Citation Nr: 18150692 Decision Date: 11/15/18 Archive Date: 11/15/18 DOCKET NO. 16-18 574 DATE: November 15, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the Army from May 1969 to April 1971. The matter on appeal before the Board of Veterans’ Appeals (Board) is from an October 2010 rating decision of a regional office of the Department of Veterans Affairs (VA). The Board notes that the claims file contains an April 2016 statement of the case pertaining to the issue of whether the Veteran is entitled to service connection for right and left ear hearing loss. However, as a timely substantive appeal has not been submitted with regard to this issue, this issue is currently not on appeal before the Board. Acquired psychiatric disorder With respect to the Veteran’s service connection claim for post-traumatic stress disorder (PTSD), the Board acknowledges that the scope of a mental health disability claim includes any mental health disorder 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, 5 (2009). Review of the record reflects that the Veteran’s mental health symptoms have resulted in various diagnoses over the years, to include acute brain disorder, PTSD, depression, and adjustment disorder. Thus, although the Veteran’s psychiatric disorder claim was substantively appealed with respect to service connection for PTSD, under Clemons it can be broadened to include a claim for service connection for any acquired psychiatric disorder. As such, the Veteran’s claim has been recharacterized on the title page of this decision. As noted, review of the record reflects that the Veteran’s mental health symptoms have been variously diagnosed over the years. For example, the Veteran’s service treatment records (STR) reflect that in 1970 he was diagnosed with acute brain disorder after receiving specialized treatment at the advanced psychiatry care ward in Frankfurt, Germany. In August 1997 and January 2012, VA treatment records reflect that he was diagnosed with PTSD. In 1998, the Veteran was diagnosed with depression and anxiety and started taking antidepressants. The Veteran spoke about his depression at the various VA doctors’ visits he had since then, sometimes explaining how his marital problems and stress caused his depression. Lastly, in 2016, the VA treating physician claimed that the Veteran did not have PTSD or depression, but that he had an adjustment disorder with depressed mood. VA must afford a veteran an examination and/or obtain an opinion when it is necessary to make a decision on the claim. 38 U.S.C. § 5103A(d) (2012); 38 C.F.R. § 3.159(c)(4) (2018). In disability compensation (service connection) claims, VA must provide a medical examination and medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81-82 (2006). To that end, when VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). While the Veteran has various psychiatric disorder diagnoses from VA treating physicians, none of them opine whether any of the conditions are related to the Veteran’s time in service, specifically his in-service brain disorder diagnosis. The various diagnoses trigger VA’s duty to assist, and, thus, this matter must be remanded for a VA examination and an opinion to determine whether or not the Veteran’s psychiatric condition is etiologically related to his military service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The matter is REMANDED for the following action: 1. Obtain updated pertinent treatment records and associate with the claims file. 2. Attempt to corroborate the Veteran’s in-service stressor[s]. If more details are needed, contact the Veteran to request the information. 3. Following completion of the above, schedule the Veteran for a VA mental disorders examination to determine the nature and etiology of any diagnosed acquired psychiatric disorder. If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not (50 percent or greater probability) related to a verified in-service stressor. If any other acquired psychiatric disorder is diagnosed, the examiner must opine whether each diagnosed disorder is at least as likely as not (50 percent or greater (CONTINUED ON NEXT PAGE) probability) related to an in-service injury, event, or disease. BARBARA B. COPELAND Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Imam, Associate Counsel