Citation Nr: 21004272 Decision Date: 01/26/21 Archive Date: 01/26/21 DOCKET NO. 15-17 141 DATE: January 26, 2021 REMANDED Entitlement to service connection for psychiatric disorder, to include depressive disorder and schizophrenia, is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1963 to October 1963. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that the Veteran requested a travel board hearing on his substantive appeal form. However, in December 2016 correspondence, he withdrew that request. Thus, the Board deems his request for a hearing withdrawn. See 38 C.F.R. § 20.704. In November 2019, the Board remanded the claim, in pertinent part, to obtain a VA examination and medical opinion. The case has been returned to the Board for further appellate review. The Board notes that the Veteran is not currently represented by an attorney, agent or Veterans Service Organization in the instant appeal. The record reflects that in a letter dated June 2020, VA notified the Veteran that his previous appointment of The American Legion as his representative (VA Form 21-22) was invalid and enclosed a VA Form 21-22. To date, the Veteran has not completed and returned a VA Form 21-22 despite the record showing VA social workers have provided the Veteran with phone numbers of local service officers to assist him with his appeal. See e.g. August 2019 VA treatment record. In remanding this matter, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran’s assertions. Neither the Veteran’s credibility nor any lack thereof should be presumed in this remand. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.800(c). 38 U.S.C. § 7107(b). Entitlement to service connection for an acquired psychiatric disorder is remanded. The Veteran contends that he has a mental disorder that began during active service and/or has been caused by his military training as well as racial discrimination. Before deciding the appeal, the Board finds that remand is necessary in order to ensure compliance with its prior remand instructions. Stegall v. West, 11 Vet. App. 268, 271(1998). Service treatment records (STRs) reflect that Veteran was referred for neuropsychiatric examination due to his glue sniffing and unpredictable behavior. The Veteran was found to have considerable difficulty with military adjustment due to irrational behavior while under the influence of glue. He was diagnosed with schizoid personality with passive-dependent and hysterical trends and was recommended for separation from service. A September 1963 separation examination reflects an abnormal clinical evaluation of the psychiatric system (schizoid personality with passive-dependent and hysterical trends) and a medical history of nightmares and depression or excessive worry was noted. The Veteran denied a history of nervous trouble of any sort. The Veteran underwent a VA mental disorders examination in February 2013. The Veteran was diagnosed with depressive disorder and no other psychiatric diagnosis was found. The examiner opined that it is less likely than not that his current depressive disorder is related to service because this condition was not diagnosed in service or within one year after service. As previously stated, the Board remanded the claim in order to obtain an additional, updated VA psychiatric examination. However, the record shows that the Puerto Rico RO, in a September 2020 examination request, stated that the Veteran did not need to report for a VA mental disorders examination. Rather, the RO instructed that the same VA examiner who conducted the February 2013 VA mental disorders examination should provide an addendum opinion to her previous examination report. In September 2020, the same VA examiner who performed the February 2013 VA mental disorders examination provided a negative nexus opinion. The opinion was based on the examiner’s review of the Veteran’s claims file without an in-person or video telehealth examination as it was determined that the medical evidence in the claims file provided sufficient information and an examination would not likely provide any additional relevant evidence. The Board finds that the September 2020 VA medical opinion is inadequate for a number of reasons. First, the examiner referred to several of the Veteran’s VA treatment records throughout the appeal period, which reflect various psychiatric diagnoses including,g but not limited to, major depression with psychotic features and schizophrenia, multiple episodes, currently in partial remission. The examiner, however, stated that because she had found that the Veteran only met the diagnostic criteria for a depressive disorder diagnosis during the February 2013 VA examination, she could not render an opinion, as directed by the Board, regarding any other formal mental conditions of record without resorting to speculation. Again, the Board emphasizes that the Veteran was not provided an in-person or video telehealth examination pursuant to its remand instructions. In addition, the examiner stated that the longitudinal medical evidence shows a continuity and chronicity of the Veteran’s depressive mental condition yet she failed to address whether the abnormal findings shown in service, to include the Veteran’s report of depression on service separation, reflected the onset of any current depressive disorder. Furthermore, the examiner noted the Veteran’s in-service diagnosis of schizoid personality with passive dependent and hysterical trends and commented that “personality disorders are defined as a longstanding, enduring pattern of inner experience and behavior that is inflexible and pervasive across a broad range of personal and social situations, not related to service.” However, the examiner did not discuss whether any current psychiatric disorder was at least as likely as not superimposed on a personality disorder shown during the Veteran’s active service, resulting in additional disability. Finally, the examiner did not address the Veteran’s lay assertions that his psychiatric symptoms had their onset during service and were caused by his military training. The Board also finds the VA examiner essentially reiterated her February 2013 medical opinion which the Board consequently found to be inadequate for adjudication purposes and thus, the basis of the prior remand. An adequate medical opinion must be "accurate and fully descriptive," and based on an accurate factual premise and consideration of a veteran's prior medical history. Ardison v. Brown, 6 Vet. App. 405, 407 (1994). In addition, the opinion "must support its conclusions with an analysis that the Board can consider and weigh against contrary opinions." Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); A medical opinion must contain clear conclusions with supporting data, and a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Given the foregoing reasons, the Board finds that the appeal cannot be resolved without conducting an in-person or video telehealth VA examination and securing an adequate opinion. The matter is REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records from August 2020 to the Present. 2. Schedule the Veteran for a psychiatric examination by an appropriate clinician, other than the psychiatrist who conducted the February 2013 VA mental disorders examination and also provided the September 2020 addendum opinion. If an in-person examination of the Veteran is not feasible, then an effort should be made to interview the Veteran via a video telehealth examination. The entire claims file, to include a copy of this remand, should be made available to and reviewed by the examiner. Based on an interview of the Veteran and review of the claims file, the examiner should detail the Veteran’s psychiatric symptoms in service and thereafter, including the nature, onset, progression and severity of his reported symptoms. If there is any medical reason to accept or reject the proposition that the Veteran’s reported psychiatric symptoms began during service, to include his report of depression at service separation, and thereafter represented the onset of his current psychiatric disorder(s), this should be noted. The examiner is asked to provide the following: (a.) Diagnose all current psychiatric disorders. The examiner should also consider the Veteran’s VA treatment records noting diagnoses of depressive disorder with psychotic features, generalized anxiety disorder, and schizophrenia, multiple episodes, currently in partial remission. If any previously diagnosed psychiatric disorders are not found on examination, the examiner should address whether they were misdiagnosed or have resolved. (b.) Opine whether it at least as likely as not (a 50 percent or greater probability), that: (i) the Veteran’s current psychiatric disorder(s), to include any symptoms thereof, manifested during active service; or (ii) the Veteran’s psychiatric disorder(s), to include any symptoms thereof, is otherwise causally or etiologically related to active service injury or disease. (c.) The examiner should address whether any current psychiatric disorder was at least as likely as not superimposed on a personality disorder shown during the Veteran’s active service and resulted in additional disability. (d.) The examiner should address whether the clinical record suggests that the Veteran developed psychosis in service or within one year after separation from service. (e.) The medical opinion should reflect consideration of the Veteran's lay assertions, including that his military training and racial discrimination contributed to or caused his current mental health problems. The opinion 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). An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. 3. Ensure that the VA medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Krunic, 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.