BVA9503917 DOCKET NO. 93-12 496 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to service connection for schizophrenia. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Lori R. Bucci, Associate Counsel INTRODUCTION The veteran served on active duty from March 22, 1989 to April 20, 1989. This appeal arises from a rating decision in August 1992 by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. On appeal the veteran appears to raise the issues of entitlement to service connection for a back disorder, and entitlement to a permanent and total disability evaluation for pension purposes. These claims have not been developed or certified for appellate review, and they are not inextricably intertwined with the issue certified for review. Accordingly, these matters are referred to the RO for appropriate action. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that his pre-existing psychiatric disorder was aggravated by his military service. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. 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 preponderance of the evidence is against the veteran's claim for entitlement to service connection for schizophrenia. FINDINGS OF FACT 1. The veteran’s schizophrenia clearly and unmistakably existed prior to service. 2. There was no increase in severity in the veteran's pre- existing schizophrenia, during his period of active duty service. CONCLUSIONS OF LAW 1. There presumption that the veteran was psychiatrically sound at enlistment is rebutted. 38 U.S.C.A. § 1111 (West 1991). 2. The veteran's pre-existing schizophrenia was not aggravated in service. 38 U.S.C.A. § 1131, 1153, 5107 (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Initially, the Board notes that the veteran's claim is well- grounded within the meaning of 38 U.S.C.A. § 5107(a). That is, he has presented a claim which is plausible. The Board is also satisfied that all relevant facts have been properly developed. No further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). Factual Background Service medical records reveal that the veteran’s February 1989 enlistment examination is negative for any complaints, history or findings referable to a psychiatric disorder. In an April 10, 1989, Entrance Physical Standards Board (EPSBD) report it was recorded that following an orientation program which outlined a soldier’s responsibility to report any previous illness such as psychiatric treatment prior to his enlistment, the veteran informed his sergeant that he had been hospitalized and diagnosed with schizophrenia beginning in 1986. The veteran was referred to a military hospital where he reported being followed by a private physician and having taken Navane and Cogentin. A phone call was made to a Doctor Stuhl and others at a clinic ultimately identified as the Weber G. Bryant Clinic in Columbia, South Carolina. Dr. Stuhl verified the veteran’s self reported diagnosis and history. On mental status examination the veteran was alert, oriented and cooperative. His speech was linear and within normal limits. The veteran was not homicidal or suicidal, and mentation seemed intact. He was responsive, although his affect was mildly inappropriate and on occasion, he would just stare for brief periods. There was a mild looseness to his thinking. He insight was limited and his judgment was fair to poor. The diagnosis was schizophrenia, in remission. The EPSBD found that the veteran did not meet induction standards; separation was recommended and accomplished. At a January 1993 personal hearing, the veteran presented testimony concerning his receipt of psychiatric treatment beginning in 1986 including several hospitalizations. He indicated that his hospital releases resulted in referrals to the Columbia Mental Health Clinic who then released him from a treatment regimen which included medication and counseling. Since he had been released from treatment, the veteran believed he had a clean bill of health and was free to enter the military. For this reason, the veteran also thought that he did not need to inform the military of his prior psychiatric illness. He stated that while in basic training and performing a clean up detail, he fell and struck his head in the shower. The veteran indicated that he did not seek help until a few days later and he was referred to a psychiatrist. When he informed the authorities about his previous psychiatric illness, they implemented procedures to discharge him from service. The veteran reported that he was advised at discharge to continue his previous psychiatric treatment. Analysis Service connection may be granted for a disability resulting from a disease or injury incurred or aggravated in service. 38 U.S.C.A. § 1131 (West 1991). A veteran is presumed in sound condition except for defects noted when examined and accepted for service. Clear and unmistakable evidence that the disability existed prior to service will rebut the presumption. 38 U.S.C.A. § 1111 (West 1991). A pre-existing disease will be considered to have been aggravated by active service where there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progression of the disease. 38 U.S.C.A. § 1153 (West 1991). In this case, as a psychiatric disorder was not noted at the veteran’s February 1989 entrance examination, the presumption of soundness applies. Crowe v. Brown, No. 93-550 (U.S. Vet. App. Dec. 20, 1994). The presumption of soundness of the veteran’s mental status, however, is rebutted by clear and unmistakable evidence that he was treated and hospitalized for schizophrenia prior to service. In this regard, the EPSBD report shows that the veteran’s self admitted preservice history of schizophrenia was verified by private health care providers, and that this care included outpatient counseling and antipsychotic medication. Moreover, at his January 1993 personal hearing, the veteran reiterated his history of schizophrenia prior to service. As the presumption of soundness has been rebutted, the remaining question is whether the veteran’s preexisting schizophrenia was aggravated by service. In this regard, the Board observes that as soon as the veteran informed officials of his prior history of schizophrenia, he was evaluated by the EPSBD for discharge. As previously noted, the EPSBD diagnosed schizophrenia, in remission, and recommended discharge for failing to meet the induction standards. More significantly, however, the service medical records show no evidence of any psychotic break, any active psychotic symptomatology in service, or any need for the veteran to begin an increased medication regimen. As there is no evidence, beyond the veteran’s mere lay assertion, of increased symptomatology in comparison with the degree of symptomatology which is known to have required inpatient hospital treatment and the use of anti-psychotic medication there is no reason or basis upon which to find the existence of aggravation. Hence, entitlement to service connection is not warranted. 38 U.S.C.A. §§ 1131, 1153. In reaching this decision the Board considered the veteran's testimony that his pre-existing psychiatric disorder was aggravated as a result of bumping his head in service. The veteran, however, as a lay affiant, is not competent to offer a medical opinion as to whether or not his underlying schizophrenia was aggravated inservice. Espiritu v. Derwinski, 2 Vet.App. 492 (1992). In this respect, the veteran's statement as to the cause for any claimed aggravation must be supported by cognizable evidence, not merely allegations. Tirpak v. Derwinski, 2 Vet.App. 609 (1992). No such evidence has been presented. Hence, his statement alone cannot serve as predicate for granting service connection for his psychiatric disorder on the basis of aggravation. While the Board has considered the doctrine of affording the veteran the benefit of any existing doubt with regard to the issue on appeal, the record does not demonstrate an approximate balance of positive and negative evidence as to warrant resolution of this matter on that basis. 38 U.S.C.A. § 5107(b). ORDER Service connection for schizophrenia, is denied. DEREK R. BROWN Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. 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.