Citation Nr: 18153286 Decision Date: 11/28/18 Archive Date: 11/27/18 DOCKET NO. 16-38 799 DATE: November 28, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia, is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1980 to July 1984. The Veteran perfected an appeal from the May 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin. The Veteran initially requested a hearing. VA acknowledged the Veteran’s choice to withdraw the request in August 2016. The Veteran filed a claim for schizophrenia in March 2016. Service treatment records do not reflect complaints or treatment relating to a psychiatric disability. The record does, however, include a current diagnosis of schizophrenia from December 2015. A private medical opinion from Dr. J providing the supporting diagnosis was silent as to onset of the disorder. The Veteran was denied service connection in the May 2016 rating decision because there was insufficient evidence in the record showing that an acquired psychiatric disorder, to include schizophrenia, had its onset in or was caused by service. Dr. J does, however, opine that the Veteran has had schizophrenia for over 20 years, which may coincide with his separation from service. Although the Veteran’s service treatment and personnel records do not reflect complaints or a diagnosis of a psychiatric disorder, the record suggests the Veteran’s current psychosis may potentially be associated with active service. There is a conspicuous and abrupt decline in the Veteran’s performance during his time in service. This is reflected in both his proficiency and conduct marks and his disciplinary record. The Veteran received high marks for his performance for more than a year after enlistment. However, in August and September of 1981, the Veteran received low marks. There are no accompanying narratives in the record explaining the reason for such low marks. Near the end of the Veteran’s enlistment, he was reduced in rank due to insubordination and drug use. The veteran has not received a VA exam to assess the etiology of his claimed schizophrenia. Without an exam the record lacks competent evidence to decide the Veteran’s claim. A VA exam must be obtained because there is insufficient competent medical evidence in the record to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The examiner must consider any mental disability that may reasonably be encompassed by the Veteran’s claim, to include the Veteran’s description of the condition and any symptoms described. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The matter is REMANDED for the following actions: 1. Obtain any outstanding treatment records pertinent to the Veteran’s claim, including any outstanding relevant VA treatment records, if any. All records/responses received must be detailed and associated with the claims file. 2. Obtain an opinion from a qualified clinician as to the nature and etiology of the Veteran’s claimed acquired psychiatric disability. The claims file should be reviewed by the clinician. An examination of the Veteran is only required if the reviewing clinician determines that such is needed to answer the below question(s). After reviewing the claims file, and conducting an examination of the Veteran, if deemed necessary, the reviewing clinician should identify all acquired psychiatric disabilities present during the appeal period. For each acquired psychiatric disability identified, the examiner should answer the following question(s): Is it at least as likely as not that the Veteran’s psychiatric disability has its onset in service or is otherwise related to a disease, event, or injury during service? If schizophrenia or another psychosis is diagnosed, is it at least as likely as not that such condition became manifest within one year of service separation? The examiner should specifically consider whether the Veteran’s behavioral and performance issues in service represent early manifestations of his psychiatric disability. All opinions must be fully explained and supported by a rationale. (Continued on the next page)   3. After completion of any other development deemed appropriate in addition to the VA examination, the service connection claim for an acquired psychiatric disorder should be readjudicated. If any benefit sought remains denied, the Veteran and his representative should be provided a Supplemental Statement of the Case. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D.J. Ballinger, Law Clerk