Citation Nr: 20003145 Decision Date: 01/15/20 Archive Date: 01/14/20 DOCKET NO. 19-11 982 DATE: January 15, 2020 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1970 to May 1972. A remand is necessary to provide the Veteran with an adequate VA examination to help determine the likely etiology of the claimed psychiatric disorder. Regarding the characterization of the claim, although the Veteran initially submitted a claim of service connection for PTSD alone, his medical record indicates that he was diagnosed with numerous psychiatric disorders. The Board, therefore, has re-characterized the PTSD claim to include entitlement to service connection for an acquired psychiatric disorder in order to contemplate the Veteran’s psychiatric symptoms, however diagnosed. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). In September 2015, the Veteran underwent a VA examination for PTSD, at which time the examiner concluded that the Veteran did not meet the diagnostic criteria for PTSD but diagnosed generalized anxiety disorder. The examiner indicated that the Veteran claimed his psychiatric disorder was due to combat in Vietnam but at the time of the examination reported a stressor related to a plane crash and fire aboard the deck of the ship he was attached to. The examiner opined that the generalized anxiety was less likely than not related to service because the Veteran’s symptoms did not begin until 2010/2011 decades after separation from service, and it would not make sense for symptoms to show up many years after service separation. The examiner then stated that based on the Veteran’s reports, his psychiatric disorder may have preexisted military service. Upon review, the Board finds many deficiencies with this opinion. First, a review of the record showed that the Veteran received mental health treatment and was diagnosed with various psychiatric disorders already in 2003 contrary to the examiner’s notation that symptoms were not noted until 2010. Second, since 2003, the Veteran was diagnosed with depression; possible childhood PTSD; mood disorder and PTSD; dysthymia; major depression, second episode, in partial remission since off medications; and, PTSD from military service; however, the examiner did not address any of these diagnoses or explain how they resolved or no longer showed any pathology. Third, the examiner suggested that the psychiatric disorder may have preexisted service but did not use the correct standard of clearly and unmistakably preexisted service and respond as to whether it clearly and unmistakably was not aggravated by service, given that a psychiatric disorder was not noted at service entry. Lastly, the examiner did not address the Veteran’s lay assertions describing the history of his symptoms nor the multiple statements received from family members and friends, some which described pre-service and post-service observations of the Veteran. Thus, to the extent that the examiner misstated the Veteran’s medical history, the opinion is of no probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). Accordingly, obtaining a new VA examination is necessary prior to deciding the claim on the merits. The matters are REMANDED for the following action: 1. Ensure that all outstanding VA treatment records are associated with the claims file. 2. Thereafter, provide the Veteran with a VA examination to help determine the likely etiology of the claimed psychiatric disorder. The claims file and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials. After a review of the record and examination of the Veteran, the examiner is asked to respond to the following: (a) Identify all currently diagnosed psychiatric disorders, to include depression; possible childhood PTSD; mood disorder and PTSD; dysthymia; major depression, second episode, in partial remission since off medications; PTSD from military service; and, generalized anxiety disorder. If the examiner concludes that a diagnosis of a psychiatric disorder previously shown by the record is not warranted, he/she is asked to address the Veteran’s reported symptoms and explain how the diagnosis resolved or no longer showed any pathology. (b) Elicit from the Veteran’s all signs and symptoms of the claimed psychiatric disorder prior to service, during service, and since separation from service. (c) For each currently diagnosed psychiatric disorder, provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) had its onset during service or is otherwise related to it. In doing so, address the Veteran’s lay assertions as well as letters authored by family members and friends regarding observable behavioral changes. See e.g., VBMS entries titled Statement in Support of Claim on 07/21/2015. (d) For any acquired psychiatric disorder that the examiner concludes clearly and unmistakably existed prior to the Veteran’s active duty service, provide an opinion whether it was clearly and unmistakably NOT aggravated by service. A complete rationale should be provided for all opinions. Please note: lack of contemporaneous medical records does not serve as an “absolute bar” to the service connection claim and cannot be used as a rationale in explaining why the current disability is not related to service. 3. Thereafter, readjudicate the remanded claim. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Yaffe, Associate 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.