Citation Nr: 20023971 Decision Date: 04/07/20 Archive Date: 04/07/20 DOCKET NO. 18-47 710 DATE: April 7, 2020 REMANDED Entitlement to service connection for an acquired psychiatric condition, claimed as combat stress anxiety disorder, is remanded. REASONS FOR REMAND The Veteran served in the Army from July 1980 to May 1991 with a period of service in Southwest Asia. 1. Entitlement to service connection for an acquired psychiatric condition, claimed as combat stress anxiety disorder is remanded. The Veteran is seeking service connection for an acquired psychiatric condition, which he attributes to his service in Southwest Asia. The Veteran was last afforded a VA Mental Condition examination in August 2015. During that examination, the VA examination found that the Veteran did not then, nor had he ever been diagnosed with a mental disorder. Furthermore, the VA examiner concluded that the Veteran did not meet the criteria for an anxiety disorder or any trauma related disorders. However, since the August 2015 VA examination, the Veteran’s VA treatment records show treatment for moderate anxiety in May 2017, a diagnosis of adjustment disorder with depressed mood in July 2017, and a May 2018 diagnosis of persistent depressive disorder. In light of these reports, which provide conflicting evidence as to whether the Veteran has a current psychiatric condition, the Board finds that the AOJ should afford the Veteran a VA examination on remand. VA’s affirmative duty to assist claimants to substantiate their claims includes an obligation to provide a medical examination of obtain a medical opinion when necessary to make a decision on a claim. See 38 U.S.C. § 5103 (a); See also McGee v. Peake, 511 F.3d 1352, 1357 (Fed. Cir. 2008). Furthermore, although the Veteran has applied for entitlement to service connection for combat stress anxiety disorder, the Board finds that a general psychiatric examination should provide testing and determine the exact diagnosis, if any, for the Veteran’s reported symptoms. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (holding that when determining the scope of a claim, the Board must consider the claimant’s description if the claim; the symptoms the claimant describes; and the information the claimant submits or that the Secretary obtains in support of that claim). The matters are REMANDED for the following action: 1. The AOJ should contact the Veteran, and, with his assistance, identify any additional outstanding records of pertinent medical treatment from VA or private health care providers that he has sought treatment from during the period on appeal. 2. After any additional records are associated with the claims file, the AOJ should schedule the Veteran for a VA examination to determine the nature and etiology of any psychiatric disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should identify all current psychiatric disorders. If any previously diagnosed psychiatric disorders are not found on examination, the examiner should address whether they were misdiagnosed or have resolved. (a) For each diagnosis identified, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) that the disorder manifested in or is otherwise causally or etiologically related to the Veteran’s military service. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. The AOJ should review the examination reports to ensure compliance with this remand. If the reports are deficient in any manner, the AOJ should implement corrective procedures. 4. After completing the above actions and any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs, the claims should be reviewed by the AOJ on the basis of additional evidence. If the benefits sought are not granted, the Veteran and his representative should be furnished a supplemental statement of the case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board James Nelson 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.