Citation Nr: 0001308 Decision Date: 01/14/00 Archive Date: 01/27/00 DOCKET NO. 93-11 029 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUE Entitlement to service connection for a psychiatric disability. ATTORNEY FOR THE BOARD J. L. Prichard, Counsel INTRODUCTION The veteran had active service from December 27, 1979 to July 15, 1980. This matter comes before the Board of Veterans' Appeals (Board) on appeal of rating decisions of the Boston, Massachusetts, Department of Veterans Affairs (VA) regional office (RO). It was previously before the Board in June 1995 and November 1995, and was remanded on those occasions to obtain additional evidence. The case was returned to the Board after the completion of the requested development. In February 1999, the Board requested a medical opinion from a VA physician in this matter, pursuant to the provisions of 38 U.S.C.A. § 5107 (West 1991); 38 C.F.R. § 20.901(a) (1999). The opinion was received in March 1999. The veteran was informed of the opinion in April 1999, and was given 60 days to submit additional evidence or argument. The veteran did not respond, and the case was returned to the Board for further review. In August 1999, the Board requested an additional medical opinion from the VA physician. This opinion was obtained in September 1999. A letter containing a copy of the opinion and notifying the veteran that he had 60 days to offer additional evidence or argument was mailed to the veteran's most recent address of record in September 1999. However, the notification and copy of the opinion were returned, and it was indicated that the veteran was no longer at this address. Therefore, the Board will proceed with its decision in this case. The Board notes that the veteran requested to appear at a hearing before a hearing officer at the RO. He failed to attend hearings scheduled in November 1992 and April 1993. In addition, the November 1995 remand requested that the veteran be afforded a VA psychiatric examination. He failed to report for examinations scheduled in July 1996 and July 1998. FINDING OF FACT The psychiatric symptoms for which the veteran were treated during service constituted prodromal symptoms of schizophrenia, which represents the early phase of the evolution of this disability. CONCLUSION OF LAW The veteran's schizophrenia was incurred during active service. 38 U.S.C.A. §§ 1131, 5107 (West 1991 & Supp. 1999). REASONS AND BASES FOR FINDING AND CONCLUSION The veteran contends that he developed a psychiatric disability as a result of active service. He notes that he was treated for depression and abnormal behavior following a suicide gesture during service, and that he received an early discharge as a result of this episode. The veteran believes that this represents the initial manifestation of his current schizo-affective disorder. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131. If a psychosis becomes manifest to a degree of 10 percent within one year of separation from active service, then it is presumed to have been incurred during active service, even though there is no evidence of the psychosis during service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Initially, the Board finds that the veteran's claim is "well-grounded" within the meaning of 38 U.S.C.A. § 5107(a); that is, a plausible claim has been presented. Murphy v. Derwinski, 1 Vet. App. 78 (1990). The veteran has submitted evidence of treatment for a psychiatric disability during service, evidence of ongoing treatment that began within two years after service, and evidence of a current disability. Caluza v. Brown, 7 Vet. App. 498 (1995); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). The Board is also satisfied that all relevant facts have been properly developed to their full extent and that the VA has met its duty to assist. White v. Derwinski, 1 Vet. App. 519 (1991); Godwin v. Derwinski, 1 Vet. App. 419 (1991). The service medical records show that an October 1979 examination conducted prior to induction was negative for a psychiatric disability. June 1980 records reveal that the veteran was brought to the hospital emergency room after he tried to jump out of a window. He had a history of suddenly acting strange, and then trying to jump out a third floor window. He was very combative, and was screaming and fighting. The diagnosis was rule out drug ingestion. Additional records show that the veteran was placed in four point restraints after he arrived at the hospital. He was very restless, very strong, and very uncooperative. The smell of alcohol was present. The assessment was a very restless and combative patient with no known supporting history in the past. Recent events suggested drug relations. Other June 1980 records state that the veteran was beginning to verbalize his feelings. The problem list included depression. He was more responsive and calm, and he did not appear anxious or agitated. The veteran moved slowly, and paused several seconds before speaking. His affect was somewhat flat, but he had a worried affect on his face. The assessment was that it appeared the veteran had an agitated episode from drinking. Still more records indicate that he said he had a lot of personal problems. It took much prodding to get him to communicate, but he discussed them to some extent. The veteran reported frequent depression, and anger without apparent cause. The assessment was that the veteran appeared depressed, and if his history was accurate he had been chronically withdrawn. The service medical records contain additional reports dated from June 1980 to July 1980 related to this episode. The veteran stated that his attempted jump had been a suicide attempt, and that he did not know what caused him to make this attempt. July 1980 records reflect that the veteran reported he had felt like laughing when he was lying down the other day, but he did not know why. He said he did not feel depressed. The veteran looked away from others when talking, smiled, and looked out the window. The assessment was questionable inappropriate affect. More July 1980 records state that the veteran began to show some improvement. He appeared depressed, but was cooperative. The veteran remained withdrawn, and liked to sleep during his hospitalization. The July 1980 diagnoses included depression and personality disorder. A July 1980 medical statement notes that the veteran had been admitted to the hospital 12 days earlier due to an attempted suicide. He had been found to have a moderate degree of personal crises, and appropriate treatment was rendered. The veteran had apathy, inability to extend efforts constructively, and an overall poor adjustment to military life. After his treatment, it was opined that he would probably benefit by removal from military life, which had caused him turmoil and inner conflicts. He was psychiatrically cleared, and referred for appropriate administrative action. Personnel records show that based on this recommendation, the veteran was given an early discharge due to his inability to adapt emotionally to the military environment. Post service medical records include private treatment records dated from August 1982 to March 1987. An August 1982 treatment plan includes a diagnosis of paranoid type schizophrenia. A January 1983 report states that the veteran had first been referred for evaluation following a court hearing for disorderly conduct in July 1981. He began treatment in August 1982. The report stated that there was no record of any previous psychiatric or criminal history. The veteran's attendance at his treatment sessions became sporadic, and he had virtually stopped participating by December 1982. The diagnosis was paranoid type schizophrenia. The report did not mention the veteran's military service. Other records from this period note that he had considered suicide in the military, but are negative for any opinion relating the veteran's schizophrenia to active service. The veteran has submitted extensive records pertaining to the treatment of his psychiatric disability for the period from 1987 to 1995. These include hospital records, treatment records, examination reports, doctor's notes, and records of his various medications. The diagnoses included paranoid schizophrenia and schizo-affective disorder. A report of a VA hospitalization from October 1990 to November 1990 states that the veteran's first psychotic break was in 1980, with progressive deterioration. However, the veteran's military service was not mentioned. None of the remaining records note the veteran's treatment in service. In February 1999, a VA psychiatrist was provided with the veteran's medical records and asked to provide an opinion as to whether it was as probable as not that the veteran exhibited a chronic psychiatric disability either during service, or within the first year after discharge from service. The opinion was received in March 1999. The psychiatrist noted that there was no history to show that the veteran had received psychiatric treatment before entering service. The failed suicide attempt during service in June 1980 was also noted, as well as the diagnoses of depression and personality disorder. There had been no follow up treatment after discharge. The first post service treatment discussed was the July 1982 private medical records, which addressed treatment received after the arrest of the veteran. The psychiatrist discussed the July 1982 evaluation of the veteran, with the diagnosis of paranoid type schizophrenia. The subsequent hospitalizations for schizophrenia were also noted. In summary, the psychiatrist stated that there was no evidence that the veteran had any acute psychotic breakdown during active service, and no concrete evidence that the veteran had any acute psychosis during the first year following discharge from service. It was noted that the veteran had a longitudinal history suggestive of serious emotional instability, and that the service medical records contained a notation of inappropriate affect which was difficult to account for on the basis of depression alone. Furthermore, the psychiatrist noted in general that prodromal signs and symptoms are almost invariably recognized retrospectively after a diagnosis of schizophrenia. The psychiatrist cited one study which found that 35 percent of chronic schizophrenics met the criteria for a personality disorder premorbidly, and another study that suggested poor premorbid adjustment could be an indication of severe schizophrenia. In conclusion, the psychiatrist opined that it was at least as likely as not that some of the symptoms in service could have been prodromal symptoms of schizophrenia. However, there was no evidence that the veteran developed a manifest psychosis either during service or within the one year presumptive period following discharge from service. An additional medical opinion was obtained in September 1999 at the request of the Board. The claims folder was available for review. This opinion was authored by the same psychiatrist who wrote the March 1999 opinion. The doctor noted that in general, schizophrenia usually begins with a prodromal phase. This was often insidious, and could last for months or even years. The next phase was the active phase, and the final phase was the residual phase. The prodromal phase is characterized by subtle changes in behavior usually affecting all facets of the person's effective adaptation in all functional areas. Symptoms included social withdrawal, inappropriate affect, flattening of affect, paucity of expressive gestures, decreased spontaneity, anhedonia, work impairment, avolition, and strange ideation. The prodromal signs and symptoms were almost invariably recognized retrospectively, usually after the diagnosis of schizophrenia had been made. The doctor reviewed the veteran's medical history from service until the initial diagnosis of schizophrenia in July 1982. Although the veteran was noted to have some emotional problems prior to discharge, he had been cleared for psychiatric disability at the time of the entrance examination. The doctor noted that many of the symptoms displayed during service and which persisted thereafter are symptoms that are often described during the evolution of schizophrenia. In particular, the examiner noted that the service medical records describe the veteran as being socially withdrawn, and not very communicative. There was no evidence that the veteran had been able to form a close relationship with anyone other than his mother. His hospital records indicated that the veteran would sit in a chair for a long time with a vacant gaze into space. His affect was described as inappropriate, which could not be accounted for on the basis of depression alone. He had never been able to adjust during service. When these symptoms were considered collectively, and evaluated in the context of the later development of an acute psychosis, it was suspected that the symptoms in service represented the early phase of evolution of a schizophrenic illness. In conclusion, the doctor opined that it was as likely as not that some of the symptoms manifested during service could have been prodromal symptoms, and that these prodromal signs and symptoms occur during the evolution of schizophrenic illness. So, it appeared as likely as not that the initial onset of the veteran's disability occurred during active service, but went unrecognized. The diagnosis of depression and personality disorder in service did not preclude a diagnosis of schizophrenia. After careful review of the veteran's contentions and his extensive medical records, the Board finds that entitlement to service connection for schizophrenia is merited. The service medical records show that the veteran was treated following a suicide attempt. The diagnoses were depression and a personality disorder. However, the March 1999 and September 1999 expert medical opinions noted that several of the symptoms displayed by the veteran during his hospitalization and subsequent treatment in service could constitute prodromal symptoms. The September 1999 opinion states that these symptoms occur during the initial phase of schizophrenia, but are often not recognized until the active phase begins. Given these findings, the September 1999 opinion added that it was as likely as not that the initial onset of the disability occurred during active service. Therefore, as this opinion places the evidence in relative equipoise, the benefit of the doubt must be resolved in favor of the veteran, and service connection for schizophrenia is warranted. 38 U.S.C.A. § 5107. ORDER Entitlement to service connection for schizophrenia is granted. THOMAS J. DANNAHER Member, Board of Veterans' Appeals