Citation Nr: 18159738 Decision Date: 12/20/18 Archive Date: 12/19/18 DOCKET NO. 16-46 370 DATE: December 20, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include adjustment disorder with mixed anxiety, insomnia, depressed mood, chronic schizoaffective disorder, and mood disorder, not otherwise specified (NOS), is remanded. REASONS FOR REMAND The Veteran had active service from November 1967 to November 1969. This matter comes to the Board of Veterans’ Appeals (Board) from a February 2015 rating decision of the Department of Veterans’ Affairs (VA) Regional Office (RO). After reviewing the claim and evidence of record, the Board finds that the issue on appeal is more accurately stated as listed on the title page of this decision. The Board notes that the United States Court of Appeals for Veterans Claims has held that when a Veteran makes a claim, he or she is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. See Brokowski v. Shinseki, 23 Vet. App. 79 (2009) (holding that a claimant may satisfy the requirement to identify the benefit sought by referring to a body part or system that is disabled or by describing symptoms of the disability); see also Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (holding that the scope of a mental health disability claim includes any mental disorder that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and other information of record). Therefore, the Board has recharacterized the claim for service connection of posttraumatic stress disorder (PTSD) as reflected on the title page. Remand A remand is necessary to provide the Veteran with a VA examination in connection with his claim for service connection of an acquired psychiatric disorder, to include adjustment disorder with mixed anxiety, insomnia, depressed mood, chronic schizoaffective disorder, and mood disorder, NOS. The Veteran initially filed a claim for service connection of PTSD that he asserted was caused by a traumatic in-service event. The Veteran’s service treatment records (STRs), dated 1968, show that he reported having chest pains and difficulty with weight management. The Veteran further reported to a physician that he was feeling tired, the physician noted that there were no physical findings to support a diagnosis for him at that time. In the record is a lay statement from the Veteran that while on the tarmac in a 4-engine propeller plane he and a group of others received a call regarding another passenger. He reported that they then began to head back to the gate when he looked out of the window and he saw a pile of shiny, jello-like material. He stated that he then looked at the propeller and it was throwing out pieces of a body onto the ground, parts of which appeared to still be moving. He then stated that there were pieces of the pile that looked like white lightning bolts, that turned out to be jagged bones sticking out of what remained of the body. He recalled that he was then told to sit down, but said that he could not help but stare. He wrote that the saddest part of the incident was that the person was out there with no one to help them. The Veteran asserts that this event caused him to develop PTSD. See April 2014 Statement in Support of Claim. The RO attempted to verify the Veteran’s stressful event with the Joint Services Records Research Center (JSRRC). The JSRRC later concluded that there was insufficient information to allow for a meaningful search and made a formal finding of lack of information to corroborate the event. See February 2015 JSRRC Memorandum. The Veteran’s lay statements describing the in-service event are competent evidence that an injury or event occurred in-service. Although the JSRRC made a formal finding that there was a lack of information to verify the event, they did not conclude that the event did not occur. While PTSD claims require a verified stressor, service connection claims for other psychiatric disabilities require only an in-service event, disease or injury. Moreover, the lack of corroborating records alone cannot be the sole reason to discount the Veteran’s lay statements regarding an in-service event. A layperson, such as the Veteran, is competent to report such an event because it requires only personal knowledge, as it comes to him through his senses. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Board notes that there is no reason to doubt the Veteran’s credibility with regard to his reported stressor. Following his separation from service, the Veteran was diagnosed with insomnia in August 2000, adjustment disorder with mixed anxiety and depressed mood in February 2005, mood disorder, NOS, in August 2009 and chronic schizoaffective disorder in November 2011. Although, the Veteran reported that he has PTSD, no diagnosis for PTSD has been noted in the record. See List of Diagnoses VA Treatment Record received February 2015. In November 2011, the Veteran was placed on a psychiatric hold; at that time his symptoms were examined. This post-service treatment record shows that he continued to report symptoms of chest pains, difficulty with weight management and trouble sleeping. See November 2011 VA Treatment Record Review of Symptoms. Notably, the examiner indicated that the Veteran’s symptoms of chest pains were related to his anxiety, while his difficulty with weight management was related to his schizoaffective disorder. The Veteran submitted evidence that his schizoaffective disorder could also be related to PTSD. See October 2013 Web Documents. Based on the record, the Veteran should be afforded a VA examination in response to his claim. VA must provide a medical examination or obtain a medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing that certain diseases manifested during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103 (2012); 38 C.F.R. § 3.159 (c)(4)(i) (2017). The third prong of McLendon, which requires that the evidence of record “indicate” that the claimed disability or symptoms “may be” associated with the established event, disease or injury is a low threshold. McLendon, 20 Vet. App. at 83. Here, there is competent evidence of a current disability or persistent or recurrent symptoms of a disability. As noted above, the Veteran has been diagnosed with an acquired psychiatric disorder, to include adjustment disorder with mixed anxiety, insomnia, depressed mood, chronic schizoaffective disorder, and mood disorder, NOS. The Veteran also reported symptoms in-service, that he has continued to report post-service. Additionally, there is competent evidence that these symptoms may be related to a current disability. See November 2011 Treatment Records. Accordingly, the Board finds that the criteria for obtaining a medical examination and opinion pursuant to the holding in McLendon are met. The Veteran’s updated treatment records should be associated with the claims file. The matter is REMANDED for the following actions: 1. Obtain and associate with the claims folder the Veteran’s updated VA treatment records. 2. Then, schedule the Veteran for a VA psychiatric examination to assist in determining the nature and etiology of his psychiatric disorder(s). Following review of the relevant evidence in the record, including a copy of this Remand and any tests deemed necessary, the examiner should provide the following opinions: a. Identify all psychiatric diagnoses present since April 2013. A diagnosis of PTSD under DSM-5 criteria must be ruled in or excluded. If PTSD is diagnosed, determine whether it is at least as likely as not (50 percent probability or higher) due to the claimed in-service stressor. b. For each diagnosis (aside from PTSD), state whether it is at least as likely as not (50 percent or greater probability) that the currently diagnosed psychiatric disorder(s) is related to a disease or injury during service, to include chest pains possibly related to anxiety. *Specific attention is drawn to the STRs, dated in 1968- 69, the November 2011 post-service psychiatric examination, and the Veteran’s lay statements. (Continued on the next page)   3. Then, readjudicate the claim on appeal. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Wagner, Counsel