Citation Nr: 21072473 Decision Date: 12/03/21 Archive Date: 12/03/21 DOCKET NO. 18-06 972 DATE: December 3, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder is remanded. INTRODUCTION The Veteran had active service from September 1976 to August 1979. In July 2021, the Veteran attended a hearing before the undersigned Veterans Law Judge. A transcript of that proceeding is of record. REASONS FOR REMAND Missing Records Initially, the Board notes that during her July 2021 Board hearing the Veteran reported receiving outpatient treatment at the Toledo VAMC. To date, the RO has not obtained those records. Pursuant to 38 C.F.R. § 3.159 (c)(2), VA must make as many requests as are necessary to obtain records in the custody of a Federal department or agency. Since these missing records will likely bear upon both the Veteran's claim for service connection, this issue cannot be decided at this time. Service Connection Claim Next, the Board notes that to be considered adequate, a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In this respect, the Board observes that a medical examiner cannot solely rely on the absence of medical records corroborating the incurrence or continuity of a disorder, and moreover, is simply not free to ignore a veteran's statements related to lay observable symptoms. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). The Veteran initiated a claim for an acquired psychiatric disorder in June 2014. She has asserted that her psychiatric manifestations first occurred in service. Additionally, she has reported that her in-service migraine headaches were also caused by her anxiety and depression. A review of her service treatment records (STRs) shows she received treatment for her anxious and depressed mood in service. In the course of February 2015 and January 2018 VA examinations, the Veteran was diagnosed with adjustment disorder with anxiety and depressed mood, as well as a bipolar disorder. However, following those examinations the examiners found the Veteran's current disabilities were less likely that not incurred in service. In support of these conclusions the examiners appeared to have relied heavily on a January 1987 National Guard annual examination wherein no psychiatric disorders were noted; however, this was an annual physical assessment, not a thorough psychiatric examination. Further, neither examiner explained how or why they came to their conclusions. Additionally, the February 2015 examiner found other life stressors were the cause of the Veteran's current acquired psychiatric disorder, but the Veteran has reported those stressors occurred well after she initiated her claim for her psychiatric disorder, and as such, could not have been the cause of the condition. As such, the Board finds these medical opinions to be insufficient. Therefore, a new examination and medical opinions must be obtained. Accordingly, this matter is REMANDED for the following actions: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran's claim, to specifically include her outpatient mental health records from the Toledo VAMC. If any requested records are not available, the record should be annotated to reflect such and the Veteran notified in accordance with 38 C.F.R. § 3.159 (e). 2. Also, afford the Veteran a VA examination by a psychiatrist or psychologist, to determine the etiology of all acquired psychiatric disorders present during the period of the claim, to specifically include bipolar disorder and adjustment disorder with anxiety and depressed mood. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated studies should be performed. Based on the review of the Veteran's pertinent history and the examination results, the examiner should identify all acquired psychiatric disorders that have been present during the period of the claim. A diagnosis of PTSD due at least in part to the Veteran's reported physical assault should be confirmed or ruled out. If the examiner determines PTSD has not been present during the period of the claim, he or she should explain why a diagnosis of PTSD is not warranted. If PTSD is diagnosed the examiner should identify the elements supporting the diagnosis. With respect to each acquired psychiatric disorder, other than PTSD, that has been present during the period of the claim, the examiner should state an opinion as to whether it is at least as likely as not (i.e., at least 50 percent probable) that such disorder originated in service or is otherwise etiologically related to service. In this regard, the examiner must consider and expressly discuss the Veteran's reports. Additionally, the examiner is asked to also consider and expressly discuss the Veteran's treatment for anxious and depressed mood in service, as well as migraine headaches. In this respect the examiner is asked to consider whether those manifestations may have been consequentially related to any currently diagnosed psychiatric disorders. A complete rationale must be provided for all opinions expressed. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. T. REYNOLDS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Fraser, 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.