Citation Nr: 18151766 Decision Date: 11/20/18 Archive Date: 11/20/18 DOCKET NO. 16-50 660 DATE: November 20, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an August 2013 rating decision that denied service-connection for PTSD. Although the Veteran initially claimed service connection for PTSD, other psychiatric diagnoses are documented in the record demonstrating that the scope of this claim should be construed more broadly as a psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board has recharacterized the issue accordingly. The Board notes that the Veteran was scheduled for a hearing before the Board on October 3, 2018. He was notified of the date, time and location of the hearing in letters dated August 23, 2018 and September 18, 2018; however, he failed to appear. Significantly, the Veteran did not submit a request for postponement prior to the Board hearing or a written motion for a new hearing date within 15 days following the scheduled hearing date. Given the above, the Veteran’s hearing request is deemed withdrawn. See 38 C.F.R. § 20.704 (c)-(d) (2017). Although the Board sincerely regrets the additional delay, this matter must be remanded for a VA examination. VA must provide a medical examination if the evidence indicates the existence of a current disability or persistent or recurrent symptoms of a disability that may be associated with an event, injury, or disease in service, and the record does not contain sufficient medical evidence to decide the claim. 38 U.S.C. § 5103A(d)(2) (2012); 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for determining whether the evidence “indicates” that there “may” be a nexus between a current disability and an in-service event, injury, or disease is low. McLendon, 20 Vet. App. at 83. The record shows that, mere months after his discharge from service, the Veteran complained of depression, anxiety, insomnia and disturbing dreams; and his doctors observed that the Veteran suffered from depression, “agitated depression,” and “depression – behavioral problems.” In addition, he was diagnosed with having both an “explosive personality” and a “borderline personality.” Treatment records from recent years indicate that the Veteran attended group mental health therapy up to 2008. The Veteran continues to assert that he suffers from depression and PTSD. The Veteran’s medical examination conducted at entry into service in April 1973 indicates that the Veteran did not suffer from any psychiatric disorders at that time. However, in June 1974, he complained of “nerves causing him to be very nervous and shaky” over the previous one or two months. He also noted that he was “very depressed” about his job and “personal situation.” The doctor noted that the Veteran was “depressed.” Later, in August 1974, on a periodic Report of Medical History, the Veteran selected “yes” to the question of whether he suffered from “nervous trouble of any sort” and “frequent trouble sleeping,” and he indicated that he suffered from “mild anxiety.” Finally, on his Report of Medical History taken at discharge from service in June 1975, the Veteran noted, again, that he experienced “nervous trouble of any sort,” specifying that he was “nervous sometimes.” Based on the foregoing, the Board finds that the low threshold to require a VA examination has been met in this case. The record shows that the Veteran suffered from psychiatric problems shortly after discharge from service and that he continues to struggle with psychiatric issues to the present day. It also shows that the Veteran experienced depression, anxiety and nervous trouble during service. Accordingly, a VA examination is warranted to clarify the Veteran’s current psychiatric condition and discuss whether that condition was incurred in or otherwise caused by service. In light of the remand, the Veteran should be provided an opportunity to submit additional treatment records. As for VA treatment records, the claims file contains records only as recent as August 2013. Thus, on remand, updated VA treatment records should be obtained and associated with the claims file. See 38 U.S.C. § 5103A(c); 38 C.F.R. § 3.159(c)(2); see also Bell v. Derwinski, 2 Vet. App. 611, 613 (1992) (holding that documents which are generated by VA agents or employees are in constructive possession of VA and, as such, should be obtained and included in the record). In closing, the Veteran is reminded that the duty to assist is a two-way street. If he does not attend his VA examination or provide sufficient justification to have it rescheduled, the claim will be denied. See 38 C.F.R. § 3.655 (“shall” language indicating this result is mandatory, not discretionary). The matter is REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for any mental health treatment records that he wishes to have associated with the claims file. Make two requests for the authorized records unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s VA treatment records for the period from August 2013 to the present. 3. Schedule the Veteran for a psychiatric examination to determine the nature and etiology of any acquired psychiatric disorder, to include PTSD. The examiner is asked to do the following: (a.) 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 related to a verified in-service stressor. (b.) For any other acquired psychiatric disorder diagnosed, opine whether it at least as likely as not had its onset during service or is otherwise related to service. (Continued on the next page)   (c.) If the Veteran is diagnosed with a personality disorder as well as any other psychiatric disorder, the examiner must opine whether the other psychiatric disorder was at least as likely as not superimposed on a personality disorder during active service and resulted in additional disability. K. PARAKKAL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Freda J. F. Carmack, Associate Counsel