Citation Nr: 21013656 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 13-08 205 DATE: March 10, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from April 1968 to April 1970, including service in the Republic of Vietnam. These matters come to the Board of Veterans’ Appeals (Board) on appeal from a September 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. In March 2016, the Board denied the claim of entitlement to service connection for a psychiatric disorder. The decision was appealed to the Court, and in September 2016, the Court vacated that portion of the March 2016 Board decision that denied service connection for a psychiatric disorder. Most recently, in a July 2018 decision, the Board remanded the issue of service connection for an acquired psychiatric disorder for additional development. 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD is remanded. The Veteran asserts that he has a psychiatric disability that is related to or had its onset in service. In light of the reasons below that require remand, the Veteran should be given another opportunity to provide lay evidence regarding the onset and or recurrence of psychiatric symptoms since service. In addition, in the March 2015 remand, the Board determined that a June 2011 VA examination and accompanying medical opinion were inadequate because the examiner provided a diagnosis of bipolar disorder by history and stated that no other mental disorders have been diagnosed, but medical records cited by that examiner also indicate that the Veteran has been diagnosed with generalized anxiety disorder, panic disorder, and posttraumatic stress disorder (PTSD). See Social Security Administration record, October 2004 (documenting a Psychiatric Medical Report of a doctor’s findings and diagnoses). The June 2011 examiner acknowledged these diagnoses but failed to address them when she offered her medical opinion. Subsequent to the March 2015 Board remand, VA provided another examination in June 2015. As noted in the September 2016 JMPR, the clinician who examined the Veteran in June 2015 did not discuss all diagnosed psychiatric disorders as requested. Thus, the Board found that VA had not complied with the directives of the March 2015 remand and requested another examination. The July 2018 Board remand specifically requested that the examiner identify all disorders diagnosed during the appeal period (since October 2010) and address the January 2017 psychologist’s opinion that the Veteran’s medical records show that the Veteran has “Other Specified Trauma and Stressor-Related Disorder (subthreshold PTSD)” and “Partial PTSD.” Unfortunately, the December 2020 medical opinion that was obtained in response to the Board’s remand did not substantially comply with this directive. The Board regrets additional delay but finds that remand is necessary to obtain a new medical opinion. Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are REMANDED for the following action: 1. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of any in-service and post-service psychiatric symptomatology. Provide the Veteran an appropriate amount of time to submit this lay evidence. 2. Schedule the Veteran for a VA psychiatric examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible). All indicated tests and studies should be performed, and all findings should be set forth in detail. This should include psychological testing necessary to determine what the Veteran’s current psychiatric disorders are. The claims folder, and a copy of this remand, must be provided to and reviewed by the examiner as part of the examination. The VA examiner should identify each disorder that has been diagnosed during the appeal period (or since October 2010), to include generalized anxiety disorder, panic disorder, and PTSD. In doing so, specifically rule in or exclude a diagnosis of PTSD under the DSM-IV and/or DSM-5 and specifically address the January 2017 opinion that the Veteran’s medical records show “Other Specified Trauma and Stressor-Related Disorder (subthreshold PTSD)” and “Partial PTSD.” For each disorder identified, provide an opinion as to whether it is at least as likely as not that the disorder was caused or aggravated by the Veteran’s active military service. For each disorder identified, provide an opinion as to whether it is at least as likely as not that the disorder was caused or aggravated by the Veteran’s service-connected nose disability or hypertension. The examiner must review the entire record and consider all pertinent medical and lay evidence. Complete medical rationale for all conclusions reached should be provided. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Sara Leigh, Attorney Advisor 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.