Citation Nr: 21007723 Decision Date: 02/10/21 Archive Date: 02/10/21 DOCKET NO. 14-41 199 DATE: February 10, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder to include post-traumatic stress disorder (PTSD), Major Depressive Disorder (MDD), is remanded. REASONS FOR REMAND The Veteran served on active duty from January 2, 1976 to February 27, 1976. This appeal to the Board of Veterans’ Appeals (Board) is from a June 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In March 2016, the Veteran requested a Board hearing, which was scheduled. The Veteran failed to report. In a May 2018 Board decision, the matter was remanded for further development of the in-service stressor and to obtain a VA examination related to his PTSD or any other acquired psychiatric disorder. That development has been completed and has been associated with the claim file in substantial compliance with remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In characterizing the issues on appeal, the Board recognizes that when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). As the medical evidence of record indicates that in the past, the Veteran has received multiple diagnoses of PTSD and MDD, the issue of entitlement to service connection has been expanded as noted above, consistent with Clemons. 1. Entitlement to service connection for n acquired psychiatric disorder to include PTSD and MDD is remanded. The Veteran contends that his PTSD is related to service due assaults by his drill instructor. See August 2020 and April 2013 VA Form 21-0781a. The Veteran underwent a VA examination in August 2020. The examiner indicated that the Veteran has PTSD but that it was less likely than not related to service. See August 2020 VA Opinion, pg. 3. The examiner determined that the Veteran’s PTSD was more likely due to a pre-service stressors of childhood abuse, a motorcycle accident and a post-service stressor of witnessing a co-worker’s accident. The examiner noted that while the Veteran was seen in sick bay numerous times for physical complaints—which can be markers of assault, these physical complaints were thoroughly investigated and found to be due to a pre-service motorcycle accident. The examiner also noted that Service Treatment Records (STR) indicate he was emotionally labile and had a poor tolerance to stress, which are also markers for assault. See id, at pg. 2. The examiner determined that these were more likely due to pre-service abuse, a pre-service motorcycle accident and forced military discharge. However, the Board notes that a February 13, 1976 STR documents a referral to a psychiatrist, which pre-dates his discharge on February 27, 1976. The examiner also noted the medical discharge determined that the Veteran was emotionally labile and had a poor stress tolerance. The medical discharge stated that his conditions pre-date service. The Board is unclear as to whether a psychiatric disorder is a separate diagnosis that pre-dated service. Finally, the Board notes that during the Veteran’s three entrance examinations he was cleared for active duty. See STRs, Entrance Examinations dated July 29, 1975; November 10, 1975; and January 2, 1976. Further, two of these examinations are after his August 1975 motorcycle accident. See STR, San Joaquin General Hospital Treatment Records, August 27, 1975, Discharge Summary (noting a “prognosis for full recovery is excellent”). Given this evidence, the question is whether clear and unmistakable evidence demonstrates that (1) a psychiatric condition clearly and unmistakably pre-existed service and (2) whether a pre-existing psychiatric condition was clearly and unmistakably not aggravated by service to rebut the presumption of soundness. See 38 U.S.C. § 1111; see also Wagner v. Principi, 370 F.3d 1089, 1086 (Fed. Cir. 2004). Although the examiner noted a diagnosis of PTSD, MDD and alcohol use disorder, the examiner did not state whether any diagnosis clearly and unmistakably existed prior to service, or whether any were clearly and unmistakably was not aggravated in service under the clear and unmistakable standard. Thus, the Board finds the opinion inadequate for adjudication purposes. See Barr v. Nicholson, 2 Vet. App. 303, 311-12 (2007). An addendum opinion is therefore required to clarify what diagnoses existed in service, if some symptoms pre-date service, and whether other symptoms were incurred in-service or were in fact clearly and unmistakably aggravated by service. The matters are REMANDED for the following action: 1. Obtain an addendum opinion addressing the nature and etiology of the Veteran’s PTSD, or any acquired psychiatric disorder, to include MDD. After review of the record, the examiner is asked to opine: a) With regard to each diagnosed acquired psychiatric disorder to include PTSD, MDD, the examiner is asked to explain whether these diagnoses existed in service. b) The examiner is asked to opine whether an acquired psychiatric disorder to include PTSD, MDD clearly and unmistakably existed (obvious, manifest, undebatable) prior to service. c) If a diagnosis clearly and unmistakably existed prior to service, the examiner is asked to opine whether any were NOT clearly and unmistakably aggravated by service, either because there was no increase in disability during service or because any increase in disability was due to the natural progress of the preexisting condition? d) If it is determined either that no psychiatric disorder clearly and unmistakably preexisted service, is it at least as likely as not (probability 50 percent of more) that any current disability had its onset in service or is otherwise related to service? A complete rationale for each opinion rendered should be included. The examiner’s attention is invited to a February 2, 1976 STR indicating that the Veteran was emotionally labile with poor tolerance to stress, which predates his February 27, 1976 medical discharge. The examiner’s attention is invited to a February 13, 1976 STR treatment note indicating a referral to psychiatry, which predates his February 27, 1976 medical discharge. K. J. ALIBRANDO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. McKenzie, 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.