Citation Nr: 22016445 Decision Date: 03/22/22 Archive Date: 03/22/22 DOCKET NO. 16-48 815 DATE: March 22, 2022 REMANDED Entitlement to service connection for bipolar disorder is remanded. Entitlement to service connection for adjustment disorder is remanded. Entitlement to service connection for polysubstance dependence in full remission is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran had honorable service from July 13, 1971 to January 13, 1972, and served on active duty under honorable conditions from January 27, 1972 to February 13, 1973. This matter is on appeal from a May 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In October 2021, a hearing was held before the undersigned. A copy of the hearing transcript has been uploaded to the Board's Veteran's Appeals Co-Locator System (VACOLS). 1. Entitlement to service connection for bipolar disorder is remanded. 2. Entitlement to service connection for adjustment disorder is remanded. 3. Entitlement to service connection for polysubstance dependence in full remission is remanded. The Veteran underwent a VA examination in April 2013 where he was diagnosed with adjustment disorder and polysubstance dependence in full remission. The examiner opined that the Veteran's claimed conditions were less likely than not incurred in and/or caused by the Veteran's claimed in-service injury, event or illness. While the examiner noted that the Veteran reported that he had some difficulty with adjustment to the military that resulted in some anxiety and also noted that the Veteran was not found to be psychotic or neurotic; it's unclear whether the examiner consider the service treatment records in May 1972 noting that the Veteran was experiencing adjustment reaction with minimal element of depression as well as symptoms of increased nervous tension, feelings of losing control, increased anxiety, and increased restlessness. At that time, he also denied the use of drugs. Thus, an addendum opinion is warranted that considers the symptoms noted in service treatment records. The Board is cognizant that the April 2013 VA examiner declined to offer a diagnosis of bipolar disorder. However, the Veteran has indicated that he recently talked with behavioral health at the Wilmington VAMC. See January 2022 statement. Thus, on remand, outstanding VA treatment records should be obtained and associated with the record. 4. Entitlement to a TDIU is remanded. A decision on the claims for service connection could significantly impact a decision on the issue of entitelemnt to a TDIU, and therefore, the issues are inextricably intertwined. Thus, remand of the claim for a TDIU is required. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all outstanding VA treatment records from September 2016 to the present, to include from the Wilmington VAMC, Bay Pines VAMC, and any associated outpatient clinics. 2. Then, schedule the Veteran for another VA examination with a qualified mental health professional. The examiner should review the claims file (including this remand), note such review in the report, and perform any examination and/or testing of the Veteran deemed necessary. Then, the examiner should answer the following questions: a. Identify any current mental health disorders present, including but not limited to bipolar disorder, alcohol abuse disorder, and/or polysubstance dependence. b. Is it at least as likely as not (probability of at least 50 percent) that any of the Veteran's current psychiatric diagnoses were incurred during or are a result of or otherwise related to his active service to include an in-service event, stressor or injury? The examiner must consider the Veteran's service treatment records reflecting symptoms of anxiety, depression, nervous tension, losing control, restlessness. See May 1972 service treatment record. Please consider this question separately as to each current psychiatric diagnosis. A rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall explain whether additional information is needed or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). Cynthia M. Bruce Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Williams, 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.