Citation Nr: 21010690 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 12-02 738A DATE: February 25, 2021 REMANDED Entitlement to service connection for bilateral knee disability is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for post-traumatic stress disorder (PTSD) is remanded. Entitlement to service connection for a substance abuse disability to include as secondary to an acquired psychiatric disorder (to include PTSD) is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include depression and schizophrenia is remanded. Entitlement to a total disability evaluation based on individual unemployability due to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran had active service from June 1974 to June 1975, during the Vietnam Era. In February 2017, the Board considered the claims, which originated from the appeal of a June 2009 rating decision of the Department of Veterans Affairs (VA) regional office (RO) in Huntington WV. The case comes to the Board from the Jackson Mississippi RO. In February 2017, the Board remanded the appeal for further development. This case has since been returned to the Board for review. In the present Board decision, the Board has recharacterized the original PTSD issue on appeal by bifurcating it into three separate issues, specifically: (1) entitlement to service connection for PTSD; (2) entitlement to service connection for an acquired psychiatric disorder, to include depression and schizophrenia (other than PTSD); and (3) entitlement to service connection for a substance abuse disability to include as secondary to an acquired psychiatric disorder (to include PTSD). The Board concludes that separating the Veteran’s acquired psychiatric claim three separate issues for independent adjudication is the most proper way of handling the Veteran’s appeal. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a disability claim includes any disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record); see also Locklear v. Shinseki, 24 Vet. App. 311 (2011) (bifurcation of a claim generally is within VA’s discretion); Tyrues v. Shinseki, 23 Vet. App. 166, 178-79 (2009), aff’d, 631 F.3d 1380 (Fed. Cir. 2011) (VA is free to dismember a claim and adjudicate it in separate pieces). Also, the Board is cognizant of the Federal Circuit Court’s holding that there is no prohibition against a Veteran potentially being service connected for more than one psychiatric disability. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009) (recognizing that bipolar disorder and PTSD could have different symptoms and it could therefore be improper in some circumstances for VA to treat these separately diagnosed conditions as producing only the same disability). 1. Entitlement to service connection for bilateral knee disability is remanded. 2. Entitlement to service connection for hypertension is remanded. A remand to develop the claims for hypertension and a bilateral knee disability is required because there is a significant gap in treatment records between the time the Veteran left service in 1975 and 2001. As far back as 2001, the Veteran had current diagnoses for hypertension and for both of his knees. It is conceded that the Veterans STR’s reflect a diagnosis in service for right and left knee chondromalacia patella in July 1974. The Veteran contends that he was treated for his hypertension and his knees very soon (within one year) after separating from service when he was incarcerated in Mississippi Department of Corrections (MDOC). See hearing testimony 2016. In order for the appellant to establish entitlement to benefits, service connection must be established. First, service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service, requiring competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the current disability and an in-service precipitating disease, injury or event. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a). Alternatively, symptoms of chronic disabilities that manifest in service or within one year of discharge from service may create a presumption of service connection. In such cases, service connection may be established either by showing that a chronic disability or disease was incurred during service and later manifestations of such chronic disability or disease are not due to intercurrent cause(s) or that a disorder or disease was incurred during service and there is evidence of continuity of symptomatology which supports a finding of chronicity since service. 38 C.F.R. § 3.303 (b). When a chronic disease becomes manifest to a degree of 10 percent within one year of a Veteran’s discharge from service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the Veteran’s period of service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309 (2017). In other situations, service connection may be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303 (d) (2017). Treatment records from the time period one year after the Veteran’s discharge are important in order to evaluate the Veteran’s claims. In 2016 at the travel hearing, the Veteran testified he was incarcerated and received medical treatment in MDOC within one year of his military separation. Medical records from the periods of the Veteran’s incarcerations in MDOC are not associated with the file. The claims file contains possible addresses and phone numbers for MDOC and these may not be current now. In January 2019 the appellant submitted a VA Form 21-4142 authorization for release of information with two addresses and a phone number: MS Department of Corrections Medical, 633 N. State St, Jackson MS 39202 and Central MS Correctional Facility, 3794 Highway 46, Pearl, MS 39202 and a phone number: 601-359-5600. In 2020, different addresses and phone numbers appear on the MDOC website. The MDOC website, Medical Division, lists a different address for medical records in Jackson MS and a different telephone number for MDOC Medical Records inquiry. The website includes a link to MDOC Authorization Medical Records Release Form, and this form might be mandatory for records requests. Attempts to locate the MDOC records have not been exhausted. In December 2019, the RO in Jackson MS associated a “second attempt” letter to the file addressed to Central MS Correctional, 3794 MS-468, Pearl, MS 39208 for records during the following periods: December 6, 2004 ending December 7th, 2006. There is no record of any “first” attempt being sent. There is no record of the RO attempting any of the other addresses or phone numbers provided by the appellant or the address or phone number on the MDOC website. In any event, the request for medical records should be inclusive from the date the Veteran separated from service (1975) to the date of his death (2016). The hearing testimony suggests that the Veteran in 2016 believed MDOC may have records that date back to 1975. All records in the possession of MDOC concerning the Veteran could be important to the claims. The MDOC medical treatment records may still be obtainable and it is not clear that further efforts to obtain the missing records from MDOC would be futile. For these reasons, the Board is remanding the claims with instructions to make new efforts to obtain the missing records from MDOC. The RO should work with the appellant and together they should research and determine the most current addresses for inquiry and obtain the records by communicating and corresponding with MDOC. All of the possible sources for records requests for MDOC should be contacted. The RO must document in detail the efforts made to obtain the MDOC records. Any treatment records from other sources dating from the time of separation in 1975 up to approximately should be requested. The Veteran’s STR’s (May 1974 to April 1975) are in evidence and 1999 records from the VA Medical Center, Biloxi MS, including a July 1999 mental health opinion of the medical examiner with regard to the Veteran’s PTSD and TDIU claims. The Veteran himself submitted a Form VA 21-4142 authorization for release listing Gulfport Memorial Hospital, Gulfport MS; Garden Park Community Hospital, Gulfport MS; Tulane Medical Center, New Orleans LA, in 2001. The RO should work with the appellant to execute authorization forms and determine any and all locations where the Veteran might have received VA treatment and/or private treatment, including but not limited to mental health and substance abuse treatment, dating back to and including the year 1975. The RO must document in detail the efforts made. In adjudicating these claims, the Board must assess the competency and credibility of the Veteran. Washington v. Nicholson, 19 Vet. App. 362 (2005). Lay testimony is competent if it is limited to matters that the witness has actually observed and is within the realm of the witnesses’ personal knowledge. Barr v. Nicholson, 21 Vet. App. 303 (2007), Layno v. Brown, 6 Vet. App. 465 (1994). The Veteran reported to the physician at a VA examination that his hypertension, depression and knee problems have been present since the mid-1970s and started when he was in active military service. See July 2001 report. At this 2001 exam, the Veteran said he was on blood pressure (and depression) medication ever since service and was currently receiving medication at the time of this 2001 examination. The RO should work with the appellant to obtain records that may show where the Veteran was receiving treatment for hypertension and medication from the time of his separation from service in 1975, and also where he was receiving treatment for his knees during this time. The Veteran reported contacts with VA Biloxi Psychiatry since about 1977. See claims file July 2001 VA exam pages 1 and 5. At present, medical records from VAMC Biloxi are associated with the file beginning in 1999 and including April 2000 to May 2001. The RO must document in detail the efforts made. 3. Entitlement to a total disability evaluation based on individual unemployability due to service-connected disabilities is remanded. With regard to the claim for total disability evaluation based on individual unemployability (TDIU) due to service-connected disabilities, the claim is remanded because the TDIU issue is inextricably intertwined with the implementation of any award of service connection for the Veteran’s open claims including PTSD, bilateral left and right knee disabilities and hypertension. In the event disability ratings are assigned, any award will impact the adjudication of the TDIU claim. See 38 C.F.R. § 4.16 (a) (2019). For this reason, the implementation of any rating award must be resolved prior to resolution of the claim for TDIU. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that the prohibition against the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation). Accordingly, a remand is required so that the RO is able to adjudicate the inextricably intertwined claims. 4. Entitlement to service connection for post-traumatic stress disorder (PTSD) is remanded. There is conflicting evidence of record regarding whether the Veteran met the diagnostic criteria for a diagnosis of PTSD at the time of his death under then current law. An examiner diagnosed the Veteran with PTSD in July 1999, but the examiner did not address whether or not the Veteran’s PTSD diagnosis conformed to DSM criteria. In addition, a current opinion is warranted to provide complete information required to properly evaluate the claim. Service connection for PTSD has unique evidentiary requirements. It generally requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. See 38 C.F.R. § 3.304 (f); see also Cohen v. Brown, 10 Vet. App. 128 (1997). As to the first requirement of a competent medical diagnosis for PTSD, effective August 4, 2014, the VA medical opinion must reference the Diagnostic and Statistical Manual (Fifth Edition) (the DSM-V). See 79 Fed. Reg. 45,094 (August 4, 2014). This interim final rule does not apply to claims that have been certified for appeal to the Board or are pending before the Board on or before August 4, 2014. See Schedule for Rating Disabilities - Mental Disorders and Definition of Psychosis for Certain VA Purposes, 80 Fed. Reg. 14,308 (March 19, 2015). Here, as the Veteran’s claim was certified to the Board after August 4, 2014, the amended regulation applies. With regard to an actual diagnosis of PTSD, lay persons are not categorically incompetent to speak on matters of medical diagnosis or etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The Board must consider the type of condition specifically claimed and whether it is readily amenable to lay diagnosis or probative comment on etiology. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). In this regard, the Federal Circuit recently held that “PTSD is not the type of medical condition that lay evidence... is competent and sufficient to identify.” Young v. McDonald, 766 F.3d 1348, 1352-53 (Fed. Cir. 2014). Regardless, the Board acknowledges the Veteran is competent to report psychiatric symptoms both during and after service. See 38 C.F.R. § 3.159 (a)(2); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (discussing that Veteran is competent to report a contemporaneous medical diagnosis); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (discussing general competency of a Veteran to report psychiatric symptoms). That is, lay evidence can be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson, 581 F.3d at 1316; see also Jandreau, 492 F.3d at1376-77. With regard to the requirement of an in-service stressor, the evidence requirements vary depending upon the circumstances of the case. VA has provided for specific types of cases where lay evidence alone may be sufficient to describe the stressor and further corroborating evidence will not be required. Corroborating evidence is not required in cases where (1) PTSD is diagnosed in service; (2) the evidence establishes the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat; (3) the stressor is related to the Veteran’s fear of hostile military or terrorist activity; or (4) the evidence establishes that the Veteran was a prisoner-of-war and the stressor is related to that prisoner-of-war experience. 38 C.F.R. § 3.304. In any of the above situations, the Veteran’s lay testimony or statement is accepted as conclusive evidence of the stressor’s occurrence and no further development or corroborative evidence is required providing that such testimony is found to be consistent with the circumstances, conditions, or hardships of service and there is no clear and convincing evidence to the contrary. See 38 U.S.C. § 1154 (b); 38 C.F.R. § 3.304. Effective July 12, 2010, VA amended its adjudication regulations governing service connection for PTSD by liberalizing, in certain circumstances, the evidentiary standard for establishing the required in-service stressor. Specifically, the final rule amends 38 C.F.R. § 3.304 (f) by re-designating current paragraphs (f)(3) and (f)(4) as paragraphs (f)(4) and (f)(5), respectively, and by adding a new paragraph (f)(3) that reads as follows: “(f)(3) If a stressor claimed by a Veteran is related to the Veteran’s fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a competent diagnosis of [PTSD] and that the Veteran’s symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran’s service, the Veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, ‘fear of hostile military or terrorist activity’ means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran’s response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror.” The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C. § 7104 (a); Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303 (a). The Veteran attended a VA examination for his acquired psychiatric disorder in July 1999. This examiner discussed the Veteran’s service connected traumatic “stressor” experience with regard to the Veteran’s PTSD symptoms. The Veteran described that he became very disturbed working with the vehicles wrecked during war each day, looking for specific damage and typing damage reports every day. The Veteran reported that he thinks about and is deeply disturbed by considering the injuries that happened to the soldiers in the war zone who occupied the wrecked and destroyed vehicles that the Veteran was examining every day. At the same time, the Veteran was required to participate in combat drills as part of his program. The Veteran described the impact these activities had on him in multiple documents in the claims file. See also Certificate of Release or Discharge from Active Duty, dated July 16, 1975, and filed at date 6/10/2016, Sections 16 (a) and (b) with regard to the Veteran’s Occupation working with the Vehicles; also Rating Decision Narrative May 2001 page 1; March 2000 Rating Decision Narrative (Rater does not believe examining combat wrecked vehicles and typing damage reports every day constitutes a stressor event page 4); hearing testimony April 2016 page 9. At other times, the Veteran reported in statements that he was afraid to leave the barracks when he was in service. See hearing testimony page 10, April 2016. The Veteran’s spouse submitted a handwritten statement indicating that ever since the Veteran came home, he was a totally different person and he seemed like he lived in fear of something or someone coming for him. She stated: “… he was not like that before he went in the Military. He was withdrawn and won’t come out of the house for weeks at a time. He had difficulty getting along with others. He seemed to have stress and was not able to sleep.” See Correspondence dated April 2016. The evidence of record reflects the Veteran’s statement that he entered service at the age of 17 and had not ever used alcohol or drugs before that time. He reported that he began drinking at age 17 in service in Germany. There is no evidence of record to indicate that the Veteran had substance abuse or alcohol dependence prior to his military service. Other symptoms began during the Veteran’s time in service. He became unable to care for his needs (counseled repeatedly about poor hygiene) unable to wake up when required, and unable to leave the barracks when required to do so. See STR’s with repeated disciplinary actions for the Veteran’s behaviors. At one medical visit during service the physician recommended that the Veteran should undergo a psychiatric examination. The Veteran described that he was told during service that he must resign and receive an honorable discharge, or if he refused to resign, then he would receive a dishonorable discharge. In the July 2016 hearing the Veteran stated he believes that his resignation from the service at that time was actually a discharge for medical reasons due to his mental health. After separation from service, post service medical evidence showed that the Veteran was treated for alcohol and substance abuse on numerous occasions. The Veteran reported that he used substances to stop thoughts and to self-medicate his symptoms. A 1999 VA examiner diagnosed post-traumatic stress disorder, chronic, moderate, and major depression. The examiner assigned a Global Assessment of Functioning (GAF) score of 55. Another VA examination of the Veteran occurred at Biloxi MS in July 2001. The Veteran reported to the examiner that he “thinks of suicide all the time, but not about doing it.” See VA Examination July 2001 page 6. In February 2012 the Veteran submitted a statement with the Form 9 and explained that while he was on active duty, he started to have mental problems, which he believes were based on his duty MOS (Military Occupation Specialty). He stated: “I was responsible for working with vehicles that were damaged (on the ground in Vietnam during the Vietnam Era). Those vehicles would be covered in blood and skin. These vehicles were coming to Germany from Vietnam. I started to think that I was one of the soldiers who were hurt in those vehicles. Every day, I would get more depressed about what I was seeing. When I had problems/depression, I was only counseled by my chain of command. Based on the number of times that I was counselled my chain of command should have been able to see that I needed was medical help.” In summary, the Veteran reported stressors of being confronted daily with wrecked vehicles shipped to Germany from war zones, which the Veteran reported contained blood and skin, contemplating the injuries to the soldier occupants of the vehicles, and engaging in “combat” drills and exercises daily (see his early handwritten statement). The Veteran also reported consistently being afraid and at other times, the Veteran reported he was afraid to leave the barracks. Accordingly, the PTSD claim is remanded. The Veteran is deceased and a medical opinion is needed as to whether the Veteran had a diagnosis of PTSD during the appeal period that was related to an in-service stressor, including fear of hostile military or terrorist activity. See C.F.R. 3.304(f)(3). 5. Entitlement to service connection for a substance abuse disability to include as secondary to an acquired psychiatric disorder (to include PTSD) is remanded. In January 2020 a VA examiner noted the Veteran’s history of a substance abuse disorder in remission. With regard to secondary service connection for drug and alcohol dependence, the law generally prohibits the payment of compensation for disabilities resulting from a claimant’s abuse of alcohol or drugs, see 38 U.S.C. §§ 105 (a). However, in Allen v. Principi, 237 F.3d 1368 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit held that 38 C.F.R. § 3.310 authorizes compensation for an alcohol or drug abuse disability when the claimant’s alcohol or drug abuse disability is the secondary result of a separate service-connected disability, such as a psychiatric disability. Id. at 1381. Accordingly, a remand is necessary for the secondary substance abuse disorder claim, so that a VA examiner can consider the extent to which the Veteran’s alcohol and drug abuse disorder was likely caused or aggravated by any claimed service-connected paranoid schizophrenia, major depressive disorder and/or PTSD diagnosis. That is, to what extent may it be concluded that the Veteran’s alcohol and drug abuse began as a coping mechanism in the military and then after his separation from the military. 6. Entitlement to service connection for an acquired psychiatric disorder, to include depression and schizophrenia is remanded. In statements and testimony, the Veteran contended that his acquired psychiatric disorder, diagnosed as paranoid schizophrenia and major depressive disorder, began when he entered into his Military Occupational Specialty (MOS). In service the Veteran displayed mannerisms and behaviors which caused him to be counselled repeatedly, to be suggested for psychiatric evaluation, and afterwards, to be discharged honorably for marginal or nonproductive service. Schizophrenia is a chronic disease (as a psychosis under 38 C.F.R. § 3.384 ) and therefore an enumerated condition under 38 C.F.R.§ 3.309 (a) and Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Certain chronic diseases will be presumed related to service if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service, with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Connected to his time in service, the Veteran was counselled for certain behaviors during his active duty. The Veteran served June 1974 to June 1975. In January 1975, while serving in Germany, the Veteran was counseled about having problems with oversleeping and issues with his personal hygiene. The Veteran’s service treatment records (STR’s) reflect that in March 1975 he was repeatedly counselled: entries include counseled about not leaving his bed (not awakening) and not doing his share of tasks. There are several incidents of the Veteran not showing up on time for various responsibilities. The records indicate that the Veteran stated he was trying but “it is all too hard for him.” In June 1975, before the Veteran separated from service, a clinician at a US Army health clinic in Hanau New York noted that a psychiatric consultation for the Veteran was recommended. The Veteran testified that his schizophrenia and hypertension were both diagnosed within one year of service when he was incarcerated in MDOC. See 2016 hearing transcript. In addition to the Veteran’s testimony and statements, the Veteran’s wife submitted a lay statement wherein she noted various changes, disabilities and behavioral difficulties when the Veteran returned from service. In November 1987, the Veteran filed a claim. On the form, the Veteran stated that he was not able to hold down a job. He listed his claimed disability is a “hygiene problem”, originating during active duty. In December 1987, the Veteran filed a request for physical examination, and claimed service connection for a hygiene problem. In June 1999 the Veteran stated that while in service he could not make formations, schedules or appointments. He was released from the military on an honorable discharge as he was unable to cope with military life. The Veteran stated that he was exposed to drug and alcohol abuse habits and behaviors upon entering the military at age 17 and this exposure caused permanent symptoms, altered his life and impacted his earning capacity. See June 1999 PTSD questionnaire. In a June 1999 VA medical examination, the Veteran stated that in service “after about a year” he told his supervisors that he could not deal with the stress of the work, at which point he said they did try to give him treatment although he was not hospitalized. The Veteran did not remember if he was given medication. He thought he was given some medication but he was not sure. He then was given an honorable discharge. In 1999, the Veteran reported that he was taking medication but had not been hospitalized for any psychiatric problems. The Veteran was diagnosed at that time with both major depression and PTSD, chronic, moderate. The Veteran’s global assessment of functioning (GAF) score was 55. In May to October 2004, the Veteran was treated and diagnosed with paranoid schizophrenia at the Biloxi VA medical facility. His GAF score was 45. In February 2012 the Veteran submitted a statement with the Form 9. The Veteran reported that on active duty June 1974 to June 1975, he started to have mental problems, which he believed were based on his duty MOS (Military Occupation Specialty). He stated as follows: “I was responsible for working with vehicles that were damaged (on the ground in Vietnam during the Vietnam Era). Those vehicles would be covered in blood and skin. These vehicles were coming to Germany from Vietnam. I started to think that I was one of the soldiers who were hurt in those vehicles. Every day, I would get more depressed about what I was seeing. When I had problems/depression, I was only counseled by my chain of command. Based on the number of times that I was counselled my chain of command should have been able to see that I needed was medical help.” In March 2015, Dr. EJH at Biloxi VAMC, a mental health provider, opined he suspects that the Veteran may have suffered his first psychotic break while in service in Germany. The Veteran in March 2015 had a competent then-current diagnosis of paranoid schizophrenia, depression NOS (not otherwise specified), a history of cocaine and ETOH (alcohol) abuse in remission. Dr. EJH reported he last saw the Veteran in 2010 although in the interim the Veteran had been seen for medication management. The Veteran described feeling occasionally down but overall his mood appeared stable. The Veteran denied any ETOH (alcohol) or illegal drug use and was attending SUDP counseling on a frequent basis. The doctor reported “TC appears reality based though he acknowledges feeling slightly uncomfortable (paranoid?) around others at times.” The Veteran expressed “resentment that I didn’t get the help I needed” when he was in the Military and that “I had to go through 40 years of not being able to provide for my family.” Dr. EJH then opined that he suspected the Veteran suffered his first psychotic break while stationed in Germany in the Army as it was then that the Veteran first began to experience “AHs” (auditory hallucinations) and “felt threatened by everybody.” The Veteran stated: “I went from top soldier to sad sack in a couple of months.” After considering the evidence, a remand is necessary so the Board can acquire the information needed to evaluate the claims. First, efforts must be made to associate the missing MDOC records, along with any other pertinent treatment records. Second, a medical examination opinion is needed to clarify information required to evaluate the service connection claims. A VA medical review and opinion is needed because in January 2020 the VA examiner noted the Veteran’s diagnosis for paranoid schizophrenia and major depressive disorder at the time of his death and then ultimately provided a negative nexus opinion based on the assertion that the Veteran’s STR’s are silent for a diagnosis and the Veteran was not diagnosed within a year of discharge. The Board affords minimal weight to the opinion since the examiner did not address the aforementioned missing MDOC records, the testimony and lay statements, nor did the examiner explain why in service the Veteran repeatedly exhibited impairments in his ability to take care of the daily necessities and requirements of his duties in service, and was counselled and ultimately discharged as a consequence of his disabilities. The examiner did not address the following: a 1975 in service Army facility note in New York suggesting the a psychiatric evaluation was required and, a March 2015 VA mental health physician who opined that based on the symptoms the Veteran reported, the physician suspected the Veteran suffered his first psychotic break while in service in Germany. The VA has a duty to ensure that a medical opinion is adequate when it undertakes to obtain a VA opinion. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The matters are REMANDED for the following action: 1. The RO is requested to review this remand in detail with regard to the further development required. Please contact the appellant, communicate with her about representation options, and document that this was accomplished. With the assistance of appellant, identify and communicate with any and all possible resources for locating the MDOC records, and all other pertinent medical treatment records as has been set forth in detail in the remand. The RO must document specifically the efforts made with regard to the MDOC records and the specific efforts made with regard to any and all other records. 2. After the efforts are made and any additional records are associated with the claims file, schedule with an appropriate qualified physician (a medical doctor) other than the most recent examiner to provide an opinion with regard to the Veteran’s service connection claims for paranoid schizophrenia, major depressive disorder, and PTSD and secondary service connection substance abuse disability claim. The VA examiner should review the details set forth in this remand, the entirety of the claims file, the history presented by the Veteran in testimony and statements, and examination results. The examiner should reflect that this required review was accomplished. The examiner is asked to offer opinions as follows: With regard to PTSD, the VA examiner should specifically note and discuss the Veteran’s claimed stressor. For any diagnosis, the examiner should provide an opinion as to whether the disability is at least as likely as not (50 percent or greater probability), incurred in service or otherwise related thereto, to include the aforementioned stressor. If PTSD is diagnosed, the examiner should specifically discuss whether the criteria for diagnosing PTSD per the DSM-V are met, and, if so, whether it is related to the stressor events mentioned by the Veteran. With regard to PTSD, the examiner is requested to comment on fear of hostile military or terrorist activity. In addition, please comment on the Veteran’s behavioral changes following the alleged in-service stressor event as evidenced by the Veteran’s statements and testimony, along with the statement submitted by the Veteran’s wife. With regard to claims for chronic paranoid schizophrenia and major depressive disorder, there are medical reports and statements from the Veteran, his wife, and various practitioners encompassing the Veteran’s time in service (STR’s) and then after service up to the time of his death. These reports and statements must be specifically evaluated with regard to the Veteran’s service connection claims for chronic paranoid schizophrenia and major depressive disorder. For the identified chronic paranoid schizophrenia and major depressive disorder, is it at least as likely as not (50 percent probability or more) that the Veteran’s chronic paranoid schizophrenia and/or major depressive disorder disability was either incurred during service or otherwise etiologically related to his service? Please comment on the Veteran’s behavioral changes from the time of his enlistment to the time of his separation. Specifically comment on the etiology of the Veteran’s behaviors that resulted in the need for him to receive continual counselling in service, the Veteran’s discharge from service due to these unacceptable behaviors and his apparent inability to conform with expectations, and the in-service file note suggesting the Veteran should receive a psychological evaluation. Please comment on the report of the Veteran’s wife regarding behavior changes to the Veteran after return from service, the Veteran’s self-reported inability to keep a job after separation, his self-reported “hygiene problem”, and the Veteran’s interpretation that his inability to meet expectations in service and after separation was due to medical reasons. Please comment on the Veteran’s statements that he was diagnosed and treated for mental health disorders immediately after (within one year) of separation from active service at MDOC, and records reflect a 2004 diagnosis of paranoid schizophrenia. Additionally, comment on the significance, if any, of a March 2015 physician treatment note that the Veteran may have suffered his first psychotic episode and auditory hallucinations while in service in Germany. (CAPRI file associated October 7, 2015). With regard to the claim for secondary service connection for a substance abuse disability, after identifying whether the Veteran’s claimed paranoid schizophrenia, major depressive disorder and/or PTSD are service connected, kindly discuss the Veteran’s substance abuse disorder as secondary to (or aggravated by) any service connected disorder(s). Kindly identify if it is at least as likely as not (i.e. probability of 50 percent or greater) that the Veteran’s history of a substance abuse disability is secondary to (or aggravated by) any service-connected disabilities. In formulating the medical opinion, the examiner is advised that the Veteran was competent to report symptoms and that his reports through statements and testimony in the claims file must be considered, referenced and discussed in formulating the requested opinion. If the Veteran’s reports are discounted, the examiner should provide specific reason(s) for doing so. It is not sufficient to base an opinion upon the absence of evidence in the STRs, by itself, for a negative opinion with regard to the claims. Please provide clearly stated rationale and identify and reference treatment records and/or Veteran statements based on the evidence to support your conclusions. Attempt to reconcile any conflicting findings. A clear explanation for all opinions based on specific facts for the case as well as relevant medical principles is needed. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.M. Schneider 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.