Citation Nr: 21012851 Decision Date: 03/05/21 Archive Date: 03/05/21 DOCKET NO. 15-06 317 DATE: March 5, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder, not including posttraumatic stress disorder (PTSD), is granted. REMANDED Entitlement to service connection for PTSD is remanded. FINDING OF FACT The evidence of record is at least in equipoise as to whether the Veteran experiences an acquired psychiatric disorder, not including PTSD, that arose during or as a result of his active service. CONCLUSION OF LAW The criteria for entitlement to service connection for an acquired psychiatric disorder, not including PTSD, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1967 to July 1987. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2011 rating decision of a VA Regional Office (RO). Prior to the Board’s June 2020 decision, VA received a 90-day extension request from the Veteran’s representative to submit additional evidence in support of the Veteran’s appeal. The extension request was granted, and the June 2020 decision denying service connection for an acquired psychiatric condition was vacated. Accordingly, this decision will reconsider the claim for service connection along with the additional evidence that was received during the extension. The Veteran asserts that he suffers from PTSD as a result of his active service. Pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Board has recharacterized the Veteran’s claims to include any psychiatric disorder. As emphasized in Clemons, though a Veteran may only seek service connection for PTSD, the Veteran’s claim cannot be limited only to that diagnosis but must rather be considered a claim for any mental disability that may be reasonably encompassed. The Board has split the claim into two issues: entitlement to service connection for an acquired psychiatric disorder, which is discussed below, and entitlement to service connection for PTSD, which is discussed in the Remand section that follows. 1. Entitlement to service connection for an acquired psychiatric disorder The Veteran asserts that he experiences an acquired psychiatric disorder that arose during or as a result of his active service. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). In this case, the Veteran’s service treatment records (STRs) are negative for complaints, treatment, or diagnosis of any acquired psychiatric disorder. The Veteran’s VA and private treatment records are negative for treatment or diagnosis of psychiatric disorders in the 12-month period immediately following separation from active service or for medical opinions tying any such conditions to his service. In an August 2010 VA treatment record, a physician stated that the Veteran did not meet the criteria for a diagnosis of PTSD, but his symptoms were consistent with adjustment disorder. During the Veteran’s January 2011 VA examination for PTSD, the examiner found that the Veteran over endorsed symptoms suggestive of PTSD and found the Veteran was generally healthy, with positive relationships and behavior. The examiner noted the Veteran had been married for 30 years. In a July 2011 VA treatment record, the Veteran was informed by a licensed clinical social worker that he did not have PTSD, and a February 2016 VA treatment reflects a negative screening for PTSD. In a March 2011 statement in support of his claim, the Veteran mentioned that he was on his second marriage, that he did experience relationship difficulties, and that he did not feel his VA examiner had given an accurate assessment of his symptoms. During the Veteran’s October 2019 VA examination for PTSD, the examiner noted that the Veteran was diagnosed with adjustment disorder, but they opined that the condition was less likely than not related to service. The examiner stated that the stressor causing the condition was the Veteran’s frustration with the bureaucracy of the VA, the Veteran was not cooperative during the interview, and he was visibly upset and hostile. In a September 2020 VA treatment record, the Veteran denied being depressed or needing to see mental health treatment providers, but he contended that he did have PTSD and was pursuing VA claims for the disability. In January 2021, the Veteran submitted a detailed opinion by a private psychiatrist in support of his claim. The psychiatrist opined that the Veteran met the criteria for a diagnosis for PTSD and MDD, these conditions were at least as likely as not due to his active service, and they likely precluded him from securing or following substantially gainful employment. The psychiatrist discussed the Veteran rescuing wounded servicemembers as part of his duties as well as him retrieving servicemembers who had been killed in action. The psychiatrist also reviewed the Veteran’s symptoms in detail and found them adequate to support diagnoses for PTSD and MDD. His symptoms included depression, diminished interest in activities, change in appetite/weight, sleep disturbance, fatigue, concentration problems, anger issues, hypervigilance, and chronic nightmares and flashbacks. Based on the detail and quality of the opinion, along with the psychiatrist’s expertise, the Board finds the January 2021 opinion to be the most probative evidence of record. The Board notes that there is significant evidence that weighs in favor of and against the Veteran’s claim for service connection. The Veteran was not diagnosed with PTSD until he provided a private psychiatrist’s opinion. The VA examination opinions of record found that the Veteran was negative for PTSD and any acquired psychiatric disorders were more likely due to post-service events. Conversely, the private psychiatrist’s opinion states that the Veteran meets the criteria for diagnoses for PTSD and MDD, despite the Veteran denying depression in VA treatment records shortly before the opinion was authored. Taking all evidence of record into account, the Board finds the evidence is roughly in equipoise as to whether the Veteran currently experiences an acquired psychiatric disorder, including MDD and adjustment disorder, as a result of his active service. Resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for an acquired psychiatric disorder, not including PTSD, is warranted. Accordingly, the claim for service connection for an acquired psychiatric disorder is granted. REASONS FOR REMAND 1. Entitlement to service connection for PTSD is remanded. The Veteran asserts that he experiences PTSD as result of his active service. Establishing service connection for PTSD requires the following: (1) medical evidence diagnosing PTSD in accordance with 38 C.F.R. § 4.125(a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptoms and the claimed in-service stressor. 38 C.F.R. § 3.304(f). These stressor verification requirements are not mandatory for other acquired psychiatric disorders. Accordingly, the claims for PTSD has been recharacterized as separate issue. In January 2021, the Veteran submitted a detailed opinion by a private psychiatrist in support of his claim. The psychiatrist opined that the Veteran met the criteria for a diagnosis for PTSD. They stated this condition was at least as likely as not due to his active service, and it likely precluded him from securing or following substantially gainful employment. The evidence of record does not clearly indicate that the Veteran experienced combat or that other in-service stressors have been corroborated. As a result, remand is necessary to corroborate the Veteran’s asserted in-service stressors and to obtain a new VA examination to determine the nature and etiology of the Veteran’s PTSD in light of the January 2021 private psychiatrist’s opinion and any stressor verification development. 38 C.F.R. § 3.159(c)(4). The matters are REMANDED for the following actions: 1. Take appropriate action to corroborate the stressors reported by the Veteran in the January 2021 private psychiatrist’s opinion. Document the claims file accordingly. 2. After completion of the above, schedule the Veteran for a VA examination, with a psychiatrist or psychologist, regarding his claim of service connection for PTSD. The examiner should review the file. The examiner should also discuss the Veteran’s military and medical history, and current complaints and symptoms, with the Veteran and document the Veteran’s assertions in the examination report. The examiner should specifically review and comment on the January 2021 psychiatrist’s opinion. All opinions must be supported by a rationale. (a.) The examiner should identify the Veteran’s current psychiatric disorder(s), including whether he meets the criteria for PTSD. If PTSD is not diagnosed, it should be explained why this is so. (b.) For each identified psychiatric disorder, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the disorder began during active duty or is related to any incident/event of active duty, including wartime activity. (c.) If PTSD is present, the examiner is requested to identify the stressor(s) that support the diagnosis. A complete rationale should be provided for all opinions. The Board recognizes the practical difficulties of scheduling an examination in view of the COVID-19 epidemic, and requests flexibility and understanding in affording the Veteran an opportunity to report for an examination. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Hicks, 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.