Citation Nr: 18151071 Decision Date: 11/16/18 Archive Date: 11/16/18 DOCKET NO. 14-41 398 DATE: November 16, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, panic disorder, anxiety disorder, personality disorder, and depressive disorder, is remanded. Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran had active service from March 2000 to July 2000, September 2004 to January 2005, and June 2007 to April 2008. This case comes before the Board of Veterans’ Appeals (Board) on appeal of an August 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Togus, Maine. The Board also acknowledges a November 2014 Form 9 and November 2018 Appellate Brief both noting that the Veteran does not work because of his mental diagnosis. The Veteran and his representative have both directly raised a claim for a total disability rating based upon individual unemployability (TDIU). This matter is referred to the Agency of Original Jurisdiction for appropriate action. Pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Board has recharacterized the Veteran’s claims to include any psychiatric disorder. The Board has reviewed the evidence presently in the record and observes that there are VA outpatient treatment records indicating that the Veteran may have multiple mental health diagnoses. For instance, in July 2013, the Veteran underwent a VA examination for mental disorders (other than PTSD) where he was diagnosed with personality disorder not otherwise specified (NOS) and anxiety disorder NOS. In his November 2013 NOD and November 2014 Substantive Appeal, he reported PTSD based on the stressors of seeing severely injured Iraqi nationals at a field hospital and fearing for his life during mortar and rocket fire. A VA examination is necessary in this instance to clarify whether the Veteran has any psychiatric diagnoses which are etiologically related to service, including the reported stressful incidents. As to the low back disorder, the Board notes that a VA opinion was obtained in August 2013. It does not appear that the Veteran was afforded a VA examination at that time. While there may be instances where a VA opinion is adequate to determine a case, this is not one. Rather, the Veteran should be afforded a VA examination so that not only the nature and symptoms of his claimed back disorder are clear to the examiner, but also so that the examiner has an opportunity to consider his lay contentions in rendering a nexus opinion. This must be corrected on remand. These matters are REMANDED for the following action: 1. Schedule the Veteran for a VA mental health examination, conducted by a psychiatrist or psychologist who has reviewed the Veteran’s claims file, to determine the nature and etiology of any acquired psychiatric disorders. The examiner should clearly state which, if any, disorders have been present during the pendency of this appeal (i.e., since May 2012). Due consideration must be provided to the Veteran’s lay contentions. If any disorders are diagnosed, the examiner must opine whether any acquired psychiatric disorders are at least as likely as not (50 percent probability or greater) related to service and any incident therein. All opinions must be supported by a rationale. 2. Schedule the Veteran for a VA spine examination, conducted by an appropriate clinician who has reviewed the claims file, to determine the nature and etiology of any current low back disorders. The examiner should clearly state which, if any, disorders have been present during the pendency of this appeal (i.e., since May 2012). Due consideration must be provided to the Veteran’s lay contentions. If any disorders are diagnosed, the examiner must opine whether any acquired low back disorders are at least as likely as not (50 percent probability or greater) related to service and any incident therein. All opinions must be supported by a rationale. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Banks, Associate Counsel