Citation Nr: 20003246 Decision Date: 01/14/20 Archive Date: 01/14/20 DOCKET NO. 17-45 495 DATE: January 14, 2020 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include adjustment disorder with depressed mood and posttraumatic stress disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from August 1969 to August 1973, and from September 1973 to May 1978. The Veteran also has active service in the United States Army from August 2009 to July 2011. This appeal comes before the Board of Veterans’ Appeals (Board) from a March 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) in Albuquerque, New Mexico. In September 2019, the Veteran testified at a video conference hearing in the Albuquerque RO before the undersigned Veterans Law Judge sitting at the Central Office in Washington, D.C. A transcript of the hearing is available in the record. 1. Entitlement to service connection for an acquired psychiatric disorder, to include Adjustment Disorder with Depressed Mood and PTSD, is remanded. The Veteran has claimed entitlement to service connection for Posttraumatic Stress Disorder (PTSD). As the Veteran’s diagnoses for his mental condition have varied, the Board has recharacterized the claim as a generalized claim for an acquired psychiatric disorder, to include adjustment disorder with depressed mood. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Over the course of his claim, the Veteran has pointed to a variety of different traumatic stressor events from his military career as the possible causes of his mental health condition. These include two reported traumatic incidents during the Vietnam War. No military records in the Veteran’s claims file indicate that he served in the Vietnam War. In April 2013, a VA official spoke with the Veteran by telephone, and noted in a report of that call, “Veteran indicated he did not serve in Vietnam.” See April 2013 VA Form 21-0820 Report of General Information. Accordingly, the Board finds the Veteran did not serve in Vietnam. The Veteran has been diagnosed with PTSD on two occasions. Both diagnoses relied upon an incorrect supposition that the Veteran fought in Vietnam. In June 2014, a private neuropsychologist diagnosed the Veteran with PTSD based on two incidents reported by the Veteran. The first incident entails that while he was in Vietnam, someone attempted to strangle the Veteran as he slept, but the attempt failed as the person accidentally wrapped the rope or wire around his feet instead of his neck. The second reported incident involves one of the Veteran’s comrades having sex with a Vietnamese prostitute who reportedly had placed razor blades in her vagina. The Veteran reported he and his colleagues heard his comrade’s screams and had to rescue him. See June 2014 Medical Treatment Record – Non-Government Facility. The private examiner relied heavily upon these two purported accounts in diagnosing the Veteran with PTSD. In December 2016, VA medical treatment records indicate another PTSD diagnosis. The records from that evaluation are cursory: the diagnosis does not provide an etiological opinion regarding the origin of the Veteran’s condition, nor note any specific stressors which may have led to the Veteran’s condition. However, the examiner made note that the Veteran served in Vietnam. See December 2016 VA Medical Treatment Record. The record contains only one psychological examination which does not rely upon purported combat experience by the Veteran. In April 2013, a VA examiner found the Veteran suffered from Adjustment Disorder with Depressed Mood under guidelines of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). The examiner considered five distinct, non-combat-related stressors reported by the Veteran, and found that none of them would be sufficient to support a diagnosis of PTSD. See April 2013 VA Examination. However, the examiner was silent as to whether the diagnosed Adjustment Disorder condition was related to any of the Veteran’s reported stressors, or is otherwise related to the Veteran’s military service. The examiner did not offer any etiological opinion regarding the diagnosed condition. Id. The Board finds that none of the mental health diagnoses of record are sufficient for the Board to reach a decision regarding the Veteran’s claim. The June 2014 and December 2016 diagnoses of PTSD each rely upon a supposition that the Veteran fought in Vietnam, which the Veteran has acknowledged is not correct. The April 2013 examination did not contain this defect, but it is insufficient for other reasons: the examination is now nearly 7 years old, and its diagnosis of Adjustment Disorder under DSM-IV guidelines did not contain an etiological statement opining whether the Veteran’s mental health condition is related to his military service. Once VA undertakes the effort to provide a medical examination or opinion, it must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). The Board additionally notes that VA has issued a memorandum in July 2017 indicating a lack of required information to verify whether the Veteran’s reported stressors actually occurred. These include three distinct non-combat stressors as follows: 1) in 1974, the Veteran reports he was on a unit hike up Mount Fuji in Japan when a gunnery sergeant had a heart attack and died in the Veteran’s arms; 2) in 1978, the Veteran reports as a drill instructor at Marine Corps Recruit Depot, San Diego, California, he watched a Marine recruit jump from a three-story building; and 3) in 2005 or 2006 in Placitas, New Mexico, the Veteran tried to help a National Guard soldier who had a heart attack during a training road march. The memorandum notes that the information in the Veteran’s claims file was insufficient to research or verify these stressors. The memorandum further notes the Veteran’s responses to requests for clarification were also insufficient, in that the Veteran has never provided a 60-day window for any of the events, nor the names of the individuals who died. During his Board hearing, the Veteran provided some additional information on the above incidents, and suggested other possible stressors that may have led to a mental health condition. The Board must consider only independent medical evidence to support its findings rather than provide its own medical judgment. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). As a result, further medical opinion is necessary. The matters are REMANDED for the following action: 1. Contact the Veteran and request that he provide any additional information, including approximate dates and specific details regarding the claimed stressors he has previously recounted in the July 2017 VA Form 9 and during the September 2019 Board hearing. 2. Schedule the Veteran for a psychological evaluation to determine the nature and etiology of any diagnosed acquired psychiatric condition, including PTSD and Adjustment Disorder with Depressed Mood. The examiner should review and consider the Veteran’s entire claims file, including this decision, in diagnosing the Veteran’s mental health condition. The examiner should directly address the etiology of any diagnosed condition. If a diagnosed condition is attributed to an in-service incident, the examiner should specifically identify that incident so that further military records verification may be conducted. a. The examiner is invited to consider the previous diagnoses of PTSD in June 2014 by a private neuropsychologist and in December 2016 by a VA physician, as well as a Buddy/Lay Statement submitted by the Veteran’s spouse, all of which have relied upon the supposition that the Veteran served in the Vietnam War. The examiner is advised that the Veteran did not serve in Vietnam. b. The examiner’s attention is invited to the April 2013 VA examination which diagnosed Adjustment Disorder with Depressed Mood. 3. If the above examination results in a diagnosis of PTSD, the agency of original jurisdiction should identify any stressors cited by the examiner as the cause of the Veteran’s PTSD, and attempt to verify whether the stressor(s) actually occurred, using updated information from the Veteran’s examination, the Veteran himself, and the Veteran’s statements during his hearing in September 2019. The AOJ should attempt to seek verification from JSRRC or another appropriate agency. If the information provided is insufficient to verify whether the stressor(s) actually occurred, the AOJ should prepare a formal memorandum documenting that finding and attach it to the Veteran’s claims file. K. J. ALIBRANDO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Hermsdorfer, 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.