Citation Nr: 21070680 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 18-41 520 DATE: November 24, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), major depressive disorder (MDD), dysthymia, and/or adjustment disorder, and to include as secondary to service-connected disabilities, is remanded. Entitlement to special monthly compensation (SMC) based on housebound status and/or the regular need for aid and attendance is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from October 1992 to June 2005, with additional active duty for training from February 1990 to June 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal from October 2013 and April 2018 rating decisions by an Agency of Original Jurisdiction (AOJ) of the Department of Veterans Affairs (VA). In this regard, new and material evidence was constructively received within one year of the October 2013 rating decision that denied entitlement to service connection for PTSD and depression, as the Veteran's VA treatment records show diagnoses of those disorders. See September 23, 2014 VA Mental Health Note. Thus, that decision did not become final, and the Veteran filed a timely appeal after the claim was readjudicated in May 2015. The Board acknowledges the Veteran's frustration with the claims adjudication process. If she wishes, she can appoint a Veteran Service Organization to represent her in her appeals at no cost. They are familiar with the appeals process and can help by filing appeals documents and explaining what VA documents mean, and how to respond. 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, MDD, dysthymia, and/or adjustment disorder, and to include as secondary to service-connected disabilities, is remanded. Remand is necessary to secure an adequate psychological examination based on the current evidence of record. In this regard, the prior examiner noted no diagnosis of depression or PTSD, see August 2013 Psychiatric Examination Report, but the Veteran now has been diagnosed with both disorders, see, e.g., September 23, 2014 VA Mental Health Note. Thus, the Veteran should be afforded a new examination addressing those disorders and a medical opinion should be secured. Complete VA treatment records and outstanding relevant private treatment records should also be secured. In addition, the record suggests that her claimed psychiatric disorder may be proximately due to or aggravated by service-connected disabilities. See, e.g., October 22, 2014 VA Mental Health Note (Veteran reporting depression and some anxiousness and frustration due to chronic pain). On remand, an opinion addressing secondary service connection should also be secured. 2. Entitlement to SMC based on housebound status and/or the regular need for aid and attendance is remanded. An April 2018 rating decision denied entitlement to SMC based on the regular need for aid and attendance and proposed a finding of incompetency. A July 2018 rating decision determined that the Veteran was not competent to handle funds. In August 2018, the Veteran filed a timely Notice of Disagreement (NOD) with those issues. She was subsequently determined to be competent to handle funds, but her NOD addressing SMC has not been addressed. On remand, a Statement of the Case (SOC) addressing her August 2018 NOD should be issued. The matters are REMANDED for the following action: 1. Secure the Veteran's complete VA treatment records. 2. With any necessary assistance from the Veteran, secure outstanding relevant private treatment records. 3. Then schedule the Veteran for an examination to determine the nature and etiology of any acquired psychiatric disorder(s) found to be present. The claims file should be made available to and should be reviewed by the examiner. The examiner should address the following. (a) Identify all current psychiatric diagnoses. If the criteria for a diagnosis of PTSD are met, please specify the stressor(s) supporting the diagnosis. The examiner's attention is invited to the Veteran's VA mental health notes showing diagnoses including MDD, PTSD, and dysthymia, as well as her August 2006 Statement in Support of Claim for PTSD. (b) For each acquired psychiatric disorder diagnosed in sub-part (a), please opine whether it is at least as likely as not (probability of 50 percent or greater) that the disability had its onset in or is otherwise etiologically related to the Veteran's active service. (c) For each acquired psychiatric disorder diagnosed in sub-part (a), please opine whether it is at least as likely as not (probability of 50 percent or greater) that the disability is proximately due to service-connected disabilities, to include as a result of chronic pain. (d) For each acquired psychiatric disorder diagnosed in sub-part (a), please opine whether it is at least as likely as not (probability of 50 percent or greater) that the disability has been aggravated (worsened beyond natural progression) by service-connected disabilities, to include as a result of chronic pain. The examiner's attention is invited to the Veteran's VA treatment notes, including mental health treatment notes and the February 11, 2016 VA Neurology Consultation Note that indicates that "pain is in control of the Veteran's life." All opinions should be accompanied by a clear rationale. If the examiner cannot answer without resorting to speculation, he or she should explain why it would be speculative to respond (i.e., insufficient evidence in the record, insufficient state of medical knowledge, examiner's lack of expertise, etc.). 4. Separately, issue an SOC addressing SMC based on housebound status and/or the regular need for aid and attendance, along with appellate rights. S. BUSH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D.M. Badaczewski, 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.