Citation Nr: 21075614 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 18-13 293 DATE: December 21, 2021 ISSUE Entitlement to an acquired psychiatric disorder to include post-traumatic stress disorder (PTSD). REMANDED Entitlement to an acquired psychiatric disorder to include post-traumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty in the Navy from October 1967 to August 1971, from April 1974 to April 1976, and from March 1986 to January 1998. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2014 rating decision, issued by a Department of Veterans Affairs (VA) Regional Office (RO) which denied entitlement to the benefits currently sought on appeal. The Veteran appeared before the undersigned Veterans Law Judge in a Board hearing in July 2021 to present testimony on the issues on appeal. A transcript of the hearing has been associated with the Veteran's claims file. The Board finds that additional evidentiary development is required before the claims on appeal are adjudicated. Entitlement to an acquired psychiatric disorder to include post-traumatic stress disorder (PTSD) is remanded. The Veteran has claimed that he has an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD), which is due to his active-duty service. In the Veteran's August 2015 Notice of Disagreement (NOD), he wrote that he "watched as my friend [T.C.] died aboard the U.S.S. Piedmont because the doctor stated that he was only trying to get out of work. It was after he died that it was figured out that he did have encephalitis." To establish entitlement to service connection for PTSD, a Veteran must establish (1) medical evidence establishing a clear diagnosis of PTSD under 38 C.F.R. § 4.125 (a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) a link, established by medical evidence, between current symptoms and a claimed in-service stressor. 38 C.F.R. § 3.304(f). The Veteran was given a hearing before the undersigned in July 2021. During the hearing, the Veteran testified that he undergoes regular counseling and group therapy sessions for his claimed PTSD. The Veteran testified that he was given a PTSD diagnosis by the VA medical center in Chillicothe, Ohio, but that sometimes "the [group] sessions actually make you worse." He also stated that he has been taking medication for his acquired psychiatric disorder, but that it has not helped his symptoms. The Veteran then testified to an in-service stressor, whereby he witnessed another sailor, T.C., die in 1968, while he was stationed aboard the U.S.S. Piedmont. The Veteran is competent to report the symptoms he experiences, such as those associated with his psychiatric disorder. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). Following the Veteran's initial claim for service connection, the RO sent the Veteran's listed stressor to the Joint Services Records Research Center (JSRRC) for corroboration. In a response from October 2015, the JSRRC noted that a review of casualty form indicated that sailor T.C. died in July 1968, at the U.S. Army Hospital at Camp Hue, in Okinawa, as a result of encephalitis. This was also confirmed in the records from the ship that the Veteran served on, the U.S.S. Piedmont. As such, the Veteran's in-service stressor has been adequately corroborated. 38 C.F.R. § 3.304(f). While the Veteran's in-service stressor has been corroborated, and while he has testified as to having a current diagnosis, that diagnosis has not been confirmed. The Veteran was given a VA psychiatric evaluation in February 2018. The Veteran was seen in-person, and his claims file was reviewed. At the top of the associated examination report, the examiner noted that the Veteran did have a current diagnosis of PTSD that conformed to the DSM-5 criteria. They later noted however that the veteran had "no mental disorder diagnosis." Following a clinical review, which included the in-person interview, the VA examiner noted that the Veteran's current mental status does "not support meeting full criteria for a DSM 5 diagnosis of PTSD (or any mental disorder)." The examiner also noted that the corroborated in-service stressor was considered. As such, a current diagnosis of PTSD was denied. The Veteran's VAMC records however do indicate a current diagnosis of PTSD. They note that the Veteran is regularly screened for PTSD, and that he has attended group therapy sessions. Nursing and treatment notes indicate a continued diagnosis of PTSD. See further VAMC notes from December 2017, February 2018, May 2018, January 2020, and February 2020. In consideration of the above, the Veteran's current diagnosis must be clarified. The February 2018 VA examiner indicated that the Veteran did have a current diagnosis of PTSD, but the rest of the report denied that diagnosis. That February 2018 report was also not compiled with the benefit of the Veteran's competent testimony, provided in July 2021. The Veteran's VAMC records often cite to a current diagnosis of PTSD, although those records are often part of routine screenings and group therapy sessions, as opposed to an in-depth psychiatric evaluation. Those VAMC records also do not provide a nexus statement, linking the Veteran's confirmed in-service stressor to any psychiatric diagnosis. 38 C.F.R. § 3.304(f). Thus, affording the Veteran the benefit of the doubt, he should be afforded an additional VA psychiatric evaluation, so that the discrepancy among the diagnoses can be addressed. If a current diagnosis of an acquired psychiatric disorder can be confirmed, an etiological opinion should also be provided, based on the Veteran's corroborated in-service stressor. The matters are REMANDED for the following action: 1. Obtain all outstanding VA and/or private treatment records. For any private treatment records, obtain the appropriate signed releases from the Veteran, and associate any additional records with the claim. Should such records exist, associate them with the electronic claims file. 2. Forward the Veteran's claims file to a VA psychiatrist for a VA mental health evaluation (or telehealth interview(s), review(s) of the record, etc., if an in-person examination(s) is not feasible) to address his claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD. A copy of this remand must be made available to the examiner for review in conjunction with this examination. After reviewing the claims file and examining the Veteran, the examiner should answer the following questions: (a.) The examiner is asked to confirm whether or not the Veteran has a current diagnosis of PTSD based on the appropriate DSM. The examiner must explain how the diagnostic criteria are met and opine whether any confirmed PTSD diagnosis is at least as likely as not related to the verified in-service stressor. The examiner is reminded that the Veteran's claimed in-service stressor that he witnessed a fellow sailor, T.C. die in July 1968 while stationed aboard the U.S.S. Piedmont has already been adequately corroborated by the Joint Services Records Research Center (JSRRC). The examiner is also reminded that the Veteran has provided competent lay statements and testimony regarding his claimed PTSD, and that VAMC records consistently note a working diagnosis of PTSD. A detailed rationale for the opinions must be provided. 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. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 3. After completing the requested actions, and any additional development deemed warranted, readjudicate the claims in light of all pertinent evidence and legal authority. If the benefits sought remain denied, furnish to the Veteran and his Representative a Supplemental Statement of the Case (SSOC) and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112. Michael A. Pappas Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Mulrain, 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.