Citation Nr: 21009252 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 16-35 481 DATE: February 22, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder to include PTSD is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from January 1964 to December 1967. The Veteran submitted an intent to file a claim in September 2015, and submitted a claim for service connection for PTSD in October 2015. This matter comes before the Board of Veterans’ Appeals (Board) from a February 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In the July 2016 VA Form 9, the Veteran elected a Board hearing. In April 2019, the Veteran and his wife testified before the undersigned Veteran’s Law Judge. A copy of the transcript is associated with the claims file. This matter was previously before the Board in January 2020. In the May 2020 decision, the Board remanded the Veteran’s PTSD claim for additional development. The Board acknowledges that, in Clemons v. Shinseki, 23 Vet. App. 1 (2009), the United States Court of Appeals for Veterans Claims held that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the Veteran’s description of the claim, reported symptoms, and the other information of record. Therefore, in applying Clemons to the present case, the Board construes the Veteran’s October 2015 submission as an application for service connection for an acquired psychiatric disorder, to include PTSD. Entitlement to service connection for an acquired psychiatric disorder to include PTSD The Veteran underwent a VA examination in January 2016 and February 2020. Neither examiner diagnosed the Veteran as having PTSD under DSM-V. The Veteran provided an October 2015 report and follow-up letter by Dr. J.P, a private psychologist, who stated that the Veteran manifested symptoms of PTSD. However, Dr. J.P. did not diagnose the Veteran as having PTSD under DSM-V. However, in both the October 2015 report and follow-up letter, Dr. J.P. opined that the Veteran is “extremely anxious” and has “an extreme anxiety disorder even at age 73.” Thus, the Veteran has a current disability. In the January 2020 Board decision, the Board directed the RO to afford a VA examination addressing the Veteran’s acquired psychic disorder, together with an opinion as to whether such a disorder is attributable to service. In February 2020, the Veteran underwent a VA examination and the RO obtained an addendum opinion. The examiner found that the Veteran experienced an in-service event based on fear of hostile military. Thus, the Veteran met the second element for service connection. In the February 2020 report, the examiner did not diagnose the Veteran as having any mental disorder by stating that the Veteran “may have subthreshold ptsd [sic] symptoms but does not qualify for any dsm-5 mental diagnosis at this time.” Consequently, the examiner conflated the standards for a PTSD diagnosis under 38 C.F.R. § 4.125(a), with those for an acquired psychiatric disorder. 38 C.F.R. § 3.303. Additionally, the examiner failed to explain why the Veteran’s diagnosis of an anxiety disorder by Dr. J.P. did not support a finding that he suffered from an acquired psychiatric disorder other than PTSD. For these reasons, the Board finds the February 2020 opinion inadequate. Once VA undertakes the effort to provide an examination when developing a service-connection claim, the examination must an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Therefore, the Board finds there has not been substantial compliance with the Board’s February 2020 remand directives regarding the issue of an acquired psychiatric disorder. Stegall v. West, 11 Vet. App. 268, 271 (1998). Further, the examiner did not address the January 2019 VA treatment record in which Dr. A.Y, a psychiatrist, diagnosed the Veteran as having anxiety secondary to a general medical condition. Service connection may be considered on a secondary basis under 38 C.F.R. § 3.310. The three elements that must be met to grant secondary service connection are: a current disability that is not already service-connected; at least one service-connected disability; and evidence that the non-service-connected disability is either: (a) proximately due to or the result of a service-connected disability, or (b) aggravated beyond its natural progress by a service-connected disability. 38 C.F.R. § 3.310. See Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran is service-connected to three physical disabilities; specifically, diabetes mellitus type II, coronary artery disease, and erectile dysfunction associated with coronary artery disease. The Board cannot make a fully-informed decision on the issue of service connection for an acquired psychiatric disorder, to include anxiety because no VA examiner has opined whether such disorder(s) are secondary to any of the Veteran’s service-connected physical disabilities. Thus, the Board finds an addendum opinion is necessary to determine whether the Veteran’s claim for an acquired psychiatric disorder, to include anxiety is proximately due to or aggravated by any service-connected physical disabilities. For the reasons described above, the Board finds that another remand is required. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. The matters are REMANDED for the following action: 1. Schedule the Veteran for an in-person VA examination with an appropriated clinician for an addendum opinion to determine the nature and etiology of the Veteran’s acquired psychiatric disorder(s), to include anxiety. 2. Provide the clinician the Veteran’s complete claims file, including the January 2020 Remand order and this Remand order, for review in connection with the examination as well as detailed clarifications as to the elements of a claim for service connection for PTSD and the elements of a claim for service connection for an acquired psychiatric disorder other than PTSD, stressing the differences between these claims. The examination report should reflect that such review was accomplished. 3. The clinician should interview and examine the Veteran. The clinician is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be considered in formulating the requested opinions. 4. Based on review of the record and examination of the Veteran, and after eliciting a detailed history of the Veteran’s conditions from the Veteran, the clinician is requested to: a. Identify and describe each current diagnosis of the Veteran’s acquired psychiatric disorder, to include anxiety. b. In the event the clinician concludes that the Veteran did not suffer from an acquired psychiatric disorder other than PTSD during at least a portion of the period on appeal, the clinician is requested to explain why the Veteran’s diagnosis recorded by the Dr. J.P. October report and follow-up letter cannot support such the diagnosis of an acquired psychiatric disorder other than PTSD. c. For each diagnosed acquired psychiatric disorder, opine whether such diagnosis is at least as likely as not (50 percent probability or greater) caused by or is otherwise attributable to service. d. For each diagnosed acquired psychiatric disorder, opine whether such diagnosis is at least as likely as not (50 percent probability or greater) proximately due to or aggravated by any of the Veteran’s service-connected physical disabilities beyond its natural progression. The term “aggravation” in the above context refers to “any incremental increase in disability - any additional impairment of earning capacity - in non-service-connected disabilities resulting from service-connected conditions regardless of its permanence.” 5. The clinician must provide detailed rationale for all opinions proffered. All appropriate studies and consultations should be accomplished, and all clinical findings should be reported in detail. If an opinion as to any aspect of the aforesaid inquiries cannot be provided without resorting to speculation, the clinician is requested to provide an explanation as to why this is so and to identify what additional development, if any, would permit the requested opinion to be rendered. 6. After completing the foregoing and any other development necessary, readjudicate the Veteran’s claims. 7. If any benefit sought on appeal remains denied, a Supplemental Summary of the Case (SSOC) should be furnished to the Veteran, and he should be afforded a reasonable opportunity to respond. Cynthia M. Bruce Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Agarwal, 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.