93 Decision Citation: BVA 93-21334 Y93 BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 DOCKET NO. 92-04 421 ) DATE ) ) ) THE ISSUE Entitlement to service connection for a psychiatric disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. P. Harris, Associate Counsel INTRODUCTION The appellant had active service from November 8, 1963, to June 1964. By a decision in March 1986, the Board of Veterans' Appeals (hereinafter Board) denied entitlement to service connection for a chronic acquired psychiatric disorder, classified as schizophrenia. This matter came before the Board on appeal from December 1990 and January and May 1991 rating decisions from the Boston, Massachusetts, Regional Office (hereinafter RO), which denied service connection for that disability on the basis that new and material evidence had not been submitted to reopen the claim. In September 1991, a notice of disagreement was received. Later that month, a statement of the case was issued which addressed the service connection issue on the merits as well on finality. A substantive appeal was received the following month. A hearing was held before a hearing officer at the RO in January 1992. In a decision the following month, the hearing officer found that new and material evidence had been submitted to reopen the claim for entitlement to service connection for a psychiatric disability, but upheld the prior denial thereof. The case was docketed at the Board in April 1992. His service representative submitted written arguments in March and June 1992. In July 1993, the Board referred the case for an independent medical expert's opinion regarding the date of onset of a chronic, acquired psychiatric disorder versus personality disorder; and whether the appellant had a psychiatric disorder prior to service and, if so, what the likely diagnosis was. An independent medical expert's opinion was rendered the following month. The appellant's service representative submitted additional written arguments in September 1993. CONTENTIONS OF APPELLANT ON APPEAL The appellant contends, in essence, that her schizophrenia did not preexist service, but had its onset in service. It is argued that clear and unmistakable evidence is required to rebut the presumption of soundness at time of enlistment into service, and that the fact that her enlistment examination revealed normal psychiatric findings, therefore, supports her contention that schizophrenia did not preexist service. She also argues that she never had psychiatric problems or treatment prior to service. Reference is made to the independent medical expert's opinion in support of the claim. It is requested that consideration be provided to certain regulatory provisions and that the benefit of the doubt doctrine be applied in this case. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered the evidence and material of record in the appellant's claims file. The Board has determined that only those items listed in the "Certified List" attached to this decision and incorporated by reference herein are relevant evidence in the consideration of the appellant's claim. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the evidence is at least in equipoise to warrant a grant of service connection for a chronic acquired psychiatric disorder. FINDINGS OF FACT 1. All available, relevant evidence necessary for disposition of the appellant's appeal has been obtained by the RO. 2. It is more likely that the appellant's psychiatric symptoms in service, which included confusion, withdrawal, auditory hallucinations, and flight of ideas, represented the onset of a chronic acquired psychiatric disorder. CONCLUSION OF LAW A chronic acquired psychiatric disorder was incurred during the appellant's military service. 38 U.S.C.A. §§ 1131, 5107(b) (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSION In light of our favorable decision, it is apparent that the appellant's claim is "well grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991) and that the evidentiary record is sufficient for deciding this case. For explanatory purposes, the issue had previously been framed by the RO as whether new and material evidence had been submitted to reopen the appellant's claim for entitlement to service connection for a psychiatric disability. The prior Board decision of March 1986, which denied service connection for a chronic acquired psychiatric disability, was final in the absence of new and material evidence. 38 U.S.C.A. §§ 5108, 7104(b) (West 1991); 38 C.F.R. §§ 3.156(a), 20.1105 (1992). "New" evidence means more than evidence which was not previously physically of record, and must be more than merely cumulative. To be "material" evidence, there must be a reasonable possibility that consideration of the new evidence, when viewed in the context of all the evidence, would change the outcome. Colvin v. Derwinski, 1 Vet.App. 171 (1991). In a February 1992 decision, the hearing officer who conducted the January 1992 hearing, held that a February 1991 report by a Department of Veterans Affairs (VA) psychiatrist constituted new and material evidence to reopen the claim for service connection for a chronic acquired psychiatric disorder, on the basis that the report directly related the appellant's schizophrenia to military service. Inasmuch as we now have new and material evidence, the issue will be decided by the Board on a de novo basis. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131. The appellant was examined for entry into service in August 1963, at which time her psychiatric status was described as normal. The service medical records show that in mid-November 1963, several days after entry into service, she reportedly became withdrawn, refused to communicate with superiors or perform tasks, and was referred for psychiatric care. Clinical records, including nursing notes, during the latter part of November 1963 reflect that she appeared to be having auditory hallucinations, exhibited flight of ideas, and was very confused. She also appeared very childish in manner. Medications prescribed included Stelazine, an antipsychotic medication. A Clinical Board report dated in January 1964 reflects that a social worker interviewed a number of persons who knew the appellant prior to service. From these sources, it was indicated that she had been a withdrawn, shy, and rather unpopular child. Also, she had dressed in a childish, unusual fashion, had a low intellect, had never received affection from her alcoholic parents, had felt rejected by others, and had had employment problems. However, her mother completed a questionnaire, and reported that the appellant had never had emotional problems or received psychiatric treatment prior to service. It is significant that when the appellant was initially treated in November 1963, schizophrenic reaction, catatonic type, was diagnosed. This diagnosis was later revised to schizophrenic reaction, simple type, in January 1964. There is some uncertainty as to whether the psychiatric symptoms manifested during service represented the initial onset of a psychosis or other chronic acquired psychiatric disorder versus a personality disorder. A personality disorder is not a disease for which service connection may be granted. 38 C.F.R. § 3.303(c) (1992). Likewise, her mental deficiency reported in service is not a disease for which service connection may be granted. 38 C.F.R. § 3.303(c). According to medical authorities, simple schizophrenia is defined as: One of the chronic forms of schizophrenia; historically, called dementia praecox, simple type... In the simple form of schizophrenia, there is an insidious psychic impoverishment that affects the emotions, the intellect, and the will....[T]he simple schizophrenic is isolated, estranged, and asocial. Affect is markedly blunted and dull....[P]atients make many foolish mistakes, are highly suggestible and gullible, and speech is filled with senseless generalizations. Thought is vacuous and banal, ideas are insipid and unintegrated. In DSM-III, many such cases would be classified as personality disorders. Robert Jean Campbell, M.D., Psychiatric Dictionary, 658-659 (6th ed., 1989). In the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 187 (3rd ed.-revised, 1987), schizophrenia is referred to in the following way: ...excludes illnesses without overt psychotic features, which have sometimes been referred to as Latent, Borderline, or Simple Schizophrenia. Such conditions are likely to be diagnosed in this manual as Personality Disorders, e.g., a Schizotypal Personality Disorder. It is more difficult to distinguish severe forms of Paranoid and Schizotypal Personality Disorders from Schizophrenia because of the difficulty in determining whether the paranoid ideation is of delusional intensity and whether the oddities of communication and perception are severe enough to meet the criteria for Schizophrenia. Id., 193. According to another medical text: Patients with personality disorders tend to show anxiety and depression when pathologic techniques fail, and their symptoms can be similar to those occurring with anxiety disorders. Occasionally, the more severe cases may decompensate into psychosis under stress and mimic other psychotic disorders. Schizotypal: Superstitious, socially isolated, suspicious, with limited interpersonal ability and odd speech. The schizophrenic disorders are a group of syndromes manifested by massive disruption of thinking, mood, and overall behavior, as well as poor filtering of stimuli. According to DSM- III-R criteria, the onset of illness occurs before age 45; signs must be continuous for at least 6 months; the illness is not preceded by a full depressive or manic syndrome; and symptoms are not due to mental retardation or organic mental disorder. The characterization and nomenclature of the disorders are quite arbitrary and are influenced by sociocultural factors and schools of psychiatric thought. At present, there is no laboratory method to confirm the diagnosis of schizophrenia. James J. Brophy, M.D. Psychiatric Disorders in Current Medical Diagnosis and Treatment, 806-807 (Steven A. Schroeder, M.D., et al. eds., 1992). During VA hospitalization from March to October 1964, during the period of military service, the appellant continued to appear confused, withdrawn, and immature, and she was treated with Thorazine, an antipsychotic medication. Schizophrenic reaction, simple type, was diagnosed. During VA hospitalization in May 1965, nearly a year after service, schizophrenic reaction, paranoid type, manifested by confusion, religious delusions, and other symptoms was diagnosed. In the 1970's and 1980's, diagnoses included schizophrenia, paranoid type and schizophrenia, chronic, undifferentiated type. In the 1990's, diagnoses have included psychotic disorder, somatization disorder, and histrionic personality disorder. Significantly, she has continued to be maintained on Thorazine for her psychiatric symptoms. The negative evidence includes the diagnosis in service of simple schizophrenia, which is a term suggestive of a personality disorder. The positive evidence includes the presence of some psychotic symptoms, such as catatonic behavior, auditory hallucinations, and incoherence during service, with residual symptoms, consistent with a psychosis. (See: Diagnostic and Statistical Manual of Mental Disorders, supra, 194-195.) Additionally, in a recent February 1991 statement, a VA psychiatrist opined that the appellant's withdrawal and psychotic symptoms in service represented the initial onset of schizophrenia. An independent medical expert's opinion rendered in August 1993 reached a similar conclusion. Both opinions emphasized that psychotic symptoms were not manifested prior to service entry in November 1963 and the independent expert stated that the first unequivocal symptoms of a diagnosable psychiatric disorder appeared in November 1963. These medical opinions, recent pieces of evidence, are of considerable evidentiary value, since they directly relate the onset of a chronic acquired psychiatric disorder to military service. Thus, the Board concludes that the negative and positive evidence is at least in equipoise to warrant a grant of service connection for a chronic acquired psychiatric disorder. 38 U.S.C.A. § 5107(b). ORDER Service connection for a chronic acquired psychiatric disorder is granted. BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 F. H. AYER H. STERLING, M.D. HOLLY E. MOEHLMANN (CONTINUED ON NEXT PAGE) NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.