Citation Nr: 1808875 Decision Date: 02/13/18 Archive Date: 02/23/18 DOCKET NO. 16-37 295 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder. 2. Entitlement to service connection for rheumatoid arthritis. REPRESENTATION Veteran represented by: Jeany Mark, Attorney at Law ATTORNEY FOR THE BOARD K. Kardian, Associate Counsel INTRODUCTION The Veteran served on active duty from June 2003 to December 2003. This matter is before the Board of Veteran's Appeals (Board) on appeal from a July 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Augusta, Maine. Jurisdiction resides with the RO in Baltimore, Maryland. The Veteran initially submitted a claim for entitlement to service connection for depression, anxiety and stress. The Board notes that, particularly with respect to psychiatric disorders, a claim of service connection encompasses all pertinent symptomatology, regardless of how that symptomatology is diagnosed. See Clemons v. Shinseki, 23 Vet. App. 1, 5, 9 (2009). In light of Clemons, the Board has recharacterized the issue, as reflected on the title page, to include a claim of entitlement to service connection for an acquired psychiatric disorder. The Board has reviewed the electronic records maintained in Virtual VA and Veterans Benefits Management System (VBMS) to ensure consideration of the totality of the evidence. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (West 2012). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran contends she is entitled to service connection for major depressive disorder, to include stress and anxiety and service connection for rheumatoid arthritis. As noted above the Board has expanded the Veteran's claim for major depressive disorder to include an acquired psychiatric disorder. The Board finds a remand is warranted for additional development. First, VA has a duty to assist in the procurement of relevant records. 38 C.F.R. § 3.159 (2017). "Relevant records" to be considered to determine a Veteran's eligibility for compensation benefits are those records that relate to the injury for which the claimant is seeking benefits and have a reasonable possibility of helping to substantiate the Veteran's claim. Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). In December 2012 correspondence, the Veteran reported receiving a fully favorable decision from Social Security Administration (SSA). See December 2012 Veterans' Application for Compensation and/or Pension. As these identified SSA records may be relevant to all the claims on appeal, the case must be remanded so appropriate attempts can be made to obtain these outstanding records. Next, the Veteran's representative in November 2017 correspondence submitted medical literature suggesting that an adjustment disorder can lead to major depressive disorder when the symptoms and stressors persist together. The Veteran was most recently afforded a VA opinion as to mental disorders in June 2016. If VA provides an examination that examination and opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The examiner noted that the Veteran's current depressive disorder was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner found the Veteran's current symptoms were not related to her period of active service, and distinguished these from the Veteran's adjustment disorder with depressed mood in-service and difficulty adapting to service. However, in light of the recently associated medical literature suggesting that a diagnosis of adjustment disorder may evolve into major depressive disorder over time a supplemental opinion is warranted to address this newly associated medical literature. As such the Board finds a remand is warranted for a supplemental VA opinion. Lastly, if additional relevant treatment records related to the Veteran's rheumatoid arthritis are associated with the claims file the case should be referred to the June 2016 VA examiner for a supplemental opinion. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Appropriate attempts should be made to obtain and associate with the claims file the Veteran's Social Security Administration (SSA) records. All actions to obtain the records should be documented. If the records cannot be located or do not exist, a memorandum of unavailability should be associated with the file, and the Veteran should be notified and given an opportunity to provide them. 2. After completing the development above, refer the case to the June 2016 VA mental health examiner for a supplemental opinion. If the same examiner is not available, the claims folder should be forwarded to another clinician. The examiner shall review the Veteran's claims file, and review any additional treatment records and private opinions associated with the claims file since the last examination and revisit all prior opinions provided. After reviewing the claims file and examining the Veteran, only if warranted, the examiner should answer the following questions: a. Is it at least as likely as not (a 50 percent probability or greater) that the Veteran's current major depressive disorder is related to active service? The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Service treatment records note the Veteran was seen by behavioral medicine and diagnosed with adjustment disorder with depressed mood. Additionally, the examiner should consider the Veteran's contentions noting ongoing symptoms of depression, sleep disturbance, decreased appetite, loss of motivation and interest and social activities and suicidal ideations since service. Also, the November 2017 correspondence and associated medical literature addressing adjustment disorder and major depressive disorder from the Veteran's representative should be addressed. 3. After completing the development above to the extent possible in directive number 1, and only if warranted based on additional treatment records being associated with the claims file, refer the case to the June 2016 VA examiner for a supplemental opinion as to rheumatoid arthritis. If the same examiner is not available, the claims folder should be forwarded to another clinician. The examiner shall review the Veteran's claims file, any additional treatment records and private opinions associated with the claims file and revisit all prior opinions provided. After reviewing the claims file and examining the Veteran, if warranted, the examiner should answer the following questions: b. Is it at least as likely as not (a 50 percent probability or greater) that the Veteran's rheumatoid arthritis is related to active service? The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Service treatment records note the Veteran was seen for bilateral knee pain, and finger pain when making a fist. Additionally, the examiner should consider the Veteran's contentions noting ongoing knee, back and feet pain since service. 4. Thereafter, readjudicate the issues on appeal. If the determination remains unfavorable to the Veteran, she and her representative, if any, should be furnished a supplemental statement of the case which addresses all evidence associated with the claims file since the last statement of the case. The Veteran and her representative should be afforded the applicable time period to respond. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (West 2012). _________________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (West 2012), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).