Citation Nr: 21011085 Decision Date: 02/26/21 Archive Date: 02/26/21 DOCKET NO. 11-18 094 DATE: February 26, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, including posttraumatic stress disorder (PTSD) and major depressive disorder, is remanded. Entitlement to service connection for migraine headaches, including as secondary to an acquired psychiatric disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from January 1999 to December 2006. The Veteran received an "other than honorable" discharge for his period of service from January 2003 to December 2006. In a February 2008 administrative decision, the Agency of Original Jurisdiction (AOJ) determined that this period of service is considered to be under dishonorable conditions for VA purposes. Thus, the Veteran's character of discharge for the period of service from January 26, 2003, to December 22, 2006, is a bar to benefits from the Department of Veteran's Affairs (VA), other than for health care under Chapter 17, Title 38, United States Code. 38 U.S.C. §§ 101, 5303; 38 C.F.R. §§ 3.12, 3.13, 3.354. Nonetheless, the Veteran may still receive VA benefits based on disabilities incurred during his period of honorable active service from January 26, 1999, to January 25, 2003. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). A claim for service connection for a psychiatric disability is deemed to encompass all psychiatric diagnoses reasonably presented in the record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Pursuant to Clemons, the Board has expanded the service connection claim for an acquired psychiatric disorder as reflected on the title page of this decision. Regrettably, additional development is necessary before the Veteran's claims can be adjudicated. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and depression. The Veteran contends that he has an acquired psychiatric disorder, to include PTSD and depression, that manifest during or is otherwise related to his honorable period of active service. Establishing service connection for PTSD requires: (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304 (f); see also Cohen v. Brown, 10 Vet. App. 128 (1997). In adjudicating a claim for service connection for PTSD, the Board is required to evaluate evidence based on places, types, and circumstances of service, as shown by the veteran's military records and all pertinent medical and lay evidence. Hayes v. Brown, 5 Vet. App. 60, 66 (1993); see also 38 U.S.C. § 1154(a); 38 C.F.R. § 3.304(f). The evidence necessary to establish the occurrence of an in-service stressor for PTSD will vary depending on whether or not the veteran "engaged in combat with the enemy." Id. If VA determines that the veteran engaged in combat with the enemy and that the alleged stressor is related to combat, then the veteran's lay testimony or statements are accepted as conclusive evidence of the occurrence of the claimed stressor. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(f). No further development or corroborative evidence is required, provided that the claimed stressor is "consistent with the circumstances, conditions, or hardships of the veteran's service." Id. If, however, VA determines that the veteran did not engage in combat with the enemy or that the alleged stressor is not related to combat, the veteran's lay testimony by itself is not sufficient to establish the occurrence of the alleged stressor. Instead, the record must contain service records or other evidence to corroborate the veteran's testimony or statements. See Moreau v. Brown, 9 Vet. App. 389, 394 (1996). In this case, the Veteran’s service records indicate that the Veteran served in combat operations from September 22, 2000, to October 8, 2000, Operation Silent Lance, Adriatic Sea; September 16, 2002, to October 21, 2002, Operation Dynamic Response, Kosovo; January 1, 2003, to March 27, 2003, Operation Southern Watch, Persian Gulf; and March 28, 2003, to April 24, 2003, Operation Iraqi Freedom, Iraq. The Veteran has also indicated that he conducted security duties in Djibouti as part of Operation Enduring Freedom. Given the character of his discharge for his second period of service, the Board notes that the Veteran is not eligible for VA disability benefits based on service after January 25, 2003, including his participation in combat operations as part of Operation Iraqi Freedom. The Veteran was provided a VA examination for PTSD in February 2010. The Veteran was diagnosed with PTSD. The examiner also noted that the Veteran was currently receiving treatment for depression and anxiety. The examiner found that the Veteran’s PTSD is most likely caused by or a result of his exposure to military combat stressor events while in service. The examiner identified the Veteran’s PTSD stressor as combat experience in Iraq in 2003. As a result, overall, this examination provides evidence against this case. The examiner appears to have related the Veteran’s PTSD to service that occurred during a period of “dishonorable” service for VA purposes and would therefore be a bar to disability benefits. However, it is unclear whether the examiner considered the Veteran’s combat service during his first period of service for which he remains eligible for disability benefits. The Veteran contends that his combat experiences prior to January 26, 2003, contributed to his current diagnosis for PTSD and depression. Considering the above, the Board finds that the VA examination was not adequate and that a remand is required to obtain an addendum medical opinion. See 38 U.S.C. § 5103(a); Barr v. Nicholson, 21 Vet. App. 31 (once VA undertakes the effort to provide an examination when developing a claim for service connection, even if not statutorily obligated to do so, it must provide an adequate one). Entitlement to service connection for migraine headaches. The Veteran contends that his migraine headaches are secondary to his acquired psychiatric disorder. As the outcome of the claim for an acquired psychiatric disorder could potentially affect the claim for migraine headaches, they are inextricably intertwined and the claim for migraine headaches is also remanded. These matters are REMANDED for the following action: 1. Obtain the Veteran's updated VA treatment records and associate them with the evidence of record. If possible, the Veteran himself should submit these records (if any), and any other new treatment for this problem, himself, to expedite the case. Any assistance on this issue would be appreciated. 2. Provide the Veteran with the requisite notice regarding what is necessary to substantiate a claim for service connection for PTSD. He must also be provided with and requested to complete and return a PTSD stressor statement for his period of honorable active service from only January 26, 1999, to January 25, 2003. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran's acquired psychiatric disorder, including PTSD and depression. Specifically, the examiner should opine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's acquired psychiatric disorder had its onset during or is otherwise related to the Veteran’s period of honorable active service from only January 26, 1999, to January 25, 2003. A complete rationale for any opinions expressed should be provided. The report should set forth all complaints, findings, and diagnoses relating to the Veteran's mental health conditions and provide a rationale for all conclusions reached. (Continued on the next page)   If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required, or the examiner does not have the needed knowledge or training. 4. After completion of the aforementioned, the AOJ should readjudicate the issues on appeal. If the benefit sought on appeal is not granted, then the AOJ should provide the Veteran with a supplemental statement of the case and afford him the appropriate opportunity to respond thereto. Thereafter, the case must be returned to the Board for further appellate review. John J. Crowley Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. VanValkenburg, 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.