Citation Nr: 18142916 Decision Date: 10/17/18 Archive Date: 10/17/18 DOCKET NO. 16-30 453 DATE: October 17, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and anxiety disorder, is remanded. REASONS FOR REMAND The Veteran served in the United States Navy from January 1973 to August 1977. This issue is before the Board of Veterans’ Appeals (Board) on appeal from a January 2015 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO). As a function of the Board's de novo review authority, the Board has characterized the Veteran's claim for PTSD as a claim for an acquired psychiatric disorder, to include PTSD and an anxiety disorder. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (finding that VA has an obligation to consider whether possible mental disorders are service connected if those disorders are indicated by the evidence in the record even if a veteran's claim does not specifically identify those disorders and instead identifies a distinct but related mental disorder). Entitlement to service connection for an acquired psychiatric disorder is remanded. The Veteran asserts that he is entitled to service connection for an acquired psychiatric disorder, including anxiety and PTSD. He has submitted lay statements indicating that he has had difficulty with anxiousness, forgetfulness, and nightmares since he left the service. Specifically, the Veteran reported that his duties in service included seeing large waves and that he feared drowning as a result, seeing U.S. planes carrying missiles taking off, climbing to high points on ships, and that he was jailed for his AWOL status. In a December 2015 VA examination for PTSD, the examiner noted that the Veteran did not have any diagnosable condition based on the DSM-5, including PTSD or anxiety. However, private treatment records from February 2015 reflect an impression that the Veteran has symptoms simliar to PTSD, including depressive feelings and heightened anxiety. Additionally, April 2015 private treatment records from a second private practitioner show that the Veteran was diagnosed with PTSD and prescribed two medications for PTSD management. Finally, a statement from a third private practitioner dated March 2003 states that while the Veteran had not been diagnosed with a psychiatric disorder, the clinic prescribed medicine to the Veteran in response to his complaints of depression and anxiety. As indicated above, there are no medical opinions currently of record which adequately address, with sufficient rationale, whether the Veteran has a current diagnosis of an acquired psychiatric disability, and whether there is a relationship between any of the Veteran's current acquired psychiatric disabilities and his military service. The December 2015 VA examination only evaluated the previously claimed PTSD and there is no indication that it adequately considered whether the Veteran had any other psychiatric diagnoses, therefore, the examination is insufficient on which to rate the current claim for an acquired psychiatric disorder. As such, remand to obtain a new examination is needed. The matter is REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from December 2015 to the present. Contact the Veteran and afford him the opportunity to identify or submit any pertinent evidence in support of his claim, to include records of any private treatment. Based on his response, attempt to procure copies of all records which have not been obtained from identified treatment sources. If any of the records requested are unavailable, clearly document the claims file to that effect and notify the Veteran of any inability to obtain these records, in accordance with 38 C.F.R. § 3.159(e). 2. After obtaining any additional records, schedule the Veteran for a VA psychiatric examination with a clinician with appropriate expertise in order to ascertain the nature and etiology of all of his current acquired psychiatric disabilities. The claims file should be made available to the clinician for review. Any indicated tests should be accomplished, and all pertinent symptomatology and findings must be reported in detail. The clinician should provide an opinion on the following questions: A) If PTSD is diagnosed, is it at least as likely as not (50 percent or greater probability) that the Veteran's PTSD is related or attributable to any incident during the Veteran's military service? B) For any diagnosed acquired psychiatric disorder other than PTSD, including anxiety disorder, is it at least as likely as not (50 percent probability or greater) that such disability was incurred in, related to, or caused by any incident of the Veteran's military service? The clinician should provide a complete rationale for any opinion provided. If the clinician cannot provide any requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K Pak, Associate Counsel