Citation Nr: 18146903 Decision Date: 11/02/18 Archive Date: 11/01/18 DOCKET NO. 16-01 055 DATE: November 2, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depression is remanded. REASONS FOR REMAND The veteran served on active duty in the Army from August 1977 to February 1986. This case comes to the Board of Veteran’s Appeals (Board) from an October 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and depression. To establish a service connection for PTSD, a veteran must establish (1) medical evidence establishing a clear diagnosis of PTSD under 38 C.F.R. § 4.125(a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) a link, established by medical evidence, between current symptoms and a claimed in-service stressor. Without proof of a present disability, there can be no claim, regardless of injuries or diseases sustained during active service. Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Veteran may be able to qualify for service-connected PTSD under the relaxed stressor fear of hostile action criteria. To qualify, a Veteran must have experienced, witnessed, or have been confronted with an event or circumstance that involved: (1) actual threatened death or serious injury; or (2) a threat to the physical integrity of the Veteran or others; and (3) the Veteran’s response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 38 C.F.R. § 3.304(f)(3). The event or circumstance in service must have been perpetrated by either a member of an enemy military or by a terrorist. Hall v. Shinseki, 717 F.3d 1369 (Fed. Cir. 2013). A veteran must provide medical evidence establishing a current diagnosis of PTSD, which must conform to the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. It can be presumed that mental health professionals are experts, and know to take into account the relevant DSM when providing a diagnosis of PTSD. Cohen v. Brown, 10 Vet. App. 128, 140 (1997). As a rule, the DSM-IV will apply to claims that were initially certified for appeal to the Board, CAVC, or the Federal Circuit prior to August 4, 2014. All applications for benefits that were certified on or after August 4, 2014 will use the DSM-5. In the case of Veterans whose stressors are based on the fear of hostile action criteria as noted above, the diagnosis and nexus to service must be made by a VA psychologist or psychiatrist. The Veterans was examined by private medical examiner, on September 2013, and diagnosed with chronic post-traumatic stress disorder (PTSD) and chronic major depression. Since the Veteran appears to have a current diagnosis of a psychiatric disorder including PTSD, the case likely turns to the second criteria and third criteria for service-connection. The Veteran claimed on December 2015 that “my unit was involved 6-2-82 when bombs hit U.S. bases in West Germany.” While the Veteran submitted an article that may corroborate his fear of potential bombings, that event would not qualify as an in-service stressor if it could not be demonstrated that the Veteran was actually present when those bombings occurred. And while his Military Personnel Record (MPN) notes that the Veteran was based in Germany from December 1981 until about July 1982, the Joint Services Records Research Center (JSSRC) was unable to place the Veteran’s unit at that location. Therefore, the second element for service connection has not been satisfied, as it cannot be corroborated that the in-service injury or event actually occurred in the vicinity of the Veteran. Notwithstanding, JSSRC has not taken into consideration the news article submitted by the Veteran towards the corroboration of his claimed stressor. Further, with respect to the nexus question, while the Veteran appears to have a current diagnosis of a psychiatric disorder including PTSD, an examiner has not addressed whether the in-service event or injury is sufficient to be a stressor, and or is related to a psychiatric disorder to include PTSD. No examiner has opined whether the current diagnosis of PTSD is at least as likely as not related to a corroborated stressor, to include bombs hitting the veterans base in West Germany, or whether any other psychiatric diagnosis is otherwise related to service. More information is needed to allow the Board to make a fully-informed decision. Because the Veteran’s entire history is reviewed when making disability evaluations, the record must be complete for such service connection determinations to be made. See Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Therefore, a remand is necessary to ensure that there is a complete record upon which to decide the Veteran’s claim for an increased rating so that he is afforded every possible consideration. 38 U.S.C. § 5103 (A); 38 C.F.R. § 3.159. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder and depression is remanded. The matter is REMANDED for the following action: 1. The RO should request from the Veteran any records or evidence of treatment while in service, as it relates to PTSD. Associate such with the Veteran’s electronic claims file. Then, the RO should send all of the Veteran’s evidence, including the New York Times article indicating that a bombing occurred, to the JSSRC, for a secondary check of where the Veteran’s unit was stationed during these bombings. Updated records provided by the JSSRC should be associated with the Veteran’s electronic claims file. 2. After the report has been received from the JSSRC the RO should make a determination as to whether the Veteran’s claimed stressor has been adequately corroborated. 3. After the foregoing has been accomplished, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any acquired psychiatric disorder, to include PTSD and depression. The electronic claims file, to include the Veteran’s service treatment records, lay statements and testimonies, and treatment records, must be reviewed by the examiner, and a note that it was reviewed should be included in the report. (a.) After reviewing the claims file and examining the Veteran, the examiner should opine to the following: If but only if PTSD is diagnosed, whether the Veteran’s PTSD is at least as likely as not related to an in-service injury, event, or disease, including but not limited to any in-service stressor that has been corroborated. (b.) If any other acquired psychiatric disorders are diagnosed, to inclue depression, the examiner must opine whether each diagnosed disorder, to include depression, is at least as likely as not related to an in-service injury, event, or disease. The examiner should also explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. The examiner should also explain the reasons behind any opinions expressed and conclusions reached. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). A complete rationale for all opinions reached must be provided. 4. After completing the requested actions, and any additional notification and/or development deemed warranted, the issues should be readjudicated in light of all the evidence of record. If a benefit sought on appeal remains denied, the AOJ should furnish to the Veteran an appropriate supplemental statement of the case (SSOC) and should afford him the appropriate time period to respond. MICHAEL A. PAPPAS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Garrett H. Mulrain, Associate Counsel