Citation Nr: 21009773 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 17-46 785 DATE: February 23, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and a major depressive disorder, is remanded. REASONS FOR REMAND The Veteran had active service from August 1958 to August 1962. A March 2019 Board of Veterans’ Appeals (Board) decision remanded this matter for further evidentiary development. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and a major depressive disorder After carefully considering this matter, and for reasons expressed immediately below, the Board finds that this case must again be remanded for further development. The Board regrets the delay associated with this remand but finds that a remand is necessary to ensure that the Veteran is accorded full compliance with VA’s statutory duty to assist. In March 2019, the Board remanded this matter to obtain specific information regarding the Veteran’s claimed in-service stressor(s) and to afford him a VA examination to determine the nature and etiology of any current acquired psychiatric disorder, to include PTSD and a major depressive disorder. Pursuant to these directives, the Veteran was accorded a VA examination in September 2020. However, the Board finds the September 2020 VA examination to be inadequate. This VA examiner diagnosed the Veteran with PTSD, a major depressive disorder, and a mild vascular neurocognitive disorder. The examiner opined that it was less likely than not that the Veteran’s depression and vascular neurocognitive disorders were caused or aggravated by the claimed in-service event. However, in providing this opinion, the examiner relied on the absence of a diagnosis, treatment, or complaint of such disorders in the record prior to 2000. As such, the Board finds this opinion inadequate as it does not provide an adequate rationale for the opinion, nor does it consider the Veteran’s lay testimony that his depression was due to his claimed stressor(s) while in service. Likewise, the examiner opined that it was at least as likely as not that the Veteran’s PTSD diagnosis was related to the Veteran’s claimed in-service stressor. However, the examiner stated that she was unable to substantiate the trauma events and that “if substantiated, [they] would fulfill the requirements for extreme trauma capable of causing PTSD.” In this regard, the Board notes that, pursuant to that last remand, the AOJ furnished the Veteran with a written request to provide specific information regarding his purported in-service stressors. Significantly, however, the Veteran failed to respond to the request. In this regard, the Board hereby notifies the Veteran that, while VA has a statutory duty to assist a veteran in developing evidence pertinent to a claim, he/she also has a duty to assist and cooperate with the VA in developing evidence. In other words, VA’s duty to assist is not a one-way street. If a veteran wishes help, he or she cannot passively wait for it in those circumstances where he or she may or should have information that is essential in obtaining the relevant evidence. Wood v. Derwinski, 1 Vet. App. 190 (1991); Hayes v. Brown, 5 Vet. App. 60, 68 (1993). VA’s duty must be understood as a duty to assist a veteran in developing his or her claim, rather than a duty on the part of VA to develop the entire claim with the veteran performing only a passive role. Turk v. Peake, 21 Vet. App. 565, 568 (2008). As such, the Veteran must make reasonable efforts to assist VA in determining the adequacy of his purported in-service stressors. Importantly, the service personnel records that are available and that have been associated with the claims folder do not support the Veteran’s assertions of having service in Thailand. Accordingly, any additional and specific information that he can provide that would aid VA in procuring any additional available service personnel records are essential in this matter. This matter is, therefore, REMANDED for the following action: 1. Obtain from the Veteran as specific information as possible regarding his claimed in-service stressor(s). Upon receipt of such information from the Veteran, take appropriate steps to verify his reported in-service stressor(s) including, obtaining all available previously unobtained SPRs. 2. Then, schedule the Veteran for a VA examination to determine the nature and etiology of any current acquired psychiatric disorder, to include PTSD and a major depressive disorder. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The claims folder should be reviewed by the examiner, who should acknowledge such review in the examination report. The examiner should identify all current acquired psychiatric disorders, to include PTSD and a major depressive disorder. If any previously diagnosed acquired psychiatric disorder (to include PTSD and a major depressive disorder) is not found on current examination, the examiner should address those prior diagnoses of record and indicate whether they may have resolved or been misdiagnosed. For each diagnosis identified other than PTSD, the examiner should state whether it is at least as likely as not (i.e. a 50 percent probability or greater) that such disorder onset in, or is otherwise related to, the Veteran’s military service. In other words, is any diagnosed psychiatric disorder other than PTSD consistent with the Veteran’s purported in-service stressors? With respect to any diagnosis of PTSD, the examiner should address whether such a disability is at least as likely as not (i.e. a 50 percent probability or greater) due to exposure to an actual confirmed in-service stressor or fear of hostile military or terrorist activity. [Fear of hostile military or terrorist activity means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the response to the event or circumstance involved psychological or a psycho-physiological state of fear, helplessness, or horror.] The examiner is hereby notified that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A complete rationale should be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. No action is required of the Veteran until he is notified by VA. However, he is advised of his obligation to cooperate in ensuring the duty to assist is satisfied. Kowalski v. Nicholson, 19 Vet. App. 171 (2005). His failure to report for a VA medical examination may impact the determination made. 38 C.F.R. § 3.655. The Veteran also is advised that he has the right to submit additional evidence and argument with respect to this matter. Kutscherousky v. West, 12 Vet. App. 369 (1999). This appeal must be afforded prompt treatment. THERESA M. CATINO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. R. Bobb, 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.