Citation Nr: 21064353 Decision Date: 10/19/21 Archive Date: 10/19/21 DOCKET NO. 15-12 773 DATE: October 19, 2021 REMANDED Service connection for an acquired psychiatric disorder, to include major depressive disorder with alcohol and cannabis use disorders and adult antisocial behavior (claimed as service connection for PTSD and depression), is remanded. REASONS FOR REMAND The Veteran, who is the Appellant, served on active duty from September 1978 to April 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2014 rating decision from the Regional Office (RO), which denied service connection for a psychiatric disorder. The Board has recharacterized the issue on appeal as service connection for an acquired psychiatric disorder, to include to include major depressive disorder with alcohol and cannabis use disorders and adult antisocial behavior, in accordance with the United States Court of Appeals for Veterans' Claims (Court) decision in Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that a claim for benefits of one psychiatric disability also encompassed benefits based on other psychiatric diagnoses and should be considered by the Board to be within the scope of the filed claim). Service connection for an acquired psychiatric disorder is REMANDED for additional development. Outstanding Service Treatment Records The Veteran contends service connection is warranted for acquired psychiatric disorder. Specifically, the Veteran asserts that he had a "nervous breakdown" during basic training in September 1978 while stationed at Fort Benning, Georgia, from September to December 1978. The Veteran asserts that he was sent for counseling during this time. Additionally, the Veteran reports having at least two mental health counseling sessions in 1979 while stationed at Fort Ord, California. A service treatment record dated November 20, 1978 indicates that the Veteran was seen at "CMHA" and that he was referred to another entity that is illegible, but notes that mental status was essentially clear; however, the record documenting the Veteran's encounter and mental evaluation is not included in the service treatment records. It does not appear that the reported record of counseling at Fort Benning or Fort Ord have been associated with the claims file. As such, the RO should request any outstanding treatment records for treatment of a psychiatric disorder from Fort Benning, Georgia, from September to December 1978, and from Fort Ord, California, from January to December 1979. Addendum Medical Opinion The Veteran was provided a VA examination and medical opinion in October 2014. The VA examiner opined that it is less likely than not that the Veteran's current mental health problems were incurred in or were caused by military service. The rationale provided was that service treatment records do not show the Veteran receiving any mental health treatment during time in the Army, and, even if he did receive treatment in the military for anger issues, these issues appear to predate the Army career; however, the VA examiner did not cite to any specific evidence in the record to explain why any anger predates service or to otherwise support the rationale. The Veteran is competent to report on any circumstances he personally observed, including treatment or symptoms he received at any time during service. See Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). In this case, the VA examiner did not adequately consider the Veteran's lay report that he received mental health counseling at some point between September and December 1978 due to a "nervous breakdown" during basic training at Fort Benning, including the Veteran's report that while at Fort Benning he received upsetting news that his parents were separating. The Veteran did not suggest that the mental health counseling at Fort Benning was for anger problems, but rather suggested some difficulty coping with family issues. A November 2013 VA treatment note also indicates that the Veteran reported that he was sent for counseling during service in 1978 due to a "nervous breakdown," and that he recalled being told he had depression. Service personnel records indicate that the Veteran received two Article 15s (nonjudicial punishment), one Court Martial (judicial punishment), and multiple reports of formal counseling related to failing to report for appointed duties between October 1979 and February 1981. As such, an addendum opinion is necessary with a well explained rationale that cites to the specific evidence of record that supports the opinion, to consider the Veteran's lay assertion of receiving counseling for a "nervous breakdown" during basic training at Fort Benning. Service connection for an acquired psychiatric disorder is REMANDED for the following action: 1. The RO should request any outstanding service treatment records for a psychiatric disability from the medical facilities at Fort Benning, Georgia from September to December 1978, and from Fort Ord, California from January to December 1979. If records cannot be obtained, the Veteran should be informed, with a formal memorandum to the file to document all efforts. 2. Return the VA October 2014 medical opinion report to the VA examiner who provided the medical opinion. If the original VA examiner is unavailable, a new examiner may be assigned to address the requested opinion. The relevant documents in the record should be reviewed by the examiner and a detailed history of relevant symptoms should be obtained from the record. A rationale for all opinions and a discussion of the facts and medical principles involved should be provided. The examiner should offer an opinion: Is it at least as likely as not (50 percent or greater probability) that the current psychiatric disorder was caused by or etiologically related to during service? In rendering the requested opinion, the examiner should address the Veteran's lay assertion that he was treated for a "nervous breakdown" in 1978 during basic training at Fort Benning; the report of additional counseling at Fort Ord in 1979; and whether the Veteran's decline in military performance between October 1979 to February 1981 represents has any significance for the development of a mental health disorder. The examiner should cite the specific evidence in the record that supports the opinion. J. PARKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Moore, Shanna 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.