Citation Nr: 21014866 Decision Date: 03/16/21 Archive Date: 03/16/21 DOCKET NO. 12-23 621 DATE: March 16, 2021 REMANDED The issue of entitlement to service connection for an acquired psychiatric disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1972 to August 1974. This matter is before the Board following his appeal of a May 2011 rating decision. In January 2014, the Veteran testified before a Veterans Law Judge (VLJ) who has since retired from the Board. By way of January 2021 correspondence, the Veteran was afforded an opportunity to testify before a different VLJ. However, because he did not respond within 30 days of the letter (or at all), it is assumed he does not want another hearing. The Board previously remanded this matter for further development in January 2015, April 2017, March 2018, and April 2020. Specifically, the Board remanded the appeal in order to obtain an adequate opinion regarding whether the Veteran has a psychiatric disorder that was incurred in service or as a result of service-connected disability. Unfortunately, because an adequate opinion is still not of record, the Board finds that further remand is, once again, necessary. In this regard, VA examiners in September 2009, May 2015, July 2017, September 2019, and September 2020 have either found that the Veteran does not have a current psychiatric disorder, or that his variously diagnosed psychiatric disorders were not related to service or to a service-connected disability. However, as discussed in the Board’s prior remands, the opinions offered by the VA examiners largely ignored lay evidence of record, including the reports of the Veteran and his brother of an onset of the Veteran’s psychiatric symptoms in service. What is more, it is questionable whether the examiners actually reviewed the claims file, or at the very least, the service treatment records (STRs), as several opinions relied on an absence of psychiatric complaints in service. However, the Board observes that in June 1974, the Veteran presented to sick call with complaints of being nervous on occasion, which caused some nausea. He also complained of general malaise at that time. Given the foregoing deficiencies, the Board finds that a new opinion is necessary. In ordering remand in the instant case, the Board is not making a preliminary formal finding as to the credibility of the Veteran’s lay reports, or those of his brother. Rather, the Board is merely requesting that the clinician on remand consider the Veteran’s own descriptions of the history of his psychiatric symptoms, and the history reported by his brother in 1985. See Smith v. Wilkie, 32 Vet. App. 332, 338-39 (2020). The matter is REMANDED for the following action: Obtain from a psychiatrist or psychologist an addendum opinion addressing the etiology of the Veteran’s acquired psychiatric disorder(s). If a new examination is deemed necessary, one should be scheduled, and should include all indicated tests and studies, to include any psychological testing deemed necessary. All clinical findings should be reported in detail. The claims file, to include a complete copy of this REMAND, must be made available to the designated clinician, and the addendum opinion/examination report should reflect consideration of the Veteran’s documented medical history and assertions. (a) For each acquired psychiatric disorder validly diagnosed at any time during or proximate to the appeal period (beginning in July 2009), to specifically include depressive, anxiety, and/or dysthymic disorders, the psychiatrist or psychologist should offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the disorder had its onset during the Veteran’s active military service, or is otherwise medically related to service. In addressing the above, the clinician must consider and discuss all pertinent medical and other objective evidence of record, as well as lay assertions, to include assertions as to the nature, onset and continuity of the Veteran’s psychiatric symptoms. The clinician is asked to specifically address: (1) the June 1974 STR documenting the Veteran’s report of nervousness causing nausea; (2) the August 1985 observations of the Veteran’s brother that the Veteran had a history of psychiatric problems since active military service; and (3) the Veteran’s report that he experienced severe social anxiety and phobia since he was in his twenties and that he coped with alcohol and drug (documented in a September 2018 VA treatment record.) Notably, the absence of documented evidence of a specific diagnosis and/or psychiatric symptoms during or shortly after service should not, alone, serve as the sole basis for a negative opinion. The clinician is advised that the Veteran is competent to report his own symptoms and history, and his brother is competent to report his observations of the Veteran; lay assertions in this regard must be considered in formulating the requested opinions. If lay assertions in any regard are discounted, the clinician should clearly so state, and explain why. The Board reminds the Veteran that in asking the examiner to accept the history he provided, the Board is not at this time making an assessment of the credibility of his statements. (b) If not related directly to service, the examiner should state whether it is at least as likely as not that any psychiatric disorder was caused or is aggravated by service-connected disabilities of bilateral hearing loss and/or tinnitus. (c) The rationale for any opinions expressed must be set forth. If the examiner cannot provide an above opinion without resorting to speculation, he/she should explain why an opinion cannot be provided (e.g. lack of sufficient information/evidence, the limits of medical knowledge, etc.) S. C. Krembs Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Fagan 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.