Citation Nr: 21029115 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 16-06 000 DATE: May 12, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from February 1970 to March 1972. Unfortunately, the Veteran died during the pendency of this appeal in April 2016. The appellant is the Veteran's surviving daughter, who has been properly substituted as the claimant. This matter is before the Board of Veterans' Appeals (Board) on appeal from a June 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In her January 2016 substantive appeal (VA Form 9), the Veteran checked the box that she did not want an optional Board hearing. However, in an April 2016 letter, which was submitted prior to the Veteran's death, the appellant requested a hearing before a member of the Board on her mother's behalf. The appellant was sent a hearing clarification letter in March 2021. However, as she did not respond to the letter within the allotted timeframe, the option for a hearing is considered to have been waived. 38 C.F.R. § 20.704. Although further delay is regrettable, the Board finds that additional development of the appellant's claim is necessary prior to appellate review. Entitlement to service connection for an acquired psychiatric disorder is remanded. As an initial matter, the Board notes that the Veteran filed an original service connection claim for posttraumatic stress disorder (PTSD), which she contended was incurred in or caused by military service. While the medical evidence does not show that the Veteran was diagnosed with PTSD at any time, at the time of her death, the Veteran had diagnoses of schizoaffective disorder, mood disorder, and anxiety disorder. Accordingly, the Board has expanded the scope of the claim to include all psychiatric diagnoses of record pursuant to Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (holding the scope of a psychiatric disability claim includes any mental disorder that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and other information of record). In a March 2014 statement, the Veteran alleged that she became paranoid and started hearing voices during Boot Camp after suffering verbal abuse and other aggressive behaviors by her drill instructor. The Veteran stated that she started having hallucinations shortly after discharge from service. In March 2014 buddy statements, the Veteran's two brothers described witnessing significant changes to her behavior after she returned home from service, including paranoia, strange behavior, and confusion. One brother, A.P., stated that his mother asked him to take the Veteran to the doctor due to her concerning behavior; at that time, she was prescribed sleeping pills and medication for "nerves." The Veteran's service treatment records are negative for complaint, treatment, or diagnosis of any mental health problems during service. However, according to a June 1983 letter from the Veteran's psychotherapist, her hallucinations "are long-standing, beginning in 1972. They [did] not interfere with daily activities until 1978, following a closed head injury in an auto accident. After the accident, the hallucinations were overwhelmingly fearful and long-lasting." In October 1983, the Veteran underwent a psychiatric evaluation at VA and was diagnosed with schizophrenia. She reported at the evaluation that she was "real nervous" while in service, but did not begin seeing a psychiatrist until 1973. The Veteran began receiving her medical treatment from VA in September 2013. According to a September 2013 VA psychiatry note, the Veteran reported that she began hearing voices during service that would say belittling and disparaging things to her. A March 2014 VA psychiatry note documents diagnoses of schizoaffective disorder, mood disorder, and anxiety disorder. The Board notes that a VA medical opinion has not yet been obtained in this appeal. In light of evidence that the Veteran's acquired psychiatric disorder may have first manifested during or within one year of service, the Board finds that remand is warranted to obtain a VA medical opinion addressing the nature and etiology of the Veteran's acquired psychiatric disorder. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the matter is REMANDED for the following action: Obtain a retrospective VA medical opinion from an appropriate VA mental health professional that addresses all psychiatric disorders diagnosed during the pendency of the appeal, including schizoaffective disorder, mood disorder, and anxiety disorder. The examiner must review the claims file in its entirety, to include a copy of this REMAND, and that review must be noted in the report. Thereafter, the examiner is asked to provide a fully-articulated medical opinion addressing the following: (a) Is it at least as likely as not (a 50 percent or higher probability) that any acquired psychiatric disorder had its onset during active duty service or was otherwise etiologically related to such service? (b) The examiner should also indicate whether it is at least as likely as not (a 50 percent or higher probability) that the Veteran manifested a psychosis within one year of her discharge from active duty in March 1972 and, if so, 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 and address the pertinent medical and lay evidence of record, to include, but not limited to: (i) the Veteran's statements that she began hearing voices during service after suffering verbal abuse by her drill instructor; (ii) buddy statements by the Veteran's brothers, who assert that they noticed significant behavioral changes in the Veteran when she returned home from service; and (iii) a June 1983 letter from the Veteran's psychotherapist, R.B., stating that the Veteran's hallucinations "are long-standing, beginning in 1972." The examiner is reminded that a lack of documented treatment or diagnosis for a psychiatric disability or symptoms during service, while probative, cannot serve as the sole basis for a negative finding. The Veteran's lay contentions of record regarding onset of her psychiatric symptoms 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 expressed, citing to the examiner's clinical experience, medical expertise, and established medical principles, as necessary. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Melissa Barbee, Associate 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.