Citation Nr: 21042492 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 17-14 588 DATE: July 13, 2021 REMANDED Service connection for an acquired psychiatric disorder, to include anxiety and depression, is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1985 to April 1998. This matter comes before the Board of Veterans' Appeals (Board) from an October 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at an August 2020 Board virtual hearing before the undersigned Veterans Law Judge (VLJ). A copy of the hearing transcript is associated with the claims file. The Veteran previously filed service connection claims for histoplasmosis and arthritis. See February 2016 Fully Developed Claim. It does not appear that any development has taken place. These issues are referred to the RO for appropriate action. Service connection for an acquired psychiatric disorder, to include anxiety and depression, is remanded. The Veteran believes that service connection for an acquired psychiatric disorder, to include anxiety and depression, is warranted. See Hearing Transcript. Generally, a VA medical examination is required for a service connection claim when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service; and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service; but (4) there is insufficient competent medical evidence on file for VA to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Veteran has diagnoses of a generalized anxiety disorder and depression. See October 2016 CAPRI. As such, the Board finds that the first prong is met. The Veteran reported that during service, he was isolated from his family and home, broke his leg and could not do much besides just sitting around, found out about the death of his grandmother who had adopted him and took care of him, and as a result of these things started having mental health problems which have continued throughout the years since. Years later, a doctor told him that he had experienced a mental health episode during service. See Hearing Transcript. As such, the Board finds that the second and third prongs of the McLendon test are met. Given these facts, the Board finds that a remand is necessary to obtain a VA examination to determine the etiology of the Veteran's acquired psychiatric disorder. See McLendon, 20 Vet. App. at 83. The matter is REMANDED for the following action: 1. Provide the Veteran with an opportunity to identify any relevant outstanding private and/or VA treatment records, including private treatment records from Dr. Wherry. After obtaining any necessary authorizations from the Veteran, make all reasonable attempts to obtain the outstanding records in accordance with 38 C.F.R. § 3.159. 2. Update VA and private treatment records. VA treatment records appear current up to October 2016. 3. Contact all appropriate sources to determine whether the Veteran had any additional active duty, ACDUTRA, and/or INACDUTRA service. All efforts to obtain this information as well as any responses should be documented. If any additional periods of service exist, attempt to obtain all related service treatment and personnel records. All efforts to obtain these records should be documented, and if the records cannot be located, a formal finding of unavailability should be associated with the Veteran's claims file. The record suggests, at a minimum, that the Veteran may have had about three months of active service and about two years and four months of inactive service prior to his active service beginning in July 1985. 4. Make a list of all periods of active service, ACDUTRA, and/or INACDUTRA in terms of specific dates and associate it with the claims file. If this cannot be accomplished, provide an explanation. 5. Schedule one or more appropriate VA examinations for the Veteran's acquired psychiatric disorder. The need for an in-person examination of the Veteran is left to the discretion of the examiner. Following a review of the claims file and a copy of this Remand, the reviewing examiner is requested to furnish an opinion with respect to the following: (A) Identify all acquired psychiatric disorders existing at any point during the pendency of the appeal (i.e. since August 2016), even if they are currently asymptomatic or have resolved during the pendency of the appeal. (B) For each identified disorder, is it at least as likely as not (a 50 percent or greater probability) that the disorder is related to the Veteran's active service, active duty for training, and/or inactive duty for training, including but not limited to service in Southwest Asia? Is yes, which periods? (C) For each identified disorder, is it at least as likely as not (a 50 percent or greater probability) that the disorder is/was caused by any or all of the Veteran's service-connected disabilities (including, but not limited to, any medications taken for the service-connected disabilities)? (D) For each identified disorder, is it at least as likely as not (a 50 percent or greater probability) that the disorder is/was aggravated beyond its natural progression by any or all of the Veteran's service-connected disabilities (including, but not limited to, any medications taken for the service-connected disabilities)? State whether there is/was a medically ascertainable increase in disability regardless of permanence. Any increase in disability should be described in terms of diagnosis, severity, and duration. The permanence of the aggravation is not at issue. (E) Is it at least as likely as not (a 50 percent or greater probability) that any or all of the Veteran's service-connected disabilities (including, but not limited to, any medications taken for the service-connected disabilities) caused or aggravated the Veteran's obesity/being overweight including whether there is/was any incremental increase in disability or aggravation as a result of service? State whether there is/was a medically ascertainable increase in disability regardless of permanence. Any increase in disability should be described in terms of diagnosis, severity, and duration. The permanence of the aggravation is not at issue. (F) If yes to question (E), is it at least as likely as not (a 50 percent or greater probability) that the obesity/being overweight caused or aggravated any or all of the Veteran's acquired psychiatric disorders including whether there is/was any incremental increase in disability or aggravation as a result of service? State whether there is/was a medically ascertainable increase in disability regardless of permanence. Any increase in disability should be described in terms of diagnosis, severity, and duration. The permanence of the aggravation is not at issue. If yes, which ones? (G) Is it at least as likely as not (a 50 percent or greater probability) that any psychoses manifested to a compensable degree within one year following separation from a period of active service? (H) Is it at least as likely as not (a 50 percent or greater probability) that any psychoses was noted during service/within one year following the Veteran's separation from a period of active service, with continuity of symptomatology since? In addition to the other relevant evidence of record, the examiner is asked to consider and address as appropriate the following information with a caution that this list is not a substitute for a review of the record: (1) The Veteran's report that during service, he was isolated from his grandmother and other family. He broke his leg, was debilitated, and could not participate in his normal duties and such. He had to just sit around. Soon after, he found out that his grandmother had died. His grandmother had adopted him and was his sole guardian. She was all that he knew up to that point in his life. He went to the funeral and then returned to service. He then had a terrible dream and his sheets were soaked. He tried going back to sleep but couldn't. He had an unnerving, terrifying fear of something. From that point on, he could not understand what was going on. He worried that if he told people about what was going on (that he was losing his mind or something), that he would get thrown out of the military and become homeless. It was very unnerving. He couldn't sleep. Trying to go to sleep was insanity and madness. He could not eat. The only thing that made him feel better was going for walks outside. Alcohol use, cigarettes, etc., did not help him feel better. He still had an unrealized fear for some reason. He was in the deep, dark grasp of it. He did not understand depression at the time. He fought it without any doctor support. He always felt like depression was a flaw in his nature and that he was less intelligent and capable than others. He resisted getting treatment during service because he thought that it was a weakness that he could power through. He did confide in his best friend during service about it and his ex-wife knew he was sick. Following service, doctors were expensive, and he could not afford to see one for many years. In the early 2000s, he was started on Wellbutrin. He had not seen any doctors until that time. The doctor told him that he had depression or something similar. The doctor also told him that he had experienced an episode during service. He finally saw a doctor because he got tired of his mental health problems, including the racing thoughts that would never stop. A VA counselor told the Veteran that he suffered depression ever since 1987, even though he was afraid to go to the doctor back then. The Veteran has dealt with anxiety and sleep problems ever since service. His other service-connected disabilities may have caused or aggravated his mental health problems. See Hearing Transcript. (2) The Veteran's report that he left service disabled. A VA counselor told him that he was eligible for depression. He suffered in silence on active duty with depression and fought it by himself for years. See August 2018 Congressionals. (3) A lay statement from someone who knows the Veteran that during service, the Veteran confided in him during the Veteran's early days of excessive alcohol abuse. Alcohol was the Veteran's only recourse at the time. The Veteran told him how important it was to keep up normal appearances since weakness was not tolerated. The Veteran did not want to be labeled as crazy or weak. His recent marriage was not going well, the Veteran was unusually stressed out, and the Veteran was drinking too much. Years later in the early 1990s, the Veteran told him about his long battle with depression. See December 2016 Buddy / Lay Statement. (4) Documents showing the deaths of his grandmother and mother. Another document shows that many service members kept quiet about mental health problems for fear of hurting their careers. See December 2016 Report of Death. (5) The Veteran's report of experiencing significant emotional and physical problems during service which had a long-term impact on his mental health. He lost his mother and grandmother during service. His grandmother was his primary caregiver from his youth. He also broke his leg during service, which caused him to be isolated. These triggers led to his abrupt and permanent fall into depression. He had night sweats, sleeplessness, and terrors. He self-medicated with alcohol and by staying isolated. He only told his closest friend about it. Soldiers of his era did not come forward formally with mental health issues due to well-known DOD barriers to soldiers receiving treatment and the fear that it would hurt their careers. He didn't come forward about his mental health problems during service because he was afraid that he would lose his support system in the military and become homeless. He purposely hid the problem from medical professionals. Since around 2005, he has been prescribed Wellbutrin for depression and anxiety and has been receiving care since 2010. See December 2016 Statement in Support of Claim. (6) The Veteran's report that service records show depression. See November 2016 NOD. (7) Medical records from 2016 showing the Veteran's report that during service, he started having nightmares and started having a constant sense of dread. At the time, he was anxious, jittery, and afraid. He eventually became depressed. He did not seek help for it at the time and learned to cope eventually. In the mid-2000s, he saw a doctor who prescribed him Wellbutrin which helped his mental health problems. The Veteran felt guilt for not being able to do more to help his mother. He had two combat deployments in the first Gulf War. There was an assessment based on the DSM-5 of unspecified depressive disorder and unspecified anxiety disorder. The Veteran reported sleep disturbance related to physical pain, among other things. There was a past medical history of PTSD. The Veteran had medical problems, including depression and obesity. See August 2016 CAPRI. (8) The Veteran's report that his diagnosed depression was related to service. See August 2016 Fully Developed Claim. (9) Medical records from 2010 showing that the Veteran had anxiety, had been in the special forces, and had served in Iraq. Medical records from 2012 showed an impression of endorsed symptoms suggestive of psychophysiological insomnia. See March 2016 CAPRI. (10) Medical records from 2010 showing anxiety and an assessment of depression. The Veteran was joining VA. Medical records from 2011 showed that the Veteran had become more depressed. There was an assessment of a generalized anxiety disorder and significant medical problems, among other things. See January 2016 CAPRI. (11) Medical records from 2011 showing an assessment of axis I anxiety and axis III medical history. There was a body mass index of 30.7. See July 2015 CAPRI. (12) Service records showing an injury to the left knee/leg around March 1987. The Veteran worked with a lot of irritants in confined spaces during service. See April 2014 STR Medical. (13) Medical records from 2005 showing anxiety. See August 2007 Medical Treatment Record. (14) All other relevant lay and medical evidence. A complete rationale for all opinions offered should be provided. Address the Veteran's documented history and assertions, including but not limited to the Veteran's report of a continuity of symptomatology since service. All necessary tests and studies should be conducted. If the examiner cannot provide an opinion without resorting to mere speculation, the examiner should provide an explanation stating why. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is due to the limits of the medical community's knowledge or due to the limits of the examiner's medical knowledge. The Veteran is competent to attest to factual matters of which the Veteran has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. 6. Readjudicate the issue on appeal. MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Dougan, 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.