Citation Nr: 1319635 Decision Date: 06/18/13 Archive Date: 06/27/13 DOCKET NO. 09-30 256 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUE Entitlement to service connection for an acquired psychiatric disability, to include undifferentiated schizophrenia, depression, anxiety, and a mood disorder. REPRESENTATION Appellant represented by: Puerto Rico Public Advocate for Veterans Affairs ATTORNEY FOR THE BOARD Scott Shoreman, Counsel INTRODUCTION The Veteran had active service from July 3, 1974 to October 25, 1974. This matter comes before the Board of Veterans' Appeals (Board) from a November 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. The Board observes that the June 2009 Statement of the Case (SOC) identifies an August 2008 rating decision as the rating action on appeal. In this case, however, following the July 2005 and February 2007 rating decisions, new and material evidence was presented or secured within one year of the date of the mailing of the notice of the decision. See Bond v. Shinseki, 659 F.3d 1362, 1367-8 (Fed. Cir. 2011); 38 C.F.R. § 3.156(b) (2012). As such, the November 2005 rating decision is the rating action on appeal. Additionally, the Board recognizes that the RO has characterized the psychiatric disorder on appeal as schizophrenia, undifferentiated type. However, the record shows that the Veteran has also been assessed with depression, anxiety, and a mood disorder. He has not filed formal claims of service connection for those disabilities; however, claims for one psychiatric disorder effectively encompass claims for all psychiatric disorders that are reasonably raised by the record. Clemons v. Shinseki, 23 Vet. App. 1 (2010). Thus, the Board must consider all of the psychiatric disorders raised by the record, as reflected on the title page of this decision. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND A July 1974 service entrance examination was negative for any complaints or clinical findings of psychiatric abnormalities. Subsequent service medical records revealed treatment for a "nervous stomach," but were otherwise devoid of any subjective or objective evidence of mental health problems. While the Veteran's service records show that he was granted an honorable discharge after three and a half months of active duty, his early release was not attributed to any disorder involving his mental health. A February 1975 VA examination report contained clinical findings of cognitive and emotional abnormalities, including disorientation to time, person and place; poor memory, judgment, and fund of knowledge; pressurized speech; inappropriate affect, and unspecified "bizarre behavior." Additionally, the report indicated that the Veteran's overall mental health symptoms had been found to warrant diagnoses of latent schizophrenia and mild mental deficiency. However, that report made no mention of whether the Veteran's mental problems were related to his military service. Puerto Rico Department of Mental Health treatment records from August 1983 to April 1985 show complaints of depression and insomnia. The Veteran said that he always felt nervous and that medication did not help. The Veteran had a VA examination in August 1985 and the examiner felt that he was out of reality. The Veteran was unable to concentrate, seemed to be hallucinating, was aggressive, and had a lack of interest in his surroundings. He was diagnosed with schizophrenic disorder, undifferentiated type, and no opinion was provided regarding whether it was related to service. At a May 1988 VA examination the Veteran complained of a nervous condition. He was unable to state where is lived of the names of his children. A diagnosis was deferred, and at an assessment later in May 1988 he was diagnosed with generalized anxiety disorder. No opinion was given as to etiology. The Veteran had a VA examination in August 1993 at which he was alert but "markedly hyperactive and restless." The examiner noted that most of the Veteran's complaints were related to a high level of anxiety. The Veteran was diagnosed with generalized anxiety disorder with somatization, and no opinion was provided on etiology. VA treatment records beginning in August 2002 show that the Veteran has had ongoing treatment for anxiety and depression. The treatment records do not provide an opinion on etiology. The Veteran had a VA examination in March 2012 at which he was diagnosed with mental retardation, and it was noted that the diagnosis from treatment was anxiety, NOS and rule out generalized anxiety disorder. The examiner felt that the mental disorder, retardation, or deficiency was not caused, related to or associated with military service because mental retardation is a generalized disorder appearing before adulthood characterized by significantly impaired cognitive functioning and deficits in two or more adaptive behaviors. The Court of Appeals for Veterans Claims has held, "...[M]ost of the probative value of a medical opinion comes from its reasoning" and the Board "must be able to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007) (holding that "a mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to a doctor's opinion."). The March 2012 opinion is insufficient because the examiner did not address why she did not agree with the previous diagnoses. Furthermore, the opinion was insufficient because the examiner did not discuss why she felt that the current mental problems were unrelated to active service despite the significant psychotic pathology that the Veteran exhibited within a year of service. In February 2013, a VA psychiatrist reviewed the claims file and opined that the Veteran does not have a current diagnosis of undifferentiated schizophrenia or other psychosis. The rationale was that the term psychotic refers to the presence of specific symptoms and the VA treatment records do not show psychotic symptoms or a diagnosis of a psychotic illness. Symptoms of psychosis include hallucinations of any type and delusions. Other manifestations include disorganized or incoherent speech, thought processes and/or behavior. The VA psychiatrist felt that there was no evidence of an acquired psychiatric disorder since July 2005. However, it was also noted that the Veteran's problem list from VA treatment showed depressive disorder, NOS since 2006 and that treatment records since July 2005 also showed anxiety disorder. The VA psychiatrist felt that there was no evidence that depressive symptoms existed prior to service and that it was less likely than not that the Veteran had anxiety prior to service. There was also no evidence that the Veteran had a personality disorder during active service. The February 2013 opinion is inadequate because the VA psychiatrist wrote that there was no evidence of an acquired psychiatric disorder since July 2005 but also noted diagnoses of depressive disorder, NOS and anxiety disorder since July 2005. Once VA undertakes the effort to provide an examination, it must obtain a fully adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Therefore, a new opinion must be obtained before the claim can be decided on the merits. The Veteran receives regular VA treatment. Complete records of his VA treatment, however, dated since February 2012, have not been physically or electronically associated with the claims folder. The records of his VA treatment are constructively before VA. See Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: 1. Request that the Veteran provide sufficient information, and, if necessary, authorization, to obtain any additional evidence, not already of record, which pertains to the claim for service connection for an acquired psychiatric disability, to include undifferentiated schizophrenia, depression, anxiety, and a mood disorder. Document all unsuccessful attempts to obtain such records. 2. Notify the Veteran that he may submit lay statements from himself and from individuals who have first-hand knowledge of his in-service and post-service psychiatric symptoms and the onset of these conditions. He should be provided an appropriate amount of time to submit this lay evidence. 3. Obtain the Veteran's VA treatment records from February 2012 to the present. 4. Thereafter, arrange for the Veteran to undergo an appropriate VA psychiatric examination. The claims file must be made available and reviewed by the examiner. All indicated studies should be performed, and all findings should be reported in detail. Then the examiner must opine as to whether the Veteran's acquired psychiatric disability, to include undifferentiated schizophrenia, depression, anxiety, and a mood disorder, is at least as likely as not related to or had its onset in service. The examiner must also opine as to whether it is at least as likely as not that any currently diagnosed undifferentiated schizophrenia or other psychoses were present within a year of active service. A complete rationale for all opinions must be provided in a legible report. 5. Then readjudicate the appeal. If the benefit sought on appeal is not granted in full, issue the Veteran and his representative a supplemental statement of the case and provide the Veteran an opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).