Citation Nr: 18158150 Decision Date: 12/14/18 Archive Date: 12/14/18 DOCKET NO. 16-19 227A DATE: December 14, 2018 REMANDED Entitlement to service connection for a psychiatric disorder, to include anxiety, depression, and posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1969 to November 1970, with service in the Republic in Vietnam from December 1969 to November 1970. The Veteran initially filed a claim of entitlement to service connection for a mental health condition, specifically PTSD, which was denied. However, in Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the United States Court of Appeals for Veterans Claims clarified how the Board should analyze claims for posttraumatic stress disorder and other acquired psychiatric disabilities. As emphasized in Clemons, a 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.” Id. As the evidence reflects that the Veteran has other psychiatric diagnoses, the issue has been recharacterized as a psychiatric disorder, to include anxiety, depression, and PTSD. 1. Entitlement to service connection for a psychiatric disorder, to include anxiety, depression, and PTSD, is remanded. The claim for service connection for a psychiatric disorder is being remanded for a new VA examination. The May 2013 VA examiner noted that the Veteran received mental health treatment prior to enlistment. However, service treatment records (STRs) reflect that the Veteran denied having any psychiatric issues and had a normal psychiatric evaluation at his enlistment examination. Therefore, the Veteran was presumed to have been in sound condition at the time of enlistment. See 38 C.F.R. § 3.304(b)(1). As the presumption of soundness has attached, VA holds the burden of proving by clear and unmistakable evidence that both (1) the Veteran’s psychiatric disorder preexisted service and (2) that it was not aggravated by service. 38 U.S.C. § 1111. Unfortunately, although he had a VA examination in May 2013, the VA examiner did not make any such findings. Furthermore, the Agency of Original Jurisdiction (AOJ) should attempt to corroborate the Veteran’s claimed stressors. The matter is REMANDED for the following action: 1. The AOJ should confirm that it has taken all steps to corroborate the Veteran’s reported stressors, to include: a) Being shot at by a disgruntled soldier in February 1970. b) Having others not like him, refuse to follow his orders, taunt him, and threaten him and his wife. c) A group of Puerto Ricans threatening him in Vietnam, refusing to show up for guard duty or clean the latrine, and threatening to “blow him away.” d) Any other stressors raised by the record. 2. Then, provide the Veteran with a VA examination to determine the nature and etiology of his claimed psychiatric disorder. All tests and studies deemed necessary shall be performed. The examiner should be provided with the Veteran’s claims file, including a copy of this remand. Although a complete review of the record is imperative, attention is called to the following: *STRs including the September 1969 enlistment examination reports and the November 1970 separation examination report, which reflect normal psychiatric evaluations and/or the Veteran’s denial of depression or excessive worry and nervous trouble of any sort. *A February 2011 VA treatment record reflecting that the Veteran was seen for depression since 1990. *A September 2011 VA treatment record reflecting that the Veteran served 10 months in combat in Vietnam as a squad leader, that his unit was fired upon, but that he felt more afraid of members on his team than the enemy. *The February 2013 claims application in which the Veteran contended that he had PTSD due to combat and noted shoot-outs on guard duty and in the barracks, others being shot down, hearing mortars in the distance, being threatened by other soldiers, and having to confront other soldiers. *A February 2013 VA treatment record reflecting the Veteran’s report of the primary stressor being “lifers” whom he commanded but who hated him, disobeying orders, threatening him with their weapons, and attempting to kill him. *A May 2013 VA examination report reflecting a diagnosis of PTSD, noting mental health treatment received prior to enlistment, and reflecting an opinion that the Veteran’s PTSD was more likely than not related to his childhood. After reviewing the claims file in its entirety, the examiner is asked to provide an opinion addressing the following: (a) Whether there is clear and unmistakable evidence that the Veteran’s claimed psychiatric disorder preexisted service. If so, whether there is clear and unmistakable evidence that it was not aggravated by service. See U.S.C. § 1111. (b) If answers to the above questions in section (a) are negative, provide an opinion as to whether the Veteran’s claimed psychiatric disorder at least as likely as not (50 percent probability or greater) had its onset during active service. **Attention is called to July 2018 statement provided by a VA psychiatrist as to the etiology of the Veteran’s psychiatric disorder. A complete rationale should be provided for any opinion provided. (Continued on the next page)   3. Thereafter, readjudicate the remanded claim on appeal. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Jane R. Lee