Citation Nr: 18145187 Decision Date: 10/30/18 Archive Date: 10/26/18 DOCKET NO. 10-31 953 DATE: October 30, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include depression, anxiety, and multiple substance use disorders, is remanded. REASONS FOR REMAND The Veteran had active service from January 1977 to December 1977. In its August 2017 Remand, the Board made a finding that the Veteran’s attorney, Evelyn D. Beacham, had not properly withdrawn from representation in accordance with 38 C.F.R. § 20.608. Subsequently, in an October 2017 letter that served as a motion, Attorney Beacham provided good cause. Accordingly, her motion is granted. The Veteran continues with his appeal unrepresented. The Veteran’s claim has been characterized as one for service connection for an acquired psychiatric disorder, to include depression. Treatment records show that the Veteran has been diagnosed with unspecified anxiety disorder; multiple substance abuse disorders, to include opioids use disorder, alcohol use disorder, cannabis use disorder, and tobacco use disorder; and unspecified mood disorder. See February 2018 VA treatment note. During service, the Veteran reported on his October 1977 Report of Medical History upon separation that he suffered from depression and excessive worry. Upon examination in 2017, the Veteran reported that had a long history of drug and alcohol use that escalated while he was in service. In other correspondence sent to VA, the Veteran asserted that in-service marital problems also contributed to his psychiatric disability, contributing to a suicidal state. The Veteran was discharged from active duty service within one year due to unsuitability. Also on remand, the Veteran should be scheduled for another VA psychiatric examination to assess the nature and etiology of his claimed disability. The November 2017 VA examiner diagnosed the Veteran exclusively with Stimulant (Cocaine) Use Disorder. The examiner noted that the Veteran’s presentation and functioning were suggestive of a psychotic disorder though there was insufficient evidence to make a definitive diagnosis. She ultimately opined against the claim, noting that the Veteran’s service records do not document substance abuse during military service, and that post-service VA treatment had been limited to substance abuse. She opined that decades of substance abuse, along with multiple incarcerations, were likely to have fostered a mood disturbance, faulty judgment, perceptual disturbances, and impaired interpersonal and social functioning. The VA examiner did not specifically discuss the diagnoses other than drug abuse disorder documented in the Veteran’s VA treatment records from other physicians, to include anxiety disorder. Although the VA examiner observed that the Veteran had disclosed having depression and excessive worry upon separation, she did not discuss this point in her rationale, noting only that the Veteran did not have documented drug use in service. On remand, a new psychiatric examination should be scheduled to clarify the Veteran’s diagnosis or diagnoses and to more fully address whether any disability is related to service. In this connection, the Board believes the Veteran’s personnel file may contain records that would aid in a decision in this case. On remand, a request should be made for the Veteran’s complete personnel file. The matter is REMANDED for the following action: 1. Provide the Veteran an opportunity to submit, or authorize VA to obtain on his behalf, any records of medical care for his claimed psychiatric disability that are not already of record. 2. Request and obtain the Veteran’s complete service personnel file, and associate it with the record. 3. Schedule the Veteran for a VA psychiatric examination. The examiner should obtain a history from the Veteran as to the progression of his claimed psychiatric disability(ies). The examiner is asked to address the following: (a.) Identify, by diagnosis, all acquired psychiatric disabilities reflected in the record during the appeal period. In providing a response, note that the Veteran has been previously diagnosed with unspecified anxiety disorder, opioids use disorder, alcohol use disorder, cannabis use disorder, tobacco use disorder, and unspecified mood disorder, by VA physicians. If current diagnoses conflict with prior diagnoses, or do not include prior diagnoses, the examiner should attempt to reconcile prior and current findings to the extent possible. (b.) For each disability diagnosed, the examiner is asked to provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that such disability was incurred in, or otherwise related to, the Veteran’s military service. In so doing, the examiner should consider the Veteran’s notation on his October 1977 report of medical history that he suffered from depression and excessive worry, and his lay statements that depression had onset during active service due to marital problems occurring at the time. A detailed rationale is required for all opinions provided. 4. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the issue on appeal. If the benefit sought on appeal remains denied, the Veteran should be provided with a Supplemental Statement of the Case and be afforded a reasonable period of time within which to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Polly Johnson, Associate Counsel