Citation Nr: 21073349 Decision Date: 12/08/21 Archive Date: 12/08/21 DOCKET NO. 18-02 794 DATE: December 8, 2021 REMANDED Entitlement to service connection for a variously diagnosed psychiatric disability is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from November 1965 to April 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal from a September 2015 rating decision, which denied service connection for left ear hearing loss, melanoma, hypertension, and major depressive disorder, moderate (also claimed as posttraumatic stress disorder [PTSD]) and granted service connection for right ear hearing loss, rated 0 percent. In June 2019, a videoconference hearing was held before the undersigned; a transcript is in the Veteran's record. In November 2019, the issue of entitlement to service connection for a variously diagnosed psychiatric disability was remanded for additional development. The November 2019 decision dismissed claims of service connection for left ear hearing loss, hypertension, and melanoma, and entitlement to a compensable rating for right ear hearing loss based on the Veteran's withdrawal of such appeals in testimony at the June 2019 hearing. Entitlement to service connection for a variously diagnosed psychiatric disability. The previous [November 2019] Board remand requested development regarding the Veteran's alleged stressors in service and for a psychiatric examination of the Veteran to confirm the nature and ascertain the likely etiology of his psychiatric disability; in pertinent part, the examiner was instructed to specifically address the July 2015 VA and private opinions. It was noted that the Board has acknowledged that the Veteran served in circumstances consistent with a fear of hostile military action/terrorist activity. A July 2021 records research response from a professional researcher from the Veterans Benefits Administration, Compensation Service, Military Records Research Center, noted that the Air Force Historical Research Agency (AFHRA) conducted a review of Air Force unit records and there was no evidence located to support documentation of the Veteran's claimed stressor incidents in service. On October 2021 VA (PTSD) examination, the consulting provider diagnosed major depressive disorder, moderate, recurrent, and found that the Veteran does not have another diagnosis of a mental disorder. The examiner addressed the July 2015 private social worker's PTSD diagnosis and opined that her letter notes that the Veteran endorses only one symptom in criterion E, a sleep disturbance. On further review of the July 2015 private medical opinion, the Board notes that the social worker described the Veteran's reports of having a hard time sleeping, having a short fuse, remaining very vigilant in unfamiliar surroundings on the lookout for danger, and jumping at loud noises. These reported symptoms would appear to closely approximate several of the criteria listed in criterion E, and the examiner did not attempt to address or distinguish the symptoms. A remand for an addendum medical opinion is necessary. See Stegall v. West, 11 Vet. App. 268 (1998). The matters are REMANDED for the following action: Arrange for the Veteran's record to be forwarded to the clinician who conducted the October 2021 examination for review and an addendum medical advisory opinion regarding the likely etiology of the Veteran's psychiatric disability. If the October 2021 provider is unavailable, the record should be forwarded to another appropriate clinician (psychiatrist or psychologist) for review [and if further examination/interview of the Veteran is deemed necessary, such should be conducted]. The consulting provider should review July 2021 research response regarding the Veteran's reported specific stressor incidents in service, but noted that it is acknowledged that the Veteran served in circumstances consistent with a fear of hostile military action and terrorist activity. The consulting provider should: (a) Identify (by diagnosis) each psychiatric disability entity shown during the pendency of this claim or shown by the record during the pendency of the claim. [If major depressive disorder, moderate, recurrent, is not diagnosed, such finding should be reconciled with the record.] (b) Noting the observations regarding reported symptoms above, and the acknowledgement that the Veteran served in circumstances consistent with a fear of hostile military action, if PTSD remains not diagnosed, identify the criteria for a PTSD diagnosis that remain lacking. (c) Identify the likely etiology for any (each) psychiatric disability entity other than PTSD diagnosed. Specifically, is it at least as likely as not (a 50 percent or greater probability) that the disability is etiologically related to the Veteran's service. All opinions must include a complete explanation of rationale, with citation to supporting factual data and medical principles, as deemed appropriate. The rationale must include comment on (express, including rationale, agreement or disagreement with) the July 2015 VA and private opinions that are already in the record in this matter. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Lederman, Michael 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.