Citation Nr: 20004542 Decision Date: 01/21/20 Archive Date: 01/21/20 DOCKET NO. 14-11 518 DATE: January 21, 2020 REMANDED Entitlement to service connection for an acquired psychiatric disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1972 to October 1973. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. In April 2017, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript is of record. The Board remanded the case for further development in December 2017. The case has since been returned to the Board for appellate review. Upon review, the Board finds that additional development is needed prior to adjudication of the claim. The Veteran was afforded a VA examination in August 2018 in connection with his claim. The examiner diagnosed him with alcohol use disorder and opined that the disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. He also found that the Veteran did not have a diagnosis of any other mental health disorders. However, the examiner did not provide any rationale for that finding, and there is evidence of record showing other diagnoses, such as an adjustment disorder and depressive disorder. The examiner did not discuss those diagnoses or whether they may have been misdiagnosed or had resolved. Therefore, the Board finds that an additional VA examination and medical opinion are needed. Moreover, in the December 2017 remand, the Board noted that the Veteran had testified that he was treated in 1970 or 1973 for a psychiatric disorder at the Jesse Brown VA Medical Center (VAMC). The Board directed the agency of original jurisdiction (AOJ) to obtain such records. Although the AOJ did request such records, the treatment records have not been associated with the claims file, and there is no documentation of any response or finding of unavailability. Thus, on remand, the AOJ should make another attempt to secure such records and document any responses received if they are unavailable. The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for an acquired psychiatric disorder. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA treatment records, including any records dated from 1970 to 1976 from the Jesse Brown VAMC. If the search for such records has negative results, the claims file should be properly documented as to the unavailability of those records. 2. After the foregoing development is completed, the Veteran should be afforded a VA examination to determine the nature and etiology of any acquired psychiatric disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, such as observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should identify all current psychiatric disorders. If any previously diagnosed psychiatric disorders are not found on examination, the examiner should address whether they were misdiagnosed or have resolved. For each disorder identified other than a personality disorder, the examiner should state whether it is at least as likely as not that the disorder manifested in service or is otherwise causally or etiologically related to the Veteran’s military service. In rendering this opinion, the examiner should specifically consider the Veteran’s April 2017 hearing testimony regarding his experience in service and reported symptomatology since that time. If the Veteran is diagnosed with a personality disorder, the examiner should state whether there was a superimposed disease or injury that occurred during service. If the Veteran is diagnosed with any psychosis, the examiner should state whether the disorder manifested within one year of the Veteran’s military service. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history[,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. The AOJ should conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K.M. Walker 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.