Citation Nr: 21068602 Decision Date: 11/10/21 Archive Date: 11/10/21 DOCKET NO. 16-14 559 DATE: November 10, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder is remanded. REASONS FOR REMAND The Veteran served active duty in the United States Air Force from September 1969 to September 1973. This matter comes to the Board of Veterans' Appeals (Board) on appeal of an April 2011 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO). The Veteran's January 2016 VA Form 9 indicated his desire for a hearing before the Board. 1. Entitlement to service connection for psychiatric disorder is remanded. The Veteran contends he is entitled to service connection for a psychiatric disorder that is related to service. The Veteran asserts he experienced psychiatric symptoms during service and has experienced an increase since his separation. In his March 2010 claim, the Veteran requested service connection for "nervous condition/anxiety." However, his April 2012 Notice of Disagreement requests review of the claim to include consideration of post-traumatic stress disorder (PTSD). Treatment records reveal the Veteran has several psychiatric diagnoses including: anxiety, PTSD, depression, and panic disorder. Accordingly, the Board has recharacterized the Veteran's claim more broadly to encompass any relevant acquired psychiatric disability. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6, 8 (2009). Service treatment records also indicate the Veteran received mental health diagnoses and treatment while on active duty; therefore, the question for the Board is whether the Veteran's current psychiatric disorder is related to his military service. Unfortunately, the Board is unable to adjudicate the claim because an adequate medical opinion has not been obtained on the issue. The Veteran was provided a VA mental health examination in February 2011. The examiner concluded the Veteran met the DSM-4 criteria for a diagnosis of panic disorder without agoraphobia, but opined the condition was less likely than not manifestations of in-service psychiatric complaints. Service records indicate the Veteran was diagnosed with anxiety neurosis with somatization in 1970, however, the VA examiner reasoned he did not display similar symptoms during the examination. She noted the Veteran reported his condition began in the late 1980s, many years after separation from service. However, the evidence shows that, while the Veteran reported he began to experience specific symptoms such as panic attacks in the mid-1980s, he reported related symptoms prior to that period. Additionally, service records indicate the Veteran reported experiencing worry and nervous trouble in 1969 and was diagnosed with "conversion reaction" in 1970 following an in-service penile surgery. STR, 1/14/2015, pgs. 8, 30/62. The Board finds the February 2011 examiner did not fully address the in-service evidence related to the Veteran's panic disorder or adequately respond to his contentions. The examiner also noted the Veteran's condition is well controlled with medication and the record confirms he has several psychiatric prescriptions. However, the Board notes that the use of medication to control a condition is not a proper consideration in formulating a negative nexus opinion. As the Veteran is competent to report observable symptoms, behavior, and experiences, and contemporaneous service records support the contentions, a medical opinion that fully considers the evidence is needed to properly adjudicate the case. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008); Layno v. Brown, 6 Vet. App. 465, 470 (1994). Further, the Board finds remand for a PTSD evaluation is necessary to adjudicate the claim. VA's duty to assist includes providing a medical examination when it is necessary to make a decision on a claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4). An examination must be provided when there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies; and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability; but (4) there is insufficient competent medical evidence on file for VA to make a decision on the claim. 38 U.S.C. § 5103A (d)(2), 38 C.F.R. § 3.159 (c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The requirement that the evidence of record "indicate" the claimed disability or symptoms "may be associated" with the established event, is a low threshold. Id. at 83. As stated above, the Veteran explicitly requested consideration of PTSD in his claim for compensation and the evidence shows the Veteran received a prior diagnosis of PTSD. The February 2011 examination report indicates the evaluation was conducted with a focus on anxiety/nervous condition but excludes consideration of PTSD. The examiner notes the Veteran's report of nightly mortar fire and rocket attacks while serving in Vietnam and a Certificate of Discharge confirms the Veteran has 11 months of foreign and/or sea service and specifically notes service in Vietnam. Further, the Veteran submitted an August 2011 statement by his VA licensed independent social worker (LISW). See Buddy/Lay Statement, 4/12/2012. She explains the Veteran receives mental health treatment at her clinic and has been found to meet the criteria for a diagnosis of PTSD. She notes the Veteran reported constant mortar and machine gun fire while serving in Cam Rahn Bay, Vietnam. He reports he was not assigned a weapon due to his military occupational specialty (MOS) as a freight specialist and, therefore, he felt a heightened state of fear for his life, and increasingly so following the removal of Army and Marine servicemembers in the area. The Veteran also reported he worried he would never meet his daughter that was born while he was stationed in Vietnam. The LISW explains the Veteran's current symptomology and its impact on his behavior and occupation. While the letter is probative, the LISW did not provide further clarification of his diagnosis as related to DSM diagnostic criteria or opine as to a nexus relationship with active duty. The Board finds the Veteran has a current psychiatric diagnosis, with credible lay statements and in-service treatment supporting an onset of the symptoms in service; however, an adequate medical opinion whether the Veteran's current disorder is related to his in-service experiences, to include surgery of the penis and Vietnam stressor events, has not been provided. Additionally, the Veteran's psychiatric evaluation was a decade ago and he has not been provided a PTSD examination in relation to his claim. An examiner has not provided a medical opinion on the matter, therefore, the record lacks sufficient medical evidence to adjudicate the claim on the merits and remand is necessary for further development. Accordingly, the matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records related to the Veteran's psychiatric disability and associate them with the file. 2. Provide the Veteran with the proper information release forms to obtain private treatment records referenced in the claims file. Attention is invited to reference of psychiatric treatment by Dr. JD from 1980 to 2009 and previous treatment by Dr. E. See Buddy/Lay Statement, 4/12/2012. 3. Schedule the Veteran for a psychiatric evaluation, to include PTSD and non-PTSD diagnoses, with an appropriate clinician to determine the nature and etiology of any acquired psychiatric disorder. Following review of the claims file and evaluation of the Veteran, the examiner is asked to provide the following for all acquired psychiatric disorders: a. Is it at least as likely as not (50 percent or greater probability) any psychiatric disorder is etiologically related to the Veteran's active service? The examiner should consider all of the Veteran's contentions and in-service evidence, to specifically include stressor events and diagnoses following surgery. Lay contentions must be considered and weighed in making the determination as to whether a nexus exists between the current disorder and service. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Tabitha Chapman, Associate 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.