Citation Nr: 18142336 Decision Date: 10/15/18 Archive Date: 10/15/18 DOCKET NO. 16-15 370A DATE: October 15, 2018 ORDER Entitlement to service connection for an acquired psychiatric disorder is denied. REMANDED Entitlement to a rating greater than 20 percent for left shoulder strain, rotator cuff tendonitis is remanded. Entitlement to a rating greater than 20 percent for right shoulder strain, rotator cuff tendonitis is remanded. FINDING OF FACT The Veteran does not have a currently diagnosed acquired psychiatric disorder. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disorder have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.102, 3.159, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1974 to September 1994. The Board has recharacterized, the claim for service connection for PTSD to include other acquired psychiatric disorders. Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that even though a veteran may only seek service connection for PTSD, the claim “cannot be limited only to that diagnosis, but must rather be considered a claim for any mental disability that may be reasonably encompassed”). The Board notes that the Veteran’s attorney attempted to withdraw representation in correspondence received at the Board after the appeal was certified. See May 16, 2017 correspondence received from attorney. As good cause for this motion, the attorney indicated that various factors made continued representation impractical or otherwise unethical. 38 C.F.R. § 20.608 (b)(2). A copy of the motion was also sent to the Veteran. Therefore, the Veteran is recognized as proceeding pro se in this appeal, on his own behalf. 1. Entitlement to service connection for an acquired psychiatric disorder Service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection. See 38 U.S.C. § 1110; Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). “In the absence of proof of a present disability there can be no valid claim.” See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In April 2014, the Veteran was afforded a VA examination. The examiner indicated that the Veteran’s symptoms do not meet the diagnostic criteria for PTSD under DSM-5 criteria. In addition, the examiner indicated that the Veteran does not have a mental disorder that conforms with DSM-5 criteria. Insomuch as the Veteran has attempted to establish a psychiatric diagnosis through his own lay assertions, the Board finds that the Veteran is not competent to diagnose that he has an acquired psychiatric disorder due to the medical complexity of the matter. See Young v. McDonald, 766 F.3d 1348, 1353 (Fed. Cir. 2014) (“PTSD is not the type of medical condition that lay evidence... is competent and sufficient to identify”); Jandreau, 492 F.3d 1372, 1377 n.4; Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009) (holding that a claimant without medical expertise cannot be expected to precisely delineate the diagnosis of his mental illness). Thus, the Veteran is not competent to render such a diagnosis. After a review of all of the evidence of record, both lay and medical, the Board finds that the weight of the competent evidence demonstrates that the Veteran does not have any diagnosed acquired psychiatric disorder. The weight of the evidence is thus against a finding that the Veteran has a current acquired psychiatric disorder. As there is no current disability, a discussion of any in-service incurrence or aggravation of a disease or injury, or nexus, is unnecessary. Entitlement to service connection for an acquired psychiatric disorder is denied. REASONS FOR REMAND 1. Entitlement to a rating greater than 20 percent for left and right shoulder strain, rotator cuff tendonitis is remanded. Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place. Barr v. Nicholson, 21 Vet. App. 303 (2007). Evaluations of joint disabilities must include a consideration of functional loss due to the factors listed under 38 C.F.R. § 4.45. DeLuca v. Brown, 8 Vet. App. 202 (1995). An examination is inadequate when the examiner declines to offer an opinion as to additional functional loss during flare ups due to a lack of direct observation of functionality under those circumstances. Sharp v. Shulkin, 29 Vet. App. 26 (2017). Instead, the examiner is required to elicit relevant information as to the Veteran’s flare ups, ask the Veteran to describe additional functional loss and then estimate the functional loss due to flare ups based on all the evidence of record. Id. at 34-35 The Veteran was provided a VA shoulder examination in May 2016. With regard to whether pain, weakness, fatigability, or incoordination significantly limit functional ability, the examiner indicated that he was unable to say without mere speculation. The examiner expressed that the physical examination was performed in a clinical environment and not in the Veteran’s typical work environment, where the Veteran reports his symptoms are exacerbated. As the May 2016 examiner declined to offer an opinion as to functional loss during flare ups due to lack of direct observation, it is inadequate. Sharp, 29 Vet. App. 26. As the May 2016 VA examination did not fully satisfy the requirements of Sharp and 38 C.F.R. § 4.59, a new examination must therefore be provided upon remand. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Thereafter, schedule the Veteran for an appropriate VA examination to determine the current level of severity of his right and left shoulder disability. The examiner should review the file and provide a complete rationale for all opinions expressed. Range of motion should be reported, including whether and the extent to which such motion is affected by pain, weakness, fatigue, lack of endurance, incoordination or other symptoms resulting in functional loss. The examiner should also test the range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. If the examination does not take place during a flare-up, the examiner should elicit relevant information as to the Veteran’s flare ups, ask the Veteran to describe additional functional loss and then estimate the functional loss due to flare ups based on all the evidence of record. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M.D., Associate Counsel