Citation Nr: 20021474 Decision Date: 03/25/20 Archive Date: 03/25/20 DOCKET NO. 15-00 644 DATE: March 25, 2020 REMANDED Entitlement to service connection for any acquired psychiatric disorder, however diagnosed and to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1969 to August 1971. This matter is before the Board of Veterans’ Appeals (Board) on appeal of a December 2012 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA). In March 2017, the Veteran testified at a hearing before the undersigned. In May 2018, the Board remanded the claim for additional development. This development is complete, and the issue is returned to the Board for additional appellate review. The Veteran filed a claim seeking service connection for PTSD. The Board notes, under the holding in Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009), such a claim is reviewed as one seeking service connection for any acquired psychiatric disorder which is encompassed by the Veteran’s reported symptomatology. Accordingly, the issue at hand has been recharacterized to reflect the broader scope of the Veteran’s claim. The Board notes, in November 2019 the Veteran submitted a VA Form 20-0996 seeking Higher Level Review under the Appeals Modernization Act (AMA system). The Veteran did not indicate on this form that he was withdrawing this appeal from the current Legacy review system and he did not submit any other written notification that he wished to withdraw from the Legacy system. Accordingly, the November 2019 Form 20-0996 did not effectuate a switch into the AMA system. Review of his claim continues under the Legacy appeal system. Entitlement to service connection for any acquired psychiatric disorder, however diagnosed and to include posttraumatic stress disorder (PTSD), is remanded. VA has a duty to ensure any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (overruled on other grounds, Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board’s evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The Board’s May 2018 decision noted the Veteran submitted records from a private mental health counselor which included a diagnosis of PTSD. As the private counselor did not provide an opinion linking the diagnosed PTSD to the Veteran’s stressor of combat or fear of hostile military activity, the Board remanded the claim so that an additional VA examination could be provided. The Board directed the VA examiner to determine whether the Veteran had a current diagnosis of any psychiatric disorder, including PTSD, and to address whether any such psychiatric disorder was related to the claimed stressors. A new VA PTSD examination was provided in March 2019. The examiner conducted an in-person examination. He reviewed the Veteran’s VA and private mental health treatment records, the March 2017 hearing transcript, and a January 2013 statement from the Veteran’s wife. Ultimately, the examiner found the Veteran reported “some mild, subclinical symptoms (i.e., increased startle, hypervigilance), but these symptoms do not result in significant functional impairment or distress, have not required consistent mental health treatment or pharmacotherapy, and do not meet the criteria for a full diagnosis of PTSD.” The examiner also found the Veteran’s symptoms did not rise “to the level of meeting DSM-5 diagnostic criteria for a mental disorder.” However, for the reasons discussed below, the March 2019 examiner’s report is insufficient to evaluate the claim. In support of his finding of no diagnosis, the examiner observed the Veteran had been married for 38 years and described his marriage as “great.” He also noted the Veteran had a long and stable career working in sales, including the last 35 years with the same company. Although the examiner listed the January 2013 letter from the Veteran’s wife as having been reviewed, he did not comment on her account of their homelife and the Veteran’s employment situation. The Veteran’s wife described the Veteran as needing to maintain tight control over his emotions and over routine household chores. She noted that any break from having this control “sets him off” which was “not pleasant to be around.” She noted his behavior might have lead them to divorce, but she was determined to stand by her family and she understood his behavior was related to his mental health. In addition, she explained that the Veteran had maintained his long career as an “outside salesperson” because of the flexibility it offered. The Veteran set his own hours and was able to curtail his schedule on bad days. Although the examiner purported to have reviewed this letter, he did not discuss these assertions. His evaluation of the Veteran’s family relationships and employment history appears to be incomplete. Further, the examiner noted the Veteran had current symptoms of nightmares, flashbacks, avoided movies about the Vietnam War or World War II, was uncomfortable in crowds, was unable to sit with his back to the door, became startled when touched unexpectedly, and was mildly irritable at times. However, in evaluating whether the diagnostic criteria for PTSD were met, the examiner only indicated current symptoms of recurrent distressing dreams and an exaggerated startle response. As no reason was provided for discounting the reported symptoms, it appears that the examiner did not considered all symptoms in evaluating the diagnostic criteria. Moreover, the Veteran provided a list of mental health symptoms (including his preference to be alone and his desire to always have a loaded gun nearby) in a statement associated with his January 2013 notice of disagreement (NOD). The examiner did not address these symptoms. Finally, the examiner’s opinion specifically pointed to the Veteran’s history of obtaining and maintaining a private pilot’s license for about 10 years in the 1970’s and his lack of sustained or prolonged mental health treatment The Board notes, the Veteran possessed the pilot’s license more than three decades prior to filing his claim and it is not clear how this achievement is relevant to the issue at hand. Although the Veteran did not seek mental health treatment for many decades following his active service, his wife testified that she had long encouraged him to seek treatment, but he was reluctant to do so. Without additional discussion, it is not clear why the examiner considered the lack of treatment to be relevant to establishing a current diagnosis. The March 2019 VA examination did not fully consider and discuss the Veteran’s mental health history, including evidence presented in a January 2013 letter and at the March 2017 Board hearing. In addition, the rationale offered to support the examiner’s conclusion was not fully explained and appeared to rely on evidence which is not relevant to the issue. The examination and medical opinion are not sufficient to evaluate the claim. An additional examination must be provided. See Stefl, supra. The matters are REMANDED for the following action: Schedule the Veteran for a psychiatric examination, by a qualified examiner who has not previously evaluated the Veteran, to determine the nature and etiology of any posttraumatic stress disorder (PTSD). If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and identify the stressor or stressors upon which the diagnosis of PTSD is based. If any other acquired psychiatric disorders are diagnosed, the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease, to include the Veteran’s service in Vietnam. The examiner must fully discuss the private mental health treatment records, the Veterans contentions in his January 2013 NOD, the January 2013 letter from the Veteran’s wife, the January 2013 letter from the Veteran’s former wife, and the March 2017 hearing transcript. Further, the examiner must provide a complete explanation for all opinions expressed. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Jeanne Celtnieks 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.