Citation Nr: 21069461 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 14-26 225 DATE: November 18, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include personality disorder, depressive disorder, anxiety disorder, schizophrenia, obsessive-compulsive disorder, posttraumatic stress disorder (PTSD), and cognitive disorder, is remanded. REASONS FOR REMAND The Veteran had active service from March 1961 to October 1961. This case initially came before the Board of Veterans' Appeals (Board) on appeal from an August 2012 rating decision. This rating decision addressed the Veteran's claims in February 2011 for service connection for schizophrenia, followed by a September 2011 claim for service connection paranoid schizophrenia, obsessive compulsive disorder, PTSD, and borderline schizotypal personality disorder. In June 2016 and August 2019, the Board remanded the matter for additional evidentiary development. As noted at those times, all acquired psychiatric disorders diagnosed during the course of the appeal will be considered in addressing the Veteran's claim. In March 2020, the Board denied the Veteran's claim. In April 2020, his attorney filed a motion for reconsideration of the denial, which the Board granted in February 2021. Another remand is necessary. 1. Service connection for an acquired psychiatric disorder is remanded A remand is needed to attempt to obtain potentially relevant medical records and provide a VA examination to address the nature and etiology of current diagnoses. The Veteran contends that he currently has a psychiatric disorder that had its onset in service. His attorney representative also argues that the Veteran was presumed sound upon entry into service and any diagnosed personality disorder was aggravated by service, or he currently has schizophrenia that first manifested during service, or a stressful event for PTSD was shown by a September 1961 service record. See, e.g., July 2014, October 2016, and August 2018 arguments. The Veteran was provided VA examinations for his claim in 2012 and 2017, and the Board remanded the matter in 2016 and 2019 for additional VA examinations. The Veteran did not report for another VA examination scheduled in January 2020. As argued in the motion for reconsideration which the Board has granted, the claims file does not reflect that the Veteran was advised of the date of his missed VA examination. Thus, another remand is needed to attempt to provide him another VA examination to clarify any mental health diagnoses that have been present since his February 2011 claim for service connection, or recent in time to the claim. The Board notes that the February 2021 Board order of reconsideration was returned as undeliverable from the Veteran's last known address, noting that the P.O. Box had been closed, although a copy of the Order was also sent to his attorney and was not returned. The Veteran (or his attorney) has a duty to inform VA of his current address. However, attempts should be made obtain his current mailing address. Furthermore, a notice letter or appointment confirmation for the scheduled VA examination should be included in the claims file. The Veteran and his attorney are advised that failure to appear for an examination or provide an address may result in denial of his claim because further information is necessary. Upon remand, a VA examiner should address the nature and etiology of any current acquired psychiatric disorders, meaning any mental health diagnoses that have been present since the Veteran's February 2011 claim or recent in time to the claim. See Romanowsky v. Shinseki, 26 Vet. App. 289 (2013); McClain v. Nicholson, 21 Vet. App. 319 (2007); Martinez-Bodon v. Wilkie, 32 Vet. App. 393 (2020). As summarized briefly in the prior remands, as well as in the May 2020 decision that has been vacated for reconsideration, there are multiple potential mental health diagnoses of record, with the earliest one during service in 1961. The evidence reflects reported events and/or abnormal behavior before, during, and after service. Some relevant records, but by no means all of them, are summarized below in the remand directives; the examiner should consider all relevant information. The examination report should opine whether any diagnosed personality disorder was subject to a superimposed disease or injury during service to result in a current diagnosis, any schizophrenia or other psychosis (to include schizoaffective disorder) first manifested to a compensable degree during service or within one year after service, any current PTSD is related to a verified stressor in service, or any other current diagnosis was incurred during service. As noted by the Veteran's attorney, servicemembers generally are presumed sound upon entry into service except for conditions or defects that are noted on an entrance examination, and no mental health disorder was noted on his entrance examination, although he reported nervous trouble. However, personality disorders and other congenital or development defects are subject to a different standard. Additionally, the Veteran has not identified a specific event during service to result in PTSD, referencing only his evaluation in September 1961 after he had cut his wrists or "stabbed" himself. See 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.384, 4.9, 4.125, 4.127. As noted in the prior Board remands, the 2012 and 2017 VA examinations did not adequately clarify or address the etiology of diagnoses noted during the appeal. There is also a suggestion of relevant outstanding medical records that should be obtained. The evidence includes VA treatment records from 2011 through 2018. In 2016, his attorney submitted copies of such records from September 2011 through July 2015. In 2019, the Board remand directed that any outstanding VA or other treatment records be obtained for the Veteran. In October 2019, the Veteran's attorney responded that he only receives VA treatment. However, no additional VA treatment records have been added to the claims file since May 4, 2018; therefore, any VA treatment or mental health records since that time should be obtained. As noted above, the Veteran reported non-VA treatment for years prior to seeking VA treatment in August 2011. In October 2016, he identified treatment from Dr. T and Dr. A. Although he did not identify dates of treatment, he stated that Dr. A had passed away seven years ago and no records were available. In November 2016, VA made second requests for records of treatment from both providers, with no success, and notified the Veteran of such attempts. VA received a notice of returned mail from Dr. T stating that he had been gone from that address for six years and was deceased. Thus, the sufficiently identified non-VA records are not available. However, there is evidence that the Veteran has been receiving disability benefits from the Social Security Administration (SSA) since 1973, which he has reported were initially due to his left leg amputation but were continued due to his mental health. See May 2011 SSA inquiry information and August 2012 VA examination. Although the initial decision and records related to those benefits are likely unavailable, any available medical records from the SSA should be obtained. The matters are REMANDED for the following actions: 1. Obtain any outstanding VA treatment records for the Veteran, to include inpatient or outpatient mental health records, dated since May 4, 2018. 2. Obtain any decision documents and mental health or medical records available from the Social Security Administration for the Veteran's disability benefits, to include the initial decision and continuing entitlement. 3. Thereafter, schedule the Veteran for a VA examination to address his claim for a mental health disability, to be completed by a psychologist or psychiatrist. Make attempts to obtain the Veteran's current mailing address, as the mail to the last reported P.O. Box address was returned as closed in April 2021. A notice letter or appointment confirmation for the scheduled VA examination should be included in the claims file. The examiner should address the following, and explain the reasons behind any opinions and conclusions reached. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. In addressing the following, the examiner should consider the lay and medical evidence summarized below, along with other relevant evidence: (a) Clarify any psychiatric disorders, personality disorder or otherwise, that have been present at any point since the February 2011 claim or recent in time to the claim. Any such disorder is a considered "current" disorder. (b) Was any current personality disorder at least as likely as not subject to (or aggravated by) a superimposed disease or injury in service to result in an additional disability other than personality disorder? If so, identify the current additional disability and the superimposed disease or injury during service. (c) Has the Veteran had schizophrenia, schizoaffective disorder, schizophreniform disorder, other specified schizophrenia spectrum or other psychotic disorder since his February 2011 claim or recent in time to that claim? If so, is at least as likely that such diagnosis first manifested during service to or compensable degree within one year after service discharge (or by October 23, 1962)? (d) Has the Veteran had PTSD at any time since his February 2011 claim or recent in time to that claim? If so, is PTSD at least as likely as not any related to service? If so, identify a verified in-service stressor for such diagnosis. (The examiner is advised that there is no possible fear of hostile military or terrorist activity, no in-service PTSD diagnosis, and no allegation of personal or sexual assault, only self-harm of cutting or stabbing during and after service.) (e) For any other mental health diagnosis that has been present since the Veteran's February 2011 claim or recent in time to that claim (to include generalized anxiety disorder or depressive disorder), was the current diagnosis at least as likely as not incurred in, caused by, or otherwise related to service? (f) Potentially relevant evidence for consideration (along with other relevant evidence or literature): After a normal service enlistment examination in March 1961, a May 2, 1961, psychiatric evaluation noted that the Veteran was referred by his Commanding Officer prior to possible administrative separation "due to behavior during basic training suggestive of mental illness." The Veteran had requested of another recruit and a cadreman that they stab him, and he had been observed putting his finger into light sockets and spoke of jumping from high places. During the interview, the Veteran stated that these were not serious and were "done in jest." He also denied any anti-social behavior or antecedent (prior) episodes of psychological illness. The Veteran did report that he was always "nervous and finicky," but he did not feel that this was incapacitating to him. The examiner found that there were no signs or symptoms of a major psychological disorder. The Veteran stated that he wanted to complete his military obligation and did not want to be out of the service. The examiner found no psychiatric disease, diagnosis, or disqualifying defect for service. Thus, the examiner recommended retention on duty and reevaluation if "further evidence of immature behavior manifest[s itself." A June 1961 examination for airborne training was also clinically normal for any psychiatric condition. The Veteran denied any nervous trouble or other symptoms. An August 11, 1961, service treatment record noted that the Veteran was seen for an evaluation interview and received psychological testing. On September 19, 1961, he was admitted to the neuropsychiatric ward for suicidal gestures. A September 27, 1961, neuropsychiatric evaluation diagnosed the Veteran with "emotional instability reaction, manifested by impulsivity, schizoid traits, erratic behavior, and irresponsibility." The record noted increasing difficulty in adjusting to the military, a chaotic family background, and a history of erratic and disordered behavior with marked nonconformity to social structures. The Veteran had been repeatedly cutting himself superficially, which the examiner stated was a prime example of an attention-gaining mechanism when faced with what he considered unpleasant situational problems. The examiner concluded that the Veteran's problem was "a personality defect or character and behavior disorder with immaturity which results in his clinical picture." Separation was recommended. A September 28, 1961, evaluation for discharge diagnosed "emotional instability reaction" as a psychiatric clinical abnormality, although the Veteran denied nervous trouble, depression or excessive worry, or other potential mental health symptoms. An October 13, 1961, Commanding Officer's Report recommended that the Veteran be discharged from service due to unsuitability. The Veteran had first come to the Captain's attention after slashing his wrist, when he stated that he had done this several times and would continue to do so, and the "reason he would try to kill himself is to get attention from other men." He had been at this assignment since September 1, 1961, and he had received counselling from several individuals. An October 18, 1961, memorandum states that the Veteran "has the attitude that he will do anything to get out of the service." He was being held in the psychiatric ward due to his attempted suicide, and the Colonel believed that the Veteran "would never be able to adjust to military life due to his personality problems." A record of military service reflects that the Veteran was deemed to have excellent or good ("G") conduct and efficiency through August 1961, but in his assignment beginning September 1, 1961 (as noted above), he was found to be unsatisfactory. He enlisted for airborne training and received training as a medical specialist. His principal duties were for basic training through early June 1961, advanced individual training through late July 1961, medical specialist training through late August 1961, and basic airborne training beginning September 1, 1961. After service, the Veteran first sought VA treatment in 2011. A September 8, 2011, VA mental health record for discharge from an admission beginning August 29, 2011, after a friend found him cutting himself, reflects diagnoses of schizophrenia (paranoid type), obsessive-compulsive disorder, PTSD, borderline personality disorder, and schizotypal personality disorder. Another record signed September 8, 2011, based on psychiatric testing conducted on September 7th, also noted a mental disorder not otherwise specified (NOS) due to a general medical condition. A September 18, 2011, followup record further noted PTSD, non-military, and the Veteran reported a long history of private mental health treatment. He reported being sexually abused by his adoptive father for years. These records also reflect that the Veteran had a history of self injury and scars of the abdominal wall, and that he cuts himself to relieve depression and agitation, not an intent to kill himself. A September 30, 2011, VA record (cosigned on October 14, 2011, by a psychologist) based on psychiatric testing noted that the Veteran had his left leg amputated above the knee in 1972 due to gangrene and severe infection. He reported that his mother died from cancer when he was three months old, his father died when he was eight years old, and he grew up at a children's home. He also stated that he quit school in the 10th grade and obtained a GED in 2008. The Veteran reported making pipe bombs and shooting at airplanes at ages 14 to 15, as well as during his adulthood, for which he reported arrests and FBI investigations. The provider noted that the Veteran had been diagnosed with depressive disorder when he was recently admitted for VA treatment, and he reported a history of cutting himself (primarily on his abdomen) on a regular basis for the past ten years, which he stated was due to feeling nervous or to relieve depressive symptoms. The provider also reviewed records from a community mental health center and summarized that they reflected treatment for chronic paranoid schizophrenia, depressive disorder NOS, and possible obsessive-compulsive disorder (OCD) from 2009 to 2010, including five inpatient hospitalizations. There were numerous prior hospitalizations noted as due to cutting himself and a chronic history of schizophrenia with some symptoms consistent with OCD. The Veteran had been hospitalized for during service in 1961 after a suicide attempt from cutting his arm. The September 30, 2011, VA treatment record stated that the results of testing overall appeared valid for assessment, and the purpose was to clarify his current diagnoses. The conclusions were that the Veteran's diagnoses were Axis I generalized anxiety disorder and cognitive disorder; and Axis II personality disorder with schizoid, antisocial, and borderline features (or mixed personality disorder), and a cognitive disorder. The current assessment did not support the diagnoses of schizophrenia or possible OCD as noted in prior treatment records. The most recent VA treatment records in the claims file are dated in January 2018 and May 2018, and such records noted treatment for current diagnoses of schizoaffective disorder (depressive type) and personality disorder (unspecified). Evidence in treatment records is not necessarily dispositive of a current mental health diagnosis or etiology, as the providers generally accept the Veteran's reports as to his history as true and may not have knowledge of all relevant evidence. A 2012 VA examiner diagnosed personality disorder, not otherwise specified (NOS) with schizoid, antisocial, and borderline personality features. The examiner noted that in October 2011 the Veteran showed evidence of generalized anxiety disorder, with anxiety likely underlying some of his somatic complaints. The previous diagnoses of schizophrenia and possible obsessive-compulsive disorder were not supported by the current assessment. The VA examiner opined that the Veteran's personality disorder, NOS, was not caused by or a result of his mental treatment in service. The rationale was that by definition a personality disorder has its onset in adolescence or early adulthood, and the Veteran began showing symptoms during childhood to early adolescence. The 2017 VA examiner opined that the Veteran does not have a diagnosis of PTSD. The examiner also opined that there is a diagnosis of unspecified personality disorder with antisocial and borderline traits, and that the signs of such disorder which were present before, during, and after service. The examiner stated the Veteran's behavior of cutting himself, which was described as "attention getting" during service, was deliberate, willful, and chronic since childhood. The VA examiner agreed with the in-service evaluation and the 2012 VA examiner that the Veteran's personality disorder was not caused in any way by military service. Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals C. CRAWFORD Veterans Law Judge Board of Veterans' Appeals Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Wheatley 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.