Citation Nr: 18153987 Decision Date: 11/29/18 Archive Date: 11/28/18 DOCKET NO. 16-51 720 DATE: November 29, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from July 2009 to March 2010, October 2010 to February 2011, and March 2013 to March 2014. Although the Veteran submitted a claim for PTSD, the Board has recharacterized the issue as a claim for an acquired psychiatric disability, generally. The Veteran cannot be required to know whether the symptoms he is claiming service connection for are related to PTSD or another psychiatric disability. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Upon review of the record, the Board finds that the issue must be remanded. The Board sincerely regrets the additional delay caused by this remand, but wishes to assure the Veteran that it is necessary for a full and fair adjudication of his claim. 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD With regard to the acquired psychiatric disorder, to include PTSD claim, it appears as though the Veteran’s March 2015 VA PTSD examination is incomplete. In section 3a of the examination, the examiner recorded the Veteran’s claimed stressor, and found that it met “Criterion A” of the PTSD criteria. However, in section 4 of the examination, the examiner did not identify how the Veteran met “Criterion A;” indeed, the examiner did not complete any part of section 4, nor did the examiner complete any part of section 5 which identifies the Veteran’s symptoms. The examiner did, however, record the Veteran’s assertion that he had a prior diagnosis of PTSD and was taking psychotropic medication until 2 months prior. Nonetheless, the examiner concluded, without further explanation, that the Veteran did not have a mental health disorder. As the examiner did not support the conclusion with supporting data and reasoned medical explanations connecting the two, the Board finds the examination inadequate. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Accordingly, the Board finds a remand is warranted for further evidentiary development. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes to provide a medical examination or opinion, it must ensure that the examination or opinion is adequate); see also Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board’s duty to return an inadequate examination report “if further evidence or clarification of the evidence . . . is essential for a proper appellate decision”). In addition, in his informal hearing presentation and Substantive Appeal, the Veteran noted that there were outstanding records from “American Lake VAMC” that may contain evidence of his diagnosis. Remand is required to attempt to obtain any outstanding records. The matter is REMANDED for the following action: 1. Assist the Veteran in associating with the claims folder updated treatment records, including, but not limited to those from “American Lake VAMC.” 2. After any additional records are associated with the claims file, schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s acquired psychiatric disorder, to include PTSD. The claims file should be made available to the examiner for review in connection with the examination. Based on review of the record and examination of the Veteran, the examiner should respond to the following: a) Provide a diagnosis for any current psychiatric disorder and identify any psychiatric conditions suffered at any time during the period on appeal. b) State whether it is at least as likely as not (probability of 50 percent or more) that any of the identified psychiatric disorders are related to the Veteran’s active service. In rendering the opinion, the examiner must address the Veteran’s contention that he had been diagnosed with PTSD and had been prescribed psychotropic medication. The examiner must provide the rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. (Continued on the next page)   3. Conduct any further development necessary as the result of directive number 2, including any needed development with regard to the Veteran’s alleged stressor(s). A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Gandhi, Associate Counsel