Citation Nr: 18139931 Decision Date: 10/01/18 Archive Date: 10/01/18 DOCKET NO. 16-15 163 DATE: October 1, 2018 ORDER New and material evidence having been presented, the claim of entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder, dysthymia, and posttraumatic stress disorder (PTSD), is reopened. REMANDED The issue of entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder, dysthymia, and PTSD, is remanded for additional development. FINDING OF FACT 1. The claim of entitlement to service connection for an acquired psychiatric disorder was originally denied in an November 1975 rating decision. The decision was not appealed and no new and material evidence was submitted within one year of the decision; the decision became final. 2. Some of the evidence received since the November 1975 rating decision is new and relates to unestablished facts necessary to substantiate the claim of entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder, dysthymia, and PTSD. CONCLUSION OF LAW 1. The November 1975 rating decision that denied the claim of entitlement to service connection for an acquired psychiatric disorder, claimed as a nervous condition, is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.156(b), 20.1103. 2. New and material evidence has been submitted, and the claim of entitlement to service connection an acquired psychiatric disorder is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1973 to February 1974. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a May 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). Pursuant to 38 C.F.R. § 3.156, a claimant may reopen a finally adjudicated claim by submitting new and material evidence. The Board finds that such evidence has been received regarding the claim of entitlement to service connection for an acquired psychiatric disorder, and, as a result, the claim is reopened. The Board observes that the RO had originally adjudicated the Veteran’s claim as entitlement to service connection for a nervous condition and entitlement to service connection for major depressive disorder and PTSD. However, the medical evidence of record reveals diagnoses of various acquired psychiatric disorders. Accordingly, the issue has been amended. Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). REASONS FOR REMAND Entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder and PTSD, is remanded. The Veteran contends that service connection is warranted for an acquired psychiatric disorder which he asserts has been manifested by symptoms of depression since service. Service treatment records document a normal enlistment examination. However, a November 1973 treatment note reflects a diagnosis of depression with alcohol abuse. The Veteran was psychiatrically admitted from November 1974 to January 1974 and diagnosed with excessive drinking and a hysterical personality before being discharged to duty. Administrative separation was recommended. The Veteran had normal psychological and neurological evaluations at his separation examination. Post-service treatment notes dated in 1974 for a back condition document the Veteran’s reports of depression. Post-service treatment records document diagnoses and treatment for major depressive disorder and PTSD as early as 2012. They do not document a diagnosis of a personality disorder. A June 2014 Disability Benefits Questionnaire by the Veteran’s treating VA psychologist notes that the Veteran has diagnoses of major depressive disorder and PTSD. The psychologist referenced that the Veteran’s in-service January discharge summary indicated psychological problems beyond alcohol (behavioral problems) that led to his separation from service. A VA mental disorders opinion was obtained in April 2015. The VA clinician opined that the Veteran’s major depressive disorder was less likely than not related to service. The clinician explained that the Veteran’s depressive disorder is related to chronic pain and post-service stressors. She further referenced that the Veteran’s treatment notes described a link between depression and chronic pain and that the Veteran was discharged from service with a personality disorder. The clinician also stated that the Veteran’s PTSD was not related to service as he did not participate in combat. Significantly, however, the clinician did not discuss whether the Veteran’s in-service symptoms or in-service diagnosis of depression were causally related to his current diagnosis of major depressive disorder. The Board also notes that the Veteran is not currently diagnosed with a personality disorder. As the question is not whether the Veteran had a psychiatric diagnosis in service, but whether the current psychiatric disabilities are related to his in-service symptoms, the Board finds that this opinion is inadequate. Based on the foregoing deficiencies, an addendum opinion is necessary prior to adjudication of the claim. See Barr v. Nicholson, 21 Vet. App. 303, 311(2007) (once VA undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). The matter is REMANDED for the following action: 1. Ask the Veteran to provide the names and addresses of any medical provider, VA or private, who has treated him for a psychiatric condition. After securing any necessary releases, the AOJ should request any relevant records identified that are not duplicates of those already contained in the claims file. Additionally, obtain VA treatment records dating from September 2016 to the present. If any requested records are unavailable, the claims file should be annotated as such and the Veteran and his representative notified of such. 2. Ask the Veteran to provide the locations and dates, within a two-month time frame, of any incidents during service that he alleges are stressors for his PTSD. If sufficient information is provided regarding any stressors, an attempt should be made to verify them through official channels. All responses received should be documented in the claims file, and the Veteran and his representative notified of any negative response. 3. After completing the above actions and associating any additional records with the claims file, schedule the Veteran for a VA mental disorders examination to determine the nature and etiology of his psychiatric conditions. All diagnostic testing deemed to be necessary by the examiner should be accomplished. The examiner should provide the following: (a.) Identify all currently diagnosed mental health disabilities. In doing so, the examiner should note that the term “current” means occurring at any time during the pendency of the Veteran’s claim; i.e., from November 2014 onward. The psychiatric disorder need not be present at the time of the examination; rather it is sufficient if it previously existed during the pendency of the claim and then resolved prior to the examination. (b.) The Board notes that the record shows past diagnoses of major depressive disorder and PTSD. All of these disorders should be considered and discussed, in addition to any other disorders that may be found. If any specific disorder is ruled out, a complete explanation must be provided. That explanation should include a discussion of all the pertinent evidence of record, to include lay evidence. So, for example, if the examiner were to find that PTSD is not a current disability, then the explanation should include a discussion of the medical records, prior VA examinations, as well as the Veteran’s lay statements regarding his condition. If the examiner determines that any prior diagnosis cannot be validated, she or he should explain why. (c.) With respect to each diagnosed psychiatric disability, the examiner should opine as to whether it is at least as likely as not (50 percent probability or greater) that the disability arose during service or is otherwise related to any incident of service. Please explain why or why not. (d.) In providing this opinion, the examiner should comment on the significance, if any, of the reports of depression, suicidal thoughts, and alcohol abuse during service, including a diagnosis of depression and a two-month admission for alcoholism. In doing so, the examiner should address the Veteran’s assertion that these episodes represented a manifestation of his psychiatric symptoms during service. (e.) A rationale for any opinions expressed should be set forth. If the examiner cannot provide an above opinion without resorting to speculation, he/she should explain why an opinion cannot be provided (e.g. lack of sufficient information/evidence, the limits of medical knowledge, etc.). 4. After completing the requested actions, and any additional action deemed warranted, readjudicate the Veteran’s claim. If the benefit sought on appeal remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration, if in order. S. C. KREMBS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Bilstein, Associate Counsel