Citation Nr: 21062098
Decision Date: 10/06/21	Archive Date: 10/06/21

DOCKET NO. 17-09 885
DATE: October 6, 2021

REMANDED

Entitlement to service connection for an acquired psychiatric disorder is remanded.

REASONS FOR REMAND

The Veteran served on active duty from January 1972 to October 1974 in the U.S. Army. This matter comes before the Board of Veterans' Appeals (Board) from an August 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO).

This matter was most recently before the Board in April 2021, at which time the issue on appeal was remanded for further development.

In May 2021, the Veteran submitted a letter from his private psychologist stating that he has a history of dysthymic disorder, depressive disorder NOS, and panic disorder, and at the present time he most likely has a diagnosis of unspecified personality disorder, however more psychological testing might be helpful. Additionally, the Veteran stated that he is currently experiencing symptoms of anxiety and depression. See May 2021 Correspondence. As such, the Board finds that the Veteran should be provided a VA examination to clarify his current diagnosis.

As the issue is being remanded, the Veteran should be provided another opportunity to submit outstanding and relevant private treatment records or provide the requisite information to allow VA to request those records on his behalf.

The matter is REMANDED for the following action:

1. Ask the Veteran to complete a VA Form 21-4142 for his treatment related to his claimed acquired psychiatric disorder, to specifically include private treatment records from Salem Psychological Associates and from Dr. M. at Brookside. If the necessary releases are provided, make two requests for the authorized records unless it is clear after the first request that a second request would be futile. If any requested records are unavailable, the claims file should be annotated as such and the Veteran notified of such.

2. Schedule the Veteran for a VA examination with an appropriate physician to determine the nature and etiology of the Veteran's claimed acquired psychiatric disability. Appropriate testing should be conducted. The claims file should be provided to the examiner for review. Following complete review of the evidence of record, the physician should address the following:

(a.) Identify all psychiatric disorders diagnosed on examination and documented in the record throughout the period on appeal (i.e., since April 2016).

(b.) For each diagnosis, the physician should opine as to whether it is at least as likely as not (50 percent or greater probability) that the psychiatric disorder had its onset during active-duty service or is otherwise etiologically related to any in-service injury, event, or disease. 

The in-service findings pertaining to opioid use, diagnosis of nervous anxiety off and on, and complaints of frequent trouble sleeping, depression, excessive worry, and nervous trouble at separation from service should be discussed. The physician should consider the Veteran's medical history and the lay statements of record. A negative opinion based on a lack of treatment or diagnosis in service will be deemed inadequate; the opinion must consider and discuss the Veteran's reports of the onset and continuity of symptoms. A complete rationale must be provided for all opinions offered.

 

 

JOHN Z. JONES

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	T. Kernen, 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.