Citation Nr: 1605419 Decision Date: 02/11/16 Archive Date: 02/18/16 DOCKET NO. 12-32 717 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUE Whether new and material evidence has been received to reopen a claim of service connection for an acquired psychiatric disorder. REPRESENTATION Appellant represented by: Joseph R. Moore, Esq. WITNESS AT HEARING ON APPEAL The Veteran and his friends ATTORNEY FOR THE BOARD S. Keyvan, Counsel INTRODUCTION The Veteran had active service from November 1968 to March 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2011 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO), in Reno, Nevada, that, in pertinent part, reopened the previously denied claim of service connection for an acquired psychiatric disorder, described as a nervous disorder, and denied the claim on the merits. The Board does not have jurisdiction to consider a claim that has been adjudicated previously unless new and material evidence is presented. See Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). Thus, the issue of whether new and material evidence has been received to reopen the claim of service connection for an acquired psychiatric disorder, is as stated on the title page. Regardless of the actions of the agency of original jurisdiction (AOJ), the Board must make its own determination as to whether new and material evidence has been received to reopen this claim. That is, the Board has a jurisdictional responsibility to consider whether a claim should be reopened. See Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). Although the RO framed the original issue on appeal as entitlement to service connection for a nervous disorder, a review of the record indicates that the Veteran has also been diagnosed as having major depressive disorder with psychotic features, generalized anxiety disorder, paranoid schizophrenia, and personality disorder not otherwise specified. During the pendency of this appeal, the United States Court of Appeals for Veterans Claims (Court) addressed the scope of claims generally in regard to what is claimed versus what should be addressed by VA. Clemons v. Shinseki, 23 Vet. App. 1 (2009). In Clemons the Court held that, in determining the scope of a claim, the Board must consider the Veteran's description of the claim, symptoms described, and the information submitted or developed in support of the claim. Id. at 5. In light of the Court's decision in Clemons, and the varying diagnoses recounted above, the Board has recharacterized the claim for a nervous disorder to entitlement to service connection for an acquired psychiatric disorder-as stated on the title page of this decision. This will provide the most favorable review of the Veteran's claims for a psychiatric disorder in keeping with the Court's holding in Clemons. In August 2013, the Veteran testified at a video conference hearing over which the undersigned Acting Veterans Law Judge presided. A transcript of that hearing has been associated with his claims file. The provisions of 38 C.F.R. § 3.103(c)(2) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: the duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). During the August 2013 hearing, the undersigned clarified the issue on appeal and inquired as to the etiology, continuity, and severity of the Veteran's asserted symptoms. The Veteran was offered an opportunity to ask the undersigned questions regarding his claim. The Board, therefore, concludes that it has fulfilled its duty under Bryant. In the September 2013 decision, the Board denied the Veteran's petition to reopen the claim for service connection for an acquired psychiatric disorder. The Veteran appealed the Board's decision to the Court. In the November 2014 Order, the Court vacated the September 2013 Board decision, and remanded the issue to the Board for development consistent with the parties' Joint Motion for Remand. In addition to the paper claims file, there are Virtual VA and Veterans Benefits Management System (VBMS) paperless claims files associated with the Veteran's claim. All records in such files have been considered by the Board in adjudicating this matter. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDINGS OF FACT 1. In a June 1998 decision, the Board determined that the Veteran had a personality disorder which manifested during service, that he did not have a psychiatric disease or injury during active service, and that he did not have or develop an acquired psychiatric disorder as a result of disease or injury during active service. 2. The evidence received since the June 1998 Board decision, by itself, or in conjunction with previously considered evidence, relates to an unestablished fact necessary to substantiate the claim for service connection for an acquired psychiatric disorder and raises a reasonable possibility of substantiating that claim. 3. Resolving reasonable doubt in favor of the Veteran, he has an acquired psychiatric disorder that is causally or etiologically related to his active service. CONCLUSIONS OF LAW 1. The June 1998 Board decision which denied the petition to reopen the claim of service connection for an acquired psychiatric disorder is final. 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. § 20.302, 20.1103 (2015). 2. The evidence received subsequent to the June 1998 Board decision is new and material, and the previously denied claim for service connection for an acquired psychiatric disorder is reopened. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156(a) (2015). 3. Resolving reasonable doubt in favor of the Veteran, he has an acquired psychiatric disorder that was incurred during active military service. 38 U.S.C.A. §§ 1131, 5107(b) (West 2014); 38 C.F.R. § 3.303 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION 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, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102 , 3.156(a), 3.159, and 3.326(a) (2015). The Board concludes that these duties do not preclude the Board from adjudicating this portion of the Veteran's claim. This is so because the Board is taking action favorable to the Veteran by reopening and granting his service connection claim. See Bernard v. Brown, 4 Vet. App. 384 (1993). Accordingly, discussion of VA's compliance with the notice and assistance requirements would serve no useful purpose. Claim to Reopen The Veteran contends that his acquired psychiatric disorder was incurred in service. His claim for an acquired psychiatric disorder was originally denied in the December 1990 rating decision, on the basis that the service treatment records were negative for signs of a nervous disorder, and no post-service treatment was indicated. The June 1998 Board decision confirmed this denial finding that the Veteran had a personality disorder that did not manifest in service, and that a psychosis, including paranoid schizophrenia, neither manifested during service, and did not manifest to a degree of 10 percent or more during the first year after the Veteran completed his active service. The Board further determined that the Veteran did not have an acquired psychiatric disorder that was incurred in or aggravated by active military service. Notice of this denial was provided to the Veteran, and the Board's decision in the matter is final. See 38 U.S.C.A. §§ 7103(a), 7104(b); 38 C.F.R. §§ 20.1100. The Veteran filed an application to reopen his claim seeking service connection for an acquired psychiatric disorder in September 2009. Despite the finality of a prior adverse decision, a claim will be reopened and the former disposition reviewed if new and material evidence is furnished with respect to the claim which has been disallowed. 38 U.S.C.A. §5108; 38 C.F.R. §§ 3.156(a), 20.1100, 20.1105. In order to reopen a claim that has been denied by a final decision, new and material evidence must be received. 38 U.S.C.A. § 5108. For applications to reopen filed after August 29, 2001, as was the application to reopen in this case, new and material evidence means evidence not previously submitted to agency decision makers; which relates, either by itself or when considered with previous evidence of record, to an unestablished fact necessary to substantiate the claim; which is neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and which raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). To reopen a previously disallowed claim, new and material evidence must be presented or secured since the last final disallowance of the claim on any basis, including on the basis that there was no new and material evidence to reopen the claim since a prior final disallowance. See Evans v. Brown, 9 Vet. App. 273, 285 (1996). For purposes of reopening a claim, the credibility of newly submitted evidence is presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, "credibility" of newly presented evidence is to be presumed unless evidence is inherently incredible or beyond competence of witness.). In Shade v. Shinseki, 24 Vet. App. 110 (2010), the Court interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and views the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4) , which "does not require new and material evidence as to each previously unproven element of a claim." Therefore, it would be illogical to require that a claimant submit medical nexus evidence when he has provided new and material evidence as to another missing element, as it would "force the Veteran to provide medical nexus evidence to reopen his claim so that he could be provided with a medical nexus examination by VA." The evidence associated with the claims file prior to the June 1998 Board decision includes, but is not limited to, the Veteran's service treatment records, the May 1991 medical report issued by W.B., M.D.; the May 1991 neurosurgery report issued by L.S., M.D.; report of the October 1991 psychological evaluation issued by the Veteran's private clinical psychologist, D.M., Ph.D., along with the September 1992 addendum report; the December 1991 Hearing Transcript; the April 1991 Disability Determination and Transmittal report; the April 1992 VA examination report; a copy of the November 1992 Social Security Administration decision; the February 1993 Disability Determination and Transmittal report; and report of the February 1998 Independent Medical Expert (IME) opinion issued by J.T., M.D. The evidence associated with the claims file subsequent to the June 1998 Board decision includes, but is not limited to, VA outpatient records dated from August 2009 to April 2010; the October 2013 letter issued by the Veteran's primary care provider at the VA, M.M., M.D., the August 2013 Hearing Transcript, the January 2016 medical report issued by M.C., M.D.; and lay assertions submitted by the Veteran and his family members. As discussed above, in the June 1998 decision, the Board determined that the preponderance of the evidence reflected that the Veteran had a personality disorder that pre-existed his service, and that he did not have a diagnosis of schizophrenia or any other acquired psychiatric disability. Specifically, the Board concluded that the Veteran did not have an acquired psychiatric disorder, and there was no evidence of a psychiatric disease or injury during active service. The Board further concluded that the Veteran did not have an acquired psychiatric disorder as a result of disease or injury during active service. During the August 2009 VA psychiatric evaluation, the VA psychologist assessed the Veteran with ongoing generalized anxiety disorder that is severe and chronic in nature. In the January 2010 VA Mental Health report, the Veteran's primary care physician, Dr. M., diagnosed the Veteran with having generalized anxiety disorder and added that the Veteran was "ok until he was exposed to some psychological trauma at the Service." Dr. M. further wrote that since his period of service, the Veteran had been anxious and isolated himself from people. In an October 2013 letter, Dr. M. described the Veteran's military history, and noted that his promotion from E2 to E4 over his fellow sailors with longer service and at a higher grade level, caused the other sailors to start harassing him out of jealousy. Dr. M. noted that the Veteran resented this harassment and "became stressed out to the point that it destroyed his desire to make Chief in the Service." According to Dr. M., the Veteran became more depressed and self-medicated himself with alcohol, which led to a chronic disabling depression. Dr. M. further concluded that the Veteran's psychiatric condition, namely, his depression, was caused by these in-service events. In a letter dated in January 2016, a private physician and psychiatrist, M.C., M.D., acknowledged that the Veteran had received diagnoses of personality disorders over the years, but these diagnoses were not consistent with the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria for these personality disorders, nor of modern psychiatric diagnostic practice. To summarize the lengthy medical opinion, based on his evaluation of the Veteran, as well as his review of the Veteran's service and post-service treatment records, Dr. C. determined that the Veteran had a diagnosis of major depressive disorder that is recurrent, severe, with psychotic features, and a substance use disorder. According to Dr. C., the Veteran meets all of the DSV-V criteria for major depressive disorder and has done so since 1970 during his period of service in the United States Navy. Dr. C. noted that the Veteran's first depressive episode was in 1970 "when he developed a precipitous and sudden decline in his capacity to function while in the United States Navy." According to Dr. C., the Veteran's depressive symptoms "have reoccurred periodically throughout the course of his life, with a waxing and waning of intensity, but never a full remission." Dr. C. concluded that the Veteran's major depressive disorder began while he was on active duty service, and was not present at any time prior to his deterioration while serving in the military. This evidence is new, in that it was not previously of record. The Board finds that collectively, the January 2016 medical opinion, in conjunction with the October 2013 opinion issued be Dr. M., as well as the August 2009 and January 2010 VA outpatient records provide further discussion concerning whether the Veteran has a psychiatric disability, and addresses the possibility of an etiological link between the Veteran's acquired psychiatric disorder and his military service. Because the Board in June 1998 denied the claim, in part, because the evidence did not reflect that the Veteran had an acquired psychiatric disability that was incurred in service, this new evidence relates to an unestablished fact necessary to substantiate the claim. Thus, the Board finds that new and material evidence has been presented to reopen the previously denied claim for service connection for an acquired psychiatric disability. This aspect of his appeal is, therefore, granted. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. §§ 1110. 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). The Veteran has consistently contended that he developed an acquired psychiatric disability as a result of his experiences during active service. According to the Veteran, as well as his family members, prior to his active service, he had gotten along well with others, he was a responsible and caring person, and he did not have difficulty adapting to difficult situations. Upon entering service, he excelled in boot camp, and was quickly promoted, which did not sit well with others. According to the Veteran, he was promoted over another serviceman who had more time in his grade, and those both under and more senior to him resented his swift rise in ranking. The Veteran stated that from this point onward, he was continually harassed by his fellow servicemen, and his life turned into a "living hell." He added that he started to become belligerent to everyone around him, and his career path quickly deteriorated after this. See August 2013 Statement of Veteran. Review of the service treatment records reflect that the clinical evaluation of the Veteran's psychiatric system was shown to be normal at the September 1968 enlistment examination. Also, the Veteran denied a history of psychiatric problems, to include frequent or terrifying nightmares, depression or excessive worry, and nervous trouble of any sort in the September 1968 medical history report. A January 1970 psychiatry sick call note reflects that the Veteran was referred to the psychiatry unit due to drastic behavioral changes upon being promoted to company commander. During the neuropsychiatric evaluation, the mental status evaluation of the Veteran revealed no functional organic or thought process disorder and no suicidal or homicidal ideation. The military psychiatrist noted that the Veteran related in a suspicious, mistrustful and guarded manner with minimal verbalizations and nearly no spontaneous speech. After interviewing the Veteran regarding his pre-military medical history, the military psychiatrist observed that the Veteran's attitude towards people had always been one of mistrust, suspicion, wariness and the feeling that people were against him and disliked him. According to the military psychiatrist, the Veteran had resented the situation he was in for some time, and felt that his mother forced him to pursue electronics, which he hated. The military psychiatrist further wrote that: "[w]hat appears to have precipitated his more overt trouble seems to have been his promotion to 3rd class which has placed him in a position of greater responsibility which to him means greater exposure and vulnerability to the attacks, real and imagined, of other people. His already pre-existing character traits of [r]eclusiveness, suspiciousness, mistrust of others and the feeling that others are out to hurt him in some way, have come to the surface even more in the service where rules, regulations and regimentation are unable to be coped with effectively by him." Based on his discussion with, as well as his evaluation of the Veteran, the military psychiatrist diagnosed the Veteran with paranoid personality which existed prior to enlistment and recommended an administrative separation from service. At the March 1970 separation examination, the clinical evaluation of the Veteran's psychiatric system was shown to be normal. VA progress notes dated in March and May 1990 revealed a diagnosis of paranoid personality and a history of dysfunctional personality. The May 1991 evaluation issued by Dr. B. reflected an Axis I diagnosis of episodic alcohol abuse and rule out chronic schizophrenia, and an Axis II diagnosis of schizotypal personality disorder. During the October 1991 psychological evaluation, the Veteran provided his medical and military history and noted that even during his childhood, he felt suspicious and distrustful toward others. With regard to his service in the Navy, the Veteran recounted his swift promotion to an E3 within less than a year in the Navy, and noted that this was when his problems began, as the guy he replaced immediately resented him, his "cliques" resented him, and his immediate superior resented him as well. The Veteran did not like having the spotlight on him, and he felt resentment both from his superiors and from those below his level who had been struggling to be promoted for years and were resentful of the fact that he had been promoted in such a short time. The Veteran stated that he did not react well to this stress, and started having trouble performing his duties as company commander. According to the Veteran, he was thereafter replaced and transferred to another class, but he was still harassed by his superiors and those below him. The Veteran recalled that his grades soon dropped and he lost interest in pursuing training in advanced electronics. After providing an extensive review and recitation of the Veteran's medical history, and taking into account the additional medical opinions provided, based on his discussion with, as well as his evaluation of the Veteran, Dr. M. diagnosed the Veteran with having a schizophrenic reaction, paranoid type. Dr. M. acknowledged evidence reflecting the Veteran's problems with his peers and with authority figures prior to his enlistment into service. Dr. M. also noted that there was ample evidence that the Veteran's military service exacerbated a pre-existing condition, "a condition which may have resolved itself in a few years, perhaps by the time the [Veteran] was in his mid or late twenties, had not the traumatic events, conflicts which occurred in the service, not occurred." After reviewing and taking all available data into consideration, Dr. M. determined that absent his traumatic experiences in the Navy, the Veteran would not be psychologically disabled currently. At the April 1992 VA examination, the examiner discussed in detail the above-referenced psychological and psychiatric evaluation reports. The diagnoses provided included alcohol dependence, ongoing since 1970, moderately severe; cannabis abuse, ongoing; amphetamine abuse, ongoing; possible paranoid schizophrenia; rule-out major depression with psychotic features; and, mixed personality disorder, with schizotypal,paranoid avoidance and schizoid features. In the September 1992 addendum to the October 1991 report, Dr. M. discussed the April 1992 VA examination findings and reasserted that the Veteran had undergone a battery of psychological tests to clarify what his psychiatric diagnosis was. Specifically, Dr. M. noted that the Veteran underwent the Minnesota Multiphasic Personality Inventory (M.M.P.I.) and the Rorschach test at the October 1991 psychological evaluation, and while the Rorschach test was not brimming with disturbances and bizarre ideation, there were sufficient distortions of reality to justify a diagnosis of paranoid schizophrenia. Dr. M. further conceded that the exam time period wherein the Veteran moved from schizotypal personality disorder to paranoid schizophrenia was not clear in his mind, although it might have been at the time of his discharge from service. A November 1992 Social Security Administration decision reflects that the Veteran was granted Social Security Administration disability benefits, effective June 1, 1989. A February 1993 Disability Determination and Transmittal report reflects a primary diagnosis of schizophrenia personality disorder and a secondary diagnosis of alcohol/cannabis dependence. In July 1997, the Board requested an outside IME opinion to address the issue, and in response to this request an IME opinion was submitted in February 1998 and issued by J.T., M.D., at the Department of Neuropsychiatry and Behavioral Science at the University of South Carolina School of Medicine. In this opinion, Dr. T. reviewed the Veteran's claims file, to include the above-referenced medical opinions submitted both in support of, and against the Veteran's claim. Dr. T. acknowledged that some of the treatment providers who issued these opinions, to include the April 1992 VA examiner, Dr. B. (see May 1991 report), and the military psychiatrist who conducted the January 1970 evaluation, all diagnosed the Veteran with various personality disorders. According to Dr. T., the classification of personality disorders has changed since the military psychiatrist's original diagnosis, but the prominent features of the disorder had remained the same. Dr. T. noted that while the VA examiner conceded the possibility of paranoid schizophrenia, he (Dr. T.) did not find the VA examiner's testing "definitively made that diagnosis." According to Dr. T.: "while it is possible for individuals initially diagnosed as schizotypal (or even paranoid) personality disorder to later move to (or be rediagnosed as) paranoid schizophrenia, [his] review of the evidence would suggest that this did not occur, at least not before [the Veteran's] graduation from college and with [his] interpretation of Dr. M's testing not-at-all." Based on his understanding of the medical principles, as well as his review of the medical evidence, Dr. T. determined that the Veteran's in-service diagnoses included paranoid personality disorder and probable alcohol dependency, and cannabis abuse. Dr. T. further concluded that the Veteran's current diagnoses from when he was last evaluated in the early 1990's included alcohol dependency, cannabis abuse, and personality disorder, not otherwise specified, with paranoid, schizoid, and antisocial traits. According to Dr. T., the Veteran's psychiatric difficulties first manifested as an adolescent and progressively worsened throughout the years. VA mental health outpatient records dated in August 2009 reflect a diagnosis of generalized anxiety disorder. During a January 2010 VA outpatient visit, the Veteran's primary care physician, Dr. M.M., diagnosed the Veteran with having general anxiety disorder, and explained that the Veteran was fine until his exposure to some psychological treatment in the military. According to Dr. M.M., the Veteran had been anxious and isolative in nature since his military service. In an October 2013 letter, Dr. M.M. took into account the Veteran's military history, and noted that his promotion from E2 to E4 created a great deal of friction between the Veteran and his fellow servicemen due to their jealousy and resentment at the fact that the Veteran had been promoted so swiftly while they had not. Dr. M.M. wrote that the other sailors started harassing the Veteran out of jealousy and the nervous tension became "unbearable" for the Veteran. As a result of this harassment, the Veteran was stressed to the point that he lost the desire to rise in the ranks and be promoted to chief in service. Dr. M.M. further wrote that the Veteran became more depressed and self-medicated himself with alcohol which ultimately lead to a chronic disabling depression. According to Dr. M.M., the Veteran's depression was caused by a condition that happened in service. In a January 2016 submission, the Veteran's attorney provided a number of documents in support of the Veteran's claim, one of which included a January 2016 psychiatric evaluation report from M.C., M.D., F.A.C.P. Dr. C. acknowledged that the Veteran had received diagnoses of personality disorders over the years, but concluded that this diagnosis was not consistent with the DSM-V criteria for these personality disorders, nor of the modern psychiatric diagnostic timeframe. According to Dr. C., the Veteran was high functioning and successful in the Navy for an extended timeframe before undergoing a drastic decline in his behavior which occurred over a relatively short timeframe. Dr. C. noted that the characteristics exhibited by the Veteran during this timeframe were inconsistent with personality disorders, and prior to his active service, there was no evidence of a personality disorder which one would expect to manifest during adolescence and young adulthood. Dr. C. determined that after interviewing the Veteran, he could find no evidence to support the diagnostic criteria for any type of personality disorder under the DSM-V. The remainder of the detailed eleven page report provided by Dr. C. summarizes the Veteran's pre-military and military history, and takes a close look at each of the above-referenced medical opinions provided throughout the years. Dr. C. noted that although the Veteran had minor legal charges associated with possession of substances prior to service, he was forthcoming about these charges at the time of enlistment, and these incidents were dismissed and considered minor in nature. Dr. C. further noted that neither of these legal issues had anything to do with a diagnosis of a personality disorder. In addition, the Veteran was described as being a typical teenager by his brothers and family members, and he entered into service without any mental healthcare issues. According to Dr. C., prior to his active service, the Veteran was described as "social, [he engaged] in all the usual activities a young man would be involved in, and [he] enjoyed his day-to-day life." According to Dr. C., it was upon his separation from service and return home that his family observed an entirely different individual than the one who left, and described him as "barely the same person having become introverted, morose, angry, depressed, and socially isolated." Dr. C. noted that the Veteran excelled during his first year of service and was promoted from E-2 to E-4 within one year. It was further noted that the Veteran was selected to participate in an advanced electronics course upon his enlistment, "which [suggests] an extremely impressive capacity to perform in a military environment." Dr. C. went on to state that it was these promotions and increasing responsibilities that led to a complete change in the Veteran's capacity to function as follows: "His capacity to function began to deteriorate, and he was resented by fellow serviceman because there was a spotlight on him, as he had been promoted over other individuals in a short timeframe and was castigated by his peers. Specifically surrounding the time of these promotions there was a sudden change in his attitude, a deterioration in his capacity to participate in educational activities within the Navy, and the potential for disciplinary action, characteristics that were diametrically opposed to his initial functioning within the Navy." Dr. C. took into consideration the medical reports reflecting that the Veteran suffered from a personality disorder that predated his service. According to Dr. C., these reports were not only constructed over twenty years ago with outdated criteria, but the February 1998 IME was not even associated with an interview with the Veteran. Dr. C. further noted that in diagnosing the Veteran with an unspecified personality disorder, Dr. T. focused on a single visit to a psychiatrist on one occasion "due to [the Veteran's] difficulties with teachers in the school setting." According to Dr. C., this had nothing to do with a diagnosis of psychiatric illness or personality disorder, and visiting with a psychiatrist on one occasion for difficulties in school is not indicative of the development of mental illness. Dr. C. further noted that there was no evidence of any mental illness at the time of the Veteran's enlistment, and if anything, his promotions and participation in an advanced electronics course indicate that he excelled in the Navy and exhibited no signs of mental illness until specific events occurred while he was enlisted in the Navy, and which led to his deteriorating mental health. Dr. C. further took note of additional factors relied upon by Dr. T. in the February 1998 IME, and addressed why these factors did not support Dr. T's conclusion, and in fact served to lessen the report's probative weight. According to Dr. T., his review of the medical record along with his interview with the Veteran does support a diagnosis of major depressive disorder, recurrent, severe, with psychotic features. Upon reviewing the Veteran's service treatment records, and specifically the January 1970 neuropsychiatric treatment report, Dr. C. observes that what is obvious from the report is a "sudden and precipitous decline in [the Veteran's] capacity to function within the United States Navy." Prior to this sudden deterioration, the Veteran held an 87 percent average in school which was considered high. According to Dr. C., the military psychiatrist incorrectly diagnosed the Veteran with "paranoid personality." In his opinion, he determined that the January 1970 report was "where the beginning of the incorrect diagnoses began, and it was, unfortunately, a result of that specific timeframe in psychiatric medicine." Dr. C. further wrote that "[f]or an individual with no previous formal psychiatric history, who was exemplary in his ability to function in the United States Navy and was promoted early and above other individuals, who then experiences precipitous decline, a personality disorder is not a diagnostic consideration." According to Dr. C., no modern psychiatrist would conclude that the Veteran carried a diagnosis of a personality disorder, when the Veteran had not exhibited any of the characteristics of a personality disorder up to that point in his life. He went on to explain that personality disorders are "disease processes that manifest themselves from adolescence through young adulthood into adulthood" and "[i]ndividuals who have no formal psychiatric history [and] who perform exceptionally in the most rigorous aspects of the United States Navy educational system, and then have a precipitous decline are not considered to have personality disorders." According to Dr. C., this report prevented the Veteran from receiving the correct diagnosis for an extended period of time. Dr. C. then addressed the remainder of the medical opinions provided, to include the May 1991 medical opinion issued by Dr. B, the October 1991 psychological evaluation with Dr. M., and the April 1992 VA examination report. One by one, Dr. C. addressed why the arguments, theories, and principles relied upon by these psychiatrists and psychologists upon reaching their assessments and diagnoses were incorrect. Dr. M. addressed why the May 1991 examination report did not document sufficient characteristics to make a diagnosis of schizotypal personality disorder that met the DSM-V criteria for schizophrenia. He concurred with the October 1991 opinion that there is a causal relationship between the Veteran's psychiatric illness and his active duty service in the Navy, but he did not find there to be sufficient evidence to suggest that there was a formal psychiatric condition that was exacerbated. Dr. C. also noted that a diagnosis of schizophrenic reaction, paranoid type no longer exists, and as such, he must conclude that "the formal diagnosis for the Veteran, in modern psychiatric terms, would be major depressive disorder, recurrent, severe, with mood congruent psychotic features." With regard to the April 1992 VA examination report, Dr. C. noted that the description of the Veteran, as provided by the examiner, was inconsistent with a diagnosis of schizophrenia. With regard to a diagnosis of mixed personality disorder, Dr. C. noted that while he could understand how this diagnosis may have been made at the time of this report, he did not concur with this diagnosis currently, given that he had the benefit of a much more extensive longitudinal view of the Veteran than the April 1992 VA examiner did. However, Dr. C. did agree that there was significant evidence for a diagnosis of major depression with psychotic features. According to Dr. C., his interview with the Veteran "revealed significant neurovegetative symptoms of depression, and he met all the diagnostic criteria for major depression with psychotic features which would incorporate his paranoid ideation, anger, and irritability." Dr. C. further noted that under the DSM-V criteria, there is no need to make a diagnosis of a personality disorder as the major depressive disorder with psychotic features "incorporates the paranoia and unusual thought processing the Veteran has experienced." According to Dr. C., the diagnosis of major depressive disorder was clear at the first neuropsychiatric assessment done in 1970 during the Veteran's service in the military, and a modern psychiatrist would not have considered a diagnosis of a personality disorder when the Veteran first presented in 1970. With regard to the February 1998 IME, Dr. C. noted that this report predominantly relied on a review of the claims folders and opinions issued by Dr. T's colleagues. According to Dr. C. "[a] retrospective review of a psychiatrically ill patient has little weight when compared to an actual diagnostic assessment with the patient as part of the process." Although he agreed with the assessment of a significant substance use disorder and that the Veteran did not have a diagnosis of schizophrenia, Dr. C. opined that "[t]he remainder of this report offers nothing other than a hypothetical view of [the Veteran] without any primary source information directly from the patient." With regard to the VA progress notes dated in 2009 and 2010, Dr. C. did not agree with the diagnosis of generalized anxiety disorder, and noted that generalized anxiety disorder would not account for the Veteran's symptomatology over the prior four decades, which included depression, hopelessness, despair, altered thought content, and paranoia. According to Dr. C., although the Veteran suffers from significant anxiety, this is associated with his major depressive disorder with psychotic features. After interviewing the Veteran, reviewing the claims file in full, to include medical records, service treatment records, and statements submitted by his family, and conducting a formal mental status examination of the Veteran, Dr. C. diagnosed the Veteran with having major depressive disorder, recurrent, severe, with psychotic features, and a substance use disorder. According to Dr. C., the Veteran meets all the DSM-V criteria for major depressive disorder, and has done so since 1970 during his period of service in the United States Navy. Dr. C. reiterated that the Veteran's first depressive episode was in 1970 "when he developed a precipitous and sudden decline in his capacity to function while in the United States Navy." According to Dr. C.: "[i]n 1970 [the Veteran] began experiencing a depressed mood most of the day nearly every day. He had diminished interest in all activities that he previously enjoyed. He noticed the beginnings of a weight gain, increased sleep, and psychomotor retardation. He began experiencing fatigue, feelings of worthlessness, decreased focus and concentration, indecisiveness, and suicidal ideation. These all occurred while he was in the Navy in 1970. The symptoms are present through the current time, and have occurred repeatedly, in varying degrees of intensity, over the last four decades. The symptoms have nothing to do with any personality disorder and, in fact, are inconsistent with the DSM-V definition of personality disorders which are not diagnosed in patients who have partially treated depressive disorders with psychotic features. [The Veteran] does not meet any of the diagnostic criteria for schizophrenia, and does not have a presentation consistent with schizophrenia; schizophrenia wouldn't not even a consideration in his diagnoses. The paranoia, irritability, anger, that has been inappropriately attributed to personality disorders is associated with major depression with psychotic features. These type of behaviors, actions, and symptoms are commonly associated with major depression with psychotic features and, given the circumstances of his discharge, would be considered mood congruent." According to Dr. C., the events that occurred while the Veteran was in the U.S. Navy "caused him, correctly and clearly, to feel that people despised him, distrusted him, disliked him, and were even 'out to get him.'" Dr. C. noted that the Veteran's rapid promotion, and the ensuing jealousy of his fellow servicemen "was the nidus for the paranoia that became a component of his major depressive disorder with psychotic features." Dr. C. opined that the psychiatric symptoms associated with the Veteran's major depressive disorder have continued to reoccur throughout the course of the Veteran's life, and although they have waxed and waned in intensity, they have never gone away. Based on his understanding of the medical principles as they currently stood, his interview with the Veteran, and his review of the claims file in its entirety, Dr. C. diagnosed the Veteran with having major depressive disorder, recurrent, severe, with mood congruent psychotic features, and concluded that said disorder began while he was on active duty service, was not present at any time before his deterioration while in the military, and the Veteran "continues to be profoundly psychiatrically impaired and has been incapable of working since his discharge from active duty." Upon review of the record, the Board finds that there is a legitimate difference of opinion from a medical standpoint as to whether the Veteran has an acquired psychiatric disorder as a result of a disease, injury or event in service. To that end, the Board places more weight on the January 2016 opinion issued by Dr. C. In his opinion, Dr. S. expressed an understanding of the Veteran's psychiatric history. As such, he had before him the same level of information the May 1991, October 1991, April 1992 and February 1998 psychologists and psychiatrists did, and in fact, given his extensive interview of the Veteran, his understanding of the principles underlying modern psychiatry as well as the DSM-V criteria for psychiatric disorders, along with his review of the Veteran's more recent VA mental health records, Dr. C. had access to a greater level of information and medical knowledge than any of the previous psychologists and psychiatrists did. In reaching his conclusion, Dr. C. provided an extensive rationale in support of the opinion reached that included references to the Veteran's medical history, as well as the DSM-V criteria for psychiatric disorders and pertinent medical literature articles. In addition, Dr. C. applied the current and relevant medical principles to the facts of the claim. Furthermore, Dr. C. reviewed the prior medial opinions provided, and discussed why he found these opinions to be inadequate. Specifically, he addressed the fallacies, discrepancies, and outdated principles and theories relied upon by the treatment providers in reaching their assessments. In a claim for VA benefits, "a Veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." Gilbert, 1 Vet. App. at 54. Entitlement need not be established beyond a reasonable doubt, by clear and convincing evidence, or by a fair preponderance of the evidence. Under the benefit of the doubt doctrine, when the evidence is in "relative equipoise, the law dictates that the Veteran prevails." Id. Based on the foregoing, the Board finds that there is reasonable doubt as to whether the Veteran has an acquired psychiatric disorder that is related to his military service. To the extent that there is reasonable doubt, that doubt will be resolved in the Veteran's favor. Accordingly, the Board concludes that service connection for an acquired psychiatric disorder is granted. ORDER New and material evidence having been received, the claim of entitlement to service connection for an acquired psychiatric disorder is reopened. Service connection for an acquired psychiatric disorder is granted. ____________________________________________ DEMETRIOS G. ORFANOUDIS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs