Citation Nr: 19143753 Decision Date: 06/06/19 Archive Date: 06/05/19 DOCKET NO. 16-52 248 DATE: June 6, 2019 REMANDED Entitlement to service connection for an acquired psychiatric disability, claimed as posttraumatic stress disorder (PTSD) and a mood disorder, is remanded. Entitlement to service connection for a sleep disability, claimed as sleep apnea, to include as due to an undiagnosed illness, is remanded. Entitlement to service connection for a respiratory disability, to include as due to an undiagnosed illness, is remanded. REASONS FOR REMAND The Veteran served on active duty from January 2007 to July 2007, July 2007 to June 2008, May 2012 to September 2012 and October 2012 to January 2014. The Veteran testified before the undersigned Veterans Law Judge in January 2019. A copy of the transcript is of record. As noted above, the Board is recharacterizing the Veteran’s PTSD claim to include all psychiatric disorders that have been diagnosed. See Brokowski v. Shinseki, 23 Vet. App. 79 (2009); see also Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record). 1. Entitlement to service connection for an acquired psychiatric disability, claimed as PTSD and a mood disorder, is remanded. Although a VA examination was most recently completed in October 2014, the Veteran has since been diagnosed with additional psychiatric disabilities not considered at this examination, PTSD (September 2015), a mood disorder (May 2015), a depressive disorder (June 2015), and a bipolar disorder (October 2015). In light of this evidence, the Veteran should be afforded an additional VA examination to determine the nature and etiology of any acquired psychiatric disability found. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). 2. Entitlement to service connection for a sleep disability, claimed as sleep apnea, to include as due to an undiagnosed illness, is remanded. The Veteran asserts that he suffers from a sleep disability due to an undiagnosed illness caused by service. Treatment records following service document complaints of sleep problems. See December 2014 VA treatment record. An October 2014 VA examiner noted that the Veteran did not meet the diagnostic criteria for sleep apnea. A VA medical opinion was not provided. It remains unclear if the Veteran’s claimed sleep problems are part of his claimed acquired psychiatric disability, or a separate problem. The Board finds that an additional VA compensation examination and medical opinion is critical to the claim and should be obtained. 3. Entitlement to service connection for a respiratory disability, to include as due to an undiagnosed illness, is remanded. The Veteran underwent a VA examination regarding his claimed respiratory disability in October 2014. The VA examiner provided a vague negative opinion without supporting rationale. Additionally, he failed to address treatment in service for several upper respiratory infections in January 2007, March 2007 and July 2012. Instead, his opinion focused on the in-service treatment for pneumonia. The Board finds that an additional VA examination and opinion are warranted. The matters are REMANDED for the following actions: 1. Arrange for the Veteran to undergo a VA psychiatric examination to determine the nature and etiology of any acquired psychiatric disability, and its relationship, if any, to his military service. Any necessary testing should be conducted. The claims file must be reviewed in conjunction with such the examination, and the examiner must indicate that such review occurred. The VA examiner is asked to address the following questions: a) The VA examiner should confirm whether any of the claimed stressors are adequate to support a diagnosis of PTSD and whether the Veteran’s symptoms are related to the claimed stressor(s). If a diagnosis of PTSD is deemed appropriate, the examiner must identify the specific stressor(s) underlying the diagnosis and should comment upon the link between the current symptomatology and the Veteran’s claimed stressor(s). b) If the examiner determines that the clinical evidence does not support a diagnosis of PTSD, to include that the claimed stressors do not support the diagnosis, the examiner should list all diagnosed psychiatric disorders and specifically state whether it is at least as likely as not (a 50 percent probability of greater) that any diagnosed psychiatric disorder, to include any diagnosed during the period on appeal, either began during or was otherwise caused by the Veteran’s military service. c) If the VA examiner determines that a diagnosis of PTSD has not been demonstrated at any point in time since the Veteran filed his claim, the VA examiner must provide rationale for this determination. Any opinions offered should be accompanied by a clear rationale consistent with the evidence of record. If the examiner finds it impossible to provide any part of the requested opinions without resort to pure speculation, he or she should so indicate and provide a rationale as to why such a finding is made. 2. Arrange for the Veteran to undergo a VA examination to determine the nature and etiology of any sleep disability found to be present, and its relationship, if any, to his military service. Any necessary testing should be conducted. The claims file must be reviewed in conjunction with such examination, and the examiner must indicate that such review occurred. a) The examiner must first provide an opinion as to whether there is objective evidence that the Veteran suffers a sleep disability. b) If a sleep disability is identified, the examiner must state whether it is as least likely as not (a 50 percent probability or greater) the disability had its onset in service or is otherwise related to service, including to service in Southwest Asia. In responding to this question, the examiner must specify whether any such diagnosis is separate from the Veteran’s acquired psychiatric disability. c) If the Veteran’s sleep symptoms cannot be ascribed to any known clinical diagnosis, the examiner must specify whether the Veteran has objective indications of a chronic disability resulting from an undiagnosed illness, as established by history, physical examination, and laboratory tests, that have either (1) existed for 6 months or more, or (2) exhibited intermittent episodes of improvement and worsening over a 6-month period. All opinions offered must be accompanied by a clear rationale consistent with the evidence of record. If the examiner finds it impossible to provide any part of the requested opinions without resort to pure speculation, he or she should so indicate and provide a rationale as to why such a finding is made. 3. Arrange for the Veteran to undergo a VA examination to determine the nature and etiology of any respiratory disability found to be present, and its relationship, if any, to his military service. Any necessary testing should be conducted. The claims file must be reviewed in conjunction with such examination, and the examiner must indicate that such review occurred. a) The examiner must first provide an opinion as to whether there is objective evidence that the Veteran suffers a respiratory disability. b) If a respiratory disability is identified, the examiner must state whether it is as least likely as not (a 50 percent probability or greater) the disability had its onset in service or is otherwise related to service, including to service in Southwest Asia. c) If the Veteran’s respiratory symptoms cannot be ascribed to any known clinical diagnosis, the examiner must specify whether the Veteran has objective indications of a chronic disability resulting from an undiagnosed illness, as established by history, physical examination, and laboratory tests, that have either (1) existed for 6 months or more, or (2) exhibited intermittent episodes of improvement and worsening over a 6-month period. All opinions offered must be accompanied by a clear rationale consistent with the evidence of record. If the examiner finds it impossible to provide any part of the requested opinions without resort to pure speculation, he or she should so indicate and provide a rationale as to why such a finding is made. CAROLINE B. FLEMING Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A.M. Clark, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.