Citation Nr: 21004059 Decision Date: 01/25/21 Archive Date: 01/25/21 DOCKET NO. 15-17 914 DATE: January 25, 2021 REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for a psychiatric disorder other than PTSD, to include bipolar disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1969 to December 1970. The Veteran also had additional periods of active duty for training (ACDUTRA) and inactive duty for training (INCDUTRA) service as a member of the California Army National Guard. Issues 1-2: Entitlement to service connection for PTSD and a psychiatric disorder other than PTSD to include bipolar disorder. On VA examination in December 2019, the examiner determined that the Veteran did not meet the DSM-5 criteria for a diagnosis of PTSD and did not have any other diagnosis of a mental disorder. In an accompanying opinion the examiner opined that the Veteran’s psychiatric disorder is less likely than not incurred in or caused by service as the Veteran did not have a diagnosis of a psychiatric disorder. While the examiner acknowledged the Veteran’s history of diagnoses of psychiatric disorders, the examiner indicated that he only reviewed a hard copy of the Veteran’s claims file and not the electronic claims file. Notably, a review of the Veteran’s electronic claims file shows that he has an extensive history of psychiatric disorders. See, e.g. treatment records showing adjustment disorder in September 1985, anxiety in May 1986, schizophrenia and adjustment disorder with depressed mood in June 1989, major depression in July 1996, depressive disorder in April 2005, and bipolar disorder in February 2013. In October 2019 VA treatment records show schizotypal personality disorder, somatization disorder, generalized anxiety disorder, and bipolar affective disorder. Furthermore, the December 2019 VA examiner did not provide a rationale for his opinion that the Veteran did not meet the criteria for a diagnosis of any psychiatric disorder. Thus, the Veteran should be afforded a new VA examination and the examiner should be asked to review the Veteran’s electronic claims file in determining the nature and etiology of the Veteran’s claimed psychiatric disorders. Further, in a September 2018 remand, the Board noted that the Veteran testified in June 2018 that in 1983, during a period of ACDUTRA in the California National Guard, there was at least one parachute mishap where a service member was injured and/or died and the Veteran asserted that his psychiatric conditions, including PTSD began during his active duty service and his time in the National Guard. Thus, the Board instructed that on remand, the Agency of Original Jurisdiction (AOJ) should take steps to verify the Veteran’s periods of ACDUTRA and INACDUTRA service in the National Guard and attempt to corroborate the Veteran’s stressor. The AOJ did not comply with the Board’s instructions. Compliance with the Board’s remand instructions is neither optional nor discretionary. See Stegall v. West, 11 Vet. App. 268, 271 Lastly, VA treatment records dated in May 2012 and received in October 2019 show that the Veteran was receiving disability benefits from the Social Security Administration (SSA). As these SSA records may be relevant to the issues being remanded herein, an attempt should be made to associate them with the file. The matters are REMANDED for the following action: 1. Obtain all the Veteran’s pertinent SSA records pertaining to the Veteran’s psychiatric disorders. Document all requests for information as well as all responses in the claims file. 2. The Veteran’s period of ACDUTRA and INACDUTRA must be verified. Please note that reports of retirement points do not contain the necessary information in this regard. If necessary, the Veteran should be requested to provide any assistance. All verified dates of service and all responses received should be documented and associated with the claims file. If such verification is not possible, notify the Veteran. 3. Attempt to verify the Veteran’s claimed in-service stressor that a service member (parachutist) crashed and was injured or died at the Veteran’s National Guard location in 1983. All attempts associated therewith should be memorialized in the Veteran’s claims file. 4. Afterwards schedule the Veteran for an examination to determine the etiology of his claimed PTSD disorder, and any other psychiatric disorder other than PTSD, to include bipolar disorder. The examiner is asked to confirm review of the Veteran’s electronic claims file in conjunction with examining the Veteran. The examiner must identify all current and prior diagnoses of an acquired psychiatric disorder, and opine as to whether each diagnosed condition is at least as likely as not (50 percent probability or greater) caused by or otherwise related to his ACDUTRA or INACDUTRA service and explain why. The examiner is hereby advised that the Veteran has an extensive history of psychiatric disorders. See, e.g. treatment records showing adjustment disorder in September 1985; anxiety in May 1986; schizophrenia and adjustment disorder with depressed mood in June 1989; major depression in July 1996; depressive disorder in April 2005; bipolar disorder in February 2013; and, schizotypal personality disorder, somatization disorder, generalized anxiety disorder, and bipolar affective disorder in October 2019. A full and complete rationale is required for all opinions expressed. As to a diagnosis of PTSD, the examiner should discuss whether the claimed in-service stressor(s) supports the diagnosis and explain why. Thomas H. O'Shay Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Mac, 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.