Citation Nr: 21001017 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 20-08 208 DATE: January 6, 2021 REMANDED Service connection for posttraumatic stress disorder (PTSD) is remanded. Service connection for an acquired psychiatric disorder other than PTSD to include depression is remanded. REASONS FOR REMAND The Veteran service honorably in the United States Navy from January 1963 to November 1967. These matters come to the Board of Veterans’ Appeals (Board) on appeal from a September 2018 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). This matter is being adjudicated under the legacy appellate framework. The Veteran testified at a personal hearing before the Board in October 2020, and a transcript of the hearing is of record. The Board notes that originally this matter was originally characterized as a single claim for service connection for PTSD. As discussed below however, the Veteran has been diagnosed with depression as well as PTSD. Consequently, the Board finds that a separate claim for service connection for an acquired psychiatric disorder other than PTSD is within the scope of the Veteran’s claim for service connection for PTSD. Clemons v. Shinseki, 23 Vet. App. 1 (2009). 1. Service connection for posttraumatic stress disorder (PTSD) is remanded. 2. Service connection for an acquired psychiatric disorder other than PTSD to include depression is remanded. The Veteran contends that she has a current diagnosis of PTSD which was caused by military sexual trauma (MST) that occurred during her period of service. Unfortunately, this matter must be remanded for further development. The Veteran has provided competent reports of MST including during sworn testimony before the Board. See Transcript. Additionally, the Veteran’s treatment records indicate that the Veteran has a current diagnosis of both PTSD and depression. Nevertheless, the Veteran underwent a VA examination in September 2018 which indicated that a medical nexus did not exists between an in-service incurrence and a current diagnosis of PTSD, because the Veteran did not have a current diagnosis of PTSD or any other mental disorder. The rationale offered by the examiner was that the Veteran reported mild mental health symptoms that were not consistent with a current diagnosis of PTSD. The examiner’s rationale, however, does not explain why the Veteran does not have a diagnose of depression or another mental health disorder. This is held in particularly sharp relief given that the examiner explicitly noted that the Veteran manifested (albeit mild) mental health symptoms. Once VA undertake the effort to provide the Veteran with an examination, it must provide the Veteran with an adequate one, and an adequate examination is sufficiently detailed in order to ensure that VA’s evaluation of the Veteran’s claim is fully formed. Barr v. Nicholson, 21 Vet. App. 303 (2007). In this particular case, the current diagnosis of an acquired psychiatric disorder other PTSD (in this case depression) as well as the Veteran’s competent reports of an in-service incurrence of MST is sufficient to give rise to a claim for service connection for an acquired psychiatric disorder other than PTSD. Unfortunately, the examination results did not explain what facts, data, principles, and methods were relied upon to rule out a diagnosis of an acquired psychiatric disorder other than PTSD, and, as a result, the Board cannot afford it any weight for the purposes of ruling out a diagnosis other than PTSD; let alone a diagnosis contained in the Veteran’s treatment records. Nieves-Rodriguez, 22 Vet. App. 295 (2008). Moreover, there is no other medical opinion indicating whether or not a medical nexus exists between such a diagnosis and an in-service incurrence. Therefore, service connection for an acquired psychiatric disorder other than PTSD must be remanded for a new VA examination discussing these matters in order to ensure that the evaluation of the Veteran’s claim is fully formed. See Barr. A new VA mental examination for an acquired psychiatric disorder other than PTSD is reasonably likely to generate evidence potentially favorable to the Veteran’s claim for service connection for PTSD. Therefore, the Veteran’s claim for service connection for PTSD must be remanded as well in order avoid piecemeal appellate litigation. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. Send a notice to the Veteran advising her that evidence from sources other than the Veteran‘s service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and requesting that she identify and ideally furnish this type of evidence or advise VA of potential sources of such evidence. 2. Thereafter, arrange to provide the Veteran with a VA examination (or if necessary, a telephone interview and a medical opinion based on the evidence of record) in order to discuss the following: (a.) Is it at least as likely as not (50 percent or more) the Veteran has a diagnosis of any mental disorder? Why or why not? If so, then please list them. (b.) What is the medical significance, if any, of the fact that the Veteran sought treatment for mental health symptoms and was diagnosed with depression and PTSD? Why? (c.) Is it at least as likely as not (50 percent or more) that a medical nexus exists between an in-service incurrence (to include military sexual trauma) and a current diagnosis of an acquired psychiatric disorder other than PTSD? Why or why not? (d.) Is it at least as likely as not (50 percent or more) that there is a medical link between a current diagnosis of PTSD and an in-service incurrence (to include military sexual trauma)? Why or why not? (e.) Does the record contain evidence of sudden behavior changes after the reported military sexual trauma? Why or why not? If so, are these   consistent with behavioral changes associated with sexual trauma? Why or why not? DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Seaton 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.