Citation Nr: 21066385 Decision Date: 10/29/21 Archive Date: 10/29/21 DOCKET NO. 12-21 606 DATE: October 29, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran had active service from March 1987 to May 1991. 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). In January 2018, the Board denied service connection for a psychiatric disorder. The Veteran appealed the decision to the Court of Appeals for Veterans Claims (Court). In October 2018, pursuant to a Joint Motion for Partial Remand (JMR), the Court vacated the decision and remanded it back to the Board for further development. The JMR found that the Board relied on an inadequate examination in adjudicating the claim as none of the opinions adequately addressed whether the Veteran's "schizotypal personality disorder was aggravated beyond its natural progression during service by the in-service assault that resulted in the facture of the Appellant's [Veteran's] facial bones." See JMR at pg. 3. The JMR also found that further examination was warranted to clarify the Veteran's psychiatric diagnosis. This matter was last before the Board in April 2021, when it was remanded for additional development. 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded. Unfortunately, there has not been substantial compliance with the prior remand directives. The April 2021 remand requested an addendum opinion addressing the Veteran's claim. While an opinion was obtained in July 2021, the opinion was not fully responsive to the remand directives. While the clinician acknowledged the documented diagnoses of adjustment disorder and depressive disorder, the clinician found they were not currently present and opined it would require speculation to determine the validity of the prior diagnoses. The clinician did not, as requested, explain whether the inability to provide a definitive opinion was the result of a need for additional information or the limits of current medical knowledge. Additionally, while the clinician opined that the Veteran's schizotypal personality disorder was less likely than not subject to a superimposed disease or injury during service, the rationale for that opinion did not explain why the Veteran's personality disorder was not aggravated by the in-service assault that resulted in the Veteran's facial injuries. The clinician also did not address all the psychiatric diagnoses present during the appeal period. See e.g., VA records from March 3, 2017 (diagnosing psychosis not otherwise specified), October 16, 2017 (diagnosing PTSD, depression, anxiety, bipolar disorder, and panic attacks), October 26, 2018 (diagnosing unspecified mood disorder), January 7, 2019 (diagnosing unspecified trauma disorder), January 11, 2019 (diagnosing adjustment disorder), and July 24, 2020 (diagnosing depressive disorder). Accordingly, another remand is required. Moreover, as the evidence indicates that the Veteran's psychiatric disorder maybe related to his chronic medical conditions and pain, the Board finds that secondary service connection is reasonably raised. See e.g., VA records from March 3, 2017 (noting Axis I diagnosis of psychosis not otherwise specified and Axis III stress of chronic pain syndrome), January 11, 2019 (noting adjustment disorder and depression secondary to chronic medical condition), and July 24, 2020 (noting depressive disorder secondary to medical condition). A VCIP Unscannable Document(s) Placeholder indicates that a compact disc (CD) that was received on July 5, 2014 could not be opened to extract images. It is unclear what documents were contained on the CD and whether the CD was submitted by the Veteran or a third party. Accordingly, the agency of original jurisdiction (AOJ) should contact the Veteran to determine whether the CD was submitted by him and if so, request he resubmit the evidence. If the Veteran indicates the CD was not submitted by him, to the extent possible, the AOJ should determine who submitted the CD and request the resubmission of the documents contained on the unscannable CD. Finally, the evidence indicates there may be outstanding relevant VA treatment records. A VA treatment record from July 30, 2021 indicates that the Veteran was to return for a follow up appointment in October 2021. VA treatment records after August 28, 2021 have not been associated with the claims file. Additionally, a VA record entry from April 21, 2020 notes that an unidentified non-VA neurology record, possibly a neuropsychological evaluation, had been scanned into VistA Imaging. It does not appear that the referenced record has been associated with the claims file. Accordingly, on remand any updated VA medical records must be associated with the claims file. The matters are REMANDED for the following actions: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities. After securing any necessary releases, the AOJ should request any relevant records identified. In addition, obtain updated VA treatment records dated since July 30, 2021 as well as the VistA Imaging record referenced in the April 21, 2020 VA record entry. If any requested records are unavailable, the Veteran should be notified of such. 2. Determine what documents are contained on the unscannable CD described in the VCIP Unscannable Document(s) Placeholder. To the extent possible, obtain a readable or scannable CD or copies of the documents that are the subject of the VCIP Unscannable Document(s) Placeholder. To the extent that readable copies are not made a part of the record, the Veteran must be notified of the unavailability of any missing documents and be afforded an opportunity to provide any copies of such records that he may have in his possession. 3. Schedule the Veteran for a VA PTSD examination. The claims file should be reviewed by the examiner in conjunction with the examination. All indicated tests should be conducted and the results reported. Following review of the claims file and examination of the Veteran, the examiner should identify all psychiatric disorders present during the pendency of the appeal and then respond to the questions presented: (a.) If the Veteran is diagnosed with PTSD, the examiner should indicate the stressor(s) upon which the diagnosis is based. (b.) For each diagnosed psychiatric condition other than PTSD and of schizotypal personality disorder, to include psychosis not otherwise specified, depression, anxiety, bipolar disorder, panic attacks, unspecified mood disorder, unspecified trauma disorder, adjustment disorder noted in treatment records, state whether it is at least as likely as not (50 percent probability or greater) that the condition arose during service or are otherwise related to the Veteran's military service. In rendering the above requested opinions, the examiner must address the in-service assault that resulted in the fracture of the Veteran's facial bones. The examiner must also address the February 1991 report of medical history where the Veteran reported depression or excessive worry, loss of memory or amnesia, nervous trouble, and a three-year history of trouble sleeping, which he self-medicated with sleeping pills. (c.) For any diagnosed psychiatric condition other than PTSD and schizotypal personality disorder, to include psychosis not otherwise specified, depression, anxiety, bipolar disorder, panic attacks, unspecified mood disorder, unspecified trauma disorder, adjustment disorder, state whether it is it at least as likely as not (50 percent probability or greater) that it was caused by the Veteran's service-connected disabilities? (d.) If not caused by the service-connected disabilities, is it at least as likely as not that any diagnosed psychiatric condition other than schizotypal personality disorder, to include PTSD, psychosis not otherwise specified, depression, anxiety, bipolar disorder, panic attacks, unspecified mood disorder, unspecified trauma disorder, adjustment disorder, is worsened beyond natural progression (aggravated) by his service-connected disabilities? If the examiner finds that any psychiatric disability was aggravated by his service-connected disabilities, the examiner should attempt to quantify the level of aggravation beyond the baseline level of the disability. In addressing secondary service connection, the examiner must address the treatise evidence submitted by the Veteran regarding the relationship between chronic pain and psychiatric disorders. For any diagnosis noted in the treatment records, including but limited to psychosis, PTSD, unspecified trauma disorder and depression, depression, anxiety, bipolar disorder, panic attacks, unspecified mood disorder, and adjustment disorder, that is not found at the time of the examination, explain whether it was a diagnosis that subsequently resolved, or whether the diagnosis was not in accordance with the Diagnostic and Statistical Manual of Mental Disorders (DSM). If the examiner finds that any diagnosis was not in accordance with the DSM or not supported by the evidence of record, please explain why. (e.) State whether it at least as likely as not (50 percent or greater probability) that the Veteran's schizotypal personality disorder, was subject to a superimposed disease or injury during service that resulted in additional disability? If so, identify any additional disability that the Veteran suffered because of the disease or injury that was superimposed on his personality disorder. In rendering the above requested opinion, the examiner must address the in-service assault that resulted in the fracture of the Veteran's facial bones. A complete rationale for all opinions expressed should be provided. If the examiner is unable to render any requested opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). K. A. BANFIELD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Anderson 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.