Citation Nr: 21002079 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 20-03 432 DATE: January 12, 2021 REMANDED The claim of entitlement to service connection for an acquired psychiatric disability, including posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1960 to March 1964, and September 1964 to October 1972. This appeal is from a July 2017 rating decision. In November 2020, the Veteran had a personal hearing with the undersigned VLJ. The claim of entitlement to service connection for an acquired psychiatric disability, including PTSD, is remanded. The record shows the Veteran has been diagnosed with PTSD, anxiety, depressive disorder, and mood disorder. He asserts that his acquired psychiatric disability is related to his active duty service. He has reported a number of stressor incidents that he feels caused his symptoms. The record also suggests that his symptoms may be related to service-connected shoulder, knee, and back disabilities. The Veteran has not been given a VA examination for this claim, which will be remedied on remand. The Board notes that medical records from the early-1980s show that the Veteran was treated for psychiatric symptoms and was diagnosed with adjustment disorder with depressed mood. These records show that records of treatment were sent to the Federal Aviation Administration in April 1983. On remand, an effort shall be made to obtain these records. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Make an effort to obtain records of psychiatric treatment dated from 1982 and 1983 that were sent to the Department of Transportation, Federal Aviation Administration, Los Angeles, in April 1983. (See Medical Treatment Record Non-Government Facility received January 2016.) 3. Following completion of the above directives, schedule the Veteran for an appropriate examination for an opinion on whether it is as likely as not (50/50 probability or greater) that any acquired psychiatric disability, including PTSD, anxiety, and depressive disorder, is related to his service or secondary to service-connected disability. The examiner is asked to review the file prior to the examination, and to conduct a thorough examination including all necessary diagnostic tests. The Veteran reports a number of stressors, as set forth in a statement received November 2016, in correspondence and a Buddy statement received in March 2018, and during the November 2020 hearing. He reported additional stressors in an August 2016 VA treatment record. The record shows that some of his symptoms have been attributed to his more recent work as a contract civilian employee in Iraq, but not that earlier events were actually considered in that determination. The examiner is asked to elicit from the Veteran details of his in-service stressors, and determine whether symptoms have resulted from those experiences. The examiner is asked to assume that the stressor reports have been corroborated. In regard to PTSD, the examiner is asked to render a diagnosis that addresses the specific diagnostic criteria from the DSM-5. If diagnosed, the examiner is asked to identify, to the extent possible, the stressor or stressors that are related. In regard to any other diagnosis, the examiner is asked whether his current symptoms are related to the reported incidents. The record suggests that his symptoms may be related to chronic back, knee, and shoulder pain, for which he is service connected. The record shows that he separated from service with low back and left knee disabilities, that have been service-connected since the day after separation. The record shows that in 1981, he reinjured his back, which resulted in an extended period of time where he was out of work. In 1982 and 1983, he was treated for adjustment disorder with depressed mood, which a June 1982 treatment record suggests was as a result of his reinjured service-connected back. The record more recently shows that symptoms may be related to his leg and knee, for instance in an October 2016 VA treatment record where the Veteran reported frustration due to pain in the leg and shoulder, and that he had a preoccupation with his left knee, all of which are service connected. To reiterate, the examiner is asked to opine on whether any acquired psychiatric disability is as likely as not related to incidents that occurred during active duty service. The record shows civilian traumatic exposure; therefore, it is essential that the examiner carefully review the evidence and explain any rendered opinion. If not related directly to incidents in service, the examiner is asked whether any diagnosis is caused or aggravated by chronic symptoms of his service-connected low back, left knee, right hip, right sciatic nerve radiculopathy, left shoulder, and/or the right shoulder. “Aggravated” means to have caused any increase in severity that is beyond the normal progression of the disability, and it need not be permanent in nature. All opinions must be accompanied with explanation. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Gibson 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.