Citation Nr: 18151179 Decision Date: 11/16/18 Archive Date: 11/16/18 DOCKET NO. 14-39 503 DATE: November 16, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder is remanded. REASONS FOR REMAND The Veteran has current psychiatric disorders, variously diagnosed, including MDD, dysthymia, an adjustment disorder, and anxiety. He asserts his pre-existing psychiatric disorder were aggravated by active service. Remand is required here as there are no medical records in the claims file prior to the Veteran’s active service. These would be relevant in determining the precise nature of the psychiatric disability as well as help to establish a baseline level of disability. In addition, remand is required to provide the Veteran with an additional VA examination. Service treatment records show that on his entrance examination, psychiatric abnormalities were not found and the Veteran did not raise pertinent complaints on the accompanying Report of Medical History. Yet, during a psychiatric admission for major depressive disorder in July 2006, the Veteran reported a history of suicidal attempts prior to service, as well as treatment for attention-deficit/hyperactivity disorder (ADHD) and MDD in the past. The Veteran’s DD-214 indicates he was separated due to condition, not a disability. During a February 2014 examination, the Veteran reported a history of psychiatric treatment including inpatient treatment in 6th grade and additional psychiatric care until the age of 17. The VA examiner determined that as the Veteran has a history of mental health problems going back to childhood, any current diagnosis of depression can be attributed to his previous history of mood difficulties versus having a direct etiology to his experiences in the military. Additionally, the examiner opined the Veteran’s symptoms were not exacerbated beyond their normal course as a result of his service in the Army. A veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service. 38 U.S.C. § 1111 (2012). When no preexisting condition is noted upon entry, the veteran is presumed to have been sound upon entry and the presumption of soundness attaches. Noted means only such conditions as are recorded in examination reports, and the history of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions. 38 C.F.R. § 3.304 (2018). In order to rebut the presumption of soundness, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. 38 U.S.C. § 1111 (2012); 38 C.F.R. § 3.304(b) (2018). The absence of evidence is not a sufficient basis to show a disease or injury was not aggravated by service. Horn v. Shinseki, 25 Vet. App. 231, 239 (2012).   The matter is REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for any provider which treated him for psychiatric symptoms prior to service. 2. After any additional records are associated with the claims file, obtain an addendum opinion regarding the etiology of the Veteran's psychiatric disorders from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. The examiner must provide an opinion as to the following questions: a. Do you believe that the Veteran's psychiatric disorder existed prior to his active duty service from January 2006 through October 2006? Why do you say so? b. Do you believe that any preexisting psychiatric disorder was NOT aggravated during the Veteran's active duty service? Why do you say so? (Continued on the next page)   c. If the answer to question (a) above is no, is it at least as likely as not (50 percent or greater probability) that the Veteran's psychiatric disorder manifested during active duty service or is otherwise related to an event, injury, or disease incurred during active duty service? M. TENNER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Diane M. Donahue Boushehri, Counsel