Citation Nr: 19178571 Decision Date: 10/15/19 Archive Date: 10/15/19 DOCKET NO. 12-21 356 DATE: October 15, 2019 REMANDED Entitlement to service connection for Tourette's syndrome is remanded for additional development. Entitlement to service connection for an acquired psychiatric disability, to include as secondary to a service-connected disability, is remanded for additional development. REASONS FOR REMAND The Veteran had active service with the U.S. Air Force from April 1972 to February 1974. During this time, he was awarded the National Defense Service Medal and the Vietnam Service Medal. These matters come to the Board of Veterans’ Appeals (Board) on appeal from a July 2009 rating decision issued by the Department of Veterans Affairs (VA) regional office (RO) in Little Rock, Arkansas. The Board notes that it most recently remanded this appeal in October 2018 for the RO to obtain the Veteran’s records regarding benefits from the Social Security Administration (SSA); these records were obtained and associated with the file in July 2019. 1. Entitlement to service connection for Tourette's syndrome is remanded. The Veteran has asserted that his Tourette’s syndrome was caused by or otherwise related to his active service; in the alternative, he maintains that it was aggravated beyond its natural progression by his active service. In conjunction with his claim, the Veteran underwent a VA examination in November 2015. See October 2015 VA Central Nervous System Disability Benefits Questionnaire (DBQ). The examiner opined that the Veteran’s “service did not aggravate his Tourette’s.” Id. No additional conclusions or rationale were provided. In March 2016, the RO requested an addendum opinion, which the examiner provided in April 2016. See, e.g., March 2016 VA request for Physical Examination (VA Form 21-2507a); April 2016 Addendum. The examiner stated that he “concluded that [the Veteran’s] Tourette’s syndrome pre-existed his active duty service. He had a definite history of tics as a child. There is clear evidence that his Tourette’s syndrome was not aggravated by military service. His progression of disease was consistent with normal clinical progression of the disease. The Tourette’s syndrome did not have its onset in service. The rationale for this reasoning is knowing the normal clinical progression of the disease.” See April 2016 Addendum. The Board finds neither the October 2015 nor April 2016 opinions to be adequate for rating purposes. In the October 2015 opinion, the examiner provided a conclusion that the Veteran’s Tourette’s syndrome preexisted his active service with no supporting rationale; in the April 2016 addendum opinion, the sole rationale for concluding that the Veteran’s condition was not aggravated beyond the natural progression was “knowing the normal clinical progression of the disease” without explaining the natural progression of the disease is, or how the evidence in the record tracked with (or did not track with) the natural progression of the disease. The Board further notes that neither the October 2015 examination and opinion nor the April 2016 addendum address the numerous lay statements the Veteran has provided during the pendency of the appeal regarding the in-service and post-service manifestations of his Tourette’s syndrome. Once VA undertakes the effort to provide a medical examination or opinion, it must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). An adequate medical opinion with regard to etiology should consist of a thorough review of the claims file and discussion of the relevant evidence (including the disability in question), a consideration of the lay contentions of the Veteran, and clear conclusions with a supporting rationale. Barr, 21 Vet. App. at 311; Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Accordingly, the Board finds that a new VA examination and opinion are warranted to determine the nature and etiology of the Veteran’s Tourette’s syndrome. 2. Entitlement to service connection for an acquired psychiatric disability, to include as secondary to a service-connected disability, is remanded. The Veteran has also asserted that has an acquired psychiatric disability that is related to his active service; in the alternative, he maintains that this disability is secondary to his Tourette’s syndrome, which he asserts also warrants service connection. In conjunction with his claim, the Veteran underwent a VA psychiatric examination in December 2015. See December 2015 Mental Disorders DBQ. The examiner ultimately diagnosed the Veteran with psychosis NOS, and opined that this condition was less likely than not related to his active service, Tourette’s syndrome, or any other service-connected condition “because there is simply no evidence to suggest a link.” Id. The examiner also noted that it was unclear if the Veteran’s history of polysubstance abuse or his family history of schizophrenia contributed to the Veteran’s diagnosis. Id. He referenced one treatment record from 2013 where the Veteran reported depression as a result of Tourette’s and stated, “previous mental health notes do not contain references to his Tourette’s as a cause of his depression.” Id. However, the Board notes that the evidence of record contains multiple lay statements regarding the relationship between the Veteran’s Tourette’s syndrome and his psychiatric symptoms. See, e.g., November 2009 SSA Function Report (reflecting that the Veteran reported that he is a” social freak” due to his Tourette’s); November 2009 SSA Mental Residual Functional Capacity Assessment (documenting that the SSA examiner’s findings that the Veteran’s Tourette’s syndrome diagnosis “is a source of distress and frustration” for him); September 2013 Board Hearing Transcript (reflecting that the Veteran testified that when he tried to control his Tourette’s symptoms in service, they worsened, which in turn led to abuse by people around him; isolation; emotional breakdowns; and depression); May 2019 North Little Rock VANPH Mental Health Diagnostic Study Note (recording that the Veteran recounted how in basic training, after being assigned extra duty, the other men wrapped him in a blanket and beat him, and that he felt inferior and like “damaged goods”). Because the December 2015 examination and opinion did not address the lay evidence submitted by the Veteran regarding his psychiatric symptoms, his Tourette’s syndrome, and the military, the Board finds them to be inadequate for rating purposes. Once VA undertakes the effort to provide a medical examination or opinion, it must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). An adequate medical opinion with regard to etiology should consist of a thorough review of the claims file and discussion of the relevant evidence (including the disability in question), a consideration of the lay contentions of the Veteran, and clear conclusions with a supporting rationale. Barr, 21 Vet. App. at 311; Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Accordingly, the Board finds that a new VA examination and opinion are warranted to determine the nature and etiology of the Veteran’s acquired psychiatric disability, to include as secondary to a service-connected disability. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records for the Veteran and associate them with the claims file. All attempts to secure any identified records and any response received must be documented in the case file. 2. After any available records are associated with the claims file, schedule the Veteran for additional VA examinations in the appropriate specialties with examiners other than the October 2015 and December 2015 examiners to address the nature and etiology of the Veteran’s 1) Tourette’s syndrome and 2) acquired psychiatric disabilities. The examination should include any diagnostic testing or evaluation deemed necessary for each specific claimed disability. 3. The electronic claims file must be made available for the examiner to review. The Veteran must be interviewed. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. The examiner must provide a clear explanation for the opinion, to include any comment on any credibility issues raised by the record from a medical perspective. 4. Based upon a review of the entirety of the claims file, the history presented by the Veteran, and the examination results as to each claimed condition, the examiner is requested to provide an opinion as to the following questions: (a.) With respect to the Veteran’s Tourette’s syndrome disability, is it at least as likely as not (50 percent probability or more) that the disability began in service, was caused by service or is otherwise related to service? (b.) If the answer to (a.) is negative, then is it at least as likely as not (50 percent probability or more) that the Veteran’s Tourette’s syndrome disability was aggravated by his active service? Aggravation is defined as a worsening beyond the natural progression of the disability. (c.) Regarding the Veteran’s acquired psychiatric disability, first, the examiner must provide diagnoses for all current and previously diagnosed psychiatric disorders found following a review of the entirety of the Veteran’s claims file. (d.) For each disorder identified, the examiner should state whether it is at least as likely as not (i.e. a 50 percent chance or greater) that the disorder manifested in service or is otherwise etiologically-related to the Veteran’s military service. (e.) For any identified psychiatric disorder for which the answer to (d.) is negative, the examiner should state whether it is at least as likely as not (i.e. a 50 percent chance or greater) that the disorder was caused by or otherwise related to the Veteran’s Tourette’s syndrome. Specifically, the examiner is asked to address the following pieces of evidence: 1) November 2009 SSA Function Report, 2) November 2009 SSA Mental Residual Functional Capacity Assessment, 3) September 2013 Board Hearing Transcript; 4) May 2019 North Little Rock VANPH Mental Health Diagnostic Study Note. The examiner must provide a complete rationale for all opinions expressed. As part of the rationale, the examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). A discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. The examiner must indicate whether an opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Raj, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.