Citation Nr: 21071065 Decision Date: 11/29/21 Archive Date: 11/29/21 DOCKET NO. 16-52 094 DATE: November 29, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran had active service in the United States Army from March 1977 to August 1994. This case comes to the Board of Veterans' Appeals (Board) on appeal from a May 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) which is the Agency of Original Jurisdiction (AOJ). The Veteran expressed timely disagreement with the AOJ's determination, and the present appeal ensued. In July of 2021, the Veteran testified at a Board hearing conducted by the undersigned Veterans Law Judge (VLJ) via videoconferencing equipment. A transcript of the hearing is associated with the electronic claims file. Characterization of issue on appeal The Board notes that the issue on appeal was characterized as entitlement to service connection for PTSD, with sleep disturbance and depression. However, in light of the evidence of record, the Board has recharacterized the issue more broadly to ensure complete consideration of the claim. Clemons v. Shinseki, 23 Vet. App. 1, 5-6, 8 (2009). Entitlement to service connection for an acquired psychiatric disability, to include PTSD While the Board sincerely regrets further delay, additional development is required before the Veteran's claim may be adjudicated on the merits. During the July 2021 hearing, the Veteran stated that she had been diagnosed with, and treated for, PTSD by a VA provider. Unfortunately, the Veteran's VA medical treatment records, from June 2015 to the present, have not been associated with the Veteran's claims file. As the current record is incomplete, and the Board is unable to adequately evaluate the Veteran's claim. Additionally, the record reflects that the Veteran was provided a VA medical examination for a psychiatric disability in March 2015. The Veteran has stated that since that time she has been diagnosed with, and treated for, PTSD. Based on the foregoing, the Board finds that an additional medical examination is needed to address any diagnosed psychiatric disability, and the etiology of each. The Board also notes the Veteran's consistent and credible testimony during the July 2021 hearing regarding her in-service stressors, including her credible statements about her experience having to spend extended time in a bunker while under attack. Additionally, the Veteran described her experience of uncertainty traveling for days at a time to obtain rations for the unit she was supporting at the time and her experience with "grave registration." In sum, the Board concludes that this appealed issue must be remanded for the purpose of obtaining the Veteran's VA medical records and providing the Veteran an additional VA psychiatric examination to determine whether the Veteran meets the criteria of any acquired psychiatric disability, and etiology of such. The matters are REMANDED for the following action: 1. The AOJ must obtain and associate with the file all updated records of VA treatment pertaining to the Veteran. 2. Thereafter, the AOJ must request that the Veteran be scheduled for an appropriate VA examination, to determine the nature and etiology of any acquired psychiatric disability identified during the appeal period. The complete electronic record must be made available to, and reviewed by, the VA examiner prior to conducting the examination. All necessary tests and studies should be conducted. 3. Thereafter, the VA examiner is requested to address the following: (a.) Identify all acquired psychiatric disabilities present during the appeal period. (b.) For any disability/disabilities identified in part (a), provide an opinion considering whether each is at least as likely as not proximately due to or the result of any incident of the Veteran's service, including the Veteran's assertions of her fear of enemy attack during the Gulf War. *In providing the requested opinions, the examiner should consider the Veteran's credible claims of in-service stressors. If the examiner cannot provide an opinion without resorting to mere speculation, this should be so stated along with supporting rationale. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to the particular question. 4. Thereafter, the AOJ must adjudicate the issues remaining on appeal in light of any additional evidence added to the record. If any benefit is not granted to the fullest extent possible, the Veteran should be furnished with a copy of this readjudication and afforded the applicable opportunity to respond. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. W. Morgan, 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.