Citation Nr: 18100713 Decision Date: 04/19/18 Archive Date: 04/19/18 DOCKET NO. 14-41 244 DATE: April 19, 2018 ISSUES DECIDED: 0 ISSUES REMANDED: 2 REMANDED ISSUES Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), to include as secondary to the service-connected residuals of traumatic brain injury (TBI) and entitlement to a higher initial disability rating in excess of 10 percent for residuals of traumatic brain injury (TBI) are remanded for additional development. The Veteran served on active duty from October 1986 to November 1990. In November 2016, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. Regarding the Veteran’s claim for an increased disability rating for TBI, during his November 2016 Travel Board hearing, he testified that his symptoms have worsened. As the Veteran last underwent VA examination for residuals of TBI in August 2010 and nearly eight years have passed since that time, a new VA examination to address the current severity of the Veteran’s service-connected residuals of TBI is warranted. Regarding the Veteran’s claim for service connection for an acquired psychiatric disorder, to include PTSD, the Veteran also testified that he thinks his psychiatric disabilities is a combination of several in-service incidents, to include the initial in-service head injury when he was attacked and witnessing several on board ship incidents, including hitting a mine and shooting down a civilian aircraft. The Board notes that the Veteran’s initial August 2010 VA mental health examination failed to diagnose an acquired psychiatric disorder. However, the Veteran’s VA treatment records contain several diagnoses, to include depressive disorder, in June 2013. In light of the above, a new VA examination is warranted. Updated treatment records should also be obtained. The matters are REMANDED for the following actions: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities. After securing any necessary releases, the AOJ should request any relevant records identified. In addition, obtain updated VA treatment records. If any requested records are unavailable, the Veteran and his representative should be notified of such. 2. After records development is completed, schedule the Veteran for a VA TBI examination to determine the current severity of the service-connected residuals of TBI. The claims file should be reviewed by the examiner. All necessary tests should be performed and the results reported. All symptomatology associated with the service-connected residuals of TBI should be reported. 3. After records development is completed, the Veteran should be afforded a VA PTSD examination. The claims file should be reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted and the results reported. Following review of the claims file and examination of the Veteran, the examiner should respond to the following: a. Please indicate whether the Veteran meets the diagnostic criteria for PTSD and if so, identify the stressors upon which the diagnosis is based. b. For any other diagnosed psychiatric disorder, to include depressive disorder as diagnosed in VA treatment records, please provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the current psychiatric disability arose during service or is otherwise related to service. c. If not related to service, is it at least as likely as not that the current psychiatric disability was caused by the service-connected residuals of TBI? d. If not caused by the service-connected residuals of TBI, is it at least as likely as not that the Veteran’s current psychiatric disability is worsened beyond natural progression (aggravated) by his service- connected residuals of TBI? If the examiner finds that the Veteran’s psychiatric disability was aggravated by his service-connected residuals of TBI, the examiner should attempt to quantify the level of aggravation beyond the baseline level of the psychiatric disability. A rationale for all opinions expressed should be provided. 4. After undertaking the development above and any additional development deemed necessary, the Veteran’s claims should be readjudicated. If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and be given an appropriate period to respond thereto before the case is returned to the Board, if in order. K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Medina, Associate Counsel