Citation Nr: 21014802
Decision Date: 03/15/21	Archive Date: 03/15/21

DOCKET NO. 18-16 088
DATE: March 15, 2021

REMANDED

1. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety, is remanded.  

2. Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded.

REASONS FOR REMAND

The Veteran served on active duty, including from June 2010 to July 2011.  

This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO).  The Veteran appeared for a Board hearing in January 2021.   

The Veteran asserts that his psychiatric symptoms are due to traumatic experiences during his service in Iraq, including fear of hostile military or terrorist activity.  

The Veteran was provided a VA examination in December 2015, which found that the Veteran did not have a diagnosis of PTSD or any other mental health disorder.  Since the December 2015 examination, the Veteran has testified and submitted additional evidence regarding his ongoing psychiatric symptoms, including medical treatment records and a statement from a fellow serviceman regarding the stressful experiences in service.  Furthermore, the Veteran testified that he has been continuing treatment for a psychiatric disorder with a private psychiatrist and has records supporting his claim; however, these records have not been submitted to VA yet.  As such, a remand is warranted in order to obtain these private treatment records.  Finally, as the last VA examination was in December 2015, a new VA examination is requested that considers and addresses the new information of record related to the Veteran’s ongoing symptoms, in-service stressors, and continued treatment.  

The matters are REMANDED for the following action:

1. Request authorization from the Veteran to obtain and associate any relevant, private treatment records with the record.  All records/responses received must be associated with the electronic claims file.

2. Schedule the Veteran for a psychiatric examination to determine the nature and etiology of any psychiatric disorder, to include PTSD and anxiety.  The entire claims file must be reviewed by the examiner.  The examiner is requested to respond to the following: 

(a) If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not (a 50 percent or greater probability) related to a claimed in-service stressor, to include fear of hostile military or terrorist activity.  

(b) If any other acquired psychiatric disorders are diagnosed, to include an anxiety disorder, the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease, to include the Veteran’s statements regarding stressful in-service incidents.

The examiner is requested to provide a clear rationale and explain in detail the underlying reasoning for any opinions expressed.  If no disorders are diagnosed, this determination must be explained in the context of the record. 

 

 

A. C. MACKENZIE

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	M. Ariasaif, 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.