Citation Nr: 18149475 Decision Date: 11/09/18 Archive Date: 11/09/18 DOCKET NO. 16-43 890 DATE: November 9, 2018 REMANDED Service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), major depressive disorder, anxiety, and somatoform disorder, as secondary to service-connected seizure disorder, is remanded. REASONS FOR REMAND The Veteran had active service in the United States Navy from March 1968 through February 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board has re-characterized the issue of entitlement to service connection for PTSD to more broadly encompass entitlement to service connection for an acquired psychiatric disorder, to include PTSD, depression, anxiety, and somatoform disorder, pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009). The claim is remanded for further development. 1. Entitlement to service connection for an acquired psychiatric disability, to include PTSD and major depressive disorder, anxiety, and somatoform disorder, as secondary to service-connected seizure disorder is remanded. The Veteran contends that he has PTSD from his active service. The record indicates the Veteran may have PTSD, as noted by an April 2011 Mental Health treatment note. A May 2016 VA psychiatric examination did not account for this preliminary treatment. The matter is REMANDED for the following action: 1. Request the Veteran provide any service treatment records he possesses or identify and secure any relevant private medical records that are not in the claims file. If the Veteran identifies private records, following the securing of the appropriate waivers, make all appropriate attempts to locate such records and to associate them with the claims file. If the Veteran has no further evidence to submit, or, if after exhaustive efforts have been made, no records can be identified, so annotate the record. 2. Obtain any outstanding VA medical records and associate them with the claims file. 3. RETURN THE FILE TO THE EXAMINER WHO CONDUCTED THE MAY 2016 VA EXAMINATION. IF THAT EXAMINER IS NO LONGER AVAILABLE, CONDUCT THE FOLLOWING DEVELOPMENT WITH A SIMILARLY QUALIFIED EXAMINER. The entire claims file, including a copy of the Remand, should be made available to, and be reviewed by, the VA examiner. All appropriate tests, studies, and consultations should be accomplished and all clinical findings should be reported in detail. An explanation should be given for all opinions and conclusions rendered. Based upon a review of the relevant evidence of record, history provided by the Veteran, and sound medical principles, the VA examiner should provide the following opinions: (a.) Identify all currently-diagnosed acquired psychiatric disorders TO INCLUDE WHETHER THE VETERAN HAS PTSD, AN ANXIETY DISORDER, A DEPRESSIVE DISORDER OR ANY OTHER MENTAL DIAGNOSIS. (b.) Identify whether any of the Veteran’s current psychiatric diagnoses incurred in service or caused by an in-service injury, event or illness. (c.) Identify whether any of the Veteran’s current psychiatric diagnoses are proximately due to or aggravated by the Veteran’s service-connected seizure disorder. The examiner must review the entire record in conjunction with rendering the requested opinions. In addition to any records that are generated because of this Remand, the VA examiner’s attention is drawn to the following: • November 1967 Report of Medical Examination indicating a normal psychiatric evaluation. See “STR – Medical,” received June 4, 1969, page 30 of 49. • October 1968 Chronological Record of Medical Care noting a diagnosis of convulsive disorder. See “STR – Medical,” received June 4, 1969, page 14 of 49. • June 1980 Hospital Summary indicating no apparent psychiatric diagnosis, but also stating “a psychological over lay is still a large part in presentation of symptoms and signs in this individual.” See “VA 10-1000 Hospital Summary and/or the Compensation and Pension Exam Report,” received June 9, 1980. • June 1985 Discharge Summary indicating no major psychiatric illnesses. See “Medical Treatment Record – Government Facility,” received August 6, 1985. • April 2011 Mental Health H & P Note indicating the Veteran has met the criteria for PTSD related to a history of physical and emotional abuse during service. See “Medical Treatment Record – Government Facility,” received May 10, 2011, page 26 of 39. • May 2016 Psychology C & P Examination Consult documenting a diagnosis of major depressive disorder and borderline personality disorder. See “C&P Exam,” received May 12, 2006. A thorough explanation must be provided for the opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, s/he should expressly indicate this and provide supporting rationale as to why the opinions cannot be made without resorting to speculation. The examiner is advised that by law, the mere statement that the claims folder was reviewed and/or the examiner has expertise is not sufficient to find the examination/opinion sufficient. Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. McLendon, Associate Counsel