufficient information to decide the appeal and a sound basis for a decision on the Veteran's claim. The examination reports were based on examination of the Veteran by examiners with appropriate expertise who thoroughly reviewed the claims file. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, VA has satisfied its duties to notify and assist, additional development efforts would serve no useful purpose, and there is no prejudice to the Veteran in adjudicating this appeal. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Merits The Veteran claims service connection for an acquired psychiatric disorder. When his appeal was last before the Board in July 2014, service connection for PTSD was denied. Therefore, only acquired psychiatric disorders other than PTSD are subject to consideration in this decision. Nevertheless, because symptoms that had been attributed to PTSD may be relevant to another psychiatric disorder, evidence of PTSD is occasionally discussed below. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires: (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); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). For certain chronic diseases, such as psychosis, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). When a chronic disease is not shown to have manifested to a compensable degree within one year after service, under 38 C.F.R. § 3.303(b) for the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support a claim for such diseases; however, such continuity of symptomatology may only support a claim for those chronic diseases listed under 38 C.F.R. § 3.309(a). 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). One factor for consideration in analyzing psychiatric disorders is the Global Assessment Functioning (GAF) score, which is based on a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed.), p. 32.). Scores ranging from 61-70 indicate some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally good functionality with meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). A GAF score ranging from 31 to 40 indicates that there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). A score ranging from 21 to 30 represents a person who demonstrates behavior that is considerably influenced by delusions or hallucinations or has serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation), or has the inability to function in most areas (e.g., stays in bed all day; no job, home, or friends). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Service treatment records do not reflect any symptoms of or treatment for any mental health conditions. An October 1975 treatment record for abdominal pain notes that the Veteran was a known opiate user who continues to deny use despite multiple positive tests. A November 1975 record notes that all symptoms had resolved, but the Veteran's urine still tested positive for opiates on a routine basis. Records indicate that in December 1975 the Veteran admitted heroin abuse and applied for rehabilitation, but an evaluation found him poorly motivated for stopping abuse. He was diagnosed as a psychologically dependent heroin abuser. Military personnel records reflect that in November 1975 the Veteran refused to sign a statement informing him that he tested positive for drugs 17 times. Records show 17 positive tests between August and November 1975. There are a number of nonjudicial punishments noted, including one in December 1975 holding that the Veteran was to be forfeit $50 pay for one month and to be confined on bread on water for three days for failure to obey a lawful order and disrespect toward a petty officer. In January 1976, the Veteran signed a statement indicating that he refused to participate in drug rehabilitation and instead wished to be separated from service. The Veteran underwent a general VA examination in May 1976. His mental health at that time was noted as normal, with no psychiatric symptoms or diagnoses. VA treatment records reflect that in June 1981 the Veteran reported depression and was referred for psychiatric treatment. He was noted to have no previous psychiatric history. He reported constant worries about his hepatitis, and the perceived lack of medical care he has received. Diagnosis was severe anxiety. He sought psychiatric treatment again in August 1982 and was diagnosed with anxiety. The Veteran was again referred for psychiatric treatment in November 1982 after reporting depression. At his referral, he reported that when he is unable to get what he wants, he has ideas of robbing a bank or holding hostages in order to be heard. He was diagnosed with anxiety, rule out personality disorder. In May 1983 the Veteran reported experiencing flashbacks of negative service memories and told his physician that he wanted to obtain monetary compensation for the suffering he endured. The Veteran underwent a general VA examination in January 1984, at which he reported that he was mentally unable to work. He stated that he was tired of being told that he was alright, stating that he was not alright but already dead. He reported that in service, he was put in prison for three days rather than being treated for his hepatitis. He stated that he has been full of anger since this happened. He reported using drugs, specifically PCP, to overcome his intense anger. He was diagnosed with adjustment disorder with anxious mood. Social Security Administration (SSA) records indicate that in January 1984 the Veteran underwent an examination related to disability benefits due to alcoholism and heroin/PCP addiction and abuse. Medical evidence indicated that the Veteran had a history of alcohol, heroin, and PCP abuse. The examiner found that he appeared preoccupied with the thought of dying or being dead. He was interested in drug rehabilitation. Private psychiatric records show that in September 1984 the Veteran was hospitalized for mental health treatment. He reported that, while in service, when he felt ill, instead of receiving treatment he was confined for three days with only bread and water for failure to report to work. He was then given an honorable discharge. He reported being accused of being a drug addict while in service and associated that charge with stress in his family and his parents' separation. He reported intrusive thoughts about being hurt or imprisoned by VA. He reported voices urging him to take a gun to VA to get the compensation he felt he deserved. He took the gun to VA, but gave it to the security guard and submitted to psychological evaluation. He reported depression and thoughts of hurting himself. He was admitted with a diagnosis of atypical psychosis, also documented as psychotic depression versus acute paranoid psychosis. After several days of treatment, he was discharged with a diagnosis of paranoia. SSA records indicate that the Veteran underwent another psychiatric examination in August 1985. He reported that he was dying of hepatitis, had a tumor in his brain, and had bleeding from his testicles because the military had wronged him. He stated that he wanted to kill himself or someone at VA. He stated that he was dead. He denied being hospitalized for mental health reasons or ever having used drugs. He reported hearing voices telling him to kill himself or someone at VA. He was diagnosed with paranoid schizophrenic disorder. A June 1987 SSA record indicates that the Veteran's father was contacted. He reported that the Veteran remained in his room, did not relate to family members or have friends. He did not do chores or leave his room. In July 1987, he underwent another psychological evaluation. He again mentioned dying of hepatitis in service and being confined instead of treated. His examiner noted that he gave irrelevant babbling answers throughout the interview. He said he does not sleep, but stays on the watch for intruders. The examiner concluded that the Veteran was in very poor contact with the situation, and if diagnosis were required it would be schizophrenic with high degree of persecution thinking bordering on paranoid possibilities. The Veteran underwent a general VA examination in May 1988. He reported restlessness, tiredness, symptoms of paranoia, nervousness, anxiety, emotional distress, unawareness of surroundings, and crying. He acted irrationally at his psychiatric examination. The Veteran's brother-in-law was contacted and reported that the Veteran has periods of depression, secluding himself in his room for three or four days at a time. The Veteran reported hearing voices. He was suspicious and sensitive to noises. He was diagnosed with disorganized schizophrenia. The Veteran underwent another general VA examination in August 1990. His sister accompanied him to the examination and reported bizarre behavior when he gets agitated. The Veteran became agitated during the examination, jumping and shouting that VA did not recognize his hepatitis. He exhibited hallucinations, delusions, and paranoia. He was diagnosed with chronic disorganized schizophrenia in exacerbation. In September 1990, the Veteran's sister, who is a nurse, examined the Veteran. She stated that his mental capacity is unstable and he is belligerent at times. She noted that he exhibits occasional loss of memory. She stated he stays in his room and talks to himself, and when he is accompanied out he walks in circles and jumps up and down. SSA records indicate that in March 1992 the Veteran underwent another psychological examination. The examiner noted that throughout the examination he was often out of touch with reality and often rambled incoherently. Bizarre thinking was evident throughout his conversation. The Veteran's wife reported that he had not had problems with drugs or alcohol. Eight times during the interview he asked what job he was applying for. The examiner diagnosed him with chronic undifferentiated schizophrenia with acute exacerbation. In April 1995, while undergoing a VA examination for a skin condition, the Veteran reported depression and suicidal thoughts. The examiner diagnosed history of schizophrenia with suicidal ideations and advised the Veteran to be admitted for care. In a May 1995 statement to VA, the Veteran reported suffering from a short mind span. SSA records indicate that in December 1995 the Veteran underwent another psychological examination. The examiner concluded that the Veteran was evidently trying to feign a serious mental disorder. He often responded inappropriately to questions, in what was deemed an apparent attempt to speak in a rambling and incoherent manner. The examiner stated he was self-dramatizing, engaging in an assortment of behaviors which were apparently designed to convey the impression that he was markedly impaired. The examiner gave a detailed description of the Veteran's nonsensical answers to his questions. The examiner noted that it was clear that at times the Veteran had to invest thought before he could come up with a suitable inappropriate response. The examiner concluded that the Veteran's approach to the evaluation did not allow for a valid appraisal of his functioning in the areas assessed, and that he was quite manipulative, raising at least the question of a possible substance abuse pattern. Diagnosis was therefore deferred. At an April 1998 VA examination for his hepatitis, the Veteran reported that he had been severely depressed for more than 15 years and had been medicated as such. He was diagnosed with severe mental depression. In a July 1998 statement, the Veteran's wife reported that he had suffered from mental depression since 1976 when he first found out he had hepatitis. In an October 1998 letter, the Veteran's private treating psychiatrist opined that the Veteran's underlying schizophrenia was aggravated and exacerbated by the hepatitis he contracted in service, causing the signs and symptoms to emerge. In February 1999, the Veteran submitted a treatise excerpt explaining that liver dysfunction can cause mental disturbances. The Veteran underwent a VA examination in March 2000. The examiner noted the tendency to give a tangential response to questions. He was diagnosed with disorganized schizophrenia. The examiner opined that schizophrenia was unrelated to hepatitis. This opinion was based on the rationale that hepatitis was not serious and occurred in 1975, but there was no evidence of a psychiatric break until 1995. Furthermore, the examiner explained that the absence of liver encephalopathy also is an indication of no relationship between schizophrenia and hepatitis, despite the October 1998 opinion provided by the Veteran's private psychiatrist. In a September 2001 statement, the Veteran disputed the findings of the VA examiner, stating that he had been diagnosed in the early 1980s, not in 1995 as stated by the examiner. In an October 2003 statement, the Veteran's wife reported that the Veteran had first been diagnosed with schizophrenia in the late 1970s while experiencing complications from hepatitis. VA treatment records reflect that the Veteran was treated in February 2005 for reports of depression. The Veteran reported difficulty dealing with his confinement while in service, stating that he was treated unfairly and wrongfully discharged. He reported that he had never had a problem with alcohol or drugs. He was given a provisional diagnosis of depressive disorder. The Veteran has provided an April 2005 letter from his private psychologist reporting that the Veteran has difficulty explaining himself clearly due to residual symptoms of schizophrenia. The psychologist stated that the Veteran reported becoming depressed when diagnosed with hepatitis in February 1976 and being diagnosed with schizophrenia by a VA psychiatrist in 1977 or 1978. Private treatment records reflect that the Veteran was treated for depression, residual psychotic symptoms, and difficulty pursuing his disability claim from July 2004 to May 2005. He was diagnosed with residual schizophrenia. His file was closed in September 2005 due to lack of contact. In January 2007, he sought to resume treatment for schizophrenia. He reported that he suffered from PTSD triggered by his dealings with VA. His diagnosis of residual schizophrenia was continued. VA treatment records reflect that the Veteran was treated for a history of depression in October and November of 2005. He reported depression related to hepatitis that caused his divorce. His psychologist noted that his reported ability to maintain two to three jobs at one time raised questions about the actual impact of his depression on his ability to function. He was further treated in January 2006, when his psychiatrist diagnosed depression, rule out psychosis. The Veteran focused on his in-service confinement and refused to discuss other issues. The psychiatrist noted that the Veteran might suffer from impaired reality contact, or purposely focused on his military suffering only during that interview. He was assigned a GAF score of 60. At a July 2007 informal hearing conference, the Veteran reported that in service he repeatedly reported to sick bay prior to his diagnosis of hepatitis. They did not know what was wrong with him and continued to return him to duty. One day he felt too ill to report for duty, and was sentenced to three days confinement with only bread and water. He attributes his psychological problems to this incident. In a July 2008 letter, the Veteran's private psychologist stated that the Veteran's symptoms support overlapping diagnoses of schizophrenia and PTSD. The psychologist further stated that given either diagnosis, his current symptoms are logically consistent with his claimed in-service confinement trauma. VA treatment records show that in November 2008 the Veteran reported feeling depressed. He was adamant that VA should diagnose him with PTSD. He was diagnosed with depression, schizophrenia per history, and rule out PTSD. The Veteran received therapy in March 2009. His social worker noted diagnoses of PTSD and disorganized schizophrenia. The social worker further noted a strong sense of entitlement, and that the Veteran seemingly has a history of at least misrepresenting the details of situations concerning himself. Later in the month, the Veteran phoned the VA suicide hotline reporting thoughts of hurting a VA employee who had denied him benefits. In April 2009, his psychiatrist noted diagnoses of PTSD and schizophrenia by history only. He was assigned a GAF score of 50. Later in the month he was diagnosed with PTSD and depression, with a GAF score of 49. At a subsequent appointment he reported auditory and visual hallucinations. In May 2009, however, his social worker diagnosed him only with depression and assigned a GAF score of 64. He continued treatment for depression in June 2009, when his social worker noted that he did not present PTSD symptoms. His depression treatment continued in July 2009, when he reported hearing voices and paranoia. In an addendum to the treatment record, his social worker stated that his diagnosis is schizophrenia, not depression. Later that month, he reported more depression and anxiety. His auditory hallucinations were at a minimum at that time, but paranoia was about the same. In August 2009, the Veteran's social worker noted that the Veteran was a limited historian in terms of how the military treated him, and that despite his complaints he remained gainfully employed as a prison guard. In September 2009, he reported depression and anxiety in regard to his financial situation. In November 2009 he was diagnosed with undifferentiated schizophrenia by a clinical nurse specialist and with anxiety and depressive disorder by his social worker. In January 2010 the Veteran reported depressed mood and increased anxiety. He was worried about lack of finances and an inability to pay his bills. He was diagnosed with PTSD and depressive disorder and assigned a GAF score of 58. In April 2010, the Veteran's social worker noted that he allegedly had PTSD symptoms including thought intrusions, flashbacks, and dissociative thoughts caused by experiences in Vietnam. He presented no PTSD symptoms at treatment. VA treatment records further reflect that in September 2010 the Veteran called the VA suicide hotline reporting suicidal ideation. At follow-up treatment, he reported hearing voices telling him to commit suicide. He again blamed VA and military for not attempting to help him or listen to him when he was sick. Later in September 2010, he was admitted for inpatient care for anxiety, PTSD, depression, homelessness, and differentiated schizophrenia. At an October 2010 psychiatry consultation, the Veteran's psychiatrist noted that he was a very vague historian and had to be reminded about past events that were recorded in his records. There were no clear psychotic symptoms evident during this treatment. He was diagnosed with paranoid schizophrenia, rule out PTSD. His psychiatrist noted that PTSD had been assigned in the past, but at present there were insufficient criteria for a diagnosis. In November 2010, the Veteran's psychiatrist noted that he perseverates on the theme of having been treated unjustly by the military and VA. There were no clear psychotic symptoms evident at this time, in December 2010, or in January 2011. VA treatment records show that in January 2011, the Veteran underwent neuropsychological testing. Based on the test results, the psychologist diagnosed probable malingering neurocognitive dysfunction in the Veteran, as tests indicated he was exaggerating the extent of cognitive difficulty based upon self-report and the extent of psychiatric disturbance, particularly depression and anxiety. The psychologist explained that this is not to say that the Veteran does not have legitimate symptoms, but rather that his self-report or cognitive presentation cannot be trusted. Specifically, the psychologist noted that the Veteran's test scores in certain areas were non-credibly poor, and that patients with dementia as severe as the Veteran was attempting to portray would, if anything, underreport their symptoms due to lack of awareness. Several days after this testing, the Veteran discharged himself from inpatient care. The Veteran underwent a VA examination for PTSD in February 2012. When confronted with service treatment records reporting him as a "self-admitted heroin user," the Veteran adamantly denied ever using heroin. He reported auditory hallucinations and stated that he was part of the witness protection program in 1999 after he noticed two men in long coats following him. The examiner concluded that the Veteran did not have PTSD but that his exhibited symptoms were most consistent with paranoid schizophrenia. The examiner further opined that there was no causality between military service and the onset of psychosis in 1984, due to the lag in time. The examiner noted that malingering must be considered, as it had been by other examiners, but the examiner was less confident in making that diagnosis. The Veteran's perseveration and insistence on discussing hepatitis was so intense that the examiner considered it part of his psychosis. VA treatment records reflect that in February 2012 the Veteran reported feeling overwhelmed with depression and re-experiencing Vietnam stressors via intrusive thoughts. He also said he was distressed because of finances. His diagnoses at this time included depression and PTSD. In March 2012, he reported hearing voices and formerly being in a witness protection program. He continued airing his frustration with VA for not being service-connected, stating that he was being persecuted for protesting his mistreatment. His psychiatrist noted prominent symptoms of paranoia and rumination. He again expressed fear, paranoia, and disappointment with VA in April 2012. In May 2012, his psychiatrist noted that he reported some vague and somewhat contradictory statements about being homicidal and suicidal. In a July 2012 psychiatry medication management note, the Veteran's psychiatrist noted that he stated he was compliant with medication. Confronted with the fact that he had not filled his prescriptions, he admitted that he was not compliant due to confusion. His psychiatrist noted that he uses this excuse on a regular basis, and that his noncompliance was a chronic concern. The psychiatrist stated that he was unsure of the Veteran's motivation is when it comes to being seen in mental health, and he did not know how sincere the Veteran is regarding his treatment. The Veteran's primary focus was his VA claim, not medication management. In January 2013, another VA examiner provided a follow-up opinion based on record evidence only. The examiner opined that it was less likely than not that the Veteran's paranoid schizophrenia was secondary to hepatitis. This opinion was based on the rationale that the Veteran did not develop schizophrenia until 10 years after developing hepatitis, and that there is no current medical evidence linking hepatitis, an infectious disease, with schizophrenia, a psychosocial disease. VA treatment records reflect that in January 2013 the Veteran did not present symptoms of psychosis. He again expressed fear, paranoia, and disappointment at his VA examination, but did not refer to hearing voices or being in the witness protection program. In a February 2013 statement, the Veteran noted that he had been diagnosed with schizophrenia multiple times, that he was diagnosed with hepatitis in 1975 and not 1974 as stated by the examiner, and that he was not a drug addict as alleged by VA. VA treatment records indicate that in May 2013, the Veteran again did not present symptoms of psychosis. He reported that he had isolated himself from many people. He presented the same in June 2013. He called his social worker in August 2013 and reported that he was being evicted and was having suicidal/homicidal thoughts but denied a plan or intent. At a December 2013 mental health initial evaluation, the Veteran reported his history of schizophrenia, but said he was not taking medication because he did not like the side effects. His social worker noted that he does not present as someone who has schizophrenia, but rather seemed depressed and at times anxious. He was diagnosed with major depression. In January 2014 the Veteran underwent a psychosocial assessment. He was diagnosed with PTSD, anxiety, and paranoia. Later in the month he declined mental health services. He was treated for depression in March 2014. A May 2014 psychiatry note indicates that the Veteran spontaneously began to describe what he perceives as being his mistreatment in service. Diagnosis at that time was deferred. VA treatment records further show that the Veteran visited the emergency room in July 2014 claiming that he had a plan to go to VA with dynamite or a bomb and kill himself and others. He was angry at being portrayed as a drug addict, which he said was untrue. He was admitted and his physician assessed symptoms suggestive of ongoing psychosis. He continued to perseverate on his service history. He was diagnosed with unspecified psychosis, rule out malingering. He attempted to be discharged but was denied. He explained that he felt better after talking about his frustrations. He ceased displaying symptoms. Psychological testing showed primary complaints consistent with symptoms of schizophrenia, paranoia, and somatic concerns. However, due to overall symptom overendorsement and inconsistent symptom report, the validity of these elevations was found to be questionable. The Veteran did not appear to be accurately articulating his current cognitive dysfunction. Subsequently, when the Veteran was discharged, he denied ever having threatened VA with a bomb or dynamite. In an August 2014 statement, the Veteran described his claimed in-service incident. He stated that in 1975 he was sick from hepatitis, becoming so sick that he almost died. He was unable to work. Because he did not work, he was confined and limited to bread and water for three days. The Veteran underwent a VA examination in August 2014. In a detailed, lengthy opinion the examiner determined that the Veteran presents a complicated clinical picture. The examiner noted that while some records endorse sporadic reports of paranoia, persecutory thoughts, and auditory and visual hallucinations, numerous records document long periods where he is symptom free and gainfully employed while not medicated. The examiner found a symptom pattern inconsistent with schizophrenia and psychotic disorders of organic basis, but rather consistent with the pseudo-psychotic symptoms which can be a part of a delusional disorder or a characterological disorder. Records show a long history of inconsistent statements, ambivalence about treatment, flat denial of statements and behaviors otherwise well documented, and noncompliance with treatment. Based on this history, the examiner diagnosed the Veteran with unspecified psychosis. The examiner further opined that there is no indication that any of his psychiatric symptoms were in any way caused by service or hepatitis. This opinion was based on the rationale that hepatitis is in remission therefore unlikely to be a medical cause of any current psychiatric diagnosis, and that schizophrenia and psychotic disorders are not a long-term consequent of either hepatitis or confinement. Furthermore, the examiner noted that depression was unlikely to be caused by service or hepatitis because of the numerous intervening stressors which are more likely causes, including limited finances, history of homelessness, a recent stroke, marital separation, diabetes, back problems, and limited social support. The only evidence that depression is related to the Veteran's service is his own statements, which the examiner considered unreliable due to his history of malingering, blatant denial of documented behavior, inconsistent statements, and well-documented exaggeration of symptoms. Due to the clear presence of malingering, the examiner found it impossible to diagnose a depressive disorder without resorting to speculation. VA treatment records indicate that in February 2015 the Veteran sought treatment for depression. His psychiatrist noted that aside from insomnia, the Veteran had zero to minimal neurovegetative symptoms of depression. His psychiatrist further noted that results of multiple psychological tests in the past do not support a psychotic disorder, nor does his background history. He was diagnosed with insomnia disorder. At a follow-up appointment in June 2015, he reported occasional suicidal ideation with no plan or intent. As an initial matter, the Board notes that in his September 2015 appellate brief, the Veteran's representative argues that remand is necessary because the August 2014 VA examination was based on medical history and not an in-person examination as instructed in the July 2014 remand. The August 2014 VA examination report, however, makes clear that information in the report was in fact based on an in-person interview. Specifically, Section II, Part 3 states that the Veteran was 15 minutes late for the appointment before describing behavioral observations, and Section II, Part 6, Note 2 states that unless otherwise stated, all information in the report is based on the Veteran's statements during the examination. Remand is therefore not necessary for an additional examination. The Board finds that the evidence weighs against a finding that any acquired psychiatric disorder is related to hepatitis or service. The August 2014 VA examiner's opinion is highly probative. It presents a detailed, persuasive explanation as to why the Veteran's statements should not be considered credible. The examiner used the Veteran's extensive medical treatment records to show that his statements have been inconsistent, as has his clinical presentation. Multiple treatment providers have considered his symptoms to be considerably exaggerated beyond reasonable levels. Thus, there is considerable evidence in the record that the Veteran's statements cannot be viewed credibly. Furthermore, the Board need not determine whether the Veteran's fixation on his reported in-service incident is a legitimate symptom of a psychiatric disorder. Even if the Veteran's symptoms were not exaggerated, an irrational fixation on an otherwise inconsequential in-service incident years after the fact cannot be a basis for service connection, particularly when the facts of that incident are exaggerated and misrepresented as a result of the fixation. Put another way, the Veteran's statements that he was treated unfairly in service are not corroborated by his documented service records, and as already discussed his statements are not credible on their own. Thus the Board finds no credible evidence that the in-service incident occurred as the Veteran reports it, and an incident that did not occur cannot have caused any disability. As to secondary service connection, there is likewise no credible evidence that the Veteran's condition was medically caused by his hepatitis, which in any event appears to be asymptomatic. Finally, the Board notes that the Veteran's first documented diagnosis of psychotic symptoms was well more than one year after separation from service. For these reasons, the Board finds that the evidence weighs against a finding that any acquired psychiatric disorder is related to hepatitis or service, and service connection must therefore be denied. ORDER Service connection for an acquired psychiatric disorder other than PTSD, to include schizophrenia and depression, and to include as secondary to service-connected hepatitis, is denied. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs