Citation Nr: 0002082 Decision Date: 01/27/00 Archive Date: 02/02/00 DOCKET NO. 98-13 868 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for paranoid schizophrenia. 2. Entitlement to service connection for an adjustment disorder. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD L. Spear Ethridge, Associate Counsel INTRODUCTION The veteran had active duty from February 1960 to June 1961. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating actions by the Waco, Texas Regional Office (RO) of the Department of Veterans Affairs (VA). The United States Court of Appeals for Veterans Claims (hereinafter, "the Court") was known as the United States Court of Veterans Appeals prior to March 1, 1999. FINDING OF FACT 1. Competent evidence that the veteran had paranoid schizophrenia in service, and that he currently has the residuals thereof, has not been submitted. 2. Competent evidence that the veteran had an adjustment disorder in service, and that he currently has the residuals thereof, has not been submitted. CONCLUSION OF LAW 1. Service connection for paranoid schizophrenia is not well-grounded. 38 U.S.C.A. § 5107 (West 1991). 2. Service connection for an adjustment disorder is not well-grounded. 38 U.S.C.A. § 5107. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service connection may be granted for a disability resulting from personal injury suffered or disease contracted in line of duty or for aggravation of preexisting injury suffered or disease contracted in line of duty. 38 U.S.C.A. § 1131 (West 1991); 38 C.F.R. § 3.303 (1999). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b) (1999). Additionally, service connection may also be established for certain disabilities, including schizophrenia, where the disability becomes compensably manifest within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 1991 & Supp. 1998); 38 C.F.R. §§ 3.307, 3.309 (1999). The threshold question to be answered is whether the veteran has presented evidence sufficient to justify a belief by a fair and impartial individual that his claim is well- grounded; that is, a claim which is plausible and capable of substantiation. See 38 U.S.C.A. § 5107(a); Chelte v. Brown, 10 Vet. App. 268, 270 (1997) (citing Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990)). Generally, a well-grounded claim for service connection requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in- service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in- service disease or injury and the present disease or injury. Caluza v. Brown, 7 Vet. App. 489, 504, 506 (1995); see also Epps v. Gober 126 F.3d 1464, 1468 (Fed. Cir. 1997) (expressly adopting definition of well-grounded claim set forth in Caluza, supra). The second and third Caluza elements can be satisfied under 38 C.F.R. 3.303(b) by (a) evidence that the condition was "noted" during service or during an applicable presumptive period; (b) evidence showing post- service continuity of symptomatology; and (c) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. 38 C.F.R. 3.303(b); Savage v. Gober, 10 Vet. App. 488, 495-97 (1997). For the purpose of determining whether a claim is well grounded, the credibility of the evidence in support of the claim must be presumed. Robinette v Brown, 8 Vet. App. 69, 75 (1995). Service medical records show that the veteran was clinically evaluated as normal for psychiatric purposes upon enlistment in January 1960. In February 1961, the veteran was seen for a neurological consultation which lead to a referral for a psychiatric evaluation. In March 1961, the veteran underwent a psychiatric evaluation. By history it was noted that the veteran had experienced severe bifrontal headaches since 1957 and occasional episodes of loss of vision, lasting up to several weeks. The veteran also reported having been hit in the head with a cast two weeks earlier when he tried to stop a fight between two other Marines. He noted that he had had severe headaches beginning when he was 12 years old. The veteran reported having headaches in boot camp, which had continued to the present time. The examiner noted that during the interview, the veteran was rather guarded, and that he appeared to be extremely limited intellectually. The veteran reported having quit school in the ninth grade because his eyes were bad, and that he had a hard time holding down after school jobs because his headaches were bothersome. He joined the service because he was unable to hold down a job on the outside. The examiner noted that the veteran had been referred for the psychiatric consultation, and was found at that time to have an intelligence quotient of 70 on the Weschler-Bellvue examination. The examiner's impression was: Inadequate personality, associated with borderline mental deficiency, manifested by inability to perform adequate duty, inability to hold a job in civilian life, and multiple conversion-like symptoms. The examiner stated that: It appears because of his borderline mental deficiency, stresses of routine military life, have been intolerable to this patient, and he has reacted to these with tension headaches, and many conversion-like symptoms. It is our recommendation that he be separated from the service on administrative grounds. There is no medical or psychiatric contraindication to such action. In a March 1961 correspondence, the Medical Officer in Charge wrote to the Commanding Officer of the Battalion that it was suggested that the veteran be considered for separation as provided since it was unlikely that he would perform effective service because of his inadequate personality. At his June 1961 discharge examination, the veteran was clinically evaluated as normal for psychiatric and neurological purposes. The notation "NE;" which could mean no effect, or not examined, was indicated; however, it was indicated under the heading for "normal" as opposed to "abnormal." The veteran has submitted numerous post service VA medical treatment and hospitalization records in support of his claims. After a complete review of the records, the Board determines that the claims on appeal are not well grounded. The RO came to the same conclusion as indicated in its February 1998 and April 1998 rating decisions. The Board notes that the Court has held that there is some duty to assist a veteran in the completion of his application for benefits under 38 U.S.C.A. § 5103(a), depending on the particular facts in each case. Beausoleil v. Brown, 8 Vet. App. 459 (1996); Robinette v. Brown, 8 Vet. App. 69 (1995). The facts and circumstances of this case are such that no further action is warranted. As spelled out above, the service medical records are completely negative for the claimed disorders of paranoid schizophrenia, and an adjustment disorder. Instead, the service medical records show only that the veteran had conversion-like symptoms related to an inadequate personality in service; for which he was ultimately discharged. The earliest post-service medical records are dated from May 1990, almost 30 years after the veteran's separation from service. Post service records reveal that from May 1990 to February 1998, the veteran has been treated and hospitalized at VA for numerous disorders, including alcoholism, physical ailments, and major depressive disorder. In particular, the records show that the veteran had consistent psychological treatment throughout 1996. He was hospitalized in October 1996 for depression and suicidal ideation. He was seen for treatment in 1997, and in January 1998, the diagnosis was adjustment disorder with depressed mood, severe. The most recent records of hospitalization in February 1998 show a diagnosis of paranoid schizophrenia. Not only is there no showing of the claimed disabilities in service, within the context of the indicated post-service medical records, there is no showing of the claimed psychiatric disabilities within one year following service separation. See 38 C.F.R. §§ 3.307, 3.309. There is no opinion relating the claimed disorders to service. See Caluza v. Brown, supra; see also Epps v. Gober, supra. Consequently the claims for entitlement to service connection for paranoid schizophrenia, and an adjustment disorder, respectively, are not well grounded and are denied. See Caluza v. Brown, supra; see also Epps v. Gober, supra. Furthermore, congenital or developmental defects, refractive error of the eye, personality disorders and mental deficiency as such are not diseases or injuries within the meaning of applicable legislation. 38 C.F.R. § 3.303(c) (1999). ORDER Entitlement to service connection for paranoid schizophrenia is denied. Entitlement to service connection for an adjustment disorder is denied. Deborah W. Singleton Member, Board of Veterans' Appeals