Citation Nr: 21075529 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 18-54 154 DATE: December 20, 2021 ORDER Service connection for an acquired psychiatric disorder, to include schizophrenia and posttraumatic stress disorder (PTSD), is granted. FINDING OF FACT The evidence is at least evenly balanced as to whether the Veteran's pre-existing schizophrenia increased in severity, beyond natural progression, during service. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disorder, on the basis of aggravation of pre-existing schizophrenia, have been met. 38 U.S.C. § 1110, 1153, 1154(b); 38 C.F.R. §§ 3.102, 3.303, 3.306. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 4, 1969 to November 10, 1969. This case is before the Board of Veterans' Appeals (Board) on appeal from a July 2016 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. In that decision, the RO denied entitlement to service connection for PTSD. In August 2016, VA received the Veteran's Notice of Disagreement (NOD). In October 2018, the RO issued a Statement of the Case (SOC). In November 2018, VA received the Veteran's VA Form 9 appeal to the Board. In January 2021, the Veteran testified at a video conference hearing at the RO before the undersigned Veterans Law Judge (VLJ). A transcript of that testimony is of record. At the outset, the claim for service connection for PTSD is expanded to include all acquired psychiatric disorders. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Additionally, the Veteran has verified service in the Merchant Marine from March to July 1968. However, his Merchant Marine service did not occur during a time period during which Merchant Marine service has been determined to be active duty for VA purposes. 38 C.F.R. § 3.7(x). Service Connection 1. Entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia and PTSD. The Veteran contends that he has a psychiatric disorder that existed prior to service and was aggravated during service. See October 2018 VA Form 9. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). The requirements for establishing a diagnosis of PTSD are set forth in 38 C.F.R. § 3.304(f) and differ from those for establishing service connection generally. Service connection for PTSD requires medical evidence establishing a diagnosis of the disorder, credible supporting evidence that the claimed in-service stressor(s) occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor(s). 38 C.F.R. § 3.304. If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(2). A diagnosis of PTSD must be established in accordance with 38 C.F.R. § 4.125(a), which mandates that, for VA purposes, all mental disorder diagnoses must conform to the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-5). At the outset, the Veteran has a current diagnosis of "Unspecified Schizophrenia Spectrum and Other Psychotic Disorder." July 2016 VA psychiatric examination report. Although an August 2019 VA psychiatric evaluation revealed an assessment of PTSD, the Veteran does not have a current diagnosis of PTSD under the DSM-5. In this case, the evidence shows Veteran had a psychiatric disorder that existed prior to service. In this regard, the Veteran's April 1969 entrance examination report reflects that he was referred for psychiatric evaluation. See Service Treatment Records (STRs) dated April 18, 1969. Thereafter, in a May 1969 letter, a treating psychiatrist who conducted the psychiatric evaluation based on the referral indicated that the Veteran was experiencing an "adjustment reaction of adult life." The Veteran's symptoms during his period of Merchant Marine service suggested that "a simple or paranoid schizophrenia may be arising." The letter also indicates that the Veteran had been prescribed Thorazine, an antipsychotic used in the treatment of schizophrenia. R.F., letter dated May 5, 1969. In June 1969, a military physician found that Veteran experienced "what was possibly a borderline psychotic reaction" that "would preclude his serving in the military at this time." Specifically, the Veteran had developed "acute and moderately severe anxiety symptoms" while serving in the Merchant Marine "with some suggestions that he was possibly having some psychotic symptoms at the time." Symptoms while he was in the Merchant Marine included "dizziness" and a "loss of perception" by which the Veteran could not judge distances. See STRs dated June 16, 1969. Notably, the May 1969 letter advised that the Veteran's planned entrance into service should be delayed by six months to allow symptoms to abate. Similarly, the June 1969 physician stated that he "would not recommend [the Veteran] for duty" but would reconsider if the Veteran remained symptom-free for six months. Given the above, a psychiatric disorder existed at entrance into service and the presumption of soundness does not apply. See 38 U.S.C. § 1111, 1137. Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment; or, where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111. A pre-existing injury or disease will be considered to have been aggravated by active military service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. Aggravation may not be conceded, however, where the disability underwent no increase in severity during service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. Temporary flare-ups of a pre-existing disorder during service, without evidence of a worsening of the underlying condition, do not constitute aggravation. Hunt v. Derwinski, 1 Vet. App. 292, 296-97 (1991). If a presumption of aggravation under section 1153 arises, due to an increase in a disability in service, the burden shifts to the government to show a lack of aggravation by establishing "that the increase in disability is due to the natural progress of the disease." 38 U.S.C. § 1153; see also 38 C.F.R. § 3.306; Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994); Wagner v. Principi, 370 F. 3d 1089, 1096 (Fed. Cir. 2004). Against the recommendations of the May 1969 psychiatrist and June 1969 physician, the Veteran was drafted into active service on September 4, 1969 prior to expiration of the six-month holding period. After approximately two weeks of service, the Veteran was referred for psychiatric care. STRs indicate that the Veteran reported "dizziness," a recurrent nightmare in which he "blows up," and "the feeling that he is about to lose control." STRs dated September 16, 1969. During an interview, the Veteran manifested "inappropriate affects, peculiar ideas, grimaces, and mannerisms." The examining psychiatrist provided a diagnosis of "schizoid personality, chronic, severe with paranoid features." STRs dated September 16, 1969. Although a military psychiatrist opined that the Veteran was not mentally ill, but instead presented with "a severe borderline personality disorder," he nevertheless found that the Veteran should be "separated from service as quickly as possible." The psychiatrist recommended that the Veteran be maintained on Stelazine, an antipsychotic, at a dose of two milligrams twice per day. See STRs dated September 15, 1969. In a September 1969 statement, the Veteran's platoon leader stated that he had "personally observed [the Veteran] go into great stress upon receiving the most routine orders." D.F., statement dated September 26, 1969. Of record are similar statements from other superior officers regarding the Veteran's constant nervousness. The Veteran was discharged from service on November 10, 1969. In an August 2019 statement regarding his brief period of service, the Veteran reported experiencing repeated panic attacks during service in response to "mortars and rapid gunfire" on the training field. Furthermore, he indicated that he became involved in physical altercations with a drill sergeant and lieutenant. During the January 2021 Board hearing, the Veteran reported facing racial discrimination and was "ostracized" during active service due to his psychiatric disorder and was accused of being a "draft dodger." He stated that he struggled to sleep, feared for his life, and felt everyone around him had turned against him. See January 2021 Board hearing transcript at 7. A May 2016 VA mental health note indicates that the Veteran "started feeling like someone was out to get me after going into the service." He reported that he started hearing voices after going for days without sleep. He feared becoming a victim of a "blanket party" assault by other soldiers at night. See VA mental health note dated May 24, 2016. A September 2017 VA mental health note indicates that the Veteran first heard "voices" prior to service, which "increased during service," and have not stopped. He also endorsed witnessing visual hallucinations, in the form of moving shadows, following service, with onset in the 1970s; he recalled that he saw them "quite frequently" after coming home from service. VA mental health note dated September 1, 2017. The Veteran received an initial VA psychiatric examination in July 2016. As noted above, the examiner provided a diagnosis of Unspecified Schizophrenia Spectrum and Other Psychotic Disorder. During the examination, the Veteran reported that his documented pre-service psychiatric treatment resulted in fellow soldiers accusing him of attempting to "duck the draft." Moreover, he indicated that he "got into a couple of fights." The Veteran stated that he worried about being "physically attacked" and "being deployed to Vietnam." The examiner also noted the Veteran's reported auditory and visual hallucinations. However, the examiner found that the Veteran's claimed in-service stressors were inadequate to support a diagnosis of PTSD. The examiner opined that it was "less likely than not that the disorder was aggravated beyond its natural progression during service." The examiner gave no additional rationale for the opinion. During the January 2021 Board hearing, the Veteran's treating therapist, R.F., MSW, LCSW, stated that he believed the Veteran suffered a second psychotic break, following the first psychotic breakdown noted during Merchant Marine service, due to schizophrenia during his two-month period of service. R.F. noted that the Veteran was "hearing voices and seeing things" during service. He also noted the prescription of Thorazine to show that the Veteran's schizophrenia is the proper diagnosis for the psychiatric disorder that preexisted service. R.F. believed that the Veteran's in-service psychotic breakdown related to his preexisting schizophrenia was caused by ostracization and stress during boot camp. As a result, R.F. concluded that the Veteran's preexisting schizophrenia was permanently aggravated during service. See January 2021 Board hearing transcript at 17. In a February 2021 supporting statement, R.F. noted that, according to the DSM-5, "prolonged stress has a negative impact on the brain and may cause psychosis." As applied to the Veteran's case, R.F. stated that "[f]or a person who has a mental illness[,] stress aggravates and exacerbates preexisting mental illnesses due to chemical build ups causing toxicity." Moreover, again citing the DSM-5, R.F. stated that "individuals experiencing a second psychotic break are more likely to experience a third and typically symptomatology worsens and becomes more pronounced." Finally, R.F. indicated that "persons with preexisting mental illnesses experiencing prolonged stress are particularly vulnerable in that it aggravates and exacerbates symptomatology." R.F., MSW, LCSW, February 2021 letter. In this case, the Veteran is competent to report lay observable symptoms, such as anxiety, panic attacks, nightmares, sleep impairment, dizziness, and auditory and visual hallucinations. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Furthermore, there is no reason to doubt his credibility in this regard, given that pre- and in-service records thoroughly document psychiatric symptomatology; although STRs do not specifically identify auditory or visual hallucinations, such symptoms are consistent with the other severe symptoms noted during service and prescription of antipsychotic drugs prior to and during service. Accordingly, the Veteran is credible in this regard. See Caluza v. Brown, 7 Vet. App. 498 (1995). Nonetheless, he is not competent to opine regarding permanent aggravation of any psychiatric disorder present during service. Jandreau, 492 F.3d at 1377 n.4. Turning to the probative value of the medical opinions of record, the following factors are considered when evaluating the probative value of medical opinions: (1) whether the examiner is informed of the pertinent factual premises i.e. medical history of the case; (2) whether the examiner provides a fully articulable opinion, avoiding speculative language that does not provide the certainty needed for medical nexus evidence; and, (3) whether the opinion is supported by a reasoned analysis. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-4 (2008). The July 2016 VA psychiatric examiner provided no discernable rationale for the negative opinion provided in the examination report. Accordingly, the July 2016 opinion is afforded no probative value. However, during the January 2021 Board hearing and in the February 2021 supporting statement, R.F. thoroughly analyzed the Veteran's medical history and applied pertinent medical literature to support the conclusion that the Veteran's schizophrenia had manifested prior to service and was permanently aggravated during service. Accordingly, R.F.'s opinion is afforded high probative value. In conclusion, the evidence is at least evenly balanced as to whether the Veteran's preexisting schizophrenia increased in severity during service. As such, there is a presumption of aggravation in this case because there is a finding that the pre-existing schizophrenia underwent an increase in severity during service. Moreover, the medical evidence of record does not meet the clear and unmistakable standard necessary to rebut the presumption of aggravation because the evidence is evenly balanced as to whether the increase in severity is due to the natural progression of the disease. Therefore, the presumption of aggravation is not rebutted. Accordingly, service connection for schizophrenia on the basis of aggravation is warranted. L. B. CRYAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Small, Attorney Advisor 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.