Citation Nr: 21003722 Decision Date: 01/22/21 Archive Date: 01/22/21 DOCKET NO. 17-04 736A DATE: January 22, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served honorably in the United States Navy from August 1989 to October 1993. He testified before the undersigned Veterans Law Judge (VLJ) at a Board of Veterans’ Appeals (Board) hearing in October 2018. A transcript of the hearing is of record. In March 2019, the Board remanded the appeal for further evidentiary development. Service connection for an acquired psychiatric disorder, to include PTSD The Veteran seeks service connection for an acquired psychiatric disorder, to include PTSD and major depressive disorder, which he asserts originated from multiple in-service stressors. At his Board hearing, he testified that these stressors included assisting in putting out engine room fires while serving aboard the USS Gallery; having an allergic reaction and passing out after eating nuts; and witnessing dead and charred bodies while traveling through the Suez Canal. In its March 2019 remand, the Board noted the Veteran’s assertions that his psychiatric symptomatology stemmed, at least in part, from his fear of hostile military or terrorist activity. As such, 38 C.F.R. § 3.304(f)(3) was for application. Under that provision, with respect to PTSD claims, if a stressor claimed by a veteran is related to the veteran’s fear of hostile military or terrorist activity and a VA psychiatrist or psychologist confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran’s symptoms are related to the claimed stressor, provided the stressor is consistent with the places, types, and circumstances of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the stressor. 38 C.F.R. § 3.304(f)(3). The Board determined that a prior VA PTSD examination, performed in February 2018, was inadequate, as the VA psychologist “did not provide a meaningful discussion as to why the Veteran’s reported stressors were insufficient to support a PTSD diagnosis.” The Board further noted that the February 2018 VA psychologist’s report did not address or reconcile the Veteran’s documented history of treatment for PTSD and major depressive disorder, and that the Veteran’s explanation that the psychologist “backed me in a corner just to talk about my life history” appeared to be undermine the psychologist’s rationale for why the Veteran’s mental health symptomatology was not service-related. An updated VA PTSD examination was provided in September 2020. The report notes the psychologist’s conclusion that the Veteran did not meet the criteria for a PTSD diagnosis, with the following rationale: “[the Veteran’s VA medical records] included a NEGATIVE PTSD screen dated 1/10/2011. As such, this Examiner is in agreement with previous C&P PTSD exam dated 2/02/2018 that [the Veteran] fails to meet full DSM 5 diagnostic criteria for PTSD.” With respect to the Veteran’s depressive disorder, the psychologist opined that the disorder was “not a result of an in-service stress related event,” as the Veteran’s “military service treatment records are also negative for any reported mental health symptoms/diagnoses or treatment.” The psychologist added, with no further explanation, that the Veteran’s “current symptoms of depression appear related to post military life stressors.” Unfortunately, the Board finds this appeal must be remanded again, as the September 2020 VA examination report fails to substantially comply with the Board’s prior remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board is disappointed to note that none of the issues raised in its March 2019 remand directives were meaningfully addressed by the VA psychologist in his September 2020 report. The September 2020 report does not contain an explanation of why the Veteran’s reported in-service stressors, to include his reported fear of hostile military or terrorist activity, were insufficient to support a diagnosis of PTSD. The basis for the psychologist’s conclusion—that there were no records of mental health treatment in service, and that a January 2011 PTSD screening was negative—is insufficient to support a decision in this matter, as it ignores the Veteran’s competent lay assertions of depression and anxiety in service as well as his documented history of treatment for PTSD at VA medical facilities. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (noting lay evidence concerning the onset of symptoms, if credible, is competent, regardless of the lack of contemporaneous medical evidence). The comment regarding the January 2011 PTSD screening is particularly confounding given the Veteran’s documented history of treatment for PTSD since that time, to include letters from care providers specifically noting a PTSD diagnosis. The Board specifically directed the VA psychologist to discuss and reconcile the Veteran’s lay statements and treatment history, a request which was apparently ignored. Finally, the Board notes that the September 2020 VA examination report is inadequate regarding the etiology of the Veteran’s depressive disorder. The report’s vague and ambiguous conclusions as to the Veteran’s “post military life stressors” being the true cause of his symptoms are insufficient. More detail is needed, with a specific emphasis on the Veteran’s own assertions regarding the chronology of his symptoms. The Veteran’s claims file must be forwarded to a different VA psychologist for an updated opinion in compliance with these directives. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The matters are REMANDED for the following action: 1. Obtain and associate with the record any outstanding VA medical records pertaining to the Veteran, to include records from August 2020 to the present. 2. Schedule the Veteran for a VA examination with a different clinician than the clinicians who examined the Veteran in February 2018 and September 2020 to determine the nature and likely etiology of any current acquired psychiatric disorders, to include (but not necessarily limited to) PTSD and major depressive disorder. The clinician should specifically discuss the following: (a) With respect to PTSD, the AOJ should again provide the clinician with a summary of any verified in-service stressors and the clinician must be instructed that only these events, or any stressor related to fear of hostile military or terrorist activity, may be considered for the purpose of determining whether exposure to an in-service stressor has resulted in PTSD. The clinician should determine whether the diagnostic criteria to support a diagnosis of PTSD have been satisfied. In so doing, the clinician must • Discuss the Veteran’s lay reports regarding his in-service experiences and the chronology of his mental health symptomatology. Also discuss his mother’s September 2011 statement noting the Veteran’s behavioral changes upon returning from active duty. • Discuss and reconcile the Veteran’s ongoing treatment for PTSD at VA medical facilities, taking into consideration the October 2018 and November 2019 letters from VA care providers noting clinical diagnoses of PTSD and major depressive disorder If a PTSD diagnosis is deemed appropriate, the clinician should then comment upon the link between the current symptomatology and any verified in-service stressor, including fear of hostile military or terrorist activity. (b) The clinician must also opine as to whether any diagnosed acquired psychiatric disorder other than PTSD, to include major depressive disorder, was at least as likely as not incurred in service or otherwise related to service. A detailed rationale should be included in support of all opinions provided. All such rationales should include a detailed discussion of the Veteran’s lay reports regarding the chronology of his mental health symptomatology, to include his testimony at his Board hearing. A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Minot, 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.