Citation Nr: 18149741 Decision Date: 11/13/18 Archive Date: 11/13/18 DOCKET NO. 18-24 756 DATE: November 13, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD) and an insomnia disorder is remanded. REASONS FOR REMAND The Veteran served in the United States Army from July 11, 1990, to March 25, 1997, from February 10, 2003, to June 6, 2004, from October 22, 2011, to September 30, 2012 and from October 15, 2012, to September 30, 2013. The Board has rephrased the Veteran’s claim of entitlement to service connection for PTSD as a claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD and an insomnia disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (stating 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). Entitlement to service connection for an acquired psychiatric disorder is remanded. More information is needed to allow the Board to make a fully-informed decision. In May 2017, and again in April 2018, the Veteran submitted a VA 21-0781 Statement in Support of Claim for PTSD. In both statements, the Veteran attributed his PTSD to mortar/rocket attacks in Iraq and witnessing service members killed in action. The Veteran’s DD Form 214 shows that he served in a designated imminent danger pay area, which supports a finidng that his stressors occurred and that he experienced fear of hostile military or terrorist activity. In an April 2017 private examination, the provider diagnosed the Veteran with PTSD and opined it is more likely than not that the Veteran’s PTSD is related to his military service. To support the opinion, the provider stated that the Veteran’s symptoms are related to the threat of death as well as witnessing the death and injury of multiple people during his military enlistment. In a June 2017 VA examination, the examiner reported that the Veteran did not have a diagnosis of PTSD that conforms to DSM-5 criteria, but found the Veteran to have insomnia disorder. The examiner recorded that the Veteran did not report a stressor. It appears that the June 2017 examiner did not consider the Veteran’s reports of mortar/rocket attacks in Iraq and witnessing service members killed in action. Additionally, the examiner reports that she reviewed the April 2017 examination, but does not comment on the Veteran’s reported stressors. This examination is inadequate because it failed to consider the Veteran’s lay statements and reported stressors. Although the April 2017 private examination provides the Veteran with a PTSD diagnosis and gives a positive nexus, a new examination is needed. According to 38 C.F.R. § 3.304(f)(3), a VA or VA-contracted psychiatrist or psychologist must confirm that the stressor is adequate to support a PTSD diagnosis and attribute the Veteran’s symptoms to his or her stressor regarding fear of hostile military or terrorist activity. Since the evidence of record does not show that the April 2017 provider is a VA or VA-contracted psychiatrist or psychologist, the claim must be remanded for a supplemental opinion. The matter is REMANDED for the following action: 1. Provide the Veteran’s claims file to a suitable psychiatrist or psychologist to determine nature and etiology of any PTSD or other psychiatric disorder. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. A new examination of the Veteran is only necessary if deemed so by the clinician. If the Veteran is diagnosed with PTSD, the examiner must opine whether it is at least as likely as not related to his stressors involving fear of hostile military or terrorist activity. For any other psychiatric disability diagnosed, including insomnia disorder, determine whether it is at least as likely as not (50 percent or greater probability) that the psychiatric disorder is related to his service, including due to his stressors. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. (Continued on the next page)   2. Then, readjudicate the claim. If any decision is unfavorable to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Fowler, Associate Counsel