Citation Nr: 21032884 Decision Date: 05/28/21 Archive Date: 05/28/21 DOCKET NO. 17-33 840 DATE: May 28, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia, alcohol use disorder, stimulant use disorder, and cannabis use disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from November 1979 to April 1984. His decorations include the Good Conduct Medal. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an April 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office in Cleveland, Ohio. In January 2021, the Veteran testified at a virtual Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the record. The Veteran's claim has been recharacterized to include all psychiatric disorders reasonably raised by the record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Although the Board sincerely regrets the additional delay, a remand is necessary to ensure that there is a complete record upon which to decide the Veteran's claim and to afford him every possible consideration. Entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia, alcohol use disorder, stimulant use disorder, and cannabis use disorder, is remanded. The Veteran contends that he has an acquired psychiatric disorder that had its onset in service. During the January 2021 Board hearing, he described developing "mental changes" during service which he believes were due, in part, to harassment he experienced. The Veteran was afforded a VA examination in connection with his claim in March 2017. The examiner diagnosed schizophrenia, alcohol use disorder in early remission, cocaine use disorder in early remission, and cannabis use disorder in sustained remission. The examiner offered an unfavorable nexus opinion, finding that it was less likely than not that the Veteran's schizophrenia was caused by, incurred in, or permanently aggravated by service. In support of that opinion, the examiner noted that there was no evidence of complaints, symptoms, and/or treatment for schizophrenia or any other mental health condition in the Veteran's service treatment or military personnel records; that treatment notes of record indicated that the Veteran had described the onset of hallucinations and the diagnosis of schizophrenia as occurring in 1990, six years after discharge from the military; and that the Veteran's weight loss in service was likely due to his efforts to meet Army physical fitness standards. The examiner also noted that the Veteran had been counseled numerous times for his behavior in service, but never provided any sort of explanation or indicated any mental health difficulties that could have been influencing his behavior; that he underwent a mental status evaluation during service in March 1984, wherein it was noted that he met retention standards from a mental health perspective; and that there was evidence to suggest that he may have been struggling with problematic drug and alcohol abuse during service, which clearly and unmistakably pre-existed service and would likely account for his pattern of misconduct. The Board finds the March 2017 VA examination report inadequate for purposes of adjudication as it currently stands. First, the Veteran has been inconsistent in his reports as to whether he had problematic use of drugs and/or alcohol prior to service. See, e.g., September 1979 Report of Medical History and January 2021 hearing testimony (both indicating that he did not). As such, it does not appear to be "clear and unmistakable" that such use existed prior to service. In addition, new evidence has been received that was not available for the examiner's review. That evidence includes a May 2019 lay statement reflecting that the Veteran's "personality completely changed" after he left the military, and the Veteran's testimony to the effect that he developed "mental changes" and began hearing voices during service. Under the circumstances, an addendum medical opinion is warranted. The Board also notes that the evidence of record indicates that the Veteran has been in receipt of disability benefits from the Social Security Administration (SSA). Thus far, it does not appear that any attempt has been made to obtain a complete copy of the medical records underlying the SSA's award. Because the records from SSA could contain information pertinent to the issue on appeal, efforts should be made to procure them. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). This matter is REMANDED for the following action: 1. Ask the SSA to provide copies of any relevant records in its possession pertaining to its consideration of the Veteran's application for SSA disability benefits, to include any medical records considered in making that award, following the procedures set forth in 38 C.F.R. § 3.159. Efforts to obtain the evidence should be fully documented and should be discontinued only if it is concluded that the evidence sought does not exist or that further efforts to obtain the evidence would be futile. 38 C.F.R. § 3.159(c)(2). The evidence obtained, if any, should be associated with the record. If any of the records sought are not available, the record should be annotated to reflect that fact and the Veteran and his representative should be notified. 2. Obtain copies of records pertaining to any VA treatment the Veteran has received since the time that such records were last procured, following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained, if any, should be associated with the record. 3. After the foregoing development has been completed to the extent possible, make arrangements to provide the record on appeal to the VA examiner who previously evaluated the Veteran in March 2017. The examiner should be asked to review the expanded record and prepare a supplemental report indicating the extent to which, if any, the additional evidence impacts on his prior opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the Veteran has an acquired psychiatric disorder that had its onset during, or is otherwise related to, service. In so doing, the examiner should presume, for analytical purposes, that the Veteran did not engage in problematic use of drugs and/or alcohol prior to service. The examiner must also consider and discuss the medical significance, if any, of the Veteran's testimony that he was harassed in service; his testimony that he developed "mental changes" and began hearing voices during service; evidence of his declining performance and behavior during service, to include his arrest for driving under the influence; and the May 2019 lay statement indicating that the Veteran's "personality completely changed" after he left the military. If the March 2017 examiner is no longer employed by VA or is otherwise unable to provide the opinion requested, arrange to obtain the requested information from another qualified examiner. The need for another examination and/or telephonic or video interview of the Veteran is left to the discretion of the examiner selected to offer the requested opinion. A complete rationale for all opinions expressed must be provided. 4. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the issue on appeal should be readjudicated based on the entirety of the evidence. If the benefit sought remains denied, the Veteran should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. DAVID A. BRENNINGMEYER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Joseph T. Leonard, 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.