Citation Nr: 18149037 Decision Date: 11/08/18 Archive Date: 11/08/18 DOCKET NO. 16-56 873 DATE: November 8, 2018 REMANDED ISSUE Entitlement to an acquired psychiatric disorder to include post-traumatic stress disorder (PTSD), anxiety, and depression, is remanded. The Veteran served on active duty in the United States Navy from January 1952 to December 1955. The issue is on appeal from a May 2015 rating decision. The Board of Veterans’ Appeals (Board) notes that the Veteran applied for entitlement to service connection for depression and anxiety in November 2016. In December 2016, the Veteran was notified that his claim of entitlement to service connection for depression and anxiety were intertwined with his ongoing appeal for entitlement to service connection for PTSD. The Board recognizes that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). As noted above, the Board has accordingly expanded the scope of the claim to consider entitlement to service connection for all psychiatric disorders, to include PTSD, anxiety, and depression. Entitlement to an acquired psychiatric disorder to include PTSD, anxiety, and depression, is remanded. In February 2015, the Veteran was afforded a VA examination for PTSD. The examiner found that the Veteran did not have a PTSD diagnosis because his stressor was the “imaginings” of another marine’s reports on shells coming down over heads and burning up. Therefore, as the stressor did not meet the qualifications for a PTSD stressor, there was no diagnosis, and no symptoms were due to PTSD. Rather, the examiner diagnosed the Veteran with persistent depressive disorder with anxious distress. The Board finds the February 2015 VA examination is inadequate. First, based on a review of the Veteran’s VA medical center (VAMC) treatment records, the Veteran has named other stressors, that were not “imaginings” of another individual’s report. In fact, the Veteran has consistently reported these other stressors in various correspondence. Notably, in November 2014, the Veteran reported two stressors in the form of memories – (1) standing on the tail of the ship and an enemy shell landing in the water next to him, splashing water on him; and (2) being the pointer and trigger man, and being responsible for ensuring the guns were level and firing the guns. The Veteran expressed guilt due to his activities in combat. The February 2015 examiner did not consider other reported stressors, despite discussing other VA treatment record notes. Additionally, on remand, the regional office (RO) should make sufficient attempts to confirm these claimed in-service stressors. Second, the February 2015 VA examiner diagnosed the Veteran with persistent depressive disorder with anxious distress, and did not provide an etiology opinion for this diagnosis. The examiner also noted that the Veteran had been diagnosed with generalized anxiety disorder and dysthymia in VA treatment records. On remand, an etiology opinion is needed for all acquired psychiatric disorder diagnoses. The matter is REMANDED for the following action: 1. Attempt to corroborate the Veteran’s in-service stressor[s], including enemy shells landing in water around the ship that the Veteran was stationed on; and serving as a pointer and trigger man. If more details are needed, contact the Veteran to request the information. 2. Obtain any additional outstanding VA treatment or private physician records for the Veteran and associate them with the claims file. The last VA treatment record is dated October 31, 2016. All attempts to secure any identified records and any response received must be documented in the case file. 3. After any available records are associated with the claims file, schedule the Veteran for an additional VA examination using DSM-V criteria to determine if the Veteran currently has any mental health disorders, to include the claimed disability of PTSD. The examination should include any diagnostic testing or evaluation deemed necessary. The VA examiner must respond to the following inquiries: a. First, the examiner must provide diagnoses for all current and previously diagnosed psychiatric disorders found following a review of the entirety of the Veteran’s claims file. For each disorder identified, other than PTSD, the examiner should state whether it is at least as likely as not (i.e. a 50 percent chance or greater) that the disorder manifested in service or is otherwise etiologically-related to the Veteran’s military service. If the VA examiner finds a psychiatric disability is not etiologically-related to the Veteran’s military service, the examiner is asked to provide a clear rationale explaining their conclusion. b. Second, the VA examiner should determine whether the Veteran meets the DSM-V criteria for a diagnosis of PTSD. The examiner should also explicitly address the in-service stressors previously reported by the Veteran. If a PTSD diagnosis is deemed appropriate, the examiner should then opine as to whether it is at least as likely as not (i.e. a 50 percent chance or greater) that the Veteran’s current PTSD symptomatology is due to any verified in-service stressors. The examiner must provide a complete rationale for all opinions expressed. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. The examiner must indicate whether an opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the specific examiner.   4. Readjudicate the claim. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Department of Veterans Affairs