Citation Nr: 18146690
Decision Date: 11/01/18	Archive Date: 10/31/18

DOCKET NO. 15-41 799
DATE:	November 1, 2018
REMANDED
Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded.
REASONS FOR REMAND
The Veteran served on active duty from December 1953 to May 1968 and February 1969 and September 1974.  His awards and decorations include the Bronze Star Medal.
The Board has recharacterized the original claim based on the evidence of record.  See Clemons v. Shinseki, 23 Vet. App. 1 (2009).  The Veteran withdrew his hearing request in October 2018.
Entitlement to service connection for a psychiatric disorder, to include PTSD, is remanded.
The Veteran seeks service connection for a psychiatric disorder that he believes is related to his combat service in Vietnam.  See July 2012 Correspondence.  While delay is regrettable, additional development is needed.
Private treatment records from Dr. Butera provided diagnoses for PTSD and Major Depressive Disorder.  In April 2012, Dr. Butera submitted an opinion that some of the Veteran’s reported combat stressors led to the PTSD diagnosis.  However, a September 2012 VA examination report indicated that the Veteran did not meet the full diagnostic criteria for PTSD or any other mental disorder.  A different VA examiner noted in April 2014 that the Veteran endorsed symptoms of depressed mood and anxiety, but the examiner opined that those symptoms were attributable to current life stresses and not to service.  A November 2015 Agent Orange Registry examination report reflects that the Veteran was negative for depression or anxiety.  In light of this conflicting medical evidence of record, a new examination and opinion is necessary on remand. 
The matter is REMANDED for the following action:
1. Obtain the Veteran’s VA treatment records dated to the present.
2. Ask the Veteran to complete a VA Form 21-4142 for any outstanding private treatment records, to include, but not limited to, updated records from Dr. Butera.  Make two requests for the authorized records unless it is clear after the first request that a second request would be futile.
3. Schedule the Veteran for a psychiatric examination to determine the nature and etiology of any psychiatric disorder to include, but not limited to, PTSD and major depression.  The entire claims folder must be reviewed by the examiner, including a copy of this Remand.  If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria were met and opine whether it is at least as likely as not related to a verified in-service stressor.  
If any other acquired psychiatric disorders are diagnosed, the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease.  
The examiner must also provide an opinion as to whether the Veteran has had ANY acquired psychiatric disorder AT ANY TIME DURING THE APPEAL PERIOD that is at least as likely as not related to an in-service injury, event, or disease; in so doing, the examiner should address the conflict (described above) between Dr. Butera’s April 2012 opinion and the September 2012 and April 2014 VA opinions.  A rationale must be provided for all offered opinions.
4.  After completing the requested actions and any additional notification and/or development deemed warranted, the AOJ should readjudicate the appeal.  If any benefit sought is not granted, the Veteran and his representative should be provided an SSOC and afforded an opportunity to respond before the record is returned to the Board for further review.
 
JEBBY RASPUTNIS
Acting Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	M. Tang, Associate Counsel