Citation Nr: 18158864 Decision Date: 12/18/18 Archive Date: 12/18/18 DOCKET NO. 15-17 266 DATE: December 18, 2018 REMANDED The issue of entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and major depressive disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1970 to April 1972. This matter comes 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 San Diego, California. The Board has expanded the claim on appeal to one for service connection for an acquired psychiatric disability, to include PTSD and major depressive disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled). Service Connection for an Acquired Psychiatric Disorder is Remanded While further delay is regrettable, the Board finds that additional development is necessary prior to adjudication of the claim. VA’s duty to assist includes a duty to provide a medical examination or obtain a medical opinion where it is deemed necessary to make a decision on the claim. A medical examination or medical opinion is necessary in a claim for service connection if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but: (A) Contains competent lay or medical evidence of a currently diagnosed disability or persistent or recurrent symptoms of disability; (B) Establishes that the Veteran suffered an event, injury or disease in service, or has a disease or symptoms of a disease listed in §§ 3.309, 3.313, 3.316, or 3.317 manifesting during an applicable presumptive period provided the claimant has the required service or triggering event to qualify for that presumption; and (C) Indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service or with another service-connected disability. See 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the Veteran asserts that his psychiatric condition is related to his service. Specifically, in the July 2014 notice of disagreement, he contended that he “witnessed firsthand an attempted suicide by a fellow soldier. I was covered in his blood and have had reoccurring nightmares and depression since that time.” The first prong of McLendon is satisfied because the record contains several current psychological diagnoses. The VA clinicians’ diagnoses of the Veteran include delirium, r/u psychotic disorder in March 2016; PTSD in January 2014; and PTSD and depression in February 2013. In addition, Dr. D.B, a private clinician, diagnosed the Veteran with major depressive disorder in September 2013. The second prong of McLendon is satisfied because the Veteran detailed his in-service stressor. He asserted that he witnessed a soldier attempt to commit suicide. A September 2013 VA treatment documented the Veteran’s report that “he believes a lot of his current mental health issues are related to PTSD and exposure to chemicals during the military.” The third prong of McLendon is satisfied because the evidence indicates that the claimed acquired psychiatric disorder may be associated with the in-service event. The VA psychologist’s January 2014 letter stated “[i]t is my professional opinion that Mr. [redacted] chronic PTSD . . . [is] due to his combat experiences during his service in the Viet Nam War while serving in Okinawa and Johnston Island.” However, there is insufficient information to make a decision in this claim, as there is no credible supporting evidence that the in-service stressor occurred, and the January 2014 opinion relating PTSD to service is therefore inadequate. See 38 C.F.R. § 3.304(f). Consequently, a VA examination is warranted. 38 U.S.C § 5103A(d); See McLendon, 20 Vet. App. at 86. The matter is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the etiology of any diagnosed psychiatric disorder. All indicated tests and studies should be conducted and all clinical findings reported in detail. Refer the Appellant’s claims file to a psychologist or psychiatrist to determine the nature and etiology of any psychiatric disorders. The entire claims file should be made available to and be reviewed by the examiner in conjunction with this request. Following review of the claims file, the examiner should respond to the following: (a.) Please identify all current psychiatric diagnoses of record. (b.) In determining whether the Veteran meets the criteria for a current diagnosis, please consider medical and lay evidence dated both prior to and since the filing of the claim for service connection (here, May 9, 2013). Please note that although the Veteran may not meet the criteria for a diagnosis at the present time, diagnoses made prior to and since the date of claim filing meet the criteria for a “current” diagnosis. Please also note that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinion. (c.) The examiner should endeavor to differentiate symptoms and impairments due to any diagnosed psychiatric disorder. If the examiner cannot differentiate symptoms and impairments, the examiner should state so and provide reasons why such differentiation cannot be made. (d.) For each diagnosed acquired psychiatric disorder, is it at least as likely as not (50 percent probability or more) that the disorder had its onset in service, is related to the Veteran’s reported in-service stressors, or is otherwise related to service? Please explain why or why not. (e.) If the criteria for a diagnosis of PTSD are met, please specify the stressor(s) supporting the diagnosis. 2. In rendering the requested opinions, please specifically discuss the significance of: (1) March 2014 correspondence that documented a diagnosis of PTSD and offered a positive nexus opinion; (2) March 2016 VA treatment record documenting a diagnosis of delirium, r/u psychotic disorder; (3) A February 2013 VA treatment record documenting a diagnosis of depression and PTSD; and (4) Dr. D.B’s September 2013 diagnosis of major depressive disorder. 3. A complete rationale for the opinions rendered must be provided. If the examiner cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why that is so. S. C. KREMBS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD I. Altendorfer, Associate Counsel