Citation Nr: 18147350 Decision Date: 11/06/18 Archive Date: 11/02/18 DOCKET NO. 15-36 117 DATE: November 6, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include major depression and anxiety disorder, is remanded. REASONS FOR REMAND The Veteran served honorably in the United States Army from March 1969 to January 1971. This matter comes before the Board of Veterans’ Appeals from a 2013 rating decision of the Department of Veterans’ Affairs in Milwaukee, Wisconsin. In October 2018, the Veteran testified on the issue of service connection for an acquired psychiatric disorder to include major depression and anxiety disorder before a Veterans Law Judge (VLJ). This remand is being processed through the Board’s One-Touch program. A hearing transcript will be associated with the claims file at a later date. 1. Entitlement to service connection for an acquired psychiatric disorder is remanded. The Veteran is seeking service connection for an acquired psychiatric disorder, to include major depression and an anxiety disorder. Prior to analyzing the merits of the Veteran’s claims for service connection, a remand is necessary to provide the Veteran with a VA compensation examination and to obtain and associate any pertinent medical records with the claims file. The Veteran asserts that he received treatment in a private facility in 1971, immediately following his separation from service. See, VA treatment records. The Veteran’s VA medical records note that the Veteran reported being seen by a psychiatrist for 4-5 years in either the Milwaukee or Stevens Point area; however, it does not appear that an attempt to secure any such records have been made. Aside from the Veteran’s treatment of a sore throat by a private physician in 1972, the earliest medical records appear to be from 1974. As such, on remand, efforts should be made to obtain any clearly identified psychiatric treatment. The Veteran’s primary contention is that he has current diagnoses of major depression and anxiety that were caused or aggravated by events during service, to include being continuously bullied and terrified for his life. Additionally, in his notice of disagreement, the Veteran noted that he experienced traumatic events prior to service and that these events caused the Veteran to enter service when his mental health was fragile. Based on this, the Veteran asserts that the thought of his service in Vietnam and the conditions of basic training aggravated his psychiatric disorder. Notably, the Veteran has not yet been afforded a VA compensation examination to ascertain the likely etiology of any currently diagnosed psychiatric disorder. In light of the evidence of a current disability and reports of inservice events, a VA examination should be provided to him. Moreover, the Board observes that despite the Veteran’s contentions, a psychiatric disability was not “noted” on his enlistment examination report. Under VA law, every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111 (2012);38 C.F.R. § 3.304 (b) (2017). A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306 (2017); Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service. 38 C.F.R. § 3.306. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. Id. Thus, the Board finds that the requested medical opinion must address whether there is clear and unmistakable evidence that a psychiatric disorder preexisted his service, and if so, whether it clearly and unmistakably was not aggravated therein. The matter is REMANDED for the following action: 1. Obtain all outstanding VA medical records and associate them with the claims file. 2. Provide the Veteran with the necessary authorization/consent forms to identify all private treatment providers who have treated him for a psychiatric disorder, particularly the provider who he states treated him in 1971 shortly after service separation. Any identified treatment should be requested and any obtained records should be added to the claims file. All efforts to obtain any such records should be clearly documented in the claims file 3. Then, schedule the Veteran for a VA examination to determine the nature and etiology of any current acquired psychiatric disorders. All required diagnostic testing should be undertaken. The claims file must be made available to and reviewed by the examiner, including a copy of this Remand. After reviewing the claims file and examining the Veteran, the examiner is asked to respond to the following: (a) Indicate all psychiatric disabilities currently shown, to include major depressive disorder and an anxiety disorder. (b) Provide an opinion as to whether a psychiatric disorder clearly and unmistakably preexisted the Veteran's active military service. In doing so, address the Veteran’s assertion that he had psychiatric issues prior to service, but also see his “normal” March 1969 induction Reports of Medical Examination and Medical History. (c) If the answer to (b) is yes, determine whether there is also clear and unmistakable evidence that such preexisting psychiatric disability did NOT undergo an increase in the underlying pathology, i.e., was not aggravated by his active military service? Attention is specifically drawn to the Veteran’s accounts of in-service acts that he asserts caused or aggravated his condition, including his fearing for his life. If there was an increase in severity of such disability during active military service, was that increase clearly and unmistakably due to the nature progression of the disability? (d) For any current psychiatric disorder that did not pre-exist service, provide an opinion as to whether it, at least as likely as not, had its onset during active service or is otherwise related to it. A complete rationale for all proffered opinions must be provided. 4. Thereafter, readjudicate the claim on appeal. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Wagner, Counsel