Citation Nr: 21075431 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 14-41 138 DATE: December 20, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include an anxiety disorder and depression, is remanded. The application to reopen a previously denied claim of entitlement to service connection for a gastrointestinal disorder, to include gastritis, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from July 1961 to July 1963. These matters come before the Board of Veteran's Appeals (Board) on appeal from an April 2012 rating decision by the Regional Office (RO). The claims were remanded by the Board in August 2018 and August 2021. 1. Entitlement to service connection for an acquired psychiatric disorder, to include an anxiety disorder and depression, is remanded. In the August 2021 Board remand, the Board directed that a new etiology opinion be obtained for this claim. The Board specifically requested the opining examiner to address the Veteran's previous diagnoses, to include November 1968 diagnosis of anxiety and a January 1993 hospital admission for major depressive disorder. A new examination and opinion were obtained in October 2021. The October 2021 examiner marked off that the Veteran has never been diagnosed with a mental disorder, found that at the time of the October 2021 examination the Veteran did not have a current psychiatric diagnosis, and stated that no opinion is warranted based on the evaluation because the Veteran does not have a current psychiatric disability diagnosis. See October 2021 VA medical opinion. However, etiology opinions must be provided for the Veteran's previous diagnoses, even if currently resolved, as the Veteran had these psychiatric disability diagnoses active at one point during the appeal period. See Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013) (A "current" disability is established if it is shown at any time during or recent to the appeal period, even if it subsequently resolved.). Therefore, the Board finds that remand is required as there was inadequate compliance with the Board's prior remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998). 2. The application to reopen a previously denied claim of entitlement to service connection for a gastrointestinal disorder, to include gastritis, is remanded. Because the November 1968 VA examination report indicated that the Veteran's gastrointestinal complaints may be physiologic and may relate to anxiety, and because the Veteran's claim for service connection for an acquired psychiatric disorder is being remanded for further development, the Board defers decision on the request to reopen the gastrointestinal claim pending completion of the development directed herein for the claimed acquired psychiatric disorder. The matters are REMANDED for the following action: 1. Obtain an addendum VA medical opinion from a new examiner, addressing the etiology of the Veteran's psychiatric disability. If deemed necessary by the examiner, afford the Veteran an additional VA examination. All indicated tests and studies should be undertaken. The entire claims file, to include a copy of this remand, should be made available to the examiner and the examiner report should include a discussion of the Veteran's documented medical history and assertions. After review of the claims file, the examiner should address the following: a. Identify any diagnosed psychiatric disability. A "current" disability is established if it is shown at any time during or recent to the appeal period (since September 9, 1968), even if it subsequently resolved. See 38 C.F.R. § 3.400(q)(1). This specifically includes: Post-service, the medical evidence shows treatment for psychotic neurosis between August 1963 and June 1968. See Records, received September 1968. A November 1968 VA examination report, which includes a very detailed psychiatric examination narrative, shows a diagnosis of anxiety reaction, chronic, with psychophysiologic and conversion features. VA medical records also show the Veteran was hospitalized from January 1993 to March 1993 for a major depressive disorder with psychotic features, and a September 2008 private treatment record shows treatment for depression. See CAPRI, received December 2020 at p.9; Records, received July 2018 at p.13 of 66; VA 10-1000, March 1993. Recently, a September 2018 record shows the Veteran was referred for mental health services for depression and anxiety. See Records, received June 2021 at p.95 of 168. FOR EACH AND EVERY DIAGNOSIS, is it "at least as likely as not (50 percent probability or greater)" that the Veteran's disability began in the service, yes or no? FOR EACH AND EVERY DIAGNOSIS, is it "at least as likely as not (50 percent probability or greater)" that the Veteran's disability is related to his time in the service, yes or no? The examiner is instructed to explicitly address and consider the Veteran's statements even if there is no contemporaneous medical record. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (an examination was inadequate where the examiner did not comment on a veteran's report of in-service injury and instead relied on the absence of evidence in a veteran's service medical records to provide a negative opinion). These include: An August 28, 2011 Veteran's Statement March 2012 Notice of Disagreement July 26, 2011 Statement from Veteran's brother July 15, 2011 Statement from Veteran's cousin The Board also acknowledges July 2011 lay statements from the Veteran's brother and cousin, as well as hearing testimony from the Veteran and his brother in June 1995, in which they reported the Veteran began to experience a nervous condition since service, and that on one occasion, he was hiding in the bathroom because "people were chasing him." See Records, received July 2018 at p.7-9 of 66. 2. For all opinions, the RO should ensure that a rationale is provided, to include specific discussion of the medical principles involved and the relevant facts. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). Furthermore, if medical literature is relied upon in rendering this determination, the VA examiner should identify and specifically cite each reference material utilized. (Continued on the next page) 3. THE AOJ MUST REVIEW THE CLAIMS FILE AND ENSURE THAT THE FOREGOING DEVELOPMENT ACTION HAS BEEN COMPLETED IN FULL. IF ANY DEVELOPMENT IS INCOMPLETE, APPROPRIATE CORRECTIVE ACTION MUST BE IMPLEMENTED. IF ANY REPORT DOES NOT INCLUDE ADEQUATE RESPONSES TO THE SPECIFIC OPINIONS REQUESTED, IT MUST BE RETURNED TO THE PROVIDING EXAMINER FOR CORRECTIVE ACTION. YVETTE R. WHITE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. J. Cho, 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.