Citation Nr: 21064883 Decision Date: 10/21/21 Archive Date: 10/21/21 DOCKET NO. 16-55 439 DATE: October 21, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia, schizoaffective disorder, and major depressive disorder with anxious distress and psychotic features, is remanded. Entitlement to service connection for right carotid artery stenosis, status-post stent and aneurysm, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from May 1982 to May 1985. These matters come 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). The Board remanded the appeal in July 2019. At that time, it expanded the Veteran's claim under Clemons v. Shinseki, 23 Vet. App. 1 (2009), and the instant Remand continues to expand the claim to include any and all psychiatric disorders reasonably raised by the record. 1. Entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia, schizoaffective disorder, and major depressive disorder with anxious distress and psychotic features, is remanded. The Veteran presented for a VA psychiatric examination in January 2020. A diagnosis of schizoaffective disorder, depressive type, was confirmed. The examiner opined that the Veteran's psychiatric disorder was not related to service, noting that although the Veteran stated the disorder onset in service, there were no in-service treatment records to confirm it. The Board finds the examiner's opinion inadequate, as it is based solely on the absence of documented symptoms during service. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (holding that a VA examination was inadequate because the examiner relied on the absence of evidence in the Veteran's service treatment records to provide a negative opinion). Additionally, the Veteran's service separation examination is not of record and should be obtained. Moreover, the February 2013 VA examination notes that the Veteran collects Social Security Administration (SSA) disability benefits. The Veteran's SSA records are not in the claims file and should be secured on remand. Finally, as the Board is remanding the claim, it will afford the Veteran another opportunity to provide the necessary information to secure records of his mental health treatment at age 26. 2. Entitlement to service connection for right carotid artery stenosis, status-post stent, and aneurysm, is remanded. The Veteran presented for a VA examination in January 2020. The examiner confirmed diagnoses of an aneurysm of the right side of the brain and a stent right carotid artery. In opining that there was no nexus established as carotid stenosis, the examiner merely stated the condition occurs over time and is not from acute trauma such as a head injury. However, there was no explanation as to why the condition was not otherwise related to the Veteran's service and such rationale should be provided on remand. The examiner should also address the etiology of the Veteran's aneurysm. Barr v. Nicholson, 21 Vet. App. 303, 310-11 (2007). The matters are REMANDED for the following action: 1. Obtain the Veteran's service separation examination and any other outstanding service treatment records. If the records are not available, a formal finding should be associated with the record and the Veteran notified of the same. 2. With any necessary assistance from the Veteran, secure all records of outpatient mental health treatment for schizophrenia in 1986. If the records are not available, a formal finding should be associated with the record and the Veteran notified of the same. 3. Obtain the Veteran's records from the Social Security Administration (SSA) and associate them with the record. If the records sought are not available, a formal finding should be associated with the record and the Veteran notified of the same. 4. Then obtain an addendum opinion from a new examiner addressing the etiology of the Veteran's psychiatric disorder. The Veteran's claims file must be made available to the examiner for review in connection with the examination. Following a review of the claims file, the examiner should address the following: (a.) For each psychiatric disorder diagnosed during the appeal period, including but not limited to schizoaffective disorder, schizophrenia and major depressive disorder, please opine as to whether it at least as likely as not (50 percent or greater degree of probability) that such disability had its onset in or is otherwise related to service. (b.) Please state, to the best of your ability, whether the prodromal period for schizoaffective disorder and schizophrenia as likely as not had its onset during the Veteran's periods of active service, considering the Veteran's report of in-service paranoia that he did not report for fear of being discharged from service. See July 2013 Notice of Disagreement. (c.) Did diagnosed schizoaffective disorder and schizophrenia manifest within one year of the Veteran's discharge from service in May 1985? Please consider the Veteran's reports to the February 2013 VA examiner about treatment of his schizophrenia around age 26 (in 1985). A complete rationale should be provided for all opinions. If an opinion cannot be provided without resorting to speculation, the examiner must explain why this is the case. 5. Then obtain an addendum opinion from a new examiner addressing the etiology of the Veteran's carotid stenosis status post stent and aneurysm. The Veteran's claims file must be made available to the examiner for review in connection with the examination. Following review of the claims file, the examiner should address the following: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's carotid stenosis status post stent had its onset during service or is otherwise related to service, to include a head injury sustained in June 1984? Please thoroughly explain why or why not, addressing the prior examiner's comment that the condition develops over time. (b.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's aneurysm is related to service, to include his head injury sustained in June 1984? A complete rationale should be provided for all opinions. If an opinion cannot be provided without resorting to speculation, the examiner must explain why this is the case. S. BUSH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. J. Rogers, 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.