Citation Nr: 21007899 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 12-27 650A DATE: February 11, 2021 REMANDED Entitlement to service connection for post-traumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from March 1969 to November 1969. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In July 2019, the Board remanded the matter for further development. Although the Board regrets the delay, remand is required to ensure there is a complete record on which to decide the Veteran’s claim. 1. Entitlement to service connection for PTSD is remanded. In July 2019, the Board remanded the matter for a new VA examination, based on an inadequate January 2018 VA examination. The Board found that the Veteran had PTSD that preexisted his entry to service. The Board stated that while the January 2018 examiner opined that she believed that it was clear and unmistakable that the Veteran’s PTSD preexisted his service, she failed to offer rationale to support a finding that the Veteran’s psychiatric symptoms increased in severity during service. Specifically, the examiner failed to address whether any increase in disability during service was beyond the natural progression of the disorder. In January 2020, the Veteran underwent a VA PTSD examination. The examiner diagnosed the Veteran with PTSD and noted that the condition clearly and unmistakably existed prior to service. However, the examiner opined that the Veteran’s PTSD was clearly and unmistakably not aggravated beyond its natural progression during service. In support of this opinion, the examiner stated that there is evidence indicating that the Veteran continued to suffer from his mental health disorder during service with “occasional waxing and waning of symptoms, which is typical of the disorder.” The Board finds this opinion to be conclusory and it fails to address several of the Veteran’s in-service mental health issues. A March 1969 treatment note indicated that the Veteran complained of chest pain and radiation. See Medical Treatment Record – Government Facility, p. 11. A note written next to the treatment note, contends that these symptoms were results of his nerves and anxiety. Id. An August 1969 treatment note indicates that the Veteran experienced almost daily nightmares, with occasional hallucinations, and that he was a “nervous wreck.” See Military Personnel Record, p. 48. It further noted that the Veteran had taken Valium without relief and had difficulty falling asleep at night. Id. An August 1969 consultation report notes that since arriving in Germany two weeks prior, his nervousness increased, and he felt like he was going to “fly apart.” Id. at 30. He expressed anxiety that his company would make him become a truck driver, and that he might kill someone in an accident. Id. He stated that he had only one friend in his company and that he disliked Germany because “everything is different.” Id. The provider noted that the Veteran was anxious, tense, and experiencing situational difficulties adjusting to Germany. The Veteran was scheduled for group therapy in September 1969. Id. at 58. In September 1969, treatment records show that a provider recommended individual psychotherapy for chronic emotional maladjustment that was exacerbated by the situation and recent trauma. Id. at 56. The provider also noted that the Veteran should be considered for separation from service. Id. In a September 1969 private correspondence, the Veteran stated that he saw a doctor once a week and he knew that as long as he stayed in the Army, his nerves would never improve. In September 1969, a treatment note indicated that the Veteran was “quite distraught” because he was frightened by the threat of disciplinary action. See Military Personnel Record, p. 31. In September 1969, a provider indicated that the Veteran was taking Thorazine every day without relief and the he was being processed for supportive therapy. See STR – Medical, p. 64. The Board finds that the January 2020 examiner’s failure to address the Veteran’s in-service mental health issues as they relate to aggravation renders the examination inadequate for adjudication. Moreover, the examiner ultimate conclusion relied in part on the finding that the Veteran’s psychiatric disability, upon entry to service, was approximately of the same level of severity as his current evaluation, and as such, no aggravation could be found. Again, the examiner failed to provide any analysis regarding the Veteran’s baseline severity upon entry into service; as such, the Board finds that such conclusory finding without rationale provides little to no probative value and renders such opinion inadequate and incomplete. Accordingly, the claim must be remanded in order to obtain an adequate examination and opinion. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The matters are REMANDED for the following action: Schedule the Veteran for an examination with an examiner other than the January 2020 examiner to determine the nature and etiology of his PTSD. All indicated tests and studies must be performed. After reviewing the claims file and conducting the appropriate examination, the examiner should address the following: Whether the Veteran’s PTSD was clearly and unmistakably (undebatable) aggravated beyond its natural progression by his active service. In forming this opinion, the examiner should consider and address all relevant lay and medical evidence of record, including evidence of mental health issues experienced by the Veteran during his service. In addition, the examiner is asked to formulate, if possible, a baseline for the Veteran’s PTSD/psychiatric disability upon entry into service. The examiner is advised that the Veteran is competent to report symptoms, treatment, and injuries and that his reports must be taken into account in formulating the requested opinions. The examiner must provide rationale for all proffered opinions. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. Zi-Heng Zhu Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Watkins, 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.