Citation Nr: 22016509 Decision Date: 03/22/22 Archive Date: 03/22/22 DOCKET NO. 18-40 829 DATE: March 22, 2022 ORDER Service connection for paranoid schizophrenia is granted. REMANDED The appeal regarding entitlement to service connection for an acquired psychiatric disorder other than paranoid schizophrenia is remanded. FINDING OF FACT The Veteran's paranoid schizophrenia was manifested to a compensable degree within one year of his separation from service. CONCLUSION OF LAW The criteria to establish service connection for paranoid schizophrenia have been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from March 1972 to February 1973. This matter comes before the Board of Veterans' Appeals (Board) from a December 2017 rating decision by the Agency of Original Jurisdiction (AOJ) that denied service connection for schizophrenia and major depressive disorder. A Board hearing was held in November 2021. A transcript is of record. Entitlement to VA compensation may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C. §§ 1110 (wartime service), 1131 (peacetime service); 38 C.F.R. § 3.303. To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service incurrence or aggravation of psychosis may be presumed to have been incurred or aggravated if the disability is manifested to a compensable degree within one year of the Veteran's discharge from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. The Veteran has a current diagnosis of paranoid schizophrenia. See November 2017 VA examination report. A May 1974 report from the State of California Department of Mental Hygiene indicates a diagnosis of schizophrenia, paranoid type. The Veteran was admitted in January 1974. At that time, he was uncooperative, and was experiencing paranoid delusions. The author noted that the Veteran had been transferred from a county mental health clinic where he had completely destroyed and demolished a room. Given the current diagnosis of paranoid schizophrenia and evidence that it manifested to a compensable degree within one year following the Veteran's separation from service, the Veteran's schizophrenia may be presumed to have been incurred during service. Thus, service connection for paranoid schizophrenia is granted. REASONS FOR REMAND The record reflects psychiatric diagnoses in addition to the Veteran's schizophrenia. An August 2017 VA outpatient treatment note indicates a past medical history of major depressive disorder. Records of mental health treatment from March 2018 to May 2018 variously indicate anxiety and depression. A diagnosis of major depressive disorder was noted in March 2019. Records of private treatment from July 2018 to January 2019 indicate depression and posttraumatic stress disorder (PTSD). Given the various diagnoses in the record, the Board concludes that an examination is necessary to determine the nature and etiology of any psychiatric diagnosis other than paranoid schizophrenia, to include whether any such diagnosis is related to the Veteran's now service-connected paranoid schizophrenia. The Board additionally notes that the Veteran has reported that he filed for Social Security Administration (SSA) benefits. See March 2017 VA Psychology Telephone Encounter Note. The record is unclear as to whether SSA awarded such benefits, and if so, whether they were based on age or disability. Clarification should be sought, and if benefits were granted based on disability, records should be obtained from SSA. The matters are REMANDED for the following action: 1. Contact SSA and inquire whether a disability benefits claim for the Veteran has been submitted and adjudicated. If so, request a copy of the complete SSA disability benefits file, including any administrative decision(s) on the Veteran's application for SSA disability benefits and all of the underlying medical records. A copy of any response(s) from SSA, to include a negative reply, should be included in the claims file. All records provided by SSA also should be included in the claims file, to include uploading any disc supplied by SSA to the Veteran's electronic record. 2. Schedule the Veteran for an examination to determine the nature and etiology of any diagnosed acquired psychiatric disorder other than paranoid schizophrenia. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the clinician. The examination must include a notation that this record review took place. After the record review and examination of the Veteran, the examiner should indicate whether the Veteran has any acquired psychiatric disorder that is separate and distinct from his service-connected paranoid schizophrenia. If so, the examiner should provide an opinion regarding whether it is at least as likely as not that such disorder was incurred in or is otherwise related to active service. The examiner should also offer an opinion as to whether it is at least as likely as not that any acquired psychiatric disorder other than paranoid schizophrenia was caused or aggravated by the Veteran's schizophrenia. In rendering this opinion, the examiner is asked to specifically address treatment records showing diagnoses of major depressive disorder, depression, anxiety, and PTSD. The examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. The complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the examiner must provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. (Continued on the next page) 3. Then, readjudicate the Veteran's claim. If the decision remains adverse to the Veteran, he and his representative should be furnished a supplemental statement of the case (SSOC) and afforded an appropriate period within which to respond thereto. DONNIE R. HACHEY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Barone, Counsel Then, readjudicate the Veteran's claims, with application of all appropriate laws, regulations, and case law, and consideration of any additional information obtained as a result of this remand. If the decision remains adverse to the Veteran, he and his representative should be furnished a supplemental statement of the case (SSOC) and afforded an appropriate period within which to respond thereto. 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.