Citation Nr: 21026717 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 17-21 495 DATE: May 3, 2021 REMANDED The issue of service connection for an acquired psychiatric disorder is remanded. REASONS FOR REMAND The Veteran had active service from November 1974 to July 1989. This matter was previously denied by the RO in a June 2013 rating decision. Generally, a finally adjudicated claim can be reopened only on the submission of new and material evidence. 38 C.F.R. § 3.156 (a). However, in contrast to the general rule, if, at any time after VA issues a decision on a claim, VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim, notwithstanding paragraph (a) of the same section (which defines new and material evidence). 38 C.F.R. § 3.156 (c) (1); see also Blubaugh v. McDonald, 773 F. 3d 1310 (2014). Additional service department records were received by the RO since June 2013. Therefore, the Board will continue with this claim without determining whether new and material evidence was received. At the July 2020 Board hearing, the undersigned Veterans Law Judge (VLJ) granted the Veteran's motion to advance his case on the Board's docket. 38 C.F.R. § 20.900 (c). 38 U.S.C. § 7107 (a) (2). The Board has recharacterized the issue of entitlement to service connection for posttraumatic stress disorder (PTSD) to more broadly encompass entitlement to service connection for an acquired psychiatric disorder pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that when a claimant makes a claim, he is seeking service connection for symptoms, regardless of how those symptoms are diagnosed or labeled). The issue is remanded for further development. Entitlement to service connection for an acquired psychiatric disorder is remanded. The matter is REMANDED for the following action: 1. BACKGROUND INFORMATION FOR THE REGIONAL OFFICE (RO) ADJUDICATOR: The VA examination opinions of record are inadequate to resolve the appeal because they do not provide adequate rationales for their conclusions. A new examination with opinions that adequately respond to the specific questions below are needed. 2. Obtain any outstanding VA medical records and associate them with the claims file, to include from Sioux City, North Dakota; Amarillo, Texas; Topeka, Kansas; and any other VA medical center (VAMC) noted in the record. 3. Contact the Social Security Administration (SSA) and obtain all medical records associated with the disability determination made by that agency with disability award dating to April 2013. Associate all records with the claims file, and if no records can be found after an exhaustive search, so annotate the claims file. 4. Schedule the Veteran for an appropriate VA examination, consistent with VA rating protocols, to determine the nature and etiology of all current psychiatric diagnoses. The entire claims file, including a copy of the Remand, should be made available to, and be reviewed by, the VA examiner. All appropriate tests, studies, and consultations should be accomplished, and all clinical findings should be reported in detail. An explanation 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: a) Does the Veteran have any current psychiatric diagnoses, to include PTSD, depression, anxiety, schizophrenia, and bipolar disorder? b) Were any of the Veteran's current psychiatric diagnoses incurred in service or caused by an in-service injury, event, or illness? c) Is there clear and unmistakable evidence that the Veteran entered service with a pre-existing psychiatric condition? Please provide a fact-based rationale for this conclusion, to include addressing the significance of the Veteran's 1974 enlistment and 1977 psychiatric evaluations that showed he did not demonstrate then-current clinical psychiatric diagnoses. PLEASE NOTE THAT A STATEMENT THAT THE VETERAN WAS EXPOSED TO A TRAUMATIC EVENT PRIOR TO SERVICE IS NOT INDICATIVE OF A PRE-EXISTING PSYCHIATRIC CONDITION. d) If the Veteran entered service with a pre-existing psychiatric condition, is there clear and unmistakable evidence that his pre-existing psychiatric condition was not aggravated beyond the natural progression of the condition? Please provide a fact-based rationale for this opinion, to include addressing the significant psychiatric treatment the Veteran underwent between 1979 and his discharge in 1989 and the Veteran's subsequent statements about in-service stressors and post-service symptomatology. e) Given the medical evidence in this case, your experience and knowledge, and the state of medical science, is the Veteran's account of the onset and/or development of his current psychiatric diagnoses during service consistent with the clinical findings? Please fully explain your answer. 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: * Service treatment records (STRs) indicate the Veteran demonstrated a clinically normal psychiatric evaluation at his October 1974 enlistment medical examination. His October 1974 report of medical history at enlistment indicates he denied frequent trouble sleeping; depression or excessive worry; and nervous trouble of any sort. See "STR Medical," received April 9, 2014, pages 20-23 of 102. * The December 1974 report of medical examination indicates the Veteran demonstrated a clinically normal psychiatric evaluation. See Id. at page 16 of 102. His December 1974 report of medical history indicates he denied frequent trouble sleeping; depression or excessive worry; and nervous trouble of any sort. See Id. at page 18 of 102. * July 1977 report of medical examination for submarine duty indicates the Veteran demonstrated a clinically normal psychiatric evaluation. His July 1977 and August 1977 reports of medical history indicates he denied frequent trouble sleeping; depression or excessive worry; and nervous trouble of any sort. See "STR Medical," received April 9, 2014, pages 70-74 of 75. See also "STR Medical," received April 9, 2014, page 14 of 102. * In a separate August 1977 psychiatric evaluation for submarine duty, the examiner opined the Veteran did not demonstrate a current psychiatric illness that warranted a formal diagnosis. See "STR Medical," received April 9, 2014, page 2 of 120. * The November 1978 report of medical examination for service extension indicates the Veteran demonstrated a clinically normal psychiatric evaluation. On his November 1978 report of medical history he denied frequent trouble sleeping; depression or excessive worry; and nervous trouble of any sort. See "STR Medical," received April 9, 2014, pages 6-9 of 102. * In April 1979 the Veteran was evaluated for cyclothymic personality disorder. The Veteran reported periods of depression, moodiness, hyperactivity, confidence, and insomnia. The examiner diagnosed the Veteran with cyclothymic personality and recommended the Veteran continue seeing the examiner. The examiner also noted the Veteran's personality problem did not affect him sufficiently to require withdrawal from the Personnel Reliability Program (PRP). See "STR Medical," received April 9, 2014, pages 3-5 of 120. * The May 1980 report of medical history at reenlistment indicates the Veteran denied frequent trouble sleeping; depression or excessive worry; and nervous trouble of any sort. See "Military Personnel Record," received April 9, 2014, page 26 of 75. His May 1980 report of medical examination indicates a clinically normal psychiatric evaluation. See "STR Medical," received April 9, 2014, pages 4-5 of 102. He was recommended for reenlistment. * In December 1982 the Veteran reported feeling "down." His mental status evaluation was within normal limits. The examiner assessed the Veteran with alcohol dependence in full remission; cyclothymia by history; and rule/out personality disorder NOS. See "STR Medical," received April 9, 2014, page 9 of 120. * The February 1983 summary of the Veteran's discharge from an Alcohol Rehabilitation Service program. The Veteran was discharged to full duty after the program. See Id. at pages 11-12 of 120. * The June 1984 report of medical examination indicates the Veteran demonstrated a clinically normal psychiatric evaluation. The Veteran qualified for reenlistment. "STR Medical," received April 9, 2014, pages 2-3 of 102. * In December 1985 the Veteran complained of depression and requested to see a psychiatrist. He was assessed with depression and referred for a psychiatrist consult. See Id. at page 13-14. * January 1986 STRs indicate the Veteran requested a psychiatric evaluation due to feelings of depression. The examiner noted the Veteran's 1979 diagnosis of cyclothymia and assessed the Veteran with an additional diagnosis of alcoholism in remission. He was prescribed lithium. See "STR Medical," received April 9, 2014, page 7 of 120. * His April 1987 report of medical examination at reenlistment indicates a clinically normal psychiatric evaluation. The examiner remarked the Veteran was seeing a psychiatrist for cyclothymic disorder; was prescribed lithium; and that he was fit for duty. See Id. at page 27 of 120. * In December 1987 the Veteran was seen for stress and anxiety. The examiner assessed him with alcohol dependence, in full remission; cyclothymia by history; and rule/out personality disorder NOS. See Id. at pages 17-18 of 120. * In January 1988 the Veteran reported feeling "more stable" with his reentry into an Alcohol Anonymous (AA) program on his own. His mental status evaluation was within normal limits. He was assessed with cyclothymia disorder not of a severity to disqualify him from full duty; and alcohol dependence in full remission. The examiner noted that it was possible the Veteran could develop a more severe manic, depressive, or bipolar disorder. Id. at page 10 of 120. * Later in January 1988 the examiner noted the Veteran demonstrated "mild" cyclothymia. See Id. at page 31 of 120. * The February 1988 report of medical history indicates the Veteran endorsed depression or excessive worry but denied frequent trouble sleeping; loss of memory or amnesia; nervous trouble of any sort. See Id. at page 25 of 120. * September 1988 STRs indicate the Veteran was hospitalized for 7 days. The discharge summary noted final diagnoses of: dysthymic disorder; alcoholism in relapse; mixed personality disorder with avoidant, passive-aggressive and inadequate features. He was found unfit for shipbound duty and returned to his home port of Yokosuka via med-evac for further evaluation, treatment and followup. See Id. at pages 33-37 of 120. * The September 1988 Medical Board Report. Documents contradict whether the Veteran's primary diagnosis of dysthymic was noted as DNEPTE (did not exist prior to entry) or as EPTE. The Medical Board agreed with the primary diagnosis and the secondary diagnosis of alcohol abuse; assigned the Veteran to 6 months limited duty onshore; and noted the Veteran had suffered from a disorder which had improved with treatment such that the Veteran was psychiatrically fit for return to limited duty. See Id. at pages 51-55 of 120. * December 1988 STRs indicate the Veteran relapsed and used alcohol to treat his pain symptoms from his recent surgery. See Id. at pages 41-46 of 120. * February 1989 narrative summary of the Veteran's hospitalization for alcohol dependence treatment. See "Personnel Record," received April 9, 2014, pages 70-73 of 148. * The February 1989 Medical Board Report. The Medical Board agreed with the diagnoses of mixed personality disorder (EPTE) and alcohol abuse (DNEPTE); that the Veteran did not suffer from a current mental disease; and that he be considered for administrative separation because his "long standing disorder of behavior and character" rendered him unsuitable for further Naval service. See "Military Personnel Record," received April 9, 2014, pages 59-62 of 75. * In April 1989 the Veteran was assessed with mixed personality disorder with borderline and avoidance features. The examiner's notes indicate although the Veteran did not demonstrate a mental disease he had a long-standing disorder of behavior and character that rendered him "unsuitable" for further military service, retention, or promotion. The examiner further stated that if the Veteran was retained in the military it was likely he would continue his self-defeating behavior. He recommended that the Veteran be separated due to a personality disorder. See "STR Medical," received April 9, 2014, page 49 of 120. * In July 1998 the Veteran reported being depressed "for a long time" and requested a mental health referral. The triage nurse noted the Veteran demonstrated active depressive symptoms. See "Medical Treatment Record Government Facility," received March 24, 2008, page 1 of 8. * June 2003 VA treatment records that show the Veteran requested a referral to resume treatment at his local VA Mental Health Center for a clinical assessment that he was "normal." The Veteran stated that he recently discovered through trial and error that most of his psychological symptoms were due to allergies. See "CAPRI," received April 27, 2013, page 586 of 637. * February 2007 VA treatment records that show the Veteran reported a current diagnosis of bipolar disorder and requested a doctor's note that he was fit to return to work as a truck driver. The examiner noted the Veteran refused to treat his disorder with medication, preferring to self-treat with diet changes and supplements. Psychological testing revealed anxiety within normal limits and minimal depression. The examiner also noted the Veteran's responses did not indicate PTSD and that no further testing for PTSD was recommended. See "Medical Treatment Record - Government Facility," received February 27, 2008, pages 20-36 of 39. * May 2010 VA mental health treatment note that indicates the Veteran stated he did not "want to blame his parents for anything that has happened to him." See "CAPRI," received April 27, 2013, page 410 of 637. * The Veteran's May 2011 statement about his in-service psychiatric stressors. See "Correspondence," received May 23, 2011, 21 pages. * The Veteran's September 2011 statement about his pre-service, service, and post-service psychiatric stressors. See "Correspondence," received September 26, 2011. * In December 2011 the Veteran was hospitalized for suicidal ideation. An examiner diagnosed the Veteran with worsening depression. See "CAPRI," received April 27, 2013, page 207 of 637. * January 2012 initial mental health assessment at the Amarillo VAMC where the Veteran reported several in-service stressors. The social worker diagnosed the Veteran with chronic PTSD; bipolar disorder not otherwise specified (NOS); depressive disorder NOS; agoraphobia; neurosis; obsessive compulsive disorder; and schizotypal personality disorder. See "CAPRI," received April 27, 2013, pages 200-207 of 637. * April 2012 VA medical examination for mental disorders and corresponding opinion. The examiner opined the Veteran's depression was at least as likely as not related to or the result of the Veteran's diabetes. The examiner did not discuss any of the Veteran's in-service psychiatric diagnoses or treatments. See "CAPRI," received June 4, 2012, pages 1-6 of 51. * May 2012 VA treatment records of the Veteran's 6-week in-patient PTSD treatment at Topeka, Kansas, VAMC. At his initial assessment, the Veteran reported symptoms of becoming easily emotional, such as crying spells, and having intrusive thoughts of his past. He also reported that he blamed himself for his father's burn accident that occurred when he was a child. The Veteran completed the program in June 2012. He also stated that he thought PTSD and schizophrenia were the most "fitting" diagnoses. See "CAPRI," received June 11, 2013, 176 pages. * October 2012 VA treatment records that indicate the Veteran reported realizing that his in-service stressors between 1980-1983 when he was stationed in the Philippines caused his marriage to fall apart and caused him to lose his seniority in the military. See "CAPRI," received April 27, 2013, page 98 of 637. * November 2012 VA medical examination for PTSD. The examiner diagnosed the Veteran with PTSD, and noted the Veteran scored in the "severe range" for depressive and anxiety symptoms. The examiner noted the Veteran's PTSD may be due to pre-service incidents of seeing his father get burned and witnessing the skin being burned, and also witnessing a person's injury after a motor vehicle accident. See "VA Examination," received November 13, 2012. * In a March 2013 addendum opinion, a different VA examiner opined the Veteran's PTSD was less likely than not incurred in or caused by mental health treatment during his military service because the Veteran's current depression was a pre-existing condition that was not aggravated beyond its natural progression by his in-service mental health treatment. The examiner further noted the Veteran's symptoms appeared to be attributable to the Veteran's trauma exposure prior to service. The examiner did not address the Veteran's induction examination that did not show any psychiatric condition at entrance, nor the Veteran's in-service 1977 psychiatric examination that did not reveal a then-current psychiatric diagnosis. See "CAPRI," received April 27, 2013, page 90 of 637. * April 2013 VA treatment records indicate the Veteran's problem list included obsessive-compulsive neurosis; bipolar disorder; agoraphobia; schizotypal personality disorder; suicidal ideation; and PTSD. See "CAPRI," received April 27, 2013, page 1 of 637. VA treatment records also show examiners have noted symptoms of depression, anxiety, and psychosis. * March 2018 statement about how the Veteran learned about PTSD and how that diagnosis might help explain what he experienced during and since service. See "VA 21-4138 Statement in Support of Claim," received March 21, 2018. * June 2020 Board hearing testimony. See "Hearing Transcript," received June 29, 2020. A thorough explanation must be provided for the opinion rendered. If the examiner cannot provide the requested opinion without resorting to speculation, s/he 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. 5. Following the review and any additional development deemed necessary, readjudicate the claim. Should the claim not be granted in its entirety, issue an appropriate supplemental statement of the case (SSOC) and forward the claim to the Board for adjudication. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (West 2014). Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Anwar, Attorney-Advisor 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.