Citation Nr: A21020481 Decision Date: 12/23/21 Archive Date: 12/23/21 DOCKET NO. 200128-60128 DATE: December 23, 2021 REMANDED Entitlement to service connection for a psychiatric disorder, to include vascular neurocognitive disorder without behavioral disturbance and major depressive disorder (MDD) (claimed as anxiety, nervousness, and psychogenic gastrointestinal reaction), to include as secondary to irritable bowel syndrome (IBS), is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1956 to May 1964. This issue was previously denied in an August 2020 Board of Veterans' Appeals (Board) decision. In July 2021, the parties entered a Joint Motion for Remand (Joint Motion), which vacated and remanded the August 2020 Board decision for failure to provide an adequate statement of reasons or bases for its denial. The Joint Motion was granted by the United States Court of Appeals for Veterans Claims (Court) the following week. Therein, the parties agreed that the Board must address whether the Veteran's April 2019 VA examination is adequate, as the examiner did not explicitly opine as to secondary causation or aggravation of the Veteran's psychiatric disorder. Rather, the examiner opined that the Veteran's current psychiatric conditions are secondary to his "medical status," and not connected to "the condition treated in 1962." The Board relied on this, as well as the examiner's statement that the Veteran's psychiatric symptoms were exacerbated by his heart condition and dementia, to find that the Veteran's MDD was not secondary to or aggravated by his service-connected IBS. The Board did not acknowledge that the examiner did not explicitly opine as to those issues, or discuss whether the examination was adequate to inform its review on the relevant medical questions. The parties agreed that this explanation was inadequate since the Board did not adequately explain why this medical opinion, which did not clearly and explicitly opine as to secondary causation or aggravation, supported its conclusion. Given the above, the Board now finds that because the April 2019 VA examination report raises the possibility that the Veteran's psychiatric disorder is either secondary to or aggravated by the Veteran's service-connected IBS, further development is warranted in order to obtain an addendum opinion that explicitly addresses secondary service connection, including both causation and/or aggravation. Additionally, the parties agreed in the Joint Motion that the Board must address the Veteran's contention that the Board has not fulfilled its duty to assist by attempting to obtain private treatment records. Specifically, the evidence indicates potential treatment records from two private sources, Dr. Bachofer and Dr. Haggstrom, that are not of record and may be relevant to the within case. Given that the Board is remanding the matter for an addendum opinion, the Board finds that the RO should also attempt to obtain any outstanding private medical records upon remand. The matter is REMANDED for the following action: 1. Request that the Veteran complete a VA Form 21-4142 to authorize VA to obtain any outstanding and relevant private treatment records, including but not limited to records of Dr. David Bachofer, Dr. Gerard Haggstrom, and any other private medical professional whose records would be relevant to the issue on appeal. Obtain and associate all such records with the claims file, to the extent possible. If the records cannot be obtained and associated with the claims file, the claims file should be so documented, and the Veteran and his representative should be notified of the same and given the opportunity to provide the records. 2. Return the claims file to the April 2019 VA examiner, or an equally qualified VA examiner, for an adequate addendum opinion as to whether the Veteran's current psychiatric disorder is secondary to his service-connected IBS. The examiner should review the complete claims file and be provided with a copy of the facts below. If the examiner believes that an in-person examination is needed to provide an informed opinion, then schedule the Veteran for an in-person examination. To assist in a review of the claims file, the examiner is informed of the following facts with citations in the record, when applicable: The Veteran served on active duty from April 1956 to May 1964. The Veteran is service connected for irritable bowel syndrome (IBS) from February 6, 2019. Service treatment records show that the Veteran was diagnosed with a psychogenic gastrointestinal reaction in June 1962. See VBMS entry with document type, "STR Medical," with "#1" in the subject field, receipt date 11/23/2018, p. 1. On separation examination in March 1964, the Veteran denied any history of frequent trouble sleeping, nervous trouble of any sort, depression or excessive worry, frequent or terrifying nightmares, and loss of memory/amnesia. He described his health as good. See VBMS entry with document type, "STR Medical," with "#2" in the subject field, receipt date 11/23/2018, p. 19. A July 2007 private treatment record notes the Veteran's past medical history, to include an anxiety disorder. See VBMS entry with document type, "Medical Treatment Record Non-Government Facility," receipt date 02/06/2019, p. 1. The Veteran underwent a VA examination in April 2019. He was diagnosed with a vascular neurocognitive disorder, as well as major depressive disorder. The Veteran reported no history of mental health treatment since leaving service nearly 55 years prior. See VBMS entry with document type, "C&P Exam," receipt date 04/16/2019. The VA examiner provided an opinion that it was less likely than not that the Veteran's psychiatric disorders were incurred in or caused by an in-service injury, event, or illness. The examiner's rationale was as follows: Veteran's Vascular Neurocognitive Disorder is less likely than not incurred in or caused by the condition treated in 1962. Veteran's neurocognitive disorder is directly related to the transient cerebral ischemic attack (TIA)s and atrial fibrillation. Veteran's Major Depressive Disorder is less likely than not incurred in or caused by the condition treated in 1962. Veteran's depression symptoms began in the 1990s and worsened with his exacerbating heart problems and subsequent diagnosis of dementia secondary to TIAs and heart conditions. There is no evidence in Veteran's service record to connect the previous treatment in 1962 with his current conditions which are secondary to his medical status. See VBMS entry with document type, "Medical Opinion," receipt date 04/16/2019, p. 2. The Veteran underwent a VA examination for assessment of his IBS in May 2019. The Veteran's symptoms were reported to include rectal bleeding, bloating/cramping, diarrhea, and constipation. He was noted to have weight loss attributable to his intestinal condition. The examiner stated that the Veteran did not have any other pertinent physical findings, complications, conditions, signs or symptoms related to the Veteran's IBS. See VBMS entry with document type, "C&P Exam," receipt date 05/02/2019. The examiner's review of the record is NOT restricted to the evidence listed above. This list is provided in an effort to assist the examiner in locating potentially relevant evidence. Following a review of the claims file, including the evidence discussed in detail above, the VA examiner is asked to answer the following questions based upon the evidence of record and sound medical principles: a) Is it at least as likely as not (50 percent or greater likelihood) that the Veteran's psychiatric disorder is caused by service-connected IBS? Please state upon what facts, medical principles, and/or medical literature support the opinion. b) If the answer to a) is negative, is it at least as likely as not (50 percent or greater likelihood) that the Veteran's psychiatric disorder is aggravated by the service-connected IBS? Aggravation is different from causation in that it did not cause the disability but rather caused an increase in severity that is not due to the natural progress of the disability. Please state upon what facts, medical principles, and/or medical literature support the opinion. (Continued on the next page) c) If the examiner finds that the service-connected IBS aggravates the Veteran's psychiatric disorder, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the psychiatric disorder prior to aggravation. If the examiner is unable to establish a baseline for the psychiatric disorder prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. A full rationale must be provided for all medical opinions given. If the examiner is unable to provide an opinion without resorting to mere speculation, he or she should explain why this is so. The examiner shall then explain whether the inability to provide a more definitive opinion is the result of a need for more information and indicate what additional evidence is necessary, or whether he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). D. C. JOHNSON Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Wonderling, 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.