Citation Nr: 18151691 Decision Date: 11/20/18 Archive Date: 11/19/18 DOCKET NO. 15-25 715 DATE: November 20, 2018 REMANDED The claim of entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran had honorable active duty service with the United States Army from February 1969 to February 1971, including service in Germany for which he earned the Army Occupation Medal (Berlin). 1. The claim of entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) is remanded. The Board cannot make a fully informed decision regarding the claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD, as the medical opinion of record is insufficient for adjudicative purposes. The Veteran served as a Military Policeman in Berlin, Germany, for the majority of his active duty service. In this capacity, he reported a number of stressful and traumatic incidents that purportedly continue to plague him decades after service. These incidents, as reported, include: 1) guarding a severed head during a police investigation; 2) witnessing a German tank crush a civilian-occupied car in an intersection; 3) witnessing someone shot to death while trying to flee East Berlin, and the body being left unattended for a prolonged period of time; 4) witnessing a U.S. military servicemember hang himself outside of the Veteran’s Berlin housing; 5) quelling a riot with West German police and witnessing them beat civilians; and, 6) physically holding the line that denoted West Berlin as a Russian tank approached the checkpoint, stopping a short distance from the Veteran. The Joint Services Records Research Center (JSRRC) could not corroborate these events, as reported in a December 2014 formal finding. The Veteran’s February 1969 enlistment examination does not note any relevant psychiatric conditions. The Veteran’s February 1971 separation examination reported frequent trouble sleeping. The Veteran does not receive formal counseling for his acquired psychiatric disorder, but VA treatment records reflect ongoing medication management for depression. The Veteran’s wife submitted a statement in August 2014 reporting a worsening of the Veteran’s associated symptomatology. She stated that he had become more frustrated and confused, and found himself unable to follow conversations. She also reported that his anger worsened over time. The Veteran also continued to have trouble sleeping, waking frequently throughout the night and yelling, kicking and hitting in his sleep. The Veteran’s wife lived in West Berlin with the Veteran during his deployment, and she reported that she had personal knowledge of some of his reported stressors. In February 2015, the Veteran stated that the events in Berlin continued to haunt him. In April 2015, he endorsed ongoing nightmares about his service that included kicking and yelling in his sleep. The Veteran’s May 2015 VA examination did not address these lay reports in the etiological opinion. The examiner diagnosed Unspecified Neurocognitive Disorder and Unspecified Depressive Disorder with Anxious Distress. These diagnoses were reportedly less likely as not related to active duty service as there was no documented history of mental health treatment prior to January 2008, in which he was not diagnosed with a mental disorder, but instead poor energy secondary to sleep apnea. The examiner then noted his treatment for depressive symptoms through his primary care clinician. Unfortunately, this nexus opinion does not have a thorough rationale to support its conclusion, and is insufficient for adjudication. The examiner previously noted in the examination that the Veteran endorsed chronic sleep impairments following his experience with the severed head. The examiner also stated that the Veteran did experience a traumatic military event, and that he engaged in other subjects to avoid thinking about these traumas. In the examination, the Veteran reported that he had been depressed since his military service. The unwillingness or failure to engage in mental health treatment after service is not a sufficient rationale on which a nexus may be denied. Furthermore, this extremely limited rationale does not address the competent lay statements provided by the Veteran and his wife regarding continuous and worsening symptomatology. Accordingly, as this opinion of record lacks a thorough rationale, a new examination is necessary on remand in order to obtain an adequate etiological opinion for the Veteran’s acquired psychiatric disorder. The matter is REMANDED for the following action: 1. Contact the Veteran and the representative of record in order to identify any outstanding non-VA treatment records regarding the issues on appeal. If non-VA providers are identified, obtain releases for those records. Make all reasonable attempts to obtain the non-VA treatment records and associate them with the claims file. If such records cannot be obtained, inform the Veteran and the representative of record, and afford an opportunity to provide these outstanding records. 2. Obtain any relevant, outstanding VA treatment records that are not already associated with the claims file. If no records are available, the claims folder must indicate this fact and the Veteran should be notified in accordance with 38 C.F.R. § 3.159 (e). All attempts to contact the Veteran should be documented in the record. 3. Once the aforementioned evidentiary development is complete, schedule the Veteran for a VA examination with a new examiner, if possible, to assess the nature and etiology of his acquired psychiatric disorder. The examiner must review the entire claims file, including a copy of this remand. The examiner must consider the lay reports from the Veteran and his wife regarding observable symptomatology associated with his diagnosis or diagnoses. After a thorough review of the record is complete, the examiner must respond to the following: (a.) List any and all acquired psychiatric disorders with which the Veteran is presently diagnosed. (b.) For each acquired psychiatric disorder, opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s acquired psychiatric disorder had its onset during active duty service, is related to an incident of service, or began within one year after discharge from active service. In this response, please specifically discuss the Veteran’s contentions regarding continuing symptomatology, his lay reports of symptoms as well as the report of difficulty sleeping on his separation examination. It is not sufficient to deny an etiological link with active duty service solely because the Veteran did not seek mental health treatment following service. The examination report should specifically state that a review of the record was conducted. The examiner should provide a complete rationale for all opinions provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. 4. Following completion of the foregoing, the AOJ should review the record and readjudicate the claim on appeal. If it remains denied, the AOJ should issue an appropriate supplemental SOC, afford the Veteran and his representative an opportunity to respond, and return the case to the Board. B. MULLINS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD H. Fisher, Associate Counsel