Citation Nr: 21023646 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 12-12 824 DATE: April 21, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia and PTSD, is granted. FINDING OF FACT 1. The Veteran served in combat in the Republic of Vietnam and was awarded the Bronze Star Medal for heroism. 2. The Veteran’s schizophrenia is due to his military service. CONCLUSION OF LAW The criteria for entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia and PTSD, are met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 4.125. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from February 1969 to January 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2011 rating decision (RD) of the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin denying the Veteran’s claim for post-traumatic stress disorder (PTSD). In July 2018 and November 2020, the Board remanded the claim for additional development and adjudication of outstanding issues. It has since been returned to the Board for further appellate consideration. The U.S. Court of Appeals for Veterans Claims (CAVC) has held that the scope of a claim for service connection for disability includes any disability that reasonably may be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). In accordance with Clemons, the Board has expanded the issue on appeal to service connection for an acquired psychiatric disability, to include schizophrenia and PTSD. 1. Entitlement to service connection for acquired psychiatric disorder, to include schizophrenia and PTSD The Veteran contends that he is entitled to service connection for PTSD due to his active service. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). In general, there must be competent 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 disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1164, 1166-67 (Fed. Cir. 2009). Service connection may be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For chronic diseases manifestation during service or within 1-year post-service or a showing of continuity of symptomatology may serve to satisfy the nexus element. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran’s reflects a longstanding diagnosis of schizophrenia. See April 1994 Medical Certificate, July 1994, September 2009, February 2011 and February 2021 VA Examinations, January 2003 Veteran Statement, August 2003 and March 2006 VA Medical Treatment Records, February 2005 Hearing Testimony, May 2012 Third Party Correspondence. The Board finds that the Veteran has a current disability of the same. Thus, the first element of service connection is satisfied. With regard to the in-service incurrence element, the Board concludes that the Veteran is entitled to application of the combat presumption. 38 U.S.C. § 1154(b). The Veteran testified that while he was stationed in Vietnam he was exposed to enemy attacks, gunfire, and explosions. See February 2005 Hearing Transcript. He testified that he initially served in the infantry and was often in heavy combat and that he never knew if he was going to survive from one day to the next. Id. The Veteran was awarded the Bronze Star Medal for heroism in connection with his actions against hostile forces when he “exposed himself to the intense hostile fire as he moved forward to the point of heaviest contact and began placing a heavy volume of suppressive fire upon insurgent forces. His actions were…instrumental in the successful completion of the mission.” See April 1995 Military Personnel Record, DD-214. As the Veteran had combat service, he is entitled to the combat presumption. The combat presumption lowers the evidentiary burden for combat veterans to show proof that they incurred their disability or injury in service. Id. In the case of a combat veteran, the presumption extends to the incurrence of an injury or disease during service and the disability itself. Reeves v. Shinseki, 682 F.3d 988, 998-99 (Fed. Cir. 2012). The Veteran’s enlistment examination was silent for any diagnosis, treatment, or history of any mental health disorders and he indicated he was in good health. See April 1995 Medical Treatment Records. Prior to enlisting, the Veteran indicated that he had worked for 3 years in the assembly department at a Ford Motor. Id. The Veteran testified that prior to service he did not have nightmares or hear any voices. See February 2005 Hearing Testimony. The Veteran testified that while on leave during active duty, he was in Hawaii with his wife and heard what may have been fireworks nearby; this caused him to drop to the ground in response. The Veteran testified this was the first time he noticed his paranoia. Id. Therefore, the Board concludes that the Veteran is presumed to have symptoms of his schizophrenia during service. Reeves v. Shinseki, 682 F.3d 988, 998-99 (Fed. Cir. 2012). Moreover, the Veteran has reported experiencing symptoms continuously since service. The record also contains notations of unusual behavior shortly after service. In a December 1974 medical note, the physician noted an incident of disruptive behavior on the ward floor after the Veteran underwent surgery on his right knee. See June 1975 Medical Treatment Record. The physician stated this was due to poor impulse control and overall immaturity, however there are no additional details of the incident provided. Id. The Veteran reported that he started receiving treatment in the mid 1970’s due to hearing voices and was hospitalized due to his condition. See September 2007 VA Examination. However, there are no medical treatment records from that period. In June 1981, the Veteran filed a Statement in Support of Claim, in which he requested the VA reopen his earlier claim for a nervous condition, noting he was being seen by two doctors and that he would submit evidence regarding that care. No evidence was actually submitted. The Veteran filed a March 1994 claim for a neurological disorder. During a July 1994 VA examination, the Veteran reported that he had been hospitalized in 1975 for his condition. He reported that he was able to communicate with the television and the radio and that he believed people were trying to read his mind and that he could read their minds. He reported hearing voices. The examiner diagnosed him with schizophrenia and determined he did not meet the criteria for a diagnosis of PTSD. During a February 2011 VA examination, the Veteran reports he was a “nervous wreck” while in service due to the constant noise level, gun fire and explosions. The Veteran reported auditory hallucinations, sleep impairment and social withdrawal. The Veteran reported being unemployed for over 20 years due to his mental health condition, including his auditory hallucinations. The examiner opined that the Veteran’s condition was less likely than not caused by his service. In a February 2021 VA examination, the Veteran reported auditory hallucinations and nightmares. The examiner diagnosed him with schizophrenia and opined his condition was less likely than not due to service because his service treatment records were silent for complaints, treatment or diagnosis or any mental health disorder while in service. Id. While the Veteran reported being unable to adjust to life after returning from service, including maintaining employment and stable housing, the examiner stated there was no evidence to suggest this was a result of his schizophrenia. Id. Although the VA examiners opinioned the Veteran’s condition was not due to service, the evidence of record is consistent that the Veteran reported hearing voices, having nightmares, flashbacks, paranoia, and hypervigilance since his separation from service. See April 1994 Medical Certificate, July 1994, September 2009, February 2011 and February 2021 VA Examinations, January 2003 Veteran Statement, August 2003 and March 2006 VA Medical Treatment Records, February 2005 Hearing Testimony, May 2012 Third Party Correspondence. In addition, the Veteran testified that during the 1970’s and 1980’s, that he was treated for his mental health disorder at the Detroit VA Medical Center, the Veteran’s Center and Michigan Osteopathic Hospital. See February 2005 Hearing Testimony. The hospital has since closed, and the medical records are unavailable. See October 2004 Third Party Correspondence. This testimony would explain the lack of medical records from the 1970s and 1980s and is further corroborated by the June 1981 request to reopen the Veteran’s prior claim for a nervous condition. See June 1981 Statement in Support of Claim. The Board finds that the Veteran’s current disability is due to service. There are numerous negative medical opinions in the record, opining that the Veteran’s disability is not due to service. See e.g., February 2021 VA examination report. The February 2021 report indicates that the disability is not due to service in large part because the Veteran’s service treatment records are silent for any mental complaints, symptoms, or diagnosis. The examiner then indicates that the Veteran reported that he began experiencing symptoms of psychosis in the mid 1970’s. However, the Veteran reported onset of symptoms during service and the lack of notation during service is overcome by the combat presumption. The negative opinions essentially rely on the absence of symptoms during service for the negative conclusions, which is erroneous. The Board finds that the Veteran’s symptoms, resulting in his current diagnosis, demonstrate onset of the disability during service. The third element of service connection is met. Shedden, 381 F3d at 1166-67. Therefore, the Board finds that, affording the Veteran the benefit of the doubt, his acquired psychiatric disorder, to include schizophrenia, is due his active military service. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, entitlement to service connection for acquired psychiatric disorder, to include schizophrenia, is granted. J. B. FREEMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Aubee, 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.