Citation Nr: 22051285 Decision Date: 09/09/22 Archive Date: 09/09/22 DOCKET NO. 18-05 357 DATE: September 9, 2022 ORDER Entitlement to service connection for a delusional disorder is granted. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDING OF FACT The Veteran has a current delusional disorder that began in service. CONCLUSION OF LAW The criteria for service connection for a delusional disorder have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from March 1983 to February 1985. This matter is on appeal before the Board of Veterans' Appeals (Board) from an August 2016 rating decision. The Veteran testified before the undersigned Veterans Law Judge in August 2019. The Board denied the claim of service connection in April 2020 and the Veteran appealed the denial to the U.S. Court of Appeals for Veterans Claims (Court). In January 2021, both parties submitted a Joint Motion for Remand in which they requested the Court to vacate the April 2020 Board decision and return the matter to the Board. The Court granted the motion in January 2021 and remanded the matter to the Board for action consistent with the terms of the Joint Motion. In June 2021, the Board remanded for a medical opinion pursuant to the Joint Motion and to obtain outstanding private medical records. The Board remanded the matter again in April 2022 to obtain an adequate medical opinion. The Board finds that there was not substantial compliance with the remand but further development is unnecessary because the appeal is satisfied. Initially, the Board finds that the Veteran's delusional disorder did not preexist service. His entrance examination did not note a psychiatric disorder, and the evidence does not clearly and unmistakably show that his delusional disorder preexisted service and was not aggravated in service. The Board previously found that the August 2016, December 2021, and January 2022 VA medical opinions did not adequately address preexistence. VA obtained another medical opinion in May 2022, and the Board finds that this medical opinion is insufficient to demonstrate preexistence. The examiner concluded that the Veteran's delusional disorder "appears to have pre-existed service" and the "preponderance of the evidence would support that the veteran's mental health conditions pre-existed his military service." These conclusions do not constitute clear and unmistakable evidence of preexistence. The Board considered that the Veteran has reported his delusional disorder began before service but, as a layperson, such statements do not constitute clear and unmistakable evidence of a preexisting disorder. Accordingly, the Board finds that the Veteran entered service without a preexisting delusional disorder. The Board has considered the lay and medical evidence and finds that service connection is warranted for a delusional disorder. The Veteran's service treatment and military personnel records are associated with the claims file. In September 1983, a counseling record stated that the Veteran had received complaints regarding lengthy conversations with patients about religion that interfered with his duties, watching television on duty, lack of initiative in performance of his duties, and personality conflicts with his coworkers. He wrote a response to this record and stated that "the document was a total surprise to me" and "I hope I will be able to continue this endeavor without too much more interference or problems." On October 20, 1983, after being counseled, the Veteran stated that he had difficulty working under "dominant type females" and it was "within his constitutional rights to express himself verbally to anyone." Shortly after, on October 25, psychiatric testing was recommended due to ongoing personality conflicts, specifically with "females in authority position." Tests were administered on October 27, 1983 and a note from November 2, 1983 states that the Veteran was seen for "continued evaluation" and there was "no indication for further followup." The record also noted that the diagnosis was "mainly character behavior disorder." On November 3, 1983, a memo was issued by the Chief of the Family-Children's Clinic. She concluded that the Veteran did not have any psychiatric disease or condition that would warrant separation from service under AFR 35-4 and documented a diagnosis of mixed personality disorder with passive-aggressive and narcissistic features. She wrote that his condition is "chronic and characterological in nature which mainly reveals itself through habitual patterns of behavior which interfere with adequate adjustment and cause conflict with the environment," and he should be closely observed for future duty performance. On November 30, 1983, he received a letter of reprimand for substandard performance, failure to obey orders, and being discourteous to a patient. In March 1984, he received an 8/9 on his performance review for the previous year and it was noted that he had made "vast improvement in his duty performance" and his relationship and rapport with other staff members also improved but still required close observation. A January 1985 record of nonjudicial punishment proceedings stated that the Veteran was "derelict in the performance" of his duties on December 3, 1984. His actions included "engaging in a conversation[] having sexual overtones with a female patient," "touching the same patient in a sexually suggestive way," and "asking her to engage in sexual intercourse." A note from December 4, 1984 stated that another battery of tests was conducted, and assessment was deferred pending interpretation. The interpretation and diagnosis are not in the claims file. Later in January 1985, the Commander of the Medical Squadron Section recommended the Veteran for discharge for a pattern of misconduct. The Commander cited the incidents from September 1983, October 1983, November 1983, and December 1984 in support of his recommendation. Notably, for the section titled "medical or other data meriting consideration," the Commander only cited the November 3, 1983 psychiatric evaluation; he did not reference the battery of tests completed in December 1984. The Commander concluded that he did not recommend probation and rehabilitation because while "his personality problems with his supervisors and patients had shown improvement...the latest incident involving a female patient is inconsistent with a quality force." His January 1985 separation examination was normal, and he denied psychiatric symptoms and a personal of history of psychosis. The Veteran also noted that he was being discharged due to "mutual agreement." The Veteran's post-service treatment records date to 2003, including records from Idaho Department of Corrections from 2003 to 2015 and VA Vet Center records from 2004 to 2006. A January 2003 psychiatric clinic record notes that the Veteran was seen two weeks before, at which time "he did seem to have some somewhat paranoid delusional kinds of ideation about seeing people who looked like people he knew" and "he thought the person who had visited him as his wife was actually an imposter." The Veteran also reported that vocational rehabilitation believed he had borderline personality disorder, which the doctor said "seems to be a pretty accurate diagnosis." He was referred again for mental health treatment in December 2003. The psychiatrist wrote that "[the Veteran] did show me an evaluation he had had from Vocational Rehabilitation indicating some personality disorders...but seems as though his symptoms have probably gone beyond into psychotic paranoia at times." He further noted the Veteran continued to experience the same paranoid delusions reported in January 2003 and that he alleged he was innocent of the charges against him. In approximately 2004 or 2005, the Veteran wrote letters to his governor and the United States President. He requested pardons from the governor and claimed that he was "totally and absolutely innocent of allegations (all), accusations (all), and charges (all)" against him. He wrote the letter to the President backwards, and he alerted the President to a potential "tactical nuclear warhead" attack. The Veteran underwent group therapy through the VA Vet Center from April 2004 to July 2005. In April 2004, he expressed concern about upgrading his discharge and lost contact with his daughter. In April 2006, the Veteran contacted the Vet Center but was determined ineligible for ongoing services. The Vet Center record noted that he showed some evidence of delusional thinking processes. In February 2010, the Veteran requested mental health treatment for emotional and psychological difficulties. He also claimed he was a different person, and his case was one of a mistaken identity. In May 2010, the Veteran was admitted to the hospital for psychiatric evaluation. The record noted that he was arrested in 2006 for attempting to fraudulently obtain false social security numbers. He was extradited to another state to face charges for failure to register as a sex offender. Two psychologists evaluated him and determined he was not fit to proceed with his legal charges, and he was transferred to the hospital for further assessment, treatment of apparent paranoia, and restoration of fitness to proceed with the current legal charges. The examiner noted he did not demonstrate paranoia, and the initial assessment was psychosis NOS, rule out malingering. He underwent further psychiatric assessment in June 2010 and tests suggested likely malingering. His treatment records show that he reportedly believed he was a different person. He was discharged in August 2010, and the discharge diagnoses were malingering and an anxiety disorder. Subsequent records from prison contain further mental health treatment. In April 2011, his thought content and processes were intact, and he denied delusions. In April 2013, he stated that "when he came in to prison in 2011...he was psychotic." He stated he was diagnosed with borderline personality disorder in service and antisocial personality disorder previously. At a follow-up visit in April 2013, he was diagnosed with no Axis I disorder but he was diagnosed with antisocial personality disorder. The Veteran underwent a private psychiatric evaluation in February 2016. He reported a long mental health history, including diagnosis of a personality disorder in service and a psychotic break 10 years before that lasted for 4 years. The initial diagnosis was schizoaffective disorder and personality disorder. He underwent a VA examination in August 2016, at which time he was diagnosed with a delusional disorder and unspecified personality disorder. He reported that he had trouble with people in authority positions "if they reminded (him) of his parents" and "treated him poorly." He also reported that he was discharged for something that he "really didn't do" and "he became so upset about this that he asked for an early release." The examiner wrote that, per the Veteran's report, his symptoms were present prior to military enlistment and the evidence suggests that his delusional beliefs have been continuous and long-standing. The Board does not find that the nexus opinion regarding preexistence is probative, so did not consider that assessment in its analysis. In August 2019, a private licensed professional counselor submitted a statement in support of the Veteran's claim. She wrote that the lack of mental health treatment provided to the Veteran in service likely exasperated his situation. She further wrote it is impossible to suggest that his mental illness solidified prior to service as it was first diagnosed during his time in service. The only disorder diagnosed during service was the Veteran's personality disorder, which cannot be service-connected. Accordingly, the Board did not consider this opinion probative. The Veteran underwent a private mental health evaluation by a clinical neuropsychologist/psychologist in June 2022. The psychologist completed a thorough review of the claims file and concluded that the Veteran has a current delusional disorder that manifested in service. She pointed to several examples in the Veteran's record to support her conclusion his delusional disorder manifested in service. For example, she noted that, in service, the Veteran claimed the allegations against him were "fabricated," he was victim of "aggressive" and "dominant type females," he was mistreated, he hoped to do his job "without too much more interference of problems," and "it was within his constitutional rights to express himself verbally to anyone." She opined that, while these manifestations are not delusions, per se, they established a pattern of behavior that intensified later in service and are consistent with the onset of a delusional disorder. She also noted that the Veteran reported his discharge was due to mutual agreement, and this delusion has persisted for decades, "morphing into the believe that he 'quit' the Air Force." She further noted that the Veteran requested a pardon from his governor because he was falsely accused, and that the Veteran believed he was wrongly accused and would receive a pardon is suggestive of delusional thinking, and similar to his behavior in service. She highlighted that the Veteran's delusions likely became more prominent in late 1984, as he received a successful performance rating in March 1984, which prompted the additional tests but the results from the December 1984 battery of tests are not in the claims file. Finally, she stated that "empirical research has shown that exposure to stressors increase the risk for onset of delusional disorders" including "mistreatment by others" and people who develop psychosis do not necessarily experience more stressors than those who do not. She opined that the Veteran's "perception that he was being attacked was a stressor for him due to his history of abuse" and that the Veteran did not report specific stressors does not weigh against his claim because the authoritative nature of his superiors was a sufficient stressor. She opined that this stressor, coupled with his childhood abuse and inability to control his life in the military, increased his risk for developing a delusional disorder. Therefore, she concluded, he has a current delusional disorder that manifested in service. After reviewing the extensive lay and medical evidence, the Board finds that service connection is warranted. While there are some factual inaccuracies in the June 2022 medical opinion, the Board overall found it highly probative as the psychiatrist thoroughly reviewed the record and supported her conclusion with (predominantly) accurate citations to the record and scientific research. The record also supports her opinion that the Veteran's behavior in service was like his behavior that led to notes of delusions or diagnoses of a delusional disorder. The Board considered the June 2022 VA medical opinion but finds that it is not as probative as the private medical opinion. Specifically, the VA opinion states the private psychiatrist did not "make any indication that the veteran's behavior was related to delusional or dissociative thought processes;" however, the Board finds that she aptly explained why the Veteran's behavior indicated the beginning of his delusional disorder. Thus, the Board finds that service connection is warranted for a delusional disorder, and the claim is granted. REASONS FOR REMAND The Veteran's attorney claimed entitlement to a TDIU related to his delusional disorder in June 2022. The Board takes jurisdiction over this claim and finds that it must be remanded to the Agency of Original Jurisdiction for evidentiary development and rating of his delusional disorder. The matters are REMANDED for the following action: Provide the Veteran with notice for his TDIU claim and develop as appropriate. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Lavan 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.