Citation Nr: 21029145 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 19-05 546 DATE: May 12, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include unspecified schizophrenia spectrum and other psychotic disorder, is granted. REMANDED Entitlement to an initial rating in excess of 10 percent for a left wrist disability is remanded. FINDING OF FACT The Veteran's acquired psychiatric disorder, to include unspecified schizophrenia spectrum and other psychotic disorder, had its onset in service. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disorder have been met. 38 U.S.C. §§ 1110,1111, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from November 1963 to November 1965. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2016 rating decision by the Little Rock, Arkansas Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge in a March 2021 video conference hearing. Inasmuch as the evidence of record reflects multiple psychiatric diagnoses, the Board has recharacterized the claim as one for service connection for an acquired psychiatric disorder, to include unspecified schizophrenia spectrum and other psychotic disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a service connection claim for a specific psychiatric entity encompasses all psychiatric diagnoses shown by the record). Service Connection Entitlement to service connection to an acquired psychiatric disorder. The Veteran contends that he is entitled to service connection for an acquired psychiatric disorder as it had its onset during service. March 2021, Hearing transcript. Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table decision). A veteran is presumed 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. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Only such conditions as are recorded in entrance examination reports are to be considered as "noted," and a history of pre-service existence of conditions recorded at the time of examination does not constitute a "notation" of such conditions. Crowe v. Brown, 7 Vet. App. 238, 245 (1994). To rebut the presumption of sound condition under 38 U.S.C. § 1111 for disorders not noted on the entrance or enlistment examination, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. VAOPGCPREC 3-2003 (July 16, 2003); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). Clear and unmistakable evidence is a more formidable evidentiary burden than the preponderance of the evidence standard. See Vanerson v. West, 12 Vet. App. 254, 258 (1999) (noting that "clear and convincing" burden of proof, while a higher standard than a preponderance of the evidence, is a lower burden to satisfy than clear and unmistakable evidence). It is an "onerous" evidentiary standard, requiring that the no-aggravation result be "undebatable." Cotant v. West, 17 Vet. App. 116, 131 (2003) (citations omitted). On the January 1963 entrance report of medical examination, the Veteran's clinical psychiatric examination was normal. In the accompanying report of medical history, the Veteran indicated he had a history of nervous trouble, excessive worry, and depression. Inasmuch as a psychiatric disorder was not found on entrance examination, and only a pre-service indication of nervousness, worry, and depression was self-reported on the entrance history report without a previous diagnosis, the presumption of soundness applies in this case and it is presumed the Veteran was in sound condition upon entry into service. The Board acknowledges that the September 1965 separation examination includes an examiner's note that the Veteran had a mild, situational nervous breakdown in 1960 that required a two-day hospital stay. However, without an independent basis in the record to support a pre-service psychiatric diagnosis, this note is insufficient to rebut the presumption of soundness. See Miller v. West, 11 Vet. App. 345 (1998). Therefore, the Board finds that the evidence is not clear and unmistakable that any psychiatric disorder pre-existed service. 38 U.S.C. § 1111. The Veteran's service treatment records (STRs) indicate a mental health interview was requested in August 1964. Post-service treatment records show a diagnosis of unspecified schizophrenia spectrum and other psychotic disorder. See December 2018, VA examination. Thus, the Veteran has a current psychiatric disorder. Medical records indicate the Veteran's complaints of depression, anxiety, and paranoia, as well as a history of psychiatric hospitalization in the 1990s with intermittent hallucinations. See VA treatment records dated August 2009, March 2016, and September 2017; December 2018, VA examination. The Veteran testified to experiencing continuous psychiatric symptoms that had its onset during active service. Specifically, the Veteran indicated psychiatric problems began in basic training after President Kennedy was assassinated because some of his fellow soldiers responded with laughter after learning of President Kennedy's death. The Veteran also stated he was assaulted by an officer. As a result, the Veteran testified that he became fearful of his fellow soldiers and lost his ability to trust others; his distrust has been continuous since discharge from service. See March 2021, Hearing transcript. The Board acknowledges the negative nexus opinion provided on the December 2018 VA examination. The Board finds the opinion to be inadequate in addressing the etiology of the Veteran's psychiatric disorder as the examiner addressed the disorder as pre-existing service. However, as noted above, the presumption of soundness applies in this case as a psychiatric disorder was not "noted" on service entrance examination. In addition, the Veteran is competent to report continuous psychiatric symptoms, and the Board does not question the credibility of the Veteran's reports of same. Accordingly, the Board finds the December 2018 VA opinion inadequate. Here, in light of the competent and credible lay evidence, the Board finds that the Veteran's diagnosed acquired psychiatric disorder became manifest while he was on active duty. As such, the Board concludes that the evidence shows that the disorder became manifest while the Veteran was on active duty and thus incurred in service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303, 3.304(b). Resolving all reasonable doubt in the Veteran's favor, service connection for an acquired psychiatric disorder is therefore warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND Entitlement to an initial rating in excess of 10 percent for a left wrist disability is remanded. The Veteran contends that his left wrist has worsened since the most recent April 2018 VA examination. Specifically, he indicated left wrist symptoms include reduced grip strength, pain, trouble buttoning things, and dropping objects because he forgets that he is holding them. See March 2021, Hearing transcript. Under the circumstances, the Board finds that VA is required to afford the Veteran a contemporaneous VA examination to assess the current nature, extent, and severity of his service-connected left wrist disability. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Thus, the issue must be remanded. The matter is REMANDED for the following action: 1. Obtain any outstanding VA treatment records since June 2018. 2. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge of the nature, extent and severity of his left wrist disability and the impact of the condition on his ability to work. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 3. Schedule the Veteran for a VA examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) to determine the current severity and impact of his service-connected left wrist disability. The examiner is asked to address the following: (a.) The examiner must attempt to elicit information regarding the severity, frequency, and duration of any left wrist problems, including all orthopedic and/or neurological manifestations present. (b.) Please provide an opinion as to the full range of motion of the Veteran's left wrist in (1) active motion, (2) passive motion, (3) in weight-bearing, and (4) in non-weight-bearing. Please specify range of motion measurements in all areas outlined above. If the examiner cannot provide an opinion without resorting to speculation, he or she should explain why an opinion cannot be provided (e.g., lack of sufficient information/evidence, the limits of medical knowledge, etc.). (c.) The examiner should describe any pain, weakened movement, excess fatigability, instability of station, or incoordination present. (d.) The examiner should state whether the examination is taking place during a flare-up. If not, the examiner should ask the Veran to describe the flare-ups he experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity, and/or extent of functional impairment he experiences during a flare-up of symptoms and/or after repeated use over time. (e.) Please identify all neurological residuals, to include reduced grip strength. The examiner should provide a detailed rationale for any opinion expressed. If an opinion cannot be rendered without resorting to speculation, the examiner should state why that is so. STEVEN D. REISS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Straughn, 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.