Citation Nr: 1752675 Decision Date: 11/16/17 Archive Date: 11/22/17 DOCKET NO. 97-13 534A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUE Entitlement to service connection for an acquired psychiatric disability, characterized as schizophrenia. REPRESENTATION Appellant represented by: Joseph R. Moore, Attorney-at-Law ATTORNEY FOR THE BOARD R. Dodd, Counsel INTRODUCTION The Veteran served on active duty from July 1973 to December 1973. He died on August 2017. In September 2017, the Appellant, the Veteran's wife, requested a substitution. When a claim is pending at the time of a Veteran's death, a request for substitution may be granted if the request is filed within a year of the death by an appropriate party. 38 U.S.C.A. § 5121A (West 2014). In September 2017, VA granted her request and she may now act as a substitute claimant in support of this appeal. This matter came to the Board of Veterans' Appeals (Board) from a June 1996 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which declined to reopen a claim of service connection for a psychiatric disability. The Veteran perfected a timely appeal. In a November 2004 decision, the Board determined that new and material evidence had been received to reopen the Veteran's claim of service connection, and remanded the claim for further development. In a December 2006 decision, the Board denied entitlement to service connection for an acquired psychiatric disability. The Veteran filed a timely appeal to the United States Court of Appeals for Veterans Claims (Court). Pursuant to a May 2008 Joint Motion for Remand (JMR) and Court Order, the Board decision was vacated and remanded. This matter was remanded by the Board in April 2009 and July 2012. The requested development having been completed, this matter is once again before the Board. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND In July 2012, the Board remanded the Veteran's claim for the provision of a new VA psychiatric examination to take consideration of additional medical evidence that had been recently associated with the claims file at that time in order to determine the etiology of the Veteran's diagnosed psychiatric disorder. The Veteran was provided with a VA examination addendum opinion in January 2015 to the Veteran's initial September 2005 VA psychiatric examination. By way of background, it is noted that, per the September 2005 VA psychiatric examination and the Veteran's outpatient psychiatric records throughout the period of appeal, the Veteran was diagnosed with schizophrenia, chronic, residual type. The January 2015 VA examiner opined that the Veteran's schizophrenia was less likely than not caused by or incurred in military service. In support, the VA examiner provided that there was no evidence of psychiatric complaints, psychiatric findings, or psychiatric treatment prior to the military service, during the military service, nor within one year after discharge from the military service. There was no history of psychiatric hospitalizations, no history of para suicidal behavior, no family history of mental illness, and no psychiatric medications. The VA examiner additionally noted that the Veteran was honorable discharged under the provision of Evaluation & Discharge of Enlistees Before 180 Active Duty Days due to: apathy, lack of appropriate interest, defective attitudes, and inability to expand effort constructively. The VA examiner stated that no objective evidence of psychiatric evaluation and/or hospitalization while in active duty was found in the claims file. However, the VA examiner went on to state as follows: Although the symptoms of: apathy, lack of appropriate interest, defective attitudes, and inability to expand effort constructively could be considered the negative symptoms of the prodromal phase of a psychotic disorder veteran did not seek psychiatric care until 05/1977, four years after his military discharge. According to the medical literature: 'Prodrome, or psychosis risk syndrome as it is also known, is a proposed syndrome to be used in the DSM-V of psychiatry[.] It is also defined as 'the aura that precedes a psychotic break by up to two or three years." Patients with this condition 'still have "insight" indicating that a patient can still recognize an altered worldview as a sign of illness.' A temporal relationship between the neuropsychiatric disorder and the military service is not established. Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place. Barr v. Nicholson, 21 Vet. App. 303 (2007). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Here, the opinion provided by the January 2015 VA examiner is unclear as to why a temporal relationship between the neuropsychiatric disorder and the military service cannot be established. While the VA examiner appears to suggest that the Veteran's symptoms in service are consistent with the onset of his psychotic disorder, manifested as schizophrenia, she also flatly states that there is no relationship within the context of the Veteran's case without a clear explanation. As such, the Board finds that an additional addendum opinion should be sought to clarify and fully explain why the apathy, lack of appropriate interest, defective attitudes, and inability to expand effort constructively seen in service, are not the early manifestations of the Veteran's subsequently diagnosed illness. . Accordingly, the case is REMANDED for the following action: 1. Return the record to the VA examiner who offered the January 2015 opinion for the Veteran's acquired psychiatric disability. The claims file must be made available to the examiner. The examiner should note in the examination report that the record has been reviewed. If the January 2015 VA examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. The examiner should provide an opinion on the following: Whether it is as likely as not (50 percent or greater probability) that the Veteran's acquired psychiatric disability was incurred coincident with his military service. In particular, the VA examiner should fully explain the prodrome or psychosis risk syndrome and its symptoms in relation to the symptoms displayed by the Veteran during military service. In so doing, the VA examiner should further elaborate on the period of time the prodrome, or psychosis risk syndrome is considered to precede a psychotic break. A fully articulated medical rationale for any opinion expressed should be set forth in the medical report. The examiner should discuss the particulars of this Veteran's medical history and the relevant medical science as applicable to this case, which may reasonably explain the medical guidance in the study of this case. 2. After completion of the above, the RO should readjudicate the claim. If the benefit sought is not granted in full, the appellant and her attorney should then be furnished an appropriate supplemental statement of the case and be afforded an opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ M. E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2015).