Citation Nr: 18153948 Decision Date: 11/29/18 Archive Date: 11/28/18 DOCKET NO. 16-29 808 DATE: November 29, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disability to include bipolar disorder and posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1975 to November 1977. This claim is on appeal from a November 2014 rating decision for entitlement to service connection for unspecified bipolar and related disorder (claimed as PTSD). As an initial matter, the Board notes that the scope of a disability claim includes any disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and other information of record. See Clemons v. Shinseki 23 Vet. App. 1 (2009). In light of the rule in Clemons, the Board has recharacterized the issue on appeal as a claim of service connection for acquired psychiatric disability, to include bipolar disorder and PTSD. A hearing was held in July 2017 before the undersigned Judge; a transcript of which is associated with the record. The Veteran contends that his condition was caused by his active duty service. Upon review of the Veteran’s submitted personal lay statement in June 2016, the Board finds that additional development and opinion is necessary before adjudicating the Veteran’s claim. The Veteran’s service treatment record (STRs) shows only two instances which the Veteran sought mental health assistance, the first for depression, and the second for nervousness and sleep issues. In November 2014 a VA examination for initial posttraumatic stress disorder (PTSD) was held for the Veteran. The VA examiner did not find a diagnosis for PTSD for the Veteran. Instead, the VA Examiner found Veteran has another Mental Disorder diagnosis for unspecified Bipolar and Related Disorder. The examiner noted the Veteran reported a long history of depression after service, agitated periods with racing thoughts, and impulsive buying. The VA examiner opined: While there is a possibility that this is a major depression, agitated, [the VA examiner is] more impressed by the likelihood of a bipolar condition given the overall history [the Veteran] presents with. It is more likely than not (more than 50-50 probability) this is a non-SC disorder. In a March 2016 addendum opinion, the same VA examiner addresses the only two events in the Veteran’s STRs which the Veteran sought mental health assistance in service. The VA examiner opined: While these symptoms [depression, nervousness and sleep issues] can be associated with a bipolar condition, the lack of their occurring on more than one occasion each would also be consistent with an adjustment reaction at those times. I would have to resort to mere speculation to opine if the Veteran’s report one time each of feeling nervous/trouble with sleep, and depressed, are related to his bipolar condition for which he was not treated until years after out of the service. The Veteran submitted a personal lay statement in June 2016 in support of his claim. In his lay statement, the Veteran described events suffered in service, including being assaulted by fellow service-members while on liberty shortly after service assignment, harassment and threats from petty officers resulting in unfavorable work assignments, and other events which the Veteran reported being beat up. The Veteran also spoke about an incident which he witnessed his friend bang his head repeatedly against the wall without anyone intervening to help; shortly after which the friend died and the Veteran was responsible to accompany the body back home. The November 2014 VA examination describes this event only that the Veteran’s friend experienced a headache and shortly died in sick bay. The VA examination does not address the other Veteran’s lay statements describing the harassments and incidents of assault in service. The Board finds that the Veteran’s June 2016 personal lay statement describes events that could potentially represent stressors relating to his claim for PTSD. While the Board notes the November 2014 VA examination does not find a diagnosis for PTSD, the Veteran’s statements came after this examination, and may be considered probative to adjudicating the Veteran’s claim. Therefore, a remand is necessary for further development and opinion. The matter is REMANDED for the following action: 1. Obtain and associate with the claims file all updated treatment records. 2. After completing the development requested above, schedule a new VA examination to determine the nature and etiology of any current psychiatric disorder, to include bipolar disorder, PTSD, and any other identified psychiatric disorder during the appeal period. The Veteran’s claims file should also be made available to and be reviewed by the reviewing clinician. In completing this examination, the examiner is asked to respond to the following: (a.) Identify all diagnosed psychiatric disorders. All diagnostic findings must be reconciled with conflicting evidence in the record. If a previously documented diagnosis is deemed incorrect or obsolete (i.e., subsumed by a more appropriate diagnosis), the examiner must explain why. (b.) For any diagnosed psychiatric disorder, is it at least as likely as not (50 percent probability or greater) the disability had its onset during, was caused by, or is otherwise related to active service? A detailed history of relevant symptoms should be obtained from the Veteran. All indicated studies should be performed. If the examiner diagnoses PTSD, the examiner should indicate the in-service stressor underlying that diagnosis; and should provide an opinion answering the following questions: 1. Is the claimed stressor(s) adequate to support a diagnosis of PTSD, and; 2. Are the Veteran’s symptoms related to the claimed stressor(s)? (c.) In providing this opinion, the examiner should also consider and address the Veteran’s June 2016 lay statements to identify any potential stressors and opine why or why not they were considered. A complete rationale for all opinions expressed should be provided. 3. After completion of the above and any additional development deemed necessary, the issues on appeal should be reviewed with consideration of all applicable laws and regulations. If any benefit sought remains denied, the Veteran should be furnished a supplemental statement of the case and be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review, if in order. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Yang, Law Clerk