Citation Nr: 18153849 Decision Date: 11/28/18 Archive Date: 11/28/18 DOCKET NO. 16-34 422 DATE: November 28, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), anxiety disorder, and depressive disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1984 to April 1988. This case is before the Board of Veterans’ Appeals (Board) on appeal from an April 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The Veteran’s psychiatric claim on appeal was initially characterized as a claim of service connection for PTSD. However, as he has also been diagnosed as having unspecified anxiety disorder with major depressed mood, the Board has more broadly recharacterized the claim as one of service connection for an acquired psychiatric disability to include PTSD, anxiety disorder, and depressive disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran seeks service connection for an acquired psychiatric disorder, which he contends is related to his service aboard the USS Midway in 1984, where he witnessed another sailor being blown overboard to his death. This stressor has been confirmed by the Department of the Navy USS Midway Command History. The record indicates that the Veteran has been receiving psychiatric treatment from various VA facilities throughout the pendency of the appeal. Specifically, in an October 2013 statement, the Veteran reported receiving treatment at a VA outpatient clinic since April 2013. Additionally, of record are two, single page active problem lists from VA medical facilities dated in February 2014 and September 2014 reflecting “problems” including general anxiety disorder, depressive disorder, and PTSD. However, the underlying treatment records have not been associated with the claims file. Accordingly, remand is required to obtain these outstanding VA treatment records. Moreover, although the Veteran was provided a VA psychiatric examination in September 2016, the examiner’s opinion disassociating the Veteran’s current psychiatric pathology from his active duty service is inadequate. First, in finding that the Veteran does not meet the criteria for a PTSD diagnosis, the examiner acknowledged, but failed to adequately address, the various PTSD diagnoses dated throughout the pendency of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Second, the examiner’s negative opinion concerning the Veteran’s diagnosed unspecified anxiety disorder with depressed mood focused solely upon whether the psychiatric condition was “caused by the confirmed in-service stressor or the sleeping disorder that was treated in service.” This improperly narrows the scope of the relevant inquiry and does not address whether the current psychiatric condition began during active service. Additionally, although the VA examiner quoted medical records reflecting consistent anxiety symptoms during and since the Veteran’s active service, she failed to reconcile these records with her conclusion that “[t]here is no evidence that the Veteran’s reported mental health symptoms have been chronic since” his active duty. Finally, the VA examination report reflects consideration of medical evidence that is not of record, including VA medical records dated in 2013. Accordingly, a new examination is warranted to diagnose and determine the etiology of any current psychiatric condition. Therefore, the matter is REMANDED for the following actions: 1. Obtain and associate with the claims file any outstanding VA treatment records, to specifically include records dated from April 2013 to April 2015. 2. Contact the Veteran and request that he identify the provider(s) of any additional treatment or evaluation he has received for his claimed psychiatric disorder, records of which are not already associated with the claims file, and to provide any releases necessary for VA to secure records of such treatment or evaluation. Obtain complete records of all such treatment and evaluation from all sources identified. 3. After all available treatment records are associated with the claims file, to the extent possible, obtain a VA examination and opinion from an appropriate examiner to determine the nature and etiology of the Veteran’s acquired psychiatric disorder. The claims folder (including a copy of this remand) must be provided to and reviewed by the examiner as part of the examination. All indicated tests should be accomplished and all clinical findings reported in detail. a) The examiner is asked to identify all current psychiatric diagnoses present during the claim. In doing so, the examiner must specifically consider and discuss the various diagnoses of PTSD throughout the Veteran’s VA treatment record. The examiner must reconcile any contradictory findings. b) For each psychiatric disorder diagnosed, the examiner is asked to provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the disorder had its onset during active service, or is otherwise related to active service. The examiner should be provided with a list of verified stressors. The examiner is advised that the Veteran is competent to report his symptoms/history and that such reports must be acknowledged and accorded proper weight in formulating any opinion. If his reports are discounted, the examiner should provide a reason for doing so. A rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that question. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Griffin, Associate Counsel