Citation Nr: 18145182 Decision Date: 10/30/18 Archive Date: 10/26/18 DOCKET NO. 11-24 701 DATE: October 30, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include residuals of a head trauma and/or a traumatic brain injury (TBI), is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1972 to September 1973. The Board acknowledges that the previous Board remand referred the issue of entitlement to a TBI to the Agency of Original Jurisdiction (AOJ). However, the Board emphasizes that the scope of a mental health disability claim includes any mental disability that reasonably may be encompassed by the claimant’s description of the claim, reported symptoms, and other information of record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Accordingly, as the service treatment records document head trauma and as the Veteran asserts that his current psychiatric disorder was aggravated by his in-service head trauma, the Board has expanded the scope of the claim as indicated above. Entitlement to service connection for an acquired psychiatric disorder, to include residuals of a head trauma and/or a TBI is remanded. The Veteran has undergone multiple examinations to assess the etiology of his psychiatric disorder. Significantly, however, no examiner has rendered an opinion as to whether the Veteran’s mental health disorder was caused, or aggravated, by his in-service head trauma. Such opinion is highly relevant as the Veteran has indicated that his in-service head trauma aggravated his mental health problems. See May 2009 Statement in Support of Claim. The record also suggests that the Veteran may have cognitive impairment as a result of in-service head trauma. See March 2009 Northern Lights Psychiatric Services Examination. The Board notes that a January 2018 VA examiner clarified that the Veteran’s schizoaffective disorder clearly and unmistakably existed prior to service and was not clearly and unmistakably aggravated by service. Nevertheless, the examiner did not discuss the Veteran’s in-service head trauma or March 2009 diagnosis for a TBI. Accordingly, the Board finds that remand is warranted for a new VA examination and opinion consistent with the directives herein. The matter is REMANDED for the following action: 1. With the Veteran’s assistance, obtain any outstanding records of pertinent medical treatment from VA or private health care providers. All reasonable attempts to obtain such records should be made and documented. 2. After the above records request has been completed, to the extent possible, obtain a VA examination from an appropriate examiner to determine the etiology of any acquired psychiatric disorder, to include residuals of a head trauma and/or TBI. The claims folder (including a copy of this remand) must be provided to and reviewed by the examiner as part of the examination. All indicated tests should be accomplished and all clinical findings reported in detail. a) The examiner must provide diagnoses for any current acquired psychiatric disabilities, to include any current residuals of a head trauma and/or TBI. b) With respect to any current acquired psychiatric disorder or residual of a head trauma and/or TBI, the examiner must determine whether there is clear and unmistakable (obvious, manifest, or undebatable) evidence that the diagnosed disorder preexisted the Veteran’s active duty service? c) If it is determined that any diagnosed acquired psychiatric disorder or residual of a head trauma and/or TBI clearly and unmistakably preexisted service, is there clear and unmistakable (obvious, manifest, or undebatable) evidence that the preexisting disorder was not aggravated beyond the natural progression of the condition? The term “aggravated” in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. d) If any diagnosed acquired psychiatric disorder or residual of a head trauma and/or TBI did not clearly and unmistakably preexist service, did it at least as likely as not (50 percent probability or greater) have its onset during service or is it otherwise related to service. In rendering the above opinions, the examiner must specifically consider and discuss the Veteran’s in-service treatment records documenting that he was hit in the head during service and the March 2009 Northern Lights Examination diagnosis for a TBI. The examiner is advised that the Veteran is competent to report his symptoms/history and that such reports must be acknowledged and considered in formulating any opinion. If his reports are discounted, the examiner should provide a reason for doing so. 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 provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. THERESA M. CATINO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P. E. Metzner, Associate Counsel