Citation Nr: 18151817 Decision Date: 11/20/18 Archive Date: 11/20/18 DOCKET NO. 16-41 449 DATE: November 20, 2018 REMANDED Entitlement to service connection for a psychiatric disability, to include post-traumatic stress disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1975 to February 2006. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In April 2018, the Veteran and a witness participated in a hearing before the undersigned Veterans Law Judge. A hearing transcript is of record. Entitlement to service connection for a psychiatric disability, to include post-traumatic stress disorder (PTSD) is remanded. The Veteran contends that he is entitled to service-connection for PTSD as the claimed disability is the result of active service, which included crawling into small spaces. An in-service stressor has already been conceded. In a July 2014 PTSD Disability Benefits Questionnaire, Dr. B.M.A. diagnosed PTSD. The examiner also indicated that there was more than one mental diagnosis present. It was noted that it was not possible to differentiate which portion of occupational and social impairment was caused by each diagnosed disability. The form itself is not very legible and the Board is unable to discern the basis of the diagnosis or the nature of the separate diagnosis. In a March 2015 and a March 2017 Initial PTSD Disability Benefits Questionnaire, the examiner opined that the Veteran did not have a PTSD diagnosis that conforms with DSM-5 criteria. The examiner also noted that the Veteran did not have more than one diagnosed mental disorder. At the April 2018 hearing before the Board, the Veteran testified that the notes recorded in the March 2015 Initial PTSD Disability Benefits Questionnaire VA examination did not adequately indicate what was reported during the examination. The Veteran asserted that he still experiences PTSD as a result of the conceded in-service stressor, and alleges that he has other mental disorders in addition to PSTD. More specifically, it was stated that the Veteran had fear of small spaces. A claim is not necessarily limited in scope to a single or particular diagnosis, and should be construed based on the reasonable expectations of the non-expert, self-represented claimant and the evidence developed in processing that claim. Because of the conflicting reports of the Veteran’s mental diagnoses, and the newly raised theory of entitlement at the April 2018 hearing, the Board finds that additional VA examination would be helpful to adjudicate a claim for all possible mental disorders. The matter is REMANDED for the following action: 1. Secure all outstanding VA medical records. If any records cannot be located, specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. If records are unable to be obtained (a) notify the claimant of the specific records that VA is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claim. The claimant must then be given an opportunity to respond. 2. Schedule the Veteran for a VA mental disorders examination by psychiatrist or psychologist to ascertain the nature and etiology of any current psychiatric disability. The examiner must review the claims file and must note that review in the report. The examiner should diagnose every psychiatric disability currently manifested or which has been manifested at any time during the course of this appeal. The examiner should specifically state whether or not each criterion for a diagnosis of PTSD is met. The examiner should reconcile the diagnoses with the previous examinations of record. The examiner must consider the Veteran’s lay statements related to in-service and post-service symptomatology, and contentions of continuous symptoms since service. The examiner must provide a rationale for any opinion provided and should attempt to reconcile any contradictory evidence of record. For each identified psychiatric disability, the examiner should opine whether it is at least as likely as not (50 percent probability or greater) that each current psychiatric disability was incurred in service or is due to any incident of service. The examiner should specifically opine whether it is at least as likely as not (50 percent probability or greater) that the Veteran has a mental disorder manifested by fear of small spaces and whether or not any such disability was incurred in service or is due to any incident of service. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. D. Cross, Associate Counsel