Citation Nr: 1334843 Decision Date: 10/31/13 Archive Date: 11/06/13 DOCKET NO. 11-07 261 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES Entitlement to service connection for an acquired psychiatric disorder, to include bipolar disorder, personality disorder, major depressive disorder, mood disorder and nervous breakdown. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and his father ATTORNEY FOR THE BOARD E. I. Velez, Counsel INTRODUCTION The Veteran had active service from February 1992 to September 1992. This case comes before the Board of Veterans' Appeals (the Board) on appeal from an October 2009 rating decision rendered by the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. The Veteran testified at a Travel Board hearing which was chaired by the undersigned at the RO in September 2011. A transcript of the hearing has been associated with the claims file. The Board notes that the United States Court of Appeals for Appellants Claims (Court) has held that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The records shows diagnoses of bipolar disorder, personality disorder, major depressive disorder and mood disorder. The Veteran has also alleged he had a nervous breakdown. The claim was initially adjudicated as three separate issues by the RO in the October 2009 rating decision. However, given the holding in Clemons, the Board has rephrased the issue as reflected on the title page to be a single issue of service connection for an acquired psychiatric disorder. 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 The Veteran seeks service connection for an acquired psychiatric disorder, to include bipolar disorder, depression and nervous breakdown, and for a personality disorder. The Board finds that additional development is required before the claim may be adjudicated. At the September 2011 hearing, the Veteran testified he was in receipt of Social Security Administration (SSA) disability benefits. However, the SSA records have not been associated with the claims file, and are possibly relevant to the Veteran's claim. See Murincsak v. Derwinski, 2 Vet. App. 363 (1992); Collier v. Derwinski, 1 Vet. App. 412 (1991). Accordingly, an attempt should be made to obtain such records. 38 C.F.R. § 3.159(c)(2). Service treatment records show that the Veteran was treated for major depressive disorder. An August 1991 Report of Medical Board shows the Veteran was found to have major depressive disorder which pre-existed service and was not aggravated by service. His DD 214 reflects he was released from active service due to a personality disorder. Post service treatment records from private psychiatrists, show the Veteran was diagnosed with and treated for bipolar disorder as early as November 1995. The Veteran was afforded a VA examination in October 2009. At the time, after a review of the claim file and examination of the Veteran, the examiner found that the a bipolar disorder diagnosis was not found and instead found that the Veteran was most likely suffering form a substance-induced mood disorder, which is less likely as not related to or a progression of his service connected major depressive disorder. The examiner noted this was a complicated case due to the history of substance abuse. The Board finds the examination and opinion to be inadequate for a number of reasons. The credentials of the VA examiner were not provided. The Board cannot determine the level of expertise of the examiner, specifically whether they are a psychologist or psychiatrist. Given that the examiner noted the case to be complicated, knowing the expertise of the examiner would be helpful in properly assessing the reliability of the opinion. Moreover, while the examiner focused on the most recent diagnosis of bipolar disorder in 2009 which was at a time when the Veteran was using methamphetamines and based the dismissal of the diagnosis on that, the examiner appears to ignore the many years of bipolar diagnoses which were provided at times when the Veteran was sober. Finally, the Board is confused by the examiner's reference to the "service connected major depressive disorder." The Veteran is not currently service connected for any psychiatric disabilities, as such, the Board is confused with the concluding statement of the opinion. It is unclear as to whether the examiner is finding that the major depressive disorder is related to service. In sum, a new VA examination and opinion by a specialist is needed. Accordingly, the case is REMANDED for the following action: 1. Contact the SSA and request all pertinent documentation pertaining to any claim for disability benefits by the Veteran including any medical records that Social Security has regarding the veteran. These records should be associated with the claims file. Any negative search must be documented in the claims folder. 2. The RO/AMC should afford the appellant a psychiatric VA examination to be conducted by a psychiatrist in order to determine the nature and etiology of his acquired psychiatric disorder. The claims file, to include a copy of this Remand, must be made available to and be reviewed by the examiner. Any evaluations, studies, and tests deemed necessary by the examiner should be conducted. The examiner should provide an opinion as to the following questions: For each currently diagnosed acquired psychiatric disorder, did such disorder clearly and unmistakably pre-exist the appellant's entry into active duty? A fully explained rationale for the opinion should be provided. (i) If so, is there clear and unmistakable evidence that the appellant's pre-existing psychiatric disorder did not undergo an increase in the underlying pathology during service, i.e., was aggravated during service? A fully explained rationale for the opinion should be provided. If there was an increase in severity of the appellant's psychiatric disorder during service, was that increase due to the natural progress of the disease, or was it above and beyond the natural progression? A fully explained rationale for the opinion should be provided. (ii) If not, is it at least as likely as not that the appellant's psychiatric disorder is casually related to any incident of service? A fully explained rationale for the opinion should be provided. Again, in offering any opinion, the examiner must consider the full record, to include the appellant's lay statements regarding the incurrence of his psychiatric disorder as well as the continuity of symptomatology. All opinions expressed should be accompanied by supporting rationale. 3. Upon completion of the above, readjudicate the issue on appeal and consider all evidence received since issuance of the most recent Supplemental Statement of the Case. If any benefit sought on appeal remains denied, the appellant and his representative should be furnished an appropriate supplemental statement of the case and be provided an opportunity to respond. Thereafter, the case should be returned to the Board for further appellate consideration, as appropriate. 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). _________________________________________________ C. TUEBA 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).