Citation Nr: 21041970 Decision Date: 07/10/21 Archive Date: 07/10/21 DOCKET NO. 14-24 402A DATE: July 10, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include adjustment disorder and major depressive disorder, is remanded. REASONS FOR REMAND The Veteran served honorably on active duty from March 1987 to December 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2013 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran testified before the undersigned Veterans Law Judge at a videoconference hearing in July 2019. A transcript of this hearing has been associated with the claims file. As an initial matter, the Board notes that the RO's January 2013 rating decision initially did not contain the issue of entitlement to service connection for major depressive disorder. However, according to the record, including the May 2014 statement of the case (SOC), the issue was clearly adjudicated by the RO and denied in January 2013, leading to the present appeal to the Board. To remedy the error, a rating decision was re-issued by the RO to the Veteran in June 2021. The Board has recharacterized the Veteran's claim for service connection for a mental health condition as reflected above, in light of the evidence contained within the record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). Entitlement to service connection for an acquired psychiatric disorder, to include adjustment disorder and major depressive disorder, is remanded. The Veteran contends that her current psychiatric disorders began during service and have persisted ever since. Specifically, the Veteran asserts that following traumatic events she experienced during her active military service, she began to suffer from depression and display other psychiatric symptoms, which have continued to the present day. See e.g., September 24, 2013 VA 21-4138 (statement in support of claim); July 17, 2019 Board hearing transcript. The Veteran underwent a VA examination for mental disorders in November 2012. The VA examiner opined that the Veteran's claimed condition was less likely than not incurred in or caused by the claimed in-service injury, events, or illness. The November 2012 VA examiner reasoned that the "November 1987 psychiatric report found no evidence of an Axis I condition and instead diagnosed [the Veteran] with severe personality disorder. Typical onset of a personality disorder is during childhood and the course is lifelong; therefore, not related to military service. It is also typical that a personality disorder will decrease in intensity with age and can exacerbate other mental conditions during times of stress. Currently, the Veteran is diagnosed with major depressive disorder by her treating providers and symptoms reported today are consistent with that diagnosis. Veteran also reported that she has been depressed all her life. Therefore, in consideration of her previously diagnosed personality disorder, report of experience of lifelong mental health symptoms, and a significant abuse history, the Veteran's mental health condition is determined to not be related to or exacerbated by military service." The Board finds the November 2012 VA opinion to be inadequate for adjudicative purposes. In concluding the Veteran's current acquired psychiatric disorder was not related to her active duty military service, the VA examiner did not consider the Veteran's diagnoses of adjustment disorder as well as depression during her active military service. See November 20, 1987 sick call note. The VA examiner did not adequately address the in-service evidence of symptom manifestation contained within the Veteran's service treatment records. See e.g., November 20, 1987 sick call note; November 25, 1987 discharge note; December 1987 separation examination, report of medical history (where the Veteran reported she experienced depression and excessive worry). Additionally, the November 2012 opinion did not indicate consideration of the Veteran's lay reports of symptoms and experiences. The record reflects and the Veteran has consistently reported that she has experienced her symptoms since, at least, her 1987 active duty. An examiner must consider whether the Veteran's reported symptoms were early manifestations of the claimed psychiatric disability, to include her adjustment disorder and major depressive disorder, rather than the personality disorder. A Veteran is competent to report observable symptoms of the disability; however, she lacks the medical training, education, and expertise to link her symptoms to a medical diagnosis. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board finds no cause for the examiner's failure to give full consideration to her contentions and experiences in formulating an opinion. Further, from review of the record, the Board finds that there may be outstanding private treatment records relevant to the matter on appeal. There are references within the record to the Veteran's private, outpatient treatment provider who was treating the Veteran for her psychiatric symptoms. Upon remand, the Agency of Original Jurisdiction (AOJ) should attempt to obtain any and all private treatment records. The matters are REMANDED for the following action: 1. After securing any necessary authorization, obtain any outstanding treatment records that the Veteran may identify as relevant to this claim, including any available treatment records from Dr. Ram. See VBMS, document labeled VA 21-0820 Report of General Information, receipt date 01/24/2013, page 1 of 1. 2. Then, obtain an addendum VA medical opinion regarding the Veteran's acquired psychiatric disorders, to include adjustment disorder and major depressive disorder. The claims file should be made available to and reviewed by the VA examiner. The examiner is directed with special attention to the Veteran's STRs, including: STR Medical, receipt date 09/28/2012, pages 44-45, 51-57, and 59 of 100. Additionally, the examiner is directed to the Veteran's lay contentions regarding her mental health symptoms during and following service. See VBMS, document labeled Hearing Transcript, receipt date 07/17/2019. Following a review of the claims file, the examiner is asked to opine whether it is at least as likely as not (a 50 percent or greater probability) that the acquired psychiatric disorders, to include adjustment disorder and major depressive disorder, (a) had onset in service; or (b) are otherwise related to an in-service injury, event, or disease, to include the Veteran's in-service treatment for suicidal ideation and depression. The examiner is asked to provide the underlying reasons for all opinions expressed, and is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. M. Lowman, 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.