Citation Nr: 21062629 Decision Date: 10/08/21 Archive Date: 10/08/21 DOCKET NO. 17-57 359 DATE: October 8, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include bipolar disorder, recurrent manic depression and affective disorder, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1972 to May 1974 and October 1979 to September 1981. This matter is before the Board of Veterans' Appeals (Board) on appeal from January 2015 (acquired psychiatric disorder) and December 2015 (TDIU) rating decisions by a Department of Veterans Affairs Regional Office (RO). In January 2021, the Veteran testified at a virtual Board hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. The Board remanded the claims in May 2021 for additional development. 1. Acquired Psychiatric Disorder In May 2021, the Board remanded this case and instructed the Agency of Original Jurisdiction (AOJ) to obtain any outstanding VA medical records from 1981 to the present, and to obtain a VA examination. The Board notes that the requested VA medical records have been associated with the claims file. The VA examination was obtained in August 2021. The examiner noted a diagnosis for bipolar I disorder, with moderate depression as the current or most recent episode. The examiner opined that it was "less likely than not (less than 50 percent probability)" that the diagnosed psychiatric disorder was etiologically related to service. The examiner based this opinion on the examination interview and the weight of the medical evidence, including relying heavily on the April 2003 negative nexus opinion, and the April 2017 letter from Dr. Shay. The Board finds that an addendum VA examination report is necessary in order to properly adjudicate this issue on appeal. In this regard, the Board would like to draw the examiner's attention to specific pieces of evidence. First, the prior April 2003 VA examiner's negative nexus opinion is based, in part, on a finding of a lack of evidence that the diagnosed psychiatric disorder (affective disorder with mixed depression and anxiety) was present during service. On the August 1981 separation report of medical examination, although the Veteran's psychiatric evaluation was normal, the examiner noted a history of depression and excessive worry since May 1981. The Board would like the examiner so specifically address the August 1981 separation notations. Further, Dr. Shay's April 2017 letter noted evidence of alcohol use disorder, personality disorder and depression/anxiety in the service treatment records (STRs), there is no mention of obvious manic or hypomanic features. Dr. Shay continued in the context of comorbid substance use disorders, it is generally not possible to establish a clear diagnosis of mood disorder, as so many of the diagnostic criteria can be confounded by the effects and consequences of substance use. Many individuals do manifest a pre-diagnostic prodrome of bipolar disorder in depressive episodes, anxiety disorders, conduct disorders, substance use disorders, and other conditions. She had further stated that "it seems very likely that symptoms in 1981 represented a bipolar depression," but that it was not diagnosed at that time. Dr. Shay stated she was unable to address the question of etiology without resorting to speculation. The Board would like the examiner to address Dr. Shay's comments about possible bipolar depression during service. The Board further notes a July 2005 VA medical record that provides a diagnosis for alcohol abuse secondary to untreated bipolar affective disorder. The Veteran reported that he had run out of his bipolar disorder medication, and that he began drinking more heavily to self-medicate. See VA Medical Records Received May 2021. This seems supportive of Dr. Shay's letter. Based on the above, a question exists as to whether the in-service treatment for alcohol abuse and noted symptoms of depression and anxiety were symptomatic of a psychiatric disorder that was later diagnosed after service. Accordingly, a Remand is necessary to obtain an addendum VA examination. 2. TDIU Lastly, entitlement to a TDIU is inextricably intertwined with the service connection claim on appeal. The matters are REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran's VA treatment facilities, and all private treatment records from not already associated with the file. 2. Then, refer the Veteran's claims file to a qualified examiner. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any diagnosed psychiatric disorder was causally or etiologically related to his service. Particular attention to whether the in-service alcoholism treatment and symptoms of depression and anxiety were symptomatic of a psychiatric disorder, to include bipolar disorder, that was first diagnosed after service would be most helpful to the Board. The examiner is asked to consider the in-service treatment for alcohol abuse, and the August 1981 separation examination noting a history of depression and excessive worry since May 1981. The examiner is further asked to consider a July 2005 VA medical record noting a diagnosis for alcohol abuse secondary to untreated bipolar affective disorder, and showing the Veteran reported self-medicating with alcohol when he ran out of his bipolar disorder medication. In connection with the above, in her April 2017 letter, Dr. Shay noted that the STRs provided ample evidence of alcohol use disorder, personality disorder and depression/anxiety, but that while there was no mention of obvious manic or hypomanic features in the STRs, that many individuals manifest pre-diagnostic syndrome of bipolar disorder in depressive episodes, anxiety disorders, conduct disorders, substance use disorders and other conditions. She further stated that "in the context of comorbid substance use disorders, it is generally not possible to establish a clear diagnosis of mood disorder, as so many of the diagnostic criteria can be confounded by the effects and consequences of substance use." The examiner is advised that a psychiatric disorder has not been found to have preexisted the Veteran's second period of active duty service. The examiner should review pertinent documents in the Veteran's claims file in connection with the examination. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. 3. Then, the AOJ must readjudicate the claims, including the claim for a TDIU. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Lamb, 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.