Citation Nr: 21015711 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 16-21 624 DATE: March 18, 2021 REMANDED The issue of an increased rating for a skin disorder is remanded. The issue of service connection for an acquired psychiatric disorder, including a major depressive disorder, is remanded. REASONS FOR REMAND The Veteran had active service from July 1977 to August 1980. In June 2019, the Veteran was afforded a videoconference hearing before the undersigned Veterans Law Judge. The undersigned noted the issues on appeal and engaged in a colloquy with the Veteran toward substantiation of the claims. See Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). A copy of the hearing transcript is in the claims file. In October 2019, the Board of Veterans’ Appeals (Board) denied service connection for posttraumatic stress disorder (PTSD) and remanded the issues of service connection for an acquired psychiatric disorder and an increased rating for a skin disorder. The Board directed the VA Regional Office (RO) to conduct additional medical development for both issues. As explained below, an additional remand is necessary to comply with the Board’s October 2019 remand directives and to fully and fairly decide the claims. Stegall v. West, 11 Vet. App. 268 (1998). REASONS FOR REMAND 1. The issue of an increased rating for a skin disorder is remanded. 2. The issue of service connection for an acquired psychiatric disorder, including a major depressive disorder, is remanded. The matters are REMANDED for the following actions: 1. BACKGROUND FOR THE RO ADJUDICATOR: The Board has identified pre-decisional duty to assist errors and will remand the matters to the RO. The October 2019 Board remand directed the RO to contact one of the Veteran’s psychologists (“S.K.R.”) and determine whether she expressed an opinion that the Veteran had a depressive disorder related to service. After doing so, the RO was directed to conduct any further medical or mental health examinations and studies. The RO obtained an addendum medical opinion in January 2020. The author stated that “S.K.C.” was unavailable through the compensation and pension (C&P) system. While S.K. C _ _ is a VA psychiatrist who also treated the Veteran, the record does not indicate that the RO attempted to contact S.K. R_ _ _ _ s, the psychologist referenced by the Board remand. The January 2020 VA examiner concluded the Veteran’s depressive disorder was related to many factors and psychosocial stressors, including a history of length incarceration, family stressors, substance abuse, and health stressors. The examiner did not address the Veteran’s psychiatric treatment during active service and whether his in-service symptoms are related to his current diagnoses. The October 2019 remand also directed the RO to obtain a VA medical opinion as to the severity of the Veteran’s skin disorder during flare-ups. The Veteran was afforded a VA skin disorders examination in December 2019. The examination report contains an opinion on “direct service connection,” however this opinion was not requested. The report did not address the severity of the Veteran’s skin disorder during flare-ups, as directed in the October 2019 remand. For the reasons above, remand is necessary to obtain more thorough medical examinations and to comply with the Board’s October 2019 remand directives. 2. REMAND DIRECTIVES: Attempt to contact S.K.R _ _ _ _ s, PhD and ascertain if she expressed an opinion that the Veteran has a depressive disorder, APART FROM PTSD, related to military service. If she has expressed such an opinion, obtain it and if necessary, request that she provide it in writing. If she has not expressed such an opinion, please report that fact. All attempts to contact S.K.R. should be documented. If the RO is unable to contact S.K.R., or finds that further attempts would be futile, annotate the record. a. ACQUIRED PSYCHIATRIC DISORDER: Request an addendum opinion from the January 2020 examiner to clarify her opinion and respond to the inquiries below. If the examiner is not available, arrange for another VA psychologist to provide an addendum medical opinion to assist in determining the relationship between the Veteran’s current psychiatric diagnoses (OTHER THAN PTSD) and his active service. The examiner may conduct any further clinical examination if the evidence is not sufficient to fully respond to the inquiries. All clinical findings should be reported in detail in the narrative portion of the examination report. A rationale should be given for all opinions and conclusions rendered. Based upon a review of the relevant evidence of record, history provided by the Veteran, and sound medical principles, the examiner should provide the following opinions: (1) State whether the Veteran’s current psychiatric disorders (OTHER THAN PTSD), including a major depressive disorder, had their onset during service or are otherwise related to service; (2) State whether the Veteran has a personality disorder, and if so, state whether the personality disorder was aggravated (permanently worsened) by his military service; (3) State whether the Veteran’s current psychiatric disorders (OTHER THAN PTSD) were caused or aggravated by any of his service-connected disorders. In addition to reviewing the entire record and any additional records generated by this remand, the examiner is requested to review the following: *January 1978 service treatment record (STR) where the Veteran reported a history of depression, difficulty sleeping, decreased appetite, and suicidal ideation while intoxicated. He reported stressors including his grandfather’s recent death, breaking up with his girlfriend, and an upcoming extended cruise. The attending clinician indicated there was no evidence of a thought disorder, paranoia or clinical depression. The clinician diagnosed the Veteran with a “situational reaction of adult life (grief reaction).” He opined that no medication was needed, and recommended that the Veteran take leave, seek counseling, and avoid alcohol use. See “STR – Medical,” received February 24, 2014, at pages 45-6. *June 1980 in-service psychiatric examination where the Veteran reported frustration, anger, depression and lack of motivation. The Veteran admitted jumping from a vessel in May 1980 due to feelings of depression and helplessness. He also reported drinking alcohol regularly and self-destructive ideations specifically during periods of anger about his situation. The examiner found no evidence of significant depression, anxiety, or organic brain syndrome. The examiner indicated an impression of “situational adjustment reaction (job-related)” and “passive-aggressive personality.” He indicated the Veteran presented no evidence of any psychotic or thought process disorder, and that no medication or psychiatric treatment was warranted at that time. The examiner concluded that the Veteran’s attitude, motivation and interest for military service was poor, and recommended administrative separation due to a diagnosed personality disorder. See “STR – Medical,” received February 24, 2014, at pages 51-3. *August 2011 private medical opinion by M. H. B., PsyD indicating diagnoses of depression, PTSD and a personality disorder. The Veteran reported experiencing psychological trauma during service that lead to heavy polysubstance use beginning in 1977. He reported engaging in drug and alcohol use from age 15 to 31 and that he had been clean since 1988. The Veteran also reported a history of trauma related to his thirteen-year incarceration for murder. He further indicated he had a family history of mental health issues. The examiner indicated the Veteran was diagnosed with a personality disorder in early adulthood and that her examination of the Veteran indicated the presence of an antisocial personality disorder. She further noted it was possible that the Veteran’s antisocial traits lead him to malinger in his complaints of depression and PTSD as he may receive a significant financial gain in doing so. See “Medical Treatment Record – Non-Government Facility,” received July 29, 2011. *September 2011 statement by the Veteran that he first experienced “PTSD symptoms” during service aboard the USS Midway. See “VA 21-4138 Statement in Support of Claim” received March 22, 2013. *May 2013 statement by the Veteran that he experienced nervousness, irregular sleep habits, cold sweats, anger, nightmares, and hypervigilance during service. See “VA 21-4138 Statement in Support of Claim” received May 24, 2013. *December 2016 VA psychology note where Veteran reported his “uncontrollable” rage caused problems in the past, including conflict with his commanding officer during service, which resulted in his discharge. The VA psychologist indicated she reviewed other factors with the Veteran that may have contributed to his discharge from the Navy, including the Veteran’s young age, history of maltreatment, disillusionment with the Navy, and drug and alcohol use at the time. See “CAPRI” records received December 2, 2016 at page 62 of 98. *October 2019 Board decision finding that the Veteran’s reports of witnessing ship fires, a plane crash, death, and injury in 1977-1978 were not credible given that the alleged events were not documented in the ship logs, and instead, the ship logs indicated that a drill simulating a plane crash took place during that time frame. See “BVA Decision,” received October 17, 2019, at page 5 of 15. A thorough explanation must be provided for the opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, she should expressly indicate the same and explain why the opinions cannot be made without resorting to speculation. THE EXAMINER IS ADVISED THAT BY LAW, THE MERE STATEMENT THAT THE CLAIMS FOLDER WAS REVIEWED AND/OR THE EXAMINER HAS EXPERTISE IS NOT SUFFICIENT TO FIND THE EXAMINATION/ OPINION SUFFICIENT. b. SKIN DISORDER: Return the file to the VA examiner who conducted the December 2019 skin examination and request that she respond to the inquiries below. If the examiner is not available, arrange for another VA PHYSICIAN to provide an addendum medical opinion to assist in determining the current severity of the Veteran’s skin disorder, including during flare-ups. The examiner may conduct any further clinical examination if the evidence is not sufficient to fully respond to the inquiries. All clinical findings should be reported in detail in the narrative portion of the examination report. A rationale should be given for all opinions and conclusions rendered. Based upon a review of the relevant evidence of record, history provided by the Veteran, and sound medical principles, the VA examiner should provide the following opinions: (1) The examiner must provide an opinion as to the severity and symptomatology of the Veteran’s skin disability during flare-ups. Specifically, the examiner must provide an opinion as to the total body area and exposed area covered by the Veteran’s rash during a flare-up. (2) If the examination is not conducted during a flare-up, the examiner must provide an analysis of the total body area and exposed area covered by the Veteran’s rash during a flare-up based on the Veteran’s reports. IN PARTICULAR, IF THE EXAMINATION DOES NOT TAKE PLACE DURING A FLARE-UP, THE EXAMINER IS REQUESTED TO EXPRESS AN OPINION OF THE WORST-CASE SEVERITY BASED ON THE VETERAN’S DESCRIPTION OF THE SYMPTOMS AND ANY SUPPORTING CLINICAL EVIDENCE. The examiner must review the entire record in conjunction with rendering the requested opinions. IN ADDITION TO ANY RECORDS THAT ARE GENERATED BECAUSE OF THIS REMAND, the VA examiner’s attention is drawn to the following: *May 2013 VA examination where the Veteran reported flare-ups of his skin disorder during summer months, but the examiner did not evaluate the Veteran’s symptoms during flare-ups. See “Medical Treatment Record – Government Facility,” received May 15, 2013. *June 2019 hearing testimony where the Veteran testified that during flare-ups, his rash spreads to his feet, neck, face and head, and reported using Tolnaftate antifungal cream and tinea cream to manage symptoms. See “Hearing Transcript,” received June 14, 2019, at pages 2 to 4. A thorough explanation must be provided for the opinion rendered. If the examiner cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide supporting rationale as to why the opinion cannot be made without resorting to speculation. THE EXAMINER IS ADVISED THAT BY LAW, THE MERE STATEMENT THAT THE CLAIMS FOLDER WAS REVIEWED, AND/OR THE EXAMINER HAS EXPERTISE IS NOT SUFFICIENT TO FIND THE EXAMINATION/OPINION SUFFICIENT. If the benefit sought is not granted, the Veteran and his representative should be provided a Supplemental Statement of the Case (SSOC) and afforded a reasonable opportunity to respond to the SSOC before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Hiaasen 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.