Citation Nr: 21073474 Decision Date: 12/08/21 Archive Date: 12/08/21 DOCKET NO. 15-00 877 DATE: December 8, 2021 REMANDED Service connection for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1988 to August 1991. In an October 2020 decision, the Board of Veterans' Appeals (Board) denied his claim for service connection for PTSD. He then appealed to the Court of Appeals for Veterans Claims, which granted a Joint Motion for Partial Remand (JMPR) in June 2021. The Board notes that the issue of service connection for an acquired psychiatric disorder other than PTSD, to include major depressive disorder, is no longer on appeal here. The Board denied service connection for such a disorder in its March 2021 decision. Service Connection for PTSD The Veteran attributes his PTSD to various in-service stressors, including witnessing the death of a friend by friendly fire near the Korean Demilitarized Zone (DMZ). The parties to the JMPR agreed that the Board's reasons and bases for denying service connection for PTSD were inadequate. Specifically, the parties agreed that the Board failed to address the Veteran's argument that the February 2020 VA examination was inadequate, and failed to address a favorable private psychological evaluation from October 2019. JMPR at 2. After carefully reexamining the record, the Board finds that remand to the agency of original jurisdiction for a new examination is necessary. The February 2020 VA examiner determined that the Veteran's PTSD was less likely than not incurred in or caused by service. The examiner reasoned that the Veteran "was not directly involved with the traumatic incident" (i.e., the death of his friend by friendly fire in Korea), that his military experience was generally positive, and that his nightmares are "only seldom related to military themes." However, on the February 2020 PTSD disability benefits questionnaire (DBQ), the same examiner indicated that the claimed in-service stressor was adequate to support a PTSD diagnosis, and that the Veteran met the other PTSD diagnostic criteria based on this stressor, including the presence of "recurrent distressing dreams ... related to the traumatic event." As the Veteran points out, the VA examiner made internally inconsistent findings and failed to fully explain the rationale for the opinion above. See e.g. October 2021 Brief. On one hand, the opinion seems to imply that the claimed in-service stressor was not traumatic enough to have caused the Veteran's PTSD. On the other, the DBQ indicates that this stressor is adequate to support a PTSD diagnosis. The examiner offered no explanation as to how both can be true at the same time. Similarly, the examiner did not explain why the Veteran's distressing dreams/nightmares were adequate to satisfy the diagnostic criteria, but not sufficient to establish a nexus between PTSD and service. Thus, the Board finds the February 2020 VA examination inadequate because it lacked sufficient detail to fully inform the Board of the examiner's medical judgment and the essential rationale for the opinion. Monzingo v. Shinseki, 26 Vet. App. 97, 105 (2012). The Board likewise finds the October 2019 private psychological evaluation inadequate to decide the claim, contrary to the assertions in the Veteran's brief. In the October 2019 evaluation, "Dr. N.M.T." determined it is at least as likely as not that the Veteran's PTSD is due to an in-service stressor. This opinion refers generally to the Veteran's "fear of hostile military activity" while serving near the Korean DMZ. Significantly, though, Dr. N.M.T. did not discuss which specific in-service stressor or stressors could have caused his PTSD. Dr. N.M.T. noted that a 2011 VA examination suggested his "service in a hostile war zone and constant fear of hostile military activity met criteria as a stressor for PTSD." However, the 2011 VA examiner actually stated that the Veteran's claimed stressors at that time were not adequate to support a PTSD diagnosis. In any event, Dr. N.M.T. did not provide a reasoned medical explanation as to how the Veteran's PTSD is related to service. Monzingo, 26 Vet. App. at 105. The medical opinions on file are inadequate and remand is warranted. On remand, the VA examiner must consider and discuss the previous examinations of record, including the October 2019 private psychological evaluation. The examiner must clearly identify the specific stressor or stressors on which any PTSD diagnosis is based. The examiner must also address the Veteran's lay statements regarding his subjective symptoms during and after service. The Board by this remand makes no determination, expressed or implied, concerning the credibility of any statements on file. The matter is REMANDED for the following action: 1. Schedule the Veteran for a mental health examination with an appropriate clinician. After reviewing the claims file, including this remand, the examiner must provide an opinion on whether it is at least as likely as not (50 percent or greater probability) that PTSD is etiologically related to a claimed in-service stressor. In providing this opinion, the examiner must consider and discuss the previous examinations of record, including the October 2019 private psychological evaluation. The examiner must clearly identify the specific stressor or stressors on which any PTSD diagnosis is based. The examiner must also address the Veteran's lay statements regarding his subjective symptoms during and after service. 2. Review the medical opinion above to ensure substantial compliance with the Board's directives. Take any necessary corrective action. 3. Readjudicate the Veteran's claim. If it remains denied, issue a supplemental statement of the case, and allow the Veteran and his representative the opportunity to respond. Then return to the Board for further appellate review. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D.Z. Wall, 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.