Citation Nr: 21075119 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 18-37 638 DATE: December 17, 2021 REMANDED Entitlement to a disability rating higher than 30 percent for adjustment disorder with mixed anxiety and depressed mood is remanded. REASONS FOR REMAND The Veteran and his wife testified before the undersigned Veterans Law Judge (VLJ) in a December 2021 virtual hearing. He testified that the most recent examination, performed May 2018, did not accurately reflect his symptoms. He stated that the duration of the examination was shorter than reflected in the examination report, and expressed how he felt that he was treated rudely by the VA examiner. He contends that the examiner did not capture an adequate picture of the severity of his adjustment disorder. Additionally, if the VLJ decided another VA examination was warranted, he expressed his willingness to appear for an additional examination. Therefore, the Board finds that a more thorough examination to account for the occupational and social impairment would prove helpful in assessing the current level of severity of the Veteran's psychiatric disorder. Lastly, the Board is cognizant of the error found in the Veteran's file. Specifically, there are three pages of mental health treatment records, dated June 22, 2018, authored by the Veteran's VA treating psychiatrist that refer to another veteran. The Veteran's VA treating psychiatrist did author a letter acknowledging such error and mental health treatment records dated June 22, 2018 for the Veteran have been submitted. The Board will highlight this error in the remand directives. The matter is REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) should arrange for the Veteran to undergo a mental health examination to determine the current symptoms, level of severity, and functional impairment associated with his adjustment disorder with mixed anxiety and depressed mood. If possible, the Veteran should be scheduled for an examination with an examiner other than the VA examiner who performed the May 2018 examination. The claims file and a copy of this remand must be made available to the examiner for review. The examiner should review the claims file (including this remand) and note such review was conducted. The examiner is advised that there are three pages of mental health treatment records for another veteran, dated June 22, 2018, that was erroneously placed in the file. These records should not be considered when assessing the level of severity of the Veteran's mental health disability. The examiner is also advised that the Veteran's VA treating psychiatrist did author a letter acknowledging such error, and mental health treatment records dated June 22, 2018 for the Veteran have been submitted. These records should be considered when assessing the Veteran's level of severity. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. To the extent possible, the examiner should identify any symptoms and functional impairments due to the adjustment disorder with mixed anxiety and depressed mood alone and discuss the effect of the Veteran's adjustment disorder with mixed anxiety and depressed mood on any occupational functioning and activities of daily living. When evaluating the current level of severity, the examiner is asked to provide an opinion assessing the level of severity of the Veteran's adjustment disorder with mixed anxiety and depressed mood from November 2014 to present, noting if there was any increase in severity at any time. The examiner is asked to provide a complete a rationale for all opinions offered. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Talamantes, 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.