Citation Nr: 18147637 Decision Date: 11/05/18 Archive Date: 11/05/18 DOCKET NO. 10-38 327 DATE: November 5, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia, anxiety, and depression is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1970 to March 1971. The Board notes that both the December 2010 VA examiner and the February 2017 VA examiner concluded that, based on the evidence of record, the Veteran did not likely suffer from a preexisting acquired psychiatric disorder or psychosis, to include schizophrenia, prior to his active duty service. Moreover, both examiners concluded that the his in-service diagnosis of schizophrenia was made in error, and the Veteran does not have a current psychosis. Rather, both examiners accepted as true the Veteran’s report that the February 1971 episode which prompted the diagnosis of schizophrenia was actually a response to being under the influence of drugs. As such, the Board will presume that that the Veteran was sound upon entrance, and that the diagnosis of schizophrenia in service was made in error. Nevertheless, as noted in the October 2013 remand, the Veteran’s service treatment records also reflect other in-service psychiatric complaints and post-service diagnoses which have not been adequately addressed by the December 2010 and February 2017 VA examiners. For example, April 1970 service treatment records note that the Veteran was experiencing bedwetting. A September 1970 service treatment record notes his report of left sided chest pain. The impression at the time was probable psychosomatic. Five days later, a service treatment record notes continued problems with chest pains, as well as the Veteran’s complaints of nightmares, and he was given a provisional diagnosis of psychoneurosis. A February 1971 service treatment record that, for two weeks prior to his admission for command hallucinations, he was followed at the Mental Hygiene Consultation Service for hyperventilation and anxiety. The December 2010 and February 2017 VA examiners have also have not addequately addressed pertinent post-service evidence including the Veteran’s July 1972 diagnosis of psychoneuroses and May 1976 diagnosis of anxiety neurosis. When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). To ensure that any opinion provided adequately addresses all pertinent evidence of record, the Board finds that an addendum opinion is necessary. On remand, the AOJ should associate with the record any outstanding VA treatment records that are not currently associated with the claims file. Additionally, the Veteran should be given the opportunity to identify any outstanding pertinent records. The matter is REMANDED for the following action: 1. Associate any VA treatment records with the Veteran’s claims file. 2. Give the Veteran an additional opportunity to identify any outstanding pertinent evidence that has not already been associated with the claims file. The AOJ should then attempt to obtain those records if the Veteran provides the appropriate authorization. 3. Thereafter, the AOJ should obtain a VA medical opinion by someone other than the examiner who performed the February 2017 VA examination to determine whether the currently-diagnosed acquired psychiatric disorder is related to his military service. The record and a copy of this Remand must be made available to the opinion provider. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the opinion. Unless the opinion provider concludes otherwise (and provides a medical reason for such conclusion), he or she should assume as true that the Veteran was sound upon entrance, and that the diagnosis of schizophrenia in service was made in error. With this understanding, and following a review of the entire record, the examiner(s) should address the following: For any acquired psychiatric diagnoses made since May 1972, is it at least as likely as not (i.e., a 50 percent or greater probability) that such had its onset in, or is otherwise related to his period of active duty service? In offering any opinion, the examiner must consider the full record, to include the lay statements of record concerning the onset and continuity of psychiatric symptomatology, and the opinion should reflect such consideration. Moreover, the examiner must discuss the relevance, if any, of his in-service treatment, including the April 1970 complaint of bedwetting; the September 1970 treatment for chest pain and nightmares, and the provisional diagnosis of psychoneurosis; and the February 1971 service treatment record that indicated treatment for hyperventilation and anxiety two weeks prior to his admission for command hallucinations. Finally, the opinion provider should address the significance of his post-service diagnoses of psychoneuroses in July 1972 and anxiety neurosis in May 1976. A complete rationale must be provided for all opinions. 4. Thereafter, and after any further development deemed necessary, the appeal should be reajudicated. If the benefits sought on appeal are not granted, the Veteran and his representative should be provided with a Supplemental Statement of the Case and afforded the appropriate opportunity to respond. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD James R. Springer, Associate Counsel