Citation Nr: 21011435 Decision Date: 03/01/21 Archive Date: 03/01/21 DOCKET NO. 13-07 859 DATE: March 1, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), major depressive disorder, anxiety disorder not otherwise specified, and adjustment disorder not otherwise specified, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from July 1956 to September 1959. This appeal comes to the Board of Veterans’ Appeals (“Board”) from a May 2012 rating decision by the Department of Veterans Affairs (“VA”) Regional Office (“RO”) in Columbia, South Carolina. A Board video hearing was held before the undersigned Judge in March 2015. The hearing transcript has been associated with the Veteran’s file. The Veteran’s appeal has previously been before the Board. In a September 2019 Board decision, the Veteran’s claim of entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), major depressive disorder, anxiety disorder not otherwise specified, and adjustment disorder not otherwise specified, was denied. Thereafter, the Veteran appealed this denial to the Court of Appeals for Veterans Claims (“CAVC”). In a July 2020 Joint Motion for Remand (“JMR”), the Court vacated the Board’s denial for the claim of entitlement to service connection of an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), major depressive disorder, anxiety disorder not otherwise specified, and adjustment disorder not otherwise specified and remanded the issue to the Board for further appellate review. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), major depressive disorder, anxiety disorder not otherwise specified, and adjustment disorder not otherwise specified, is remanded. The Veteran’s claim must be remanded before the Board is able to make a determination on the merits and ensure compliance with the JMR. Specifically, with regard to examinations, the Veteran should be afforded a VA examination for the purpose of providing an opinion as to the nature and etiology of any psychiatric disorder diagnosed. The examiner should make specific findings with regard to the claimed existence of a diagnosis for each of the following: posttraumatic stress disorder (PTSD), major depressive disorder, anxiety disorder not otherwise specified, and adjustment disorder not otherwise specified, as well as for any other psychiatric disorder that may be diagnosed. With regard to compliance with the April 2015 remand directives, the RO should assure that all outstanding treatment records from the Charleston VA Medical Center dated from 1972 to the present are obtained, to include an April 11th, 2011 mental health evaluation. The RO should document the efforts made in the file. In addition, the RO should work with the Veteran in order to associate any other pertinent medical treatment records up to the present time. The Board cannot make a determination as to the Veteran’s claim until any outstanding medical records are obtained, and a VA examination and medical opinion regarding the nature and etiology for a claimed acquired psychiatric disorder, to include claimed posttraumatic stress disorder (PTSD), major depressive disorder, anxiety disorder not otherwise specified, and adjustment disorder not otherwise specified, or any other psychiatric diagnosis, is completed. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (finding that when VA undertakes to provide an examination or obtain an opinion, it must ensure that the examination or opinion is adequate). Therefore, the case is remanded. The matters are REMANDED for the following action: 1. Ensure that all outstanding treatment records from the Charleston VA Medical Center dated from 1972 to the present are obtained, to include an April 11, 2011 mental health evaluation. If any records are not available, then document in the claims file the steps taken and the response(s). If the records are unavailable, the RO should clearly document the claims folder to that effect and notify the Veteran of any inability to obtain these records. 2. Ask the Veteran to identify, and authorize the release of, any outstanding private medical records related to his claim of service connection for his acquired psychiatric disorders. All records received must be associated with the claims file. If any of the records requested are unavailable, clearly document the claims file to that effect and notify the Veteran of any inability to obtain these records. 3. After the records development is completed, schedule the Veteran for a VA PTSD/mental disorders examination by an appropriate specialist, or to qualified VA psychologist. The electronic claims file must be provided to and reviewed by the examiner in conjunction with the examination. All necessary diagnostic testing and evaluation should be performed, and all findings set forth in detail. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, such as observable symptomatology. If there is a clinical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. Based upon a review of the entirety of the claims file, the history presented by the Veteran, and the examination results, the examiner is requested to provide an opinion as to the following questions: a) First, the examiner must provide diagnoses for all current and previously diagnosed psychiatric disorders following a review of the entirety of the Veteran’s claims file. b) For each disorder identified, other than PTSD, the examiner should state whether it is at least as likely as not that the disorder manifested in service or is otherwise causally or etiologically related to the Veteran’s military service. If the VA examiner finds a psychiatric disability is not causally or etiologically related to the Veteran’s military service, the examiner is asked to provide a clear rationale explaining their conclusion. Specifically, there must be a rationale which adequately connects data and conclusions. b) The VA examiner should determine whether the Veteran meets the DSM-V criteria for a diagnosis of PTSD. If a PTSD diagnosis is deemed appropriate, the examiner should then opine as to whether there is a link between any current PTSD symptomatology and the Veteran’s reported in-service stressors. The examiner must provide a complete rationale for all opinions expressed. As part of the rationale, the examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). A discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the examiner cannot provide the requested opinion(s) without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. The examiner must indicate whether an opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 4. The RO should remind the Veteran that it is his responsibility to cooperate in the development of the claim, and the RO should document efforts made in this regard. 5. After completing the above development, the RO should review the claims file and ensure that all of the   foregoing development actions have been conducted and completed in full. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.M. Schneider 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.