Citation Nr: 18143003 Decision Date: 10/17/18 Archive Date: 10/17/18 DOCKET NO. 16-42 483 DATE: October 17, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depression, and anxiety is remanded. REASONS FOR REMAND The Veteran served on active duty in the Army National Guard from May 1997 to July 1997, October 2003 to March 2005, April 2005 to June 2006, and February 2009 to April 2010. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, depression, and anxiety is remanded. The Veteran seeks service connection for an acquired psychiatric disorder, to include PTSD, depression, and anxiety. The Veteran contends his PTSD is due to traumatic events he encountered while deployed in Iraq. At his August 2013 VA examination, the Veteran disclosed two stressors which he related to his PTSD symptoms. In 2005, the Veteran’s unit came upon a Humvee that was hit by an explosive device. Also, while in a convoy, the Veteran witnessed another truck in the convey blow up, with a man inside. In a February 2016 Statement in Support of Claim, the Veteran disclosed that there was a loud explosion near the post exchange in Iraq and several people were injured. The Veteran also recounted when he met several allied Iraqi soldiers on the base. Shortly after taking a picture with them, the Iraqi soldiers died in a bus explosion. The Veteran underwent a VA examination for PTSD in August 2013. The VA examiner determined that the Veteran did not suffer from PTSD. However, the VA examiner noted that the Veteran had been diagnosed with depression and anxiety by reviewing the Veteran’s medical records. In characterizing the issues on appeal, the Board recognizes that when a Veteran makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or characterized. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (holding that the scope of a mental health disability claim includes any mental health disability that could reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record). As the Veteran’s claim for PTSD encompasses all acquired psychiatric disorders, these VA examination results are insufficient to determine whether the Veteran has an acquired psychiatric disorder related to service. Id. While the Veteran’s service treatment records (STRs) include documents from February 1996 to November 2013, the STRs are incomplete and contain little information regarding any acquired psychiatric disorder. To accurately assess the Veteran’s claim of entitlement to service connection for an acquired psychiatric disorder, VA requires the Veteran’s complete STRs and military personnel records, including records held by the Army National Guard. In November 2001 and December 2002, STRs noted that the Veteran was not suffering from any psychiatric disorders and he did not suffer from depression. In May 2006, the Veteran suffered a psychotic episode. He was admitted to Walter Reed National Military Medical Center and was discharged days later with a psychosis diagnosis. The Veteran’s claims file did not include treatment records of this psychotic event. Treatment records from Walter Reed are needed to fully assess the Veteran’s claim. VA treatment records are incomplete and show that the Veteran may have been diagnosed with various acquired psychiatric disorders, including: depression, anxiety, a personality disorder, and substance abuse. VA treatment records do not include a definitive diagnosis for any acquired psychiatric disorder or an etiological opinion. In October 2012, a notation was made in the Veteran’s VA treatment records that he was diagnosed with PTSD. There was no examination within the VA treatment records which included a definitive diagnosis for PTSD or an etiological opinion. In November 2012, a notation was made in the Veteran’s VA treatment records that he was diagnosed with PTSD and major depressive disorder (MDD). There was no examination within the Veteran’s VA treatment records which included a definitive diagnosis for PTSD or depression or an etiological opinion. In a March 2013 Statement in Support of Claim, the Veteran stated that he had not yet been diagnosed with PTSD, though VA treatment records showed the Veteran participated in group therapy related to PTSD and depression. The Veteran was admitted to a VA hospital in April 2014 for substance abuse and in October 2017 for depression. Treatment records from these VA hospitals are needed to fully assess the Veteran’s claim. Whether and when the Veteran has been diagnosed with an acquired psychiatric disorder must be determined by obtaining complete military personnel records, to the extent available, as well as STRs and VA treatment records, including complete medical records pertaining to the Veteran’s psychotic event in May 2006 at Walter Reed and his VA hospitalization for substance abuse in April 2014 and for depression in October 2017. The Veteran has four distinct periods of service, including multiple deployments to warzones, with four dates of entry and four dates of separation. The presumption of soundness is called into question. The Veteran has an incomplete claims file. It is unclear when and if the Veteran has received a diagnosis for an acquired psychiatric disorder and which deployments may have initiated or aggravated an acquired psychiatric disorder. A Veteran is presumed in sound condition except for defects noted when examined and accepted for service. 38 C.F.R. § 3.304(b). Clear and unmistakable evidence that (1) the disability existed prior to service and (2) was not aggravated by service will rebut the presumption of soundness. See 38 U.S.C. § 1111; see also Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). The Board finds that the Veteran’s STRs, military personnel records, and VA treatment records are potentially incomplete. The evidence currently within the claims file suggests that the Veteran may have one or more acquired psychiatric disorder that may be related to his military service. The August 2013 VA examination is inadequate because it failed to take into account the Veteran's full medical history and did not opine as to any acquired psychiatric disorder the Veteran may have and whether or not it is at least as likely as not (a 50 percent probability or greater) that any acquired psychiatric disorder the Veteran may have is related to the claimed in-service stressors or otherwise related to active duty service. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Accordingly, the Board finds that a new VA examination is warranted to identify any current psychiatric diagnoses and to have a VA examiner provide an opinion that addresses whether any diagnosed acquired psychiatric disorder rendered during the course of the appeal is related to the Veteran's claimed in-service stressors or is otherwise attributable to the Veteran's active military service. The VA examiner must evaluate the Veteran's psychiatric disorders by applying the correct diagnostic criteria, DSM-5. The matter is REMANDED for the following actions: 1. Obtain any outstanding STRs, military personnel records, and VA treatment records and those STRs and military personnel records specifically held by the Army National Guard. 2. Obtain mental health treatment records from Walter Reed National Military Medical Center for Veteran’s May 2006 psychotic event and any other records related to the Veteran, contained at that facility. 3. Confirm which VA hospitals treated the Veteran during his April 2014 hospital stay for substance abuse and his October 2017 hospital stay for depression. Obtain treatment records, related to the Veteran, from those VA hospitals, to the extent available. 4. Undertake appropriate efforts to attempt to verify the Veteran’s reported in-service PTSD stressors, to include: a. In 2005, the Veteran’s unit came upon a Humvee that was hit by an explosive device. b. While in a convoy, the Veteran witnessed another truck in the convoy blow up, with a man inside. c. An explosion near the post exchange in Iraq and several people were injured. d. Allied Iraqi soldiers dying in a bus explosion shortly after leaving the base. Requests should be made to all appropriate official sources. All attempts to verify the Veteran’s reported stressors must be documented in the claims file. If the stressors are not verifiable, the Veteran must be notified and given an opportunity to respond. 5. Following requested development, schedule the Veteran for a VA examination with the appropriate medical professional to determine the nature and etiology of any currently diagnosed acquired psychiatric disorders, to include PTSD, depression, and anxiety. The entire claims file, to include a copy of this REMAND, must be provided to the examiner and reviewed in full. That review must be noted in the report. A complete history of symptoms should be elicited from the Veteran. All appropriate tests or studies should be accomplished, and all clinical findings should be reported in detail. The VA examiner should set forth all currently diagnosed acquired psychiatric disorders. Thereafter, the examiner is asked to provide an opinion with respect to the following: a. If the examiner finds that a diagnosis of PTSD is warranted, is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s PTSD is related to the combat in-service stressors, or if non-combat, related to verified active duty service stressors? b. Is it at least as likely as not (a 50 percent probability or greater) that any other diagnosed psychiatric disorder was incurred in or caused by the Veteran’s active duty service? The examiner is reminded that the term “at least as likely as not” does not mean “within the realm of possibility.” Rather, it means that the weight of the medical evidence both for and against the claim is so evenly divided that it is as medically sound to find in favor of the claim as it is to find against it. The examiner should set forth a complete rationale for the conclusions reached. If an opinion cannot be reached without resorting to speculation, the examiner must explain why. 6. Readjudicate the issue on appeal with consideration of all the evidence associated with the claims file since the issuance of the December 2015 Statement of the Case (SOC). If any benefit sought on appeal remains denied, issue an Supplemental Statement of the Case (SSOC) and allow the appropriate time for response. Then, return the case to the Board for further appellate review. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Mahaffey, Associate Counsel