Citation Nr: 21075370 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 01-02 539 DATE: December 20, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disability, to include major depressive disorder, dysthymic disorder with anxiety, and generalized anxiety disorder, to include as secondary to service-connected low back disability, to include as secondary to service-connected lumbar spine disability, is remanded. Entitlement to a total disability rating, based on individual unemployability, due to service-connected disabilities (TDIU), is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1966 to April 1968. In January 2016, October 2020, and May 2021, the Board remanded the case for further development by the originating agency. The case has been returned to the Board for further appellate action. 1. Entitlement to service connection for an acquired psychiatric disability, to include major depressive disorder, dysthymic disorder with anxiety, and generalized anxiety disorder, to include as secondary to service-connected low back disability, is remanded. The Veteran contends that his acquired psychiatric disability is secondary to his service-connected lumbar spine and cervical spine disabilities. A June 1994 private medical record revealed a diagnosis of atypical depression with anxiety. It was noted that the Veteran had a chronic back condition which limited him physically and caused chronic pain, and that "due to this he developed emotional symptoms" and was being evaluated by a psychiatrist who diagnosed slight major depressive disorder. On a VA examination in December 1994, the Veteran reported difficulties with sleep at night due to lower back and neck pain. The diagnosis was sleep disorder due to cervical disk herniation and peripheral neuropathy. An April 1997 private psychiatric report revealed a diagnosis of severe dysthymic disorder with anxiety. Pursuant to the Board's May 2021 remand directives, the Veteran was afforded a VA examination in September 2021. The examiner noted that the Veteran received psychiatric treatment from 1994-1997 and was diagnosed with anxiety and depression, but he concluded that as there was no Axis I diagnosis of a mental illness on mental evaluation at that time, and no medical evidence in the claims file that meets the DSM-V criteria for a mental disability, he could not give an opinion on whether the claimed psychiatric disability was related to the service-connected lumbar spine or cervical spine disabilities. However, the examiner did not give an opinion as to the etiology of the major depressive disorder and dysthymic disorder with anxiety diagnosed earlier during the appeal period. Therefore, the Board finds the September 2021 VA examiner's opinion inadequate for evaluation purposes. Therefore, a remand is required in order to obtain another VA examination and medical opinion to determine the etiology of any current psychiatric disability. 2. Entitlement to a total disability rating, based on individual unemployability, due to service-connected disabilities (TDIU) is remanded. The Board also notes that because a decision on the remanded claim for service connection for an acquired psychiatric disability could significantly impact a decision on the TDIU issue, the issues are inextricably intertwined. Thus, a remand of the claim for entitlement to TDIU is required. The Board, by this remand, makes no determination, expressed or implied, concerning the credibility of any statements on file. The matters are REMANDED for the following action: 1. Updated treatment records should be obtained and added to the claims folder/efolder. 2. Following completion of the above, afford the Veteran an appropriate VA examination to determine the nature and etiology of any currently diagnosed psychiatric disorder(s). The claims folder should be made available to the examiner for review in connection with the examination and the examiner should acknowledge such review in the examination report or in an addendum. The examiner should provide the following opinions: a) Is it at least as likely as not (50 percent or more probability) that any psychiatric disorder, diagnosed at any time during the course of the appeal, had its onset in or is etiologically-related to the Veteran's active duty service? b) If the answer to part (a) above is "no," is it at least as likely as not (50 percent probability or more) that a psychiatric disorder, is (a) proximately due to or the result of the Veteran's service-connected disabilities, or (b) aggravated or permanently worsened by his service-connected disabilities? If it is determined that the psychiatric disorder is related to any service-connected disability, to the extent possible, the examiner should indicate the approximate degree of disability or baseline before the onset of aggravation. A complete rationale should be given for all opinions and conclusions expressed, and a discussion of the facts and medical principles involved must be provided. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and whether there is additional evidence that would permit the opinion to be provided. 3. After completing the above, and any other development deemed necessary, readjudicate the Veteran's claims based on the entirety of the evidence. If any benefit sought on appeal is not granted, the agency of original jurisdiction should issue a supplemental statement of the case, and the case should then be returned to the Board, if otherwise in order. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board F. Yankey, 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.