Citation Nr: 18151841 Decision Date: 11/20/18 Archive Date: 11/20/18 DOCKET NO. 16-37 259 DATE: November 20, 2018 REMANDED Entitlement to service connection for acquired psychiatric disorders, to include posttraumatic stress disorder (PTSD), generalized anxiety, and depression is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1985 to July 1987. This matter comes before the Board of Veterans’ Appeals (Board) from a January 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran contends that his current psychiatric disorders are directly related to mental and physical abuse he experienced during service. The November 2015 VA treatment records contain the Veteran’s statements regarding the way he was treated by his drill sergeant during his active basic training for the Marine Corp, including being hit with a hammer, being made to stand upside down with legs against the wall and arms outstretched for an extended period of time, and being exposed to ridicule and excessive verbal abuse.   The Board notes that the Veteran initially filed a claim to service connection for unspecified depressive disorder. However, as emphasized in Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the Veteran’s claim cannot be “limited only to that diagnosis, but must rather be considered a claim for any mental disability that may be reasonably encompassed.” Therefore, applying the holding in Clemons to the present case, the claim on appeal has been recharacterized as a claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD, generalized anxiety and depression. The record reflects that the Veteran has not been afforded a VA examination for this claim. Pursuant to McLendon v. Nicholson, 20 Vet. App. 79 (2006), VA’s duty to assist in obtaining a VA examination is triggered when (1) there is evidence of a current disability, (2) evidence establishing an “in-service event, injury or disease,” or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. The requirement that the evidence of record “indicates” that a disability, or persistent or recurrent symptoms of a disability, “may be associated” with the Veteran’s service establishes “a low threshold.” McLendon, 20 Vet. App. at 83. Here, the Veteran’s medical records show the presence of acquired psychiatric disorders, to include PTSD, major depression, and anxiety. See November 2015 VAMC treatment records; see also 2016 VAMC treatment records, dated March 18, 2016; see also December 2017 VAMC treatment records. Further, the Veteran’s psychiatrist’s November 2015 VA treatment records indicate that the Veteran’s current psychiatric disorders may have originated during his active duty service. However, this evidence is inadequate to adjudicate the Veteran’s appeal on the merits. The psychiatrist’s November 2015 statement lacks the degree of certainty necessary to establish a medical nexus in VA compensation proceedings, for it merely provides a tentative medical opinion concerning the Veteran’s alleged in-service stressor. There is also an indication in the medical records that his psychiatric conditions originated with post-service events. The Veteran’s statements are accepted as credible for the purpose of determining whether an examination is needed (the credibility of those statements will be assessed when adjudicating the merits of the claim). Thus, the Board finds that the McLendon elements have been satisfied, and a VA examination is warranted. In order for the examination and opinion to be fully informed, there is evidence not currently in the file that should be obtained. When the Veteran established medical care with VA in 2011, he reported taking medication for depression. In later records, the Veteran gave a history of taking depression medication from approximately 2000, which was prescribed by his primary care physician. His 2011 VA records identify his private primary care doctor as Dr. Van Vranken. These private records are critical to a complete picture of the Veteran’s mental health history, and they should be requested. Furthermore, the 2011 VA records indicate that the Veteran was receiving Social Security disability benefits. The matter is REMANDED for the following action: 1. Ask the Veteran to complete a release authorizing VA to obtain his records from any private physician(s), to include Dr. Van Vranken, who prescribed medication for depression between approximately 2000 and 2014. If any records are requested but not received, advise the Veteran of that fact. 2. Request the Veteran’s disability claim records from the Social Security Administration. 3. Obtain and associate with the claims file all VA treatment records from December 2017 to present. 4. DO NOT SCHEDULE THE EXAMINATION until all the above records have been obtained to the extent possible.   5. Schedule a psychiatric examination and opinion. The examiner must review the complete claims file, including this remand. Then, the examiner must address the following, with full supporting rationales: (a) Determine whether the Veteran has a current disability, to include PTSD, generalized anxiety and depression. (b) If the examiner diagnoses PTSD, then explain how the relevant diagnostic criteria are met, and answer the following: Whether the evidence of record, including the Veteran’s lay statements and VA treatment records, corroborate the claim that a personal assault occurred in service (38 C.F.R. § 3.304(f)(5)). If the examiner finds that evidence indicates that a personal assault occurred during the Veteran’s active service, the examiner must opine whether PTSD is at least as likely as not related to the Veteran’s claimed in-service personal assault. If an opinion cannot be made without resort to speculation, the examiner must explain why this is so and note what, if any, additional evidence would permit an opinion to be made. (c) For all other acquired psychiatric disorders diagnosed, the examiner must opine whether each diagnosed disorder is not at least as likely as not related to an in-service injury, event, or disease, to include mental and physical abuse that the Veteran claims to have suffered during his training for the Marine Corps. In doing so, the examiner should discuss the Veteran’s mental health history, to include the role, if any, that post-service events played in the development of his psychiatric conditions. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Lee, Associate Counsel