Citation Nr: 21031191 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 16-34 878 DATE: May 20, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include depression, anxiety, and mood disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from June 1977 to July 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Board previously remanded this issue in October 2018. Unfortunately, another remand is needed to obtain an addendum opinion that considers all the relevant evidence and to attempt to obtain relevant private treatment records. Entitlement to service connection for an acquired psychiatric disorder, to include depression, anxiety, and mood disorder Service treatment records show one encounter for mental health evaluation in May 1978 with a diagnosis of immature personality. The Veteran continued service until receiving an administrative discharge for shortcomings in military performance. A July 1981 discharge physical examination was silent for any psychiatric abnormalities, and the Veteran denied an nervous trouble or depression. He also denied that his discharge was for physical or mental reasons. The October 2018 Board remand directed, in part, that the RO schedule the Veteran for a VA examination. The September 2019 VA examiner diagnosed the Veteran with unspecified personality disorder. The examiner indicated there were no records to review or substantiate the Veteran's claim that he was treated at the Lyons VA in 1981 for alcohol dependence and hospitalized at Hunterdon Medical Center for three days in 1981. Additionally, treatment notes from 2007 mention two hospitalizations, one in 2006 at Hunterdon Medical Center after he had a plan to drink brake fluid to commit suicide and over 20 years ago at the same hospital. These notes also refer to the Veteran attending a substance abuse treatment program at East Orange VA in 1981 upon separating from the military. Lay statements need not be corroborated by contemporaneous medical records to have probative value and may, on their own, support a claim for benefits. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Veteran's statements regarding this treatment and hospitalizations have been consistent throughout the record. VA New Jersey Health Care System-Lyons indicated in an October 2020 letter that it was unable to locate medical records from July 8, 1981 through December 26, 2007. However, particularly considering the age of the records from 1981, the fact that the records were not found does not eliminate the possibility that the hospital treatment for substance abuse had occurred. The examiner mentioned that the Veteran's treating psychiatrist diagnosed the Veteran with an adjustment disorder. Treatment notes from July 2019 reflect the Veteran was assessed with adjustment disorder with mixed anxiety and depressed mood and alcohol use disorder in remission. However, this diagnosis was not addressed in the diagnosis section of the report. It is unclear whether the examiner believes the Veteran has never had an adjustment disorder, and if so, how she has come to that conclusion. Additionally, further rationale regarding the examiner's assessment that the Veteran's past diagnosis of bipolar disorder is in error is needed. The examiner noted that the symptoms that were used to "make the case for bipolar disorder are more reflective of the Veteran's personality disorder (impulsivity, irresponsibility, grandiosity)." However, it is unclear how the examiner determined which symptoms were used to make an initial assessment of bipolar disorder in 2006 because those records are not included in the file. The 2007 treatment notes discuss impulsivity, but it is unclear what the examiner is citing when she mentions irresponsibility and grandiosity. Additionally, subsequent treatment records indicate the Veteran was prescribed medication for anxiety, depression, mood stabilization, paranoid ideation, and insomnia. Also, the Veteran's statements provide additional context that does not appear to have been considered by the examiner. For example, while the examiner indicated that the Veteran did not endorse any mental health symptoms on his report of medical history upon discharge, the Veteran's July 2016 Form 9 provides additional detail regarding the circumstances. The Veteran explained that he did not seek additional treatment while in service because, at the time, he perceived that he was in an oppressive situation having been demoted and that he was depressed about the situation and felt he did not have support from his superiors to even seek medical assistance for his state of mind or admit that his anger and depression were because of a mental health issue. He did not want to give his superiors and fellow shipmates any ammunition to label him as a "shirker" or "nutcase" in need of mental health treatment. He tried to continue and stay under their radar. He goes on to explain that just because he refused to accept that he had a problem did not mean that he did not have a problem and that problem continued after discharge. This explanation may pertain to seeking treatment while serving aboard ships but has less probative weight as applicable to a discharge physical examination. It has impaired his ability to work and to work with others and he is now homeless. However, he is now getting treatment for his mental health condition. Moreover, even if the Veteran has a diagnosis of a personality disorder, an addendum opinion is warranted to answer the question of whether any diagnosed psychiatric disorder was superimposed on the Veteran's preexisting personality disorder. Furthermore, the record reflects the Veteran was hospitalized at Hunterdon Medical Center in 2006 and in the 1980s for suicide attempts. While the Veteran filed a fully developed claim, considering this issue must be remanded for an addendum opinion, further development of these relevant private records is warranted. The matter is REMANDED for the following actions: 1. Obtain any outstanding VA treatment records and associate those documents with the Veteran's claims file. 2. Ask the Veteran to complete a VA Form 21-4142 for Hunterdon Medical Center and any other private provider of mental health treatment. Make two requests for the authorized records unless it is clear after the first request that a second request would be futile. 3. Once the above development has been completed, obtain an addendum opinion from a qualified clinician. Whether another examination is needed is left to the discretion of the clinician. The Veteran's claims file must be reviewed by the clinician. The clinician must identify all psychiatric disabilities diagnosed during the period on appeal. The examiner must consider the service treatment records and discharge physical examination and history questionnaire and the diagnoses of bipolar disorder, bipolar spectrum illness, and adjustment disorder with mixed anxiety and depressed mood that are referenced in the Veteran's post-service treatment records. If the clinician finds the Veteran did not have these diagnoses during the period on appeal, she should explain how she has reached this conclusion. The Board notes the September 2019 VA examiner's assessment that the Veteran's past diagnosis of bipolar disorder is in error, does not include sufficient rationale. The examiner noted that the symptoms that were used to "make the case for bipolar disorder are more reflective of the Veteran's personality disorder (impulsivity, irresponsibility, grandiosity)." However, it is unclear how the examiner determined which symptoms were used to make an initial assessment of bipolar disorder in 2006 because those records are not included in the file. The 2007 treatment notes discuss impulsivity, but it is unclear what the September 2019 examiner is referring to when she mentions irresponsibility and grandiosity. Additionally, subsequent treatment records indicate the Veteran was prescribed medication for anxiety, depression, mood stabilization, paranoid ideation, and insomnia. These symptoms should be addressed by the clinician. The clinician should review all relevant records and clearly identify records relied upon to render her opinions. The examiner must also consider the Veteran's statements, including his June 2019 statement in support of claim and timeline of events (labeled as military personnel record); November 2018 statement in support of claim; July 2016 Form 9; May 2016 statement in support of claim; April 2016 notice of disagreement; and August 2015 statement in support of claim. For any diagnosed acquired psychiatric disability the clinician should provide an opinion as to whether the Veteran's psychiatric disability is at least as likely as not onset in or caused by any in-service disease, event, or injury, including the depression he experienced in service, which was caused by demotion and what he perceived as unfair treatment by his superiors. If the examiner finds the Veteran has a personality disorder, she should address whether it is at least as likely as not (50 percent probability or greater) that the Veteran's personality disorder was subject to any diagnosed superimposed psychiatric disorder resulting in additional disability. The examiner should cite to the medical and competent lay evidence of record and explain the rationale for all opinions given. If after consideration of all pertinent factors it remains that the opinion sought cannot be given without resort to speculation, it should be so stated and the provider must (to comply with governing legal guidelines) explain why the opinion sought cannot be offered without resort to speculation. 4. After the above development has been completed, review the file, and ensure that all development sought in this remand is completed. Undertake any additional development indicated by the results of the development requested above, and re-adjudicate the claim. If the issue remains denied, issue an appropriate supplemental statement of the case and afford the Veteran and his representative the opportunity to respond. The case should then be returned to the Board, if in order, for further review. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Vemulapalli, 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.