Citation Nr: 23017441 Decision Date: 03/21/23 Archive Date: 03/21/23 DOCKET NO. 19-00 499 DATE: March 21, 2023 REMANDED Entitlement to service connection for schizophrenia is remanded. REASONS FOR REMAND The Veteran had active military service from April 1979 to July 1979. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In March 2022, the Veteran testified before a Board hearing. The transcript of the hearing is of record. By way of background, in August 2022, the Board remanded the issue on appeal for further evidentiary development and adjudication. 1. Entitlement to service connection for schizophrenia is remanded. The Board's review of the claims file reveals that further action on the claim of entitlement to service connection for schizophrenia is needed. In August 2022, the Board determined that the Veteran has a current diagnosis of schizophrenia. The Board also noted that the service treatment records (STRs) showed that he had normal psychiatric condition with no endorsement of having frequent trouble sleeping, depression or excessive worry, loss of memory, or nervous trouble of any sort in the March 1979 examination. On April 20, 1979, he was admitted for extreme depression with suicidal ideation with possible hallucinations. Shortly thereafter, he was admitted again on May 9, 1979 for great deal of evidence of paranoid ideation and paranoid delusion. He was diagnosed with schizophrenia, paranoid type. See May 1990 STR Medical. On May 18, 1979, he underwent a medical separation examination wherein he was noted to have schizophrenia, paranoid type. He endorsed having frequent trouble sleeping, depression or excessive worry, loss of memory, nervous trouble of any sort, and periods of consciousness. He was considered medically unfit for service. See March 1980 Physical Evaluation Board Proceedings. The July 2019 VA examiner opined that the Veteran's acquired psychiatric disability pre-existed service and is unrelated to service. However, as the examiner did not use the correct legal standard for pre-existing disability the Board remanded the issue for further evidentiary development. Pursuant to the August 2022 Board remand order, the Veteran was afforded a VA examination in September 2022. The examiner opined that the claim condition, which clearly and unmistakable existed prior to service, was aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner explained due to the Veteran's dementia it is impossible to determine with any accuracy as to his military stressors which may have contributed to his schizophrenia. However, based on a thorough review of the records from Biloxi VA where Veteran received mental health care it was evident that multiple providers diagnosed and treated him for PTSD secondary to a military sexual trauma (MST) event. Despite his inability to describe the MST event, the examiner relied on the medical records of providers who worked with him prior to dementia diagnosis. An MST event would likely aggravate the Veteran's schizophrenia beyond its natural progression. This is not included anywhere in the military records, but it is well documented in post-military mental health records. It is well documented in medical literature that stressor events can either cause a psychotic break or exacerbate already present symptoms. As such it is more likely than not that the Veteran's schizophrenia was aggravated beyond its natural progression by the MST event in service. Oddly, the examiner also opined that there is no clear and unmistakable evidence that the Veteran's acquired psychiatric disability, to include schizophrenia, pre-existed his service. The examiner explained that the only documentation of a pre-existing condition was when the Veteran reported to the examiner that he had a previous suicidal gesture with auditory hallucinations in 1972 prior to service. This may have been false information and given at a time when he was experiencing psychosis and thus unreliable. The examiner opined that the claimed condition is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that although the Veteran's STRs documented that the Veteran had previous psychotic episode prior to service, this is documented nowhere else in the record. The examiner noted that the Veteran may have given incorrect information as he was psychotic at the time. Then, later, the examiner opined that it is at least as likely as not that the Veteran's acquired psychiatric disability began during, or is otherwise related to, his service. The examiner explained that he did not experience or endorse psychotic symptoms during the first few weeks of basic training. He had psychotic break a few weeks in. He reported that an MST event occurred to mental health providers post military. He was focused on a drill sergeant. He had hallucination about his drill sergeant wanting him to kill himself. The examiner again opined that it is at least as likely as not that his acquired psychiatric disability began, during, or is otherwise related to his service. The examiner noted that the Veteran had paranoid delusion in service at the time of hospitalization. He did not endorse having delusions prior to service. He also reported that he had nightmares during this time. He also hallucinated that his drill sergeant wanted him to kill himself. This appears to be a worsening of his psychotic symptoms if they did indeed exist prior to service. Although the examiner did not explicitly opine as to aggravation, the examiner noted that the Veteran had paranoid delusion in service at the time of hospitalization. He did not endorse having delusions prior to service. He also reported that he had nightmares during this time. He also hallucinated that his drill sergeant wanted him to kill himself. This appears to be a worsening of his psychotic symptoms if they did indeed exist prior to service. In an October 2022 VA addendum medical opinion, the same examiner noted that the August 2022 Board decision determined that the Veteran is an unreliable historian. As such, the examiner opined that it is less likely than not that the Veteran's schizophrenia and major neurocognitive disorder due to Alzheimer's disease were aggravated beyond natural progression. In a November 2022 VA addendum medical opinion, the same examiner noted that the Veteran is an unreliable historian and as such it is less likely than not that the Veteran's acquired psychiatric disability, to include schizophrenia, began in or was otherwise related to his service. Additionally, his schizophrenia and major neurocognitive disorder due to Alzheimer's disease were less likely than not aggravated beyond natural progression or incurred or caused by service. The Board finds a remand is warranted for various reasons. First, as noted above, the September 2022 VA examiner gave inconsistent medical opinion. The examiner opined that the claim condition, which clearly and unmistakable existed prior to service, was aggravated beyond its natural progression by an in-service injury, event, or illness. However, later, the examiner also opined that there is no clear and unmistakable evidence that the Veteran's acquired psychiatric disability, to include schizophrenia, pre-existed his service. The examiner also opined that the claimed condition is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. Then, later, the examiner opined that it is at least as likely as not that the Veteran's acquired psychiatric disability began during, or is otherwise related to, his service. The examiner submitted addendum medical opinions in October 2022 and November 2022 with no rationale. Second, the examiner hinted that although there was no evidence of MST in service his worsening condition supports his claim of a stressor. Although the Board finds that the Veteran is not a reliable historian and cannot confirm the MST event, the examiner's opinion appears to indicate that although the stressor cannot be confirmed, the worsening of his condition shows that a stressor occurred which was a catalyst to worsening of his condition. However, as the medical opinion is inconsistent, the Board finds that a remand is warranted to obtain clarification. The matter is REMANDED for the following action: 1. Obtain an addendum medical opinion by an appropriately qualified examiner to determine the nature and etiology of any current psychiatric disorder except PTSD. The claims file, including a copy of this remand, must be made available to the examiner. A record of the review of the claims file should be documented in the examination report. (a) The examiner must identify each current psychiatric diagnosis found to be present (except PTSD). (b) After providing any current diagnoses pertaining to the claim for an acquired psychiatric disorder, to include schizophrenia, is there clear and unmistakable (i.e., undebatable) evidence that the Veteran's acquired psychiatric disability, to include schizophrenia, pre-existed his active-duty service? Clear and unmistakable evidence means evidence that cannot be misinterpreted and misunderstood, i.e., it is undebatable. If clear and unmistakable evidence if found, it must be clearly identified for the record. (1) If the response to (b) is "yes," that there is clear and unmistakable evidence that an acquired psychiatric disability/schizophrenia pre-existed his service, is there clear and unmistakable evidence that his pre-existing psychiatric disability/ schizophrenia was NOT aggravated during his service? (2) If the response to (b)(1) is "no," the examiner should opine as to whether it is at least as likely as not (a fifty percent probability or greater) that the Veteran's acquired psychiatric disability (to include schizophrenia) began during, or is otherwise related to, his active-duty service. (3) If the response to (b) is "no," that there is NOT clear and unmistakable evidence that an acquired psychiatric disability/schizophrenia pre-existed his military service, the examiner should opine as to whether it is at least as likely as not (a fifty percent probability or greater) that the Veteran's acquired psychiatric disability (to include schizophrenia) began during, or is otherwise related to, his active-duty service. The Board notes that the September 2022 examiner hinted that although there was no evidence of MST in service his worsening condition supports his claim of a stressor. Although the Board finds that the Veteran is not a reliable historian and cannot confirm the MST event, the examiner's opinion appears to indicate that although the stressor cannot be confirmed, the worsening of his condition shows that a stressor occurred which was a catalyst to worsening of his condition. The examiner should address whether this is a medically sound logic. A detailed rationale for the opinion must be provided. If the examiner is unable to offer the requested opinion, it is essential that he or she offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. Christopher Seppanen Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Noh, 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.