Citation Nr: 21001629 Decision Date: 01/11/21 Archive Date: 01/11/21 DOCKET NO. 16-25 433 DATE: January 11, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran had active duty in the United States Army from May 1966 to April 1972. During the majority of his active duty service, the Veteran’s military occupational specialty was an explosive ordnance disposal officer. The Veteran is the recipient of multiple decorations and commendations, including a Bronze Star Medal. This case comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In November 2020, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran’s claims file. The Board has recharacterized the issue on appeal as entitlement to service connection for an acquired psychological disorder, to include PTSD. In Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the United States Court of Appeals for Veterans Claims (Court) held that when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. Regrettably, a remand is necessary in this case to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. 38 U.S.C. § 5103; 38 C.F.R. § 3.159. Acquired psychiatric disorder, to include PTSD The Veteran contends that an acquired psychiatric disorder, to include PTSD, was incurred in, aggravated by, or otherwise attributable to, active duty service. Here, the Board observes that the Veteran has reported extensive accounts of in-service events which caused his alleged acquired psychiatric disorder. See, e.g., February 13, 2013 VA 21-0791; October 10, 2014 NOD; November 11, 2020 Hearing Transcript. The Board finds that this extensive body of lay evidence is plausible, consistently reported, and consistent with his service records as an artillery officer in Vietnam and as an explosive ordnance disposal officer (EOD) after Vietnam service. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995). The Board finds that additional development is necessary to the adjudicate the Veteran’s acquired psychiatric disorder service connection claim. Specifically, the Board requires additional and current psychological guidance concerning divergent findings in a July 2013 VA PTSD examination report and a private psychologist’s initial psychological evaluation (facially dated February 2012 and received by VA in February 2013). Whereas the VA psychologist indicated that the Veteran did not meet the applicable criteria for a diagnosis of PTSD (or any other mental health disorder), the private psychologist provided a diagnosis of PTSD, moderate and chronic. Even though the VA psychologist did not provide a mental health diagnosis, this clinician made positive findings as to diagnostic axes and symptomatology (psychosocial and environmental problems manifesting as mild interpersonal dysfunction associated with perfectionist and control tendencies; mild transient and expectable reactions associated with mild difficulty in social or occupational functioning). This psychologist further opined that one stressor was present and the Veteran had experienced or witnessed or was confronted with an event that involved actual or threatened death or serious injury. Consequently, according to this psychologist, “response” involved intense fear, helplessness, or horror. And, the psychologist indicated that the Veteran evinced a feeling of detachment or estrangement from others; a restricted range of affect; hypervigilance; and exaggerated startle response. The private psychologist, who did not indicate that either a claims file review or note the performance of psychometric testing, did report current symptoms of diminishing concentration; hypervigilance; strong reactions to loud noises; and insistence upon directly facing doors; propensity to be irritated easily; experience of incessant worry; and emotional numbness. This clinician also noted that the Veteran reported that he avoids combat footage (to prevent crying); has few friends; and feels that few people understand him. Upon the rendering of a diagnosis of PTSD, this psychologist opined that the Veteran’s psychological problems (as is the case with many Veterans) have become more noticeable with age, adding that the Veteran should consider some psychological attention to assist in the amelioration of chronic tension and irritability. During the Board hearing, the Veteran acknowledged that he has not undergone any regular treatment or therapy for a mental health disorder and no records are in the file. The divergences in these two psychologist’s impressions and diagnoses (or lack thereof) require reconciliation for the Board to evaluate the Veteran’s claim in a fully informed way. See Ardison v. Brown, 6 Vet. App. 405, 407 (1994). The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all outstanding VA treatment records. 2. After obtaining the necessary authorization from the Veteran and his representative, obtain and associate with the claims file any additional identified and relevant private mental health treatment records. All attempts to secure these records must be documented in the record. If any requested records are unavailable, the Veteran should be notified of such in accordance with 38 C.F.R. § 3.159(e). 3. Upon completion of the above, arrange for a VA addendum opinion and telehealth consultation (or mental health examination if possible) with a VA psychiatrist or psychologist to reconcile the psychological findings in the July 2013 VA PTSD examination report and the private psychologist’s initial psychological evaluation (facially dated February 2012 and received by VA in February 2013). The selected psychiatrist or psychologist must review the claims file and refer to specific medical and lay evidence when rendering opinions. Upon completion of the above, the VA psychiatrist or psychologist is asked to opine to the following inquiries: a. What psychological diagnosis, if any, is apposite to the Veteran’s current acquired psychiatric disorder? b. Whether this current psychiatric disorder, if any, was at least as likely as not (50 percent probability or more) incurred in, aggravated by, or otherwise attributable to, the Veteran’s active duty service? The VA psychiatrist or psychologist should keep in mind that the Veteran is competent to report his symptoms and history. Such reports, including those of continuity of symptomatology and functional limitations, must be acknowledged and considered in formulating any opinion. If the psychiatrist or psychologist rejects the Veteran’s reports, she/he must provide an explanation for such rejection. The psychiatrist or psychologist should note any points of agreement or disagreement between the July 2013 VA psychologist and the private psychologist. Rationales must be provided for each conclusion reached. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. J. Komins, 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.