Citation Nr: 0000794 Decision Date: 01/11/00 Archive Date: 01/27/00 DOCKET NO. 97-13 313A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUE Entitlement to service connection for schizophrenia, psychotic disorder. REPRESENTATION Veteran represented by: AMVETS ATTORNEY FOR THE BOARD Maureen A. Young, Associate Counsel INTRODUCTION The veteran had active military service in the United States Army from December 1995 to August 1996. He also served a three-year period of reserve duty with the United States Marine Corps prior to entry into the Army. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 1996 rating decision by the Department of Veterans' Affairs (VA) Regional Office (RO) in Oakland, California. FINDING OF FACT Schizophrenia, psychotic disorder began during active service. CONCLUSION OF LAW Schizophrenia, psychotic disorder was incurred in active service. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. §§ 3.303, 3.304 (1999). REASONS AND BASES FOR FINDING AND CONCLUSION Factual Background The September 1991 examination for enlistment into the Marine Corps and the December 1995 examination for enlistment into the Army noted the veteran's psychiatric and neurologic systems were normal. He reported no nervous trouble of any sort and indicated that he had never been treated for a mental condition. Service medical records dated in June 1993, March and April 1994 and August 1995 note that there were no significant changes in the veteran's physical condition since his last examination in September 1991. He was found physically qualified for active duty for training or annual training duty. In December 1993 it was noted on an Annual Certificate of Physical Condition form that the veteran had no mental problems which might restrict his performance on active duty or prevent his mobilization. It was further noted that he had no illness or disease within the past twelve months that required hospitalization or prescription medications. In November 1994, prior to entry into active duty, the veteran was seen at the San Francisco General Hospital with complaints of having an "anxiety attack" during which he heard voices telling him to do dangerous things. He reported that his heart beats fast and he gets cold all over. He related coldness of his extremities to "maybe my father is reaching for me" and expressed a wish for closeness with and support from his [deceased] father. He also reported that he had similar symptoms the night before and went to Seaton [sic] where he was referred to San Francisco General Hospital. He complained of increased stress due to being a full-time student, working part-time and arguing frequently with his mother. He also complained of decreased sleep, appetite and concentration. He stated that when he is angry with his mother he sometimes has a strong desire to drive a car into a pole. A mental status evaluation revealed he was casually dressed and appeared drowsy. His affect was slight. His mood was stressed; his speech was slow, sublingual, vague and tangential. On concentration evaluation he performed serial 7s with some difficulty. He was oriented x4 and short-term and long-term memory was okay. He did not appear preoccupied but admitted to "buzzing" in his ears. There were no apparent delusions but he did admit to anxiety about having touched his father's corpse while in the Philippines. He denied suicidal and homicidal ideation. It was noted that there were no current or past medications. The initial assessment as reported on the intake evaluation form was an Axis I diagnosis of psychosis, not otherwise specified. His Axis IV diagnosis was moderate. His current Global Assessment Functioning (GAF) was 60, and his past year GAF was 65. Later the same day, the physician provided Axis I diagnoses of a rule out of adjustment disorder with mixed emotional features, anxiety disorder not otherwise specified and schizophreniform (doubt). His Axis V diagnosis GAF was 49. The physician noted that the veteran may have psychotic core, but it was not in evidence currently. No medication was prescribed. In January 1996, while in active duty status, the veteran was admitted at Walter Reed Army Medical Center (MC). He was referred to Walter Reed Army MC from the emergency room at Kenner Army Community Hospital after he developed hallucinations and delusions. A mental status examination at Walter Reed Army MC revealed that the veteran was medicated with Ativan, 1 milligram. His stated mood was "less agitated. His affect was sleepy. His thought process was logical and goal-oriented. He denied hearing his father's voice, but, described sensing his father's presence during meditation. He endorsed mild depression and poor appetite over the past two weeks, but no weight loss. He denied suicidal and homicidal ideation, anxiety symptoms and mania. At that time, judgment and insight could not reliably be assessed. Cognition appeared preserved. His mini mental status examination score was 23/30; points were lost on measures of attention and short- term memory, consistent with his degree of sedation. It was noted that while hospitalized, the veteran's acute symptoms resolved rapidly but there was evidence of restricted affect and guarded approach to interpersonal relationships. He was prescribed fluphenazine and benztropine. The veteran's condition just prior to leaving the hospital was noted as free of active psychosis, although he did demonstrate some residual delusional thinking. He was alert and oriented, interactive and appropriate in both conversation and behavior. His mood was euthymic with appropriate but restricted affect. He was free of suicidal or homicidal ideation, hallucinations or delusions. His Axis I diagnoses were schizophrenia, paranoid type, episodic with inter-episode residual symptoms, manifested by bizarre delusions of communication with a dead relative or "the grim reaper," non-bizarre delusions that others suspect homosexuality, auditory and visual hallucinations of the dead relative and disorganized speech. The veteran had marked impairment for further military duty and severe impairment for social and industrial adaptability. The line of duty assessment was that the mental disorder existed prior to service and was aggravated by service. His Axis V diagnoses had a GAF 30 at admission; GAF 65 at that time and GAF 70 was the highest level in the past year. The examiner noted in his recommendation that the veteran was medically unacceptable. The examiner referred him to the Physical Evaluation Board (PEB) for final determination. He noted that the veteran received maximum benefit from the hospitalization. He further noted that the veteran was mentally competent, able to manage his own financial affairs and could be discharged to his own care. It was recommended that he continue in outpatient supportive psychotherapy at a VA facility near his home. In May 1996 PEB determined that there was sufficient evidence to substantiate that the veteran's mental disorder existed prior to service and had rendered him unfit for service. It also determined that his condition was not aggravated by service but was the result of natural progression. In November 1996 the veteran underwent a VA mental disorders examination. He reported that he had come to VAMC in September 1996 because he was running out of medications. He reported that he was treated at Walter Reed Army MC from January 31, 1996 to March 20, 1996. He was treated on Haldol, then Prolixin, and Cogentin. He was followed as an outpatient at Fort Lee until August of 1996 when he was discharged from the service. He stated that he had been followed by VAMC Psychiatry Department and was currently participating in a research protocol for treatment of schizophrenia. He was currently taking Prolixin and Cogentin. He reported that his symptoms of hallucinations and paranoid thinking stopped several months earlier as the result of medications. He stated that he was sleeping much better now and his moods were stable. He said his concentration ability was good, his memory was stable and he related well to people. On examination the veteran was observed as a well developed and well nourished man. He was clean-shaven, simply dressed and his mannerisms were described as "a bit stiff and formal." His speech was fluent and logically constructed. His mood was formal but cooperative. There was no active psychotic thinking, paranoid ideation or hallucinations. He was alert and oriented in all spheres. He performed mental arithmetic, proverb abstraction, and judgment testing well. His recall memory was 4/4 objects recalled after a five- minute delay. His insight was good. The Axis I diagnosis was psychosis, not otherwise specified; Axis IV was moderate and Axis V was 62. The examiner noted that the veteran did not have prodromal symptomatology that would be expected for a schizophrenic process. He had had prompt resolution of his psychotic symptomatology. The diagnostic picture, therefore, appeared best described as a psychotic disorder, not otherwise specified. In March 1997 a VAMC clinician telephoned the veteran to discuss ongoing psychiatric treatment. It was reported that the veteran was very upset about "being in a study." The clinician noted that the veteran was quite paranoid about taking psychiatric medication and wanted to discontinue taking it. VAMC medical record of April 1, 1997 noted that the veteran was out of control. He was screaming about being the devil. It was further noted that he had been discharged from the psychiatric intensive care unit (PICU) on March 7, 1997. A history of schizophrenia was also noted. His medications at that time were Prolixin, Cogentin and Trazodone. He was not a suicide risk and had no intention to harm others. Acute psychosis was indicated. He was admitted to the PICU where he stayed for ten days. A VAMC psychiatric-post evaluation of April 23, 1997 noted that the veteran entered the Seroquel study and decompensated. He was restarted on Prolixin and Cogentin in PICU from March 2 to March 7, 1997. He was non-compliant with medications and was readmitted to PICU from April 1 to April 11, 1997. The diagnosis was schizophrenia diagnosed in January 1996; currently stable on Olanzapine. In a May 1997 psychiatric-post progress note it was noted that the veteran had been seen for a follow-up of schizophrenia. It was further noted that he was stable on Olanzapine, 5 milligrams. The veteran reported daytime sedation with Olanzapine. No dizziness or other side effects were reported. He denied hallucinations or paranoid ideation. The diagnosis was schizophrenia. In June, August, September and October 1997 the veteran was seen for follow-up visits at VAMC psychiatric clinic. It was reported that he was doing well on Olazapine, 5 milligram. On the November 1997 visit it was indicated that his problem was schizophrenia. Criteria Pursuant to 38 U.S.C.A. § 5107(a), a person who submits a claim for benefits under a law administered by the Secretary shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. The United States Court of Appeals for Veterans Claims (Court) has held that a well-grounded claim is "a plausible claim, one which is meritorious on its own or capable of substantiation. Such a claim need not be conclusive but only possible to satisfy the initial burden of § [5107(a)]." Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). The Court has also held that although a claim need not be conclusive, the statute provides that it must be accompanied by evidence that justifies a "belief by a fair and impartial individual" that the claim is plausible. Tirpak v. Derwinski, 2 Vet. App. 609, 610 (1992). The Court has held that "where the determinative issue involves medical causation or a medical diagnosis, competent medical evidence to the effect that the claim is 'plausible' or 'possible' is required." Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993) (citing Murphy, at 81). The Court has held that a well grounded claim requires competent evidence of current disability (a medical diagnosis), of incurrence or aggravation of a disease or injury in service (lay or medical evidence), and of a nexus between the in-service injury or disease and the current disability (medical evidence). See Epps v. Brown, 9 Vet. App. 341, 343-44 (1996); Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). In order to establish service connection for a claimed disability the facts must demonstrate that a disease or injury resulting in current disability was incurred in the active military service or, if pre-existing active service, was aggravated therein. 38 U.S.C.A. § 1131 (West 1991); 38 C.F.R. § 3.303 (1999). If a disability is not shown to be chronic during service, service connection may nevertheless be granted when there is continuity of symptomatology post service. 38 C.F.R. § 3.303(b) (1999). See Savage v. Gober 10 Vet. App. 488 (1997). Regulations also provide that service connection may be granted for a disease diagnosed after service discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. See Watson v. Brown, 4 Vet. App. 309, 314 (1993). 38 U.S.C.A. § 1111 provides that every person employed in the active military, naval, or air service, in wartime, shall be taken to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. Id.; 38 C.F.R. § 3.304(b) (1999). Analysis The veteran's claim for service connection for schizophrenia is well grounded within the meaning of 38 U.S.C.A. § 5107(a). See Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990); Tirpak v. Derwinski, 2 Vet. App. 609, 610 (1992). The veteran has submitted competent medical evidence of a current diagnosis of schizophrenia. Medical evidence submitted also established that schizophrenia was incurred during active military service. See Epps v. Brown, 9 Vet. App. 341, 343-44 (1996); Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996); Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993) (citing Murphy, at 81). Service medical records at enlistment in December 1995 noted no psychiatric disorders of any kind. The November 1994 medical report from the San Francisco General Hospital provides no firm diagnosis of a mental disorder. In fact the physician notes that the veteran "may have psychotic core, but not in evidence now." The record is devoid of further medical evidence of a mental disorder prior to the time the veteran enlisted in active duty. In January 1996 Walter Reed Army MC diagnosed schizophrenia as existing prior to service. While Walter Reed Army MC found that the veteran's schizophrenia preexisted service, that conclusion is unfounded. The opinion appears largely based on the November 1994 diagnosis, which as stated above, provided no clear diagnosis of a psychiatric disorder. Under 38 U.S.C.A. § 1111 clear and unmistakable evidence that the disability was manifested prior to service is necessary to rebut the presumption that the veteran was in sound condition when examined and accepted for service. A bare conclusion, even one written by a medical professional, without a factual predicate in the record, does not constitute clear and unmistakable evidence sufficient to rebut the presumption of soundness on entrance into service. Miller v. West, 11 Vet. App. 345 (1998). Since a psychiatric disorder was not noted at enlistment, and there is no clear and unmistakable evidence that a chronic acquired psychiatric disorder existed before entry into active duty, the veteran is presumed to have been in sound condition when he enlisted for active duty. Schizophrenia first became manifest during active duty in January 1996, after the veteran completed about one month of service. The veteran was seen for psychiatric symptoms and was diagnosed as having schizophrenia, paranoid type. Treatment for schizophrenia continued for the remainder of service, in the period immediately following service, and thereafter. From January 1996 to March 1996 he was treated at Walter Reed Army MC. Subsequent thereto, he received outpatient treatment at Fort Lee until his discharge in August 1996. There is no separation examination of record. The evidence shows, however, that one month following discharge he went to VAMC because he was running out of medications. In November 1996 upon VA mental disorder examination he was diagnosed with psychosis, not otherwise specified. VAMC medical records dated in 1997 indicate treatment or diagnosis of schizophrenia. Based upon the foregoing, the Board finds that schizophrenia was incurred in service, and service connection is warranted. The benefit-of-the-doubt rule, 38 U.S.C.A. § 5107(b) has been applied in reaching this decision. ORDER Entitlement to service connection for schizophrenia, psychotic disorder is granted. RONALD R. BOSCH Member, Board of Veterans' Appeals