Citation Nr: 21010951 Decision Date: 02/26/21 Archive Date: 02/26/21 DOCKET NO. 15-46 623 DATE: February 26, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depression, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from October 1976 to October 1978. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran's initial claim for service connection for PTSD has been recharacterized by the Board as entitlement to service connection for any acquired psychiatric disability, to include PTSD. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record). In July 2015, the Veteran testified at a hearing at the RO before a Decision Review Officer (DRO). A transcript of that hearing has been associated with the record. In his December 2015 substantive appeal, the Veteran requested a Board videoconference hearing. In November 2017, the Veteran withdrew his hearing request. In an August 2019 decision, the Board denied entitlement to service connection for an acquired psychiatric disorder, to include PTSD. The Veteran appealed the August 2019 decision to the United States Court of Appeals for Veterans Claims (Court). In a September 2020 Order, the Court granted a Joint Motion for Partial Remand (Joint Motion) and vacated the portion of the August 2019 decision denying the issue listed above and remanding the issue to the Board. The Veteran’s appeal originally included a claim for entitlement to service connection for a bilateral foot disorder. The Board remanded this issue in August 2019 and March 2020. Thereafter, in an October 2020 rating decision, the RO granted service connection for hyperkeratotic palmoplantar psoriasis (claimed as left and right foot disorders) and assigned a noncompensable evaluation, effective from June 16, 2014. The grant of service connection for a bilateral foot disability constitutes a full award of the benefits sought on appeal with respect to such claim. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997). Thus, the issue is no longer before the Board. Entitlement to service connection for an acquired psychiatric disorder is remanded. In light of the Joint Motion, the Board finds that additional development is needed prior to adjudication of the claim. In a September 2020 statement, the Veteran’s representative pointed out that a June 2016 VA mental health note indicated that the Veteran wanted to resume psychiatric treatment and that he had an appointment scheduled at the Omaha VA Medical Center in September 2016. However, as noted in the September 2020 statement and the September 2020 Joint Motion, there were no VA treatment records dated after June 2016 in the record. Thus, on remand, any outstanding VA treatment records should be associated with the claims file. In addition, in the September 2020 statement, the Veteran’s representative noted that the Veteran had applied for Social Security Administration (SSA) disability benefits twice in the past and that he was in the process of appealing the most recent denial. Consequently, as such records may be relevant to the instant claim, a remand is necessary in order to obtain any determination pertinent to the Veteran’s claim for SSA benefits, as well as any medical records relied upon concerning that claim. Murincsak v. Derwinski, 2 Vet. App. 363 (1992) (where VA has actual notice of the existence of records held by SSA which appear relevant to a pending claim, VA has a duty to assist by requesting those records from SSA). Thus, on remand, any SSA decisions and records associated with the decisions should be obtained and associated with the record. Likewise, a review of the record indicates that there may be outstanding Vet Center treatment records that are relevant to the claim. Specifically, in a January 2016 VA psychotherapy note, the Veteran was referred for treatment at a Vet Center. Thus, on remand, any Vet Center treatment records should be identified, obtained, and associated with the claims file. Finally, in the September 2020 Joint Motion, the parties determined that the November 2014 VA examiner relied on a lack of evidence in the Veteran’s service treatment records that a reported assault did not occur. In addition, the VA examiner did not address the markers of personal assault within the Veteran’s service treatment records and service personnel records, to specifically include multiple instances of unauthorized absence, substance abuse, and disciplinary action. Furthermore, the VA examiner did not address the Veteran’s contentions in the examination report. Therefore, on remand, another VA medical opinion should be obtained. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records for psychiatric disorders, to include mental health clinic records. A specific request should be made for any records dated from June 2016 from the Omaha VA Medical Center. 2. Identify and obtain any outstanding Vet Center records. 3. Obtain the Veteran’s complete SSA records, including any administrative decision(s) and underlying medical records. All reasonable attempts should be made to obtain such records. 4. Obtain a VA medical opinion from an appropriate VA mental health professional identifying all psychiatric disabilities diagnosed during the appeal period, including PTSD and depression. The examiner must review the claims file and note that a review has taken place in the report. The examiner is asked to address the following: a) Identify all current acquired psychiatric disorder(s) that have been present at any time during the appeal period. If the examiner finds PTSD has not been diagnosed at any time, the examiner should explain why. b) If the Veteran’s PTSD diagnosis is confirmed, the examiner must identify the specific stressor(s) underlying any PTSD diagnosis and comment upon the link between the current symptomatology and the Veteran’s stressor(s) and must specifically address whether the Veteran’s identified stressor(s) are related to personal assault or a fear of hostile military or terrorist activity; whether the identified stressor(s) are adequate to support a diagnosis of PTSD; and whether his symptoms are related to the identified stressor(s). c) For each psychiatric disorder other than PTSD diagnosed during the appeal period, the examiner should opine whether it is at least as likely as not that such disorder had its onset during active duty service or was otherwise etiologically related to the Veteran’s active duty service. d) The examiner should also indicate whether the Veteran manifested a psychosis within one year of his discharge from active duty in October 1978 and, if so, should describe the manifestations of such psychosis. For VA purposes, a “psychosis” includes a brief psychotic disorder, delusional disorder, psychotic disorder due to general medical condition, psychotic disorder not otherwise specified, schizoaffective disorder, schizophrenia, schizophreniform disorder, shared psychotic disorder, and substance-induced psychotic disorder. In providing the requested opinion, the examiner must consider the Veteran’s reported in-service stressors from his service. In doing so, the VA examiner should specifically comment on markers of personal assault in the claims file, to specifically include deterioration in work performance, including multiple instances of unauthorized absence, disciplinary action, and substance abuse. The examiner is reminded that a lack of documented treatment or diagnosis for a psychiatric disorder or symptoms during service, while probative, cannot serve as the sole basis for a negative finding. The Veteran’s lay contentions regarding onset and continuity of symptoms of his psychiatric disorder must be considered and weighed in making the determination as to whether a nexus exists between the claimed disability and military service. The examiner must provide a complete rationale for any opinion offered, citing to medical evidence, such as examination findings, or other evidence in the record, when necessary, to support the conclusion reached. If an opinion cannot be reached without resorting to speculation, the examiner must fully explain why that is so. J. B. FREEMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Osegueda, 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.