Citation Nr: 21073548 Decision Date: 12/09/21 Archive Date: 12/09/21 DOCKET NO. 15-40 832 DATE: December 9, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and unspecified depressive disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1976 to January 1979. This case was previously before the Board, most recently in June 2021, and remanded for additional development. As such, the case has returned to the Board for further appellate proceedings. However, as explained below, the Board finds that another remand is necessary in order to address the Veteran's contentions of an additional theory of entitlement. Historically, the Veteran contends that he developed an acquired psychiatric disorder as a result of an in-service personal assault. The record shows that he was not diagnosed as having PTSD at his most recent VA examination in October 2021 and the diagnosis of unspecified depressive disorder was confirmed. See October 2021 VA examination report. However, in a correspondence received on April 27, 2020, the Veteran explicitly raised the theory of entitlement to service connection for an acquired psychiatric disorder as secondary to his service-connected back, neck, and/or shoulder disabilities. See April 2020 Veteran statement. The Veteran went on to explain that these service-connected conditions affect "my emotional and mental stability." Id. While the Veteran has been afforded VA examinations in October 2021 and January 2020, neither examiner addressed his secondary theory of entitlement. The Board cannot make a fully informed decision on the issue of secondary service connection because no VA examiner has opined whether the Veteran's acquired psychiatric disorder is proximately due to or aggravated by his service-connected conditions. As such, the Board finds that remand is required in order to afford the Veteran with an opinion that adequately addresses all theories of entitlement raised by the Veteran, including secondary service connection. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records relevant to treatment the Veteran received for his acquired psychiatric disorder that are not already of record. All obtained records should be associated with the evidentiary record. If any identified records are not obtainable (or none exist), the Veteran and his representative should be notified, and the record clearly documented. 2. Thereafter, schedule the Veteran for an examination to determine the nature and etiology of his claimed acquired psychiatric disorder. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. The examination report must include a notation that this record review took place. After the record review and examination of the Veteran, the examiner should identify all psychiatric disorders present. For each identified psychiatric disability, the clinician is asked to respond to the following: (a.) If a diagnosis of PTSD is made, the examiner should identify the stressor(s) upon which such diagnosis is made. (b.) For any diagnosis other than PTSD, the examiner should provide an opinion regarding whether it is at least as likely as not that any such condition was incurred in, or is otherwise related to, active service, to include his alleged in-service personal assault. (c.) The examiner should also render an opinion as to whether it is at least as likely as not that the Veteran's psychiatric disorder was caused OR aggravated by his service-connected back, neck and/or shoulder disabilities. In rendering these opinions, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. The complete rationale for all opinions should be set forth, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the examiner must provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner must 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 that particular question. 3. After the above has been completed to the extent possible, readjudicate the claim. If any benefit sought remains denied, provide the Veteran and his representative with a supplemental statement of the case (SSOC), and return the case to the Board. DONNIE R. HACHEY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Katie Poe, 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.