Citation Nr: 21065411 Decision Date: 10/26/21 Archive Date: 10/26/21 DOCKET NO. 14-24 521 DATE: October 26, 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 on active duty from April 1978 to April 1982 and from June 1982 to August 1987. The latter period of service has been found to be dishonorable for VA purposes. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO), which is the Agency of Original Jurisdiction (AOJ). In January 2015, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the record. In September 2016, the Board remanded the case to the AOJ for further development. The case has since been returned to the Board for appellate review. The Board notes that the appeal originally included the issues of entitlement to service connection for left knee and left foot disorders. However, in a February 2020 rating decision, the AOJ granted service connection for left knee strain, shin splint, and arthritis; pes planus of the left foot; hallux rigidus with mild first metatarsophalangeal (MTP) joint osteoarthritis of the left foot; and a left foot scar. The AOJ's grant of service connection constitutes a full award of the benefits sought on appeal. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). Therefore, those matters are no longer on appeal, and no further consideration is necessary. The Board also notes that the Veteran's representative has raised a challenge to the administrative determination finding the Veteran's latter period of service dishonorable for VA purposes. He has contended that the claim is inferred with the Veteran's appeal for service connection for a psychiatric disorder. See May 2021 informal hearing presentation. However, the RO previously issued a decision on that issue. The Veteran was notified of that determination and of his appellate rights, but he did not appeal that that decision. The Board also notes that, effective March 24, 2015, VA amended its regulations to require that all claims governed by VA's adjudication regulations be filed on a standard form. The amendments implement the concept of an intent to file a claim for benefits, which operates similarly to the informal claim process, but requires that the submission establishing a claimant's effective date of benefits must be received in one of three specified formats. See 79 Fed. Reg. 57,660 (Sept. 25, 2014) (now codified at 38 C.F.R. §§ 3.1(p), 3.151, 3.155). The Veteran and his representative have not filed a claim on the standard form to reopen the issue of the character of discharge for the Veteran's second period of service. If they want to pursue the issue, they are advised that they may file a claim to reopen on the proper form. In the September 2016 remand, the Board directed the AOJ to afford the Veteran a VA examination to determine the nature and etiology of any psychiatric disorder that may be present. In a February 2020 VA examination report, the VA examiner determined that the Veteran had a diagnosis of PTSD that conformed to the DSM-5 criteria for PTSD; however, the Veteran's reported stressor was not related to the Veteran's fear of hostile military or terrorist activity. Further, the examiner noted that there was no verifiable evidence other than the Veteran's self-report to substantiate his claim of ongoing symptoms due to an in-service stressor. Thus, the examiner opined that the Veteran's PTSD was less likely than not incurred in or caused by service. However, the examiner did not address the diagnoses of major depressive disorder, adjustment disorder, generalized anxiety disorder, and schizoaffective disorder, which are noted throughout the record. Therefore, the Board finds that a remand is necessary in order to obtain another VA medical opinion. In addition, in a December 2020 statement, the Veteran reported that he was admitted to a psychiatric ward due to major depression, PTSD, and anxiety from approximately June 2016 to September 2016. On remand, the AOJ should attempt to obtain records of this hospitalization. The matter is REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for an acquired psychiatric disorder. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records. A specific request should be made for any outstanding VA medical records pertaining to a psychiatric hospitalization from approximately June 2016 to September 2016. See December 2020 statement submitted by the Veteran. 2. After completing the foregoing development, the Veteran should be afforded a VA examination to determine the nature and etiology of any psychiatric disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. The Veteran reported that he witnessed the stabbing of a fellow service member and friend outside of a club in Omaha, Nebraska, in September 1980 or October 1980. See hearing transcript at 17-21. He has also indicated that he was assaulted by two individuals at a bar in 1981. See April 2016 VA treatment record. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should identify all current psychiatric disorders. If any previously diagnosed psychiatric disorders are not found on examination, the examiner should address whether they were misdiagnosed or have resolved. The examiner should specifically comment on the diagnoses of major depressive disorder, adjustment disorder, generalized anxiety disorder, and schizoaffective disorder, which are noted throughout the record. For each diagnosis identified other than PTSD, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder manifested in or is otherwise causally or etiologically related to the Veteran's military service. With regard to PTSD, the AOJ should provide the examiner with a summary of any verified in-service stressors, and the examiner must be instructed that only these events that the examiner determines to have occurred during service may be considered for the purpose of determining whether exposure to an in-service stressor has resulted in PTSD. If there is a verified stressor or if the examiner determines that a personal assault occurred in service, he or she should determine whether the diagnostic criteria to support the diagnosis of PTSD have been satisfied. If the PTSD diagnosis is deemed appropriate, the examiner should then comment upon the link between the current symptomatology and any verified in-service stressor. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. The AOJ should review the examination report to ensure that it is in compliance with this remand. If the report is deficient in any manner, the AOJ should implement corrective procedures. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Osegueda, 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.