Citation Nr: 18146363 Decision Date: 10/31/18 Archive Date: 10/31/18 DOCKET NO. 16-40 266 DATE: October 31, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from August 1971 to January 1978 and from February 1979 to September 1992. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an August 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. Thus far, the RO has limited its consideration of the Veteran’s psychiatric claim to the matter of his entitlement to service connection for PTSD. The evidence shows that he has been diagnosed in the past with a psychiatric disorder other than PTSD, however; namely, an adjustment disorder. Under the circumstances, the Board finds that the Veteran’s claim should be expanded. See, e.g., Clemons v. Shinseki, 23 Vet. App. 1 (2009) (indicating that a veteran’s claim for service connection for psychiatric symptoms should not be limited to consideration of a specific diagnosis where the pleadings and evidence suggest a claim of broader scope). In this regard, the Board notes that service connection for a nervous condition was initially denied in a February 1993 rating decision. It was noted that the Veteran had been anxious in service, and had an adjustment disorder, but that his problems had since resolved. The Veteran did not appeal that decision or submit new and material evidence within one year. As such, the decision became final. See 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.156(b), 20.1103. Since that decision, new and material evidence has been associated with the claims file; in particular, evidence of current psychiatric symptomatology. Accordingly, the claim is reopened. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded. The Veteran seeks to establish service connection for an acquired psychiatric disorder, claimed as PTSD. His reported stressors pertain to the death of two fellow soldiers in a tanker truck explosion and fear of hostile military or terrorist activity during service in Desert Storm/Desert Shield. The RO and Joint Services Records Research Center (JSRRC) have been unable to verify the stressor pertaining to deaths in the reported tanker truck explosion. In addition, the evidence of record does not contain confirmation that the Veteran served in the Southwest Asia theater of operations during the Persian Gulf War, as he appears to allege. Under applicable law, a medical examination and/or opinion is deemed “necessary” if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent lay or medical evidence of a current diagnosed disability or persistent or recurrent symptoms of disability; (2) establishes that the veteran suffered an event, injury, or disease in service, or has a disease or symptoms of a disease listed in 38 C.F.R. §§ 3.309, 3.313, 3.316, and 3.317 manifesting during an applicable presumptive period, provided the claimant has the required service or triggering event to qualify for that presumption; and (3) indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for determining whether the evidence “indicates” that there “may” be a nexus between a current disability and an in-service event, injury, or disease is a low one. McLendon, 20 Vet. App. at 83. Here, the Veteran has not been afforded a VA examination in connection with the present claim. The record contains evidence of psychiatric symptoms, however, both during service and presently, and the Veteran has made statements suggesting continuity of symptomatology for many years. Further development is required. Accordingly, this matter is REMANDED for the following action: 1. Ask the service department to verify that the Veteran served in the Southwest Asia theater of operations from December 1990 to January 1991, as alleged. The response(s) received should be associated with the record. 2. After the foregoing development has been completed to the extent possible, arrange to have the Veteran scheduled for a mental disorders examination, to be conducted by a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted. The examiner should review the record. All indicated tests (to include psychological testing, if necessary) should be conducted and the results reported. After examining the Veteran and reviewing the record, to include the results of any necessary testing, the examiner should indicate whether the Veteran has met the DSM-5 diagnostic criteria for PTSD. If it is the examiner’s opinion that the diagnostic criteria for PTSD have been met, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the diagnosis is related to a verified stressor and/or the Veteran’s reported fear of hostile military or terrorist activity. If psychiatric disorders other than PTSD are diagnosed (or are found to have been present at any time pertinent to the present appeal), the examiner should provide an opinion, with respect to each such disorder, as to whether it is at least as likely as not that the disorder had its onset in, or is otherwise attributable to, service. In so doing, the examiner should discuss the medical significance, if any, of the Veteran’s report on examination during service in February 1986 that he was “very nervous most of the time.” The examiner should also comment on the medical significance, if any, of the fact that the Veteran underwent treatment for alcohol dependence during service in 1989; the Veteran’s report during service in December 1991 to the effect that he had trouble sleeping; his report in May 1992 to the effect that he thought he had a lot of stress; and the notations on the report of his July 1992 service retirement examination wherein he reported a history of night sweats and insomnia. A complete medical rationale for all opinions expressed must be provided. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraph, the Veteran’s claim should be readjudicated based on the entirety of the evidence. If the benefit sought remains denied, the Veteran should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. DAVID A. BRENNINGMEYER Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Riordan, Associate Counsel