Citation Nr: 19169986 Decision Date: 09/10/19 Archive Date: 09/10/19 DOCKET NO. 19-06 276 DATE: September 10, 2019 ORDER Service connection for acquired psychiatric disorder, to include schizoaffective disorder and alcohol use disorder, is granted. REMANDED Service connection for diabetes is remanded. Service connection for neuropathy is remanded. Service connection for sleep apnea is remanded. FINDINGS OF FACT 1. Resolving all reasonable doubt in favor of the Veteran, his currently diagnosed schizoaffective disorder and alcohol use disorder is due to his active service. CONCLUSIONS OF LAW 2. The criteria for service connection for an acquired psychiatric disorder, to include schizoaffective disorder and alcohol use disorder, have been met. 38 U.S.C. §§ 1131, 5107 (b); 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1009 to August 1998. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2017 and May 2018 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). While the Board notes the Veteran submitted a RAMP opt-in form for the claim for service connection for schizophrenia, the Veteran failed to submit the RAMP opt-in election form prior to implementation of the Appeals Modernization Act. Accordingly, the Veteran has not validly opted-in to RAMP regarding his claim for schizophrenia and the claim will proceed under the legacy system. 38 C.F.R. § 19.2 (d) (2). Service Connection for Schizophrenia Generally, service connection may be established if the evidence demonstrates that a current disability resulted from a disease or injury incurred in or aggravated by active duty service. 38 C.F.R. § 3.303. To that end, service connection may be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to the period of service, establishes the disease was incurred during active duty service. 38 C.F.R. § 3.303 (d). To prove service connection, there must be competent and credible evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus or link between the current disability and the in-service disease or injury. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Board has recharacterized the issue on appeal as service connection for an acquired psychiatric disorder to include schizophrenia and other related mental conditions. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran seeks service connection for schizophrenia as due to or otherwise related to his military service. A review of the Veteran’s service treatment records (STRs) shows that in February 1998 he was referred to the mental health clinic after he displayed some problems with impulse control with a provisional diagnosis of functional personality disorder After the consultation, he was subsequently diagnosed as relational problems NOS. In April 1998, he overdosed on medication and alcohol with a suicide attempt. It was noted that he was “angry and depressed” and went to sleep after overdosing on medication and was intoxicated with alcohol. He was awakened later that morning by his coworkers after he missed showing up to work that day. He was admitted to the hospital in May 1998 for another attempted suicide from medication overdose. Later that month, the Veteran was diagnosed with relational problems. The Veteran was afforded a VA examination in September 2017. The Veteran was diagnosed with schizoaffective disorder and alcohol use disorder. The VA examiner stated that it was not possible to differentiate what symptoms are attributable to each diagnosis as the diagnoses are independent of each other and result from separate etiologies, however, the symptoms that comprise each disorder are similar and overlap significantly. The VA examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. She stated that the current diagnosis meets the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria, but there is no evidence that is it related to the Veteran’s military service. She indicated that the Veteran was diagnosed/treated for mental health issues in service, but those symptoms are not consistent with the Veteran’s current mental health symptoms, or there is no evidence that the symptoms were continuous or the same entity since military service. The VA examiner concluded that therefore, there is no nexus between military service and the current diagnosis. In April 2019, the Veteran’s submitted a mental disorders Disability Benefits Questionnaire (DBQ) from a private psychologist H.H-G., who diagnosed the Veteran with schizoaffective disorder, depressive type under the DSM-5 criteria. The mental health examination took place in February 2019. At the examination, the Veteran stated that he has great ongoing difficulty with his symptom patterns and he can no longer enjoy the simplest of activities. Upon mental status examination, the Veteran’s attention was normal, and concentration appeared variable. He complained of increased trouble with short-term memory. He struggled remembering basic information. The Veteran’s speech flow was normal, although he was brief with information offered. His thought content was appropriate for the circumstance. The Veteran’s organization of though was goal directed. There was report of overt hallucinations. His mood was anxious and nervous, and affect was restricted. He reported feeling anxious and depressed. He also endorsed symptomology of schizoaffective disorder, as he was vague with response, suspicious, and seemed rather paranoid when speaking with the examiner. The psychologist stated that due to the complex overlap of endorsed symptoms it is inconceivable to differentiate specific causation for disability. Therefore, it should be noted that the disease pattern cannot be attributed to one particular issue; rather, all issues may indeed contribute to the overall decompensation and disability of the Veteran. She opined that that the Veteran suffers from schizoaffective disorder which more likely than not began in military service and continues uninterrupted to the present. In support of her conclusion, the psychologist indicated she reviewed the Veteran’s claim folder, to include VA treatment records, and performed a mental status examination. She also referenced the statements that were submitted by the Veteran’s father and sister in March and April 2018. These statements endorsed that the Veteran’s mental symptoms were a result of his military service and have exacerbated since military separation. The statements indicated that prior to military service, the Veteran was a loving, fun, and active person who enjoyed having a good time and going places with his friends and family. The statements also reflect that during military service, the Veteran distanced himself from family and became severely depressed to the point of attempting suicide and returned home from service a different person. Additionally, the psychologist also provided information from medical journal articles, which found that active military service impacts depression, anxiety and quality of life satisfaction, to support the Veteran’s claim. The opinion reflects consideration of the complete record to include the STRs, VA treatment records, the September 2017 VA examination, the Veteran's contentions, statements from the Veteran’s family members, and medical journal articles. The opinion was supported with thorough rationales which the Board finds are consistent with the evidence of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). Weighing the positive findings of the private psychologist against those of the VA examiner, the evidence is at least in relative equipoise as to whether the Veteran’s mental health disability is related to service. Therefore, resolving all reasonable doubt in the Veteran’s favor, the Board finds that the requirements for service connection have been satisfied, and that service connection for acquired psychiatric disorder, to include schizoaffective disorder and alcohol use disorder, is warranted. REASONS FOR REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. See U.S.C. § 5103A; 38 C.F.R. § 3.159. 1. Service Connection for Diabetes The Veteran believes that he is entitled to service connection for diabetes. The Veteran’s STR shows an elevated glucose reading from April 1998. An April 2018 VA examination for neuropathy notes a diagnosis of diabetes, and at the examination, the Veteran reported that he had had diabetes since around 2003. He has not been afforded a VA examination in connection with this claim. Because diabetes ia a chronic disease listed in 38 C.F.R. § 3.309 (a), service connection for the disease may be established by showing manifestation to a compensable degree within a year following separation from service (and by showing continuity). A June 2017 VA treatment record notes the Veteran reporting that he has many issues and is currently going outside the VA. Records of the initial diagnosis for diabetes and treatment may contain pertinent information and must be sought. Considering there may be indication in the record of remote onset and the state of the medical evidence of record, an examination to obtain a medical opinion regarding the nature of the diabetes is needed. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). If records received on remand suggest the Veteran’s diabetes may be related to his service, an examination to obtain a medical opinion may be necessary. Once private treatment records are received, and diabetes is not diagnosed within the one-year presumptive period, a medical opinion must be obtained as to whether the Veteran's in-service elevated glucose level indicated a relationship between his diabetes and his active duty service. Even if elevated glucose levels were not diagnostic of diabetes, and whether, even if not sufficient to diagnose diabetes in service, the elevated glucose level may indicate a relationship between Veteran's current diabetes and his active duty service. Therefore, the Board must remand this matter to the RO to obtain a medical opinion. 2. Service Connection for Neuropathy The issue of entitlement to service connection for peripheral neuropathy is inextricably intertwined with the issue of service connection for diabetes, as it was noted at the April 2018 VA examination that neuropathy was secondary to diabetes. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). Thus, this issue must also be remanded. 3. Service Connection for Sleep Apnea The Veteran contends that he has sleep apnea as the result of active service. The Veteran’s service treatment records (STRs) document trouble sleeping in May 1991. As noted in the diabetes discussion previously, the VA treatment records reflect that the Veteran receives health care primarily outside the VA. The Veteran should be afforded an opportunity to provide any records related to his claim for sleep apnea. As such, a remand is necessary to provide the Veteran with an opportunity to submit any private treatment records that may be relevant to his claim. The matters are REMANDED for the following action: 1. Obtain additional VA medical treatment records from March 2018 to present. All reasonable attempts should be made to obtain any identified records. 2. The Veteran should also be afforded the opportunity to identify and submit any outstanding private treatment records that relate to the treatment of diabetes, neuropathy, and sleep apnea since his discharge from service. He should provide those records or in the alternative, provide a release so that VA can attempt to obtain those records. 3. Once the above has been completed, obtain a VA examination with medical opinion to address the claim for disability for diabetes. The decision for an in-person examination of the Veteran is left to the discretion of the examiner. The electronic records, to include a copy of this remand, should be made available to and reviewed by the examiner, and an opinion as follows is requested: a) Whether the Veteran’s currently diagnosed diabetes is at least as likely as not related to an in-service injury, event, or disease. b) The examiner must also opine whether the Veteran’s currently diagnosed diabetes at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptoms since service. c) If the answer to any of the above is no, whether the Veteran's elevated glucose levels documented in service treatment records from April 1998 is at least as likely as not etiologically related to the later onset of diabetes and whether these glucose readings represent a precursor to or an initial manifestation of diabetes. d) If the answer to question (c) is no, whether, even if not sufficient to diagnose diabetes in service, the elevated glucose levels indicated a relationship between Veteran's current diabetes and his active duty service. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. In considering any lay statements of record, the examiner should note that the Veteran is competent to attest to matters of which he had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examination report must include a complete rationale for any opinion provided. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. 3. Only after obtaining private treatment records for sleep apnea, obtain a VA examination with medical opinion to address the claim for disability for sleep apnea. The decision for an in-person examination of the Veteran is left to the discretion of the examiner. The electronic records, to include a copy of this remand, should be made available to and reviewed by the examiner, and an opinion as follows is requested: Is it at least as likely as not (a 50 percent or greater probability) that the Veteran has sleep apnea that a) had an onset in service; or b) is otherwise related to service? The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. In considering any lay statements of record, the examiner should note that the Veteran is competent to attest to matters of which he had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. [CONTINUED ON NEXT PAGE] The examination report must include a complete rationale for any opinion provided. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Kim, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.