Citation Nr: 21014910 Decision Date: 03/16/21 Archive Date: 03/16/21 DOCKET NO. 15-18 793A DATE: March 16, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), traumatic amnesia, and insomnia, is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1966 to August 1968. The Veteran’s DD Form 214 also reflects that he was transferred to Reserve service. This matter again comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. The Board previously remanded this matter in March 2019. 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, traumatic amnesia, and insomnia, is remanded. As a preliminary matter, the Board acknowledges that the record reflects psychiatric diagnoses of PTSD, traumatic amnesia, and insomnia. Because the scope of a psychiatric disability includes any mental disorder that may reasonably be included with the claimant’s account of the claim, reported symptoms, and all other information of record, the Board finds that it is more appropriate to characterize the Veteran’s mental health claim broadly, as a single claim for entitlement to service connection for an acquired psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). As noted above, the Veteran’s August 1968 DD Form 214 indicates that, after separation from active duty, he was transferred to Reserve service. There are some service treatment records and some service personnel records affiliated with the claims file revealing the Veteran’s education, performance, assignments, points, and awards; however, the precise dates of all periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) are not available. On remand, the RO should confirm the Veteran’s periods of ACDUTRA and INACDUTRA. The Board also acknowledges the possibility and probability that there will be additional service treatment records associated with periods of ACDUTRA and/or INACDUTRA and therefore requests that said records also be obtained and associated with the claims file. In the March 2019 remand, the Board requested that the Veteran undergo a new examination to confirm whether he had a current diagnosis of PTSD. However, the remand directives also requested opinions as to the nature and etiology of any and all psychiatric conditions attributable to the Veteran. Accordingly, the Veteran was evaluated in December 2019, at which time the examiner diagnosed the Veteran as not having any psychiatric conditions in accordance with the DSM 5. However, as noted above, the Veteran was previously diagnosed as having PTSD, traumatic amnesia, and insomnia. See August 2012-July 2013 Prescott Vet Center Notes; November 2012 VA C&P Examination. The presence of the claimed disability at any time during the claim process can justify a grant of service connection even if the disability has since resolved or where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). As the December 2019 examiner did not provide an opinion as to the Veteran’s diagnosed psychiatric disabilities despite evidence that a condition was noted during the appeal period, the Board finds that an addendum opinion regarding the nature and etiology of any and all psychiatric condition(s) attributable to the Veteran throughout the appeal period should be obtained. The matters are REMANDED for the following action: 1. The RO should determine the specific dates of when the Veteran served on ACDUTRA and/or INACDUTRA. In this regard a report detailing the Veteran’s award of reserve retirement points will NOT represent compliance with this instruction. Rather, each and every date of active duty, ACDUTRA and INACDUTRA must be verified. Then, issue a memorandum for inclusion in the claims file detailing each period of verified active military service, whether on active duty, ACDUTRA, or INACDUTRA. All medical treatment records associated with the Veteran’s Reserve service should also be affiliated with the claims file. 2. After completing the foregoing development, forward the claims file to an appropriate psychologist or psychiatrist for an addendum opinion to determine the nature and etiology of any and all psychiatric conditions attributable to the Veteran throughout the appeal period. The psychologist or psychiatrist should note review of the claims file. If the psychologist or psychiatrist determines that a new examination (or telehealth interview, etc., if an in-person examination is not feasible) would be beneficial, one is to be provided. (a) The psychologist or psychiatrist should identify any and all psychiatric condition(s) attributable to the Veteran throughout the appellate period. (b) For each condition so identified, the psychologist or psychiatrist should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s condition manifested during, or is the result of, his active duty service, ACDUTRA, and/or INACDUTRA. (c) If the psychologist or psychiatrist finds that a diagnosis of PTSD is appropriate, he or she must explain how the diagnostic criteria are met and opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s PTSD manifested during, or is the result of, his active duty service, ACDUTRA, and/or INACDUTRA, including such reported in-serve stressors as his experience in Vietnam including being under fire and loading wounded and dead soldiers on to a medivac. In formulating his or her opinions, the psychologist or psychiatrist should consider and address the competent medical and lay evidence of record, including but not limited to: (i) The Veteran’s service treatment records; (ii) The Veteran’s post-service VA treatment records; (iii) The Veteran’s post-service Prescott Vet Center treatment records; and (iv) The Veteran’s various competent lay statements of record regarding his in-service experiences and the onset and continuity of his psychiatric symptomatology. If the psychologist or psychiatrist determines that the Veteran’s acquired psychiatric condition(s) is/are less likely than not due to his active duty service, ACDUTRA, and/or INACDUTRA, the psychologist or psychiatrist should discuss what other factor(s) caused the disorder(s). The psychologist or psychiatrist must discuss and reconcile any conflicting medical evidence or opinions of record. The psychologist or psychiatrist must provide a comprehensive report that includes a complete rationale for all opinions and conclusions reached. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Seserman 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.