Citation Nr: 21041280 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 15-25 878 DATE: July 8, 2021 ORDER Service connection for a psychiatric disorder variously diagnosed as an anxiety disorder, adjustment disorder, and excoriation disorder, is granted. Service connection for a left hand/finger condition secondary to a psychiatric disorder is granted. REMANDED The issues of entitlement to service connection for respiratory and lower leg conditions are remanded. FINDINGS OF FACT The Veteran's psychiatric disorder was incurred during active service, and his left-hand finger condition is secondary to his psychiatric disorder. CONCLUSIONS OF LAW 1. The criteria for service connection for a psychiatric disorder variously diagnosed as an anxiety, adjustment, or excoriation disorder, have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.304. 2. The criteria for finger condition have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 2009 to March 2013. This matter is before the Board following his appeal of a July 2014 rating decision. In April 2019, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The Board remanded this appeal in October 2019 for additional development. Service Connection The Veteran contends that he has a current psychiatric disorder with a related "finger" condition that was incurred during service such that service connection is warranted. Following a review of the record, the Board agrees. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service if they were shown as chronic (reliably diagnosed) in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service, with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303, 3.307, 3.309. In this case, the record establishes a current psychiatric disability, as VA treatment notes show treatment for anxiety, an adjustment disorder with anxious features, generalized anxiety disorder, and excoriation disorder. See, e.g., December 2015, April 2018, and October 2018 VA treatment notes. More recently, a February 2021 VA examiner diagnosed excoriation disorder, also referred to as compulsive skin picking, and described it as a mental illness associated with anxiety or an obsessive-compulsive disorder. Next, the record supports in-service incurrence, as the Veteran has competently reported that the onset of his anxiety was during his active service, and his report is deemed credible as it is consistent with his report during his February 2013 separation examination that he had "a very hard time sleeping at night" because his mind wandered, as well as his report during April 2014 VA mental health treatment, of a 2-3 history of progressive onychophagia (nail-biting), placing the onset during service. Also consistent with the Veteran's report of an onset of psychiatric problems in service is a July 2019 written statement from the Veteran's wife attesting to changes in the Veteran's mood and behavior during service, pointing out that she had known the Veteran since age 15. Specifically, she reported an onset of irritability, moodiness, restlessness, depression, and withdrawal. Finally, the record establishes a nexus between the Veteran's currently diagnosed psychiatric disorder and service, as the Veteran has competently reported an onset of his psychiatric symptoms in service, and the record shows a continuation of those symptoms following service. For example, in October 2013, just months following separation, the Veteran reported problems sleeping, anxiety, and depression and, at that time, depression not otherwise specified was diagnosed. In March 2014, he was seen for "prominent anxiety" and an adjustment disorder with mixed anxiety and a depressed mood was assessed, along with excoriation disorder. Clinical records thereafter show active prescription medications to treat anxiety and sleep; continued periodic treatment for psychiatric symptoms including anxiety, depression, sleep impairment, and finger picking; and, assessments of adjustment disorder with anxious features, excoriation disorder, and generalized anxiety disorder. See, e.g., November 2015, April 2016, October 2016, April 2018, July 2018, and May 2019 VA treatment notes. The Board is cognizant that an examiner provided an opinion in January 2021 that the Veteran had PTSD from a head injury that preexisted service, and that the Veteran's other psychiatric issues, including anxiety, depression, and skin-picking, were secondary to PTSD. The January 2021 examiner also found that the Veteran's PTSD was unrelated to and did not first manifest in service, and that the Veteran's report of difficulty sleeping during his separation exam "may have been due to phase of life" or "could have been related to his pre-existing head injury." Similarly, the examiner noted that the Veteran's mood and anger issues in service could have been related to marital issues or a pre-service head injury. However, the Board places no probative value on that opinion for several reasons. Initially, an opinion that the Veteran's reported mood or anger problems in service, or his sleep problems reported at separation, "may have been" or "could have been" related to other issues, including a preexisting head injury, is entirely speculative and, regardless the reason, the record establishes that those symptoms began in service. The Board notes that no psychiatric history was reported during a September 2008 enlistment examination, nor was any psychiatric condition observed at that time. The Board also finds that the examiner's conclusions that the Veteran's PTSD did not manifest in service but that his anxiety, depression, and finger picking were secondary to PTSD to be irreconcilable. In this regard, the Veteran was not diagnosed with any psychiatric disorder during a September 2008 enlistment examination, nor is there any evidence to support that the Veteran ever experienced psychiatric symptoms prior to service as a result of his pre-service head injury. However, the competent and credible evidence places the onset of anxiety and a finger-picking disorder in service. Thus, it follows then that if the anxiety and finger-picking disorder first manifested in service and were secondary to PTSD, then PTSD also first manifested in service. Even further, the January 2021 examiner has offered no basis or supporting evidence for concluding that the Veteran had a pre-service traumatic brain injury and PTSD, as it is certainly possible to have a head injury without a TBI or resultant PTSD. And, in this case, while the Veteran may have had a pre-existing head injury, there is no clear and unmistakable evidence that he had a TBI or a psychiatric condition that preexisted service. Thus, in short, the Board finds that the competent and credible evidence places the onset of the Veteran's current and variously diagnosed chronic psychiatric disorder, to include excoriation disorder, in service. Accordingly, service connection for a psychiatric disorder is warranted. Additionally, VA examiners in December 2020 and February 2021 found that the Veteran's claimed left-hand fingers condition, manifested by picking of the fingers and/or biting of nails and/or a left finger sprain with a bruise, was proximately due to the psychiatric disorder (excoriation disorder). Notably, there is no medical evidence to the contrary and, as discussed in more detail above, the Veteran has also competently and credibly placed the onset of his finger-picking and nail-biting disorder in service. As such, service connection is also warranted for a left-hand condition, as either secondary to his psychiatric disorder, or as directly related to service. 38 C.F.R. §§ 3.303, 3,304, 3.310. REASONS FOR REMAND 1. The issue of entitlement to service connection for a respiratory condition is remanded. Unfortunately, the Board finds that remand of the Veteran's claim of entitlement to service connection for a respiratory condition is once again necessary for an addendum opinion. In this regard, the February 2021 opinion obtained pursuant to the Board's prior remand contains inadequate rationale for the conclusion offered. Specifically, the examiner focused entirely on an absence of evidence that the Veteran continued to cough up of blood during and after service to conclude that the Veteran's respiratory disorder was not related to service, but offered no explanation for why coughing up blood would be required to establish a nexus between the Veteran's currently-diagnosed acute bronchitis and his duties in service requiring use of a respirator; any potential asbestos exposure; or renovating, tearing down walls, and sanitizing living areas aboard a ship in drydock. Nor did the examiner provide any other rationale for why the Veteran's acute bronchitis was not related to exposures in service. As such, an addendum is necessary. Additionally, the Veteran should be provided one last opportunity to identify any sources of outstanding treatment records related to his claimed respiratory condition. In December 2020 it was noted that the Veteran had a history of asthma, he has reported recurrent bronchitis, and the February 2021 examiner noted current treatments to include an "inhaler and medications." Additionally, in April 2014 it was noted that the Veteran had intermittent chest pain and was getting tested by an outside provider. However, while the RO has made numerous requests to the Veteran that he identify sources of private treatment, the Veteran has not responded. Indeed, it also appears that he reported to the February 2021 VA examiner that he had not received treatment for his condition. On remand, one last attempt should be made to clarify whether the Veteran has received private treatment post service for respiratory problems and if so, to obtain records related to that treatment. 2. The issue of entitlement to a lower leg disability, claimed as shin splints, is remanded. The Board finds that remand of the Veteran's claim of entitlement to service connection for a claimed lower leg disability is also necessary for an addendum opinion. In this regard, pursuant to the Board's prior remand, a VA opinion was obtained in February 2021 (following a December 2020 examination) that it was less likely than not that the Veteran's claimed shin splints were incurred during service. Indeed, the examiner found that there was no objective evidence of shin splints on examination and, instead, diagnosed a bilateral knee strain. However, the examiner did not offer an opinion as to whether the Veteran's bilateral knee strain was incurred in service. The Board is cognizant that the Veteran specifically claimed service connection for "shin splints," and not for a knee or a lower leg disability, generally. Additionally, despite the Veteran's hearing testimony of being treated for shin splints following service, post-service treatment records are silent for complaints of shin splints. Those records do, however, document complaints of knee pain, including in August 2013, just six months following service. Moreover, in describing his claimed "shin splints" condition to the December 2020 examiner, the Veteran complained of knee pain. Given the Veteran's description of his "shin splints" to include knee pain, and because he was diagnosed with a bilateral knee strain by the December 2020 examiner, the Board finds that his "shin splints" claim encompasses a knee disability and a nexus opinion should be obtained. See Grimes v. McDonough, 2021 U.S. App. Vet. Claims, LEXIS 742; Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). The matters are REMANDED for the following action: 1. Request that the Veteran provide or authorize VA to obtain records of his relevant treatment that have not yet been associated with the claims file, including records related to private or Emergency Room treatment for shin splints, and any respiratory conditions. 2. Associate with the claims file updated VA treatment records. 3. Obtain an addendum from the examiner who provided the February 2021 respiratory opinion, if available, or another qualified examiner regarding the nature and etiology of any respiratory condition. If a new examination is deemed necessary, one should be scheduled. Specifically, the examiner must opine whether it is at least as likely as not that any respiratory condition found is related to an in-service injury, event, or disease, including: (1) July 2011 in-service treatment for coughing up blood (notably immediately following his renovation duties); (2) his duties requiring use of a respirator; (3) his work renovating, tearing down walls, and sanitizing living areas aboard the ship while in drydock; or, (4) any potential asbestos exposure. The examiner should provide a complete rationale for any opinion offered, to include an explanation as to why any current respiratory disorder is or is not related to occupational/environmental exposures in service. 4. Obtain an addendum from the VA examiner who provided the February 2021 shin splints opinion, if available, or from another qualified examiner, regarding the nature and etiology of any bilateral lower leg condition. If a new examination is deemed necessary, one should be scheduled. Specifically, the examiner the examiner must opine whether it is at least as likely as not that any lower leg condition, to include bilateral knee strain or shin splints, is related to an in-service injury, event, or disease, including the Veteran's duties as a barber and his report of falling from a ladder well in service. In providing the foregoing opinion, the examiner should address the Veteran's lay testimony, to include his reports of an onset of shin splints in service and continuation of shin splints post service, as well as his August 2013 report of knee problems during VA treatment just six months following separation. A complete rationale for any opinion offered should be provided. S. C. Krembs Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Fagan 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.