Citation Nr: 21016047 Decision Date: 03/19/21 Archive Date: 03/19/21 DOCKET NO. 16-59 447 DATE: March 19, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disability, including posttraumatic stress disorder (PTSD) and depressive disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1984 to November 1991, to include service in the Gulf War. In her notice of disagreement, the Veteran also appealed the issues of service connection for cervical strain, right ankle disability and left ankle disability. However, service connection for a cervical spine sprain was granted in an October 2016 rating decision; representing a full grant of the benefit sought on appeal. The issues of entitlement to service connection for left and right ankle sprains were addressed in the November 2016 statement of the case. However, in her substantive appeal, the Veteran indicated that she did not wish to appeal these issues and, thus, these matters are not currently before the Board. The Veteran testified at a Board hearing before the undersigned Veterans Law Judge in November 2020; a transcript has been associated with the record.   Entitlement to service connection for an acquired psychiatric disability, including PTSD and depressive disorder, is remanded. The Veteran asserts that she has a psychiatric disability that was either incurred in or aggravated by service. Service treatment records show that she reported depression and excessive worry upon discharge. Post-service clinical records show treatment for depression and anxiety. The April 2015 VA examiner found that the Veteran’s depressive disorder was not service related, but did not offer any clear rationale for this finding. The June 2015 VA examiner found that the Veteran’s claimed condition was not incurred in or caused by service. The examiner indicated that the Veteran’s disability stemmed from her pre-military experience of being sexually abused by her stepfather. Significantly, the Veteran’s entrance examination dated in June 1983 shows that the Veteran was clinically evaluated as psychiatrically normal. Thus, the Veteran is presumed to have been in sound condition with respect to any psychiatric disorders upon entrance into service. See 38 U.S.C. § 1111. Clear and unmistakable evidence that the disability existed prior to service and was not aggravated by service will rebut the presumption of soundness. 38 U.S.C. § 1111; VAOPGCPREC 3-2003. A pre-existing disease will be considered to have been aggravated by active service where there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progression of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. Independent medical evidence is needed to support a finding that the preexisting disorder increased in severity in service. See Paulson v. Brown, 7 Vet. App. 466, 470-471 (1995); Crowe v. Brown, 7 Vet. App. 238, 246 (1994). In light of the fact that the Veteran is presumed sound, she was afforded another VA examination in March 2017. The examiner indicated that the condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. However, in the rationale, the examiner used the wrong standard stating that the Veteran’s depressive disorder was less likely than not aggravated by service. Given these contradictions and that the examiner applied the wrong standard in the rationale, the examination is inadequate. Moreover, the examiner also failed to address the Veteran’s lay statements concerning her in-service symptoms or her service in a combat zone in the Gulf War. Further, the evidence shows that the Veteran has a Master’s degree in mental health and is a licensed professional counselor. Thus, given her background, she is also competent to opine as to whether her symptoms were incurred in or aggravated in service. Thus, the examiner must also consider the Veteran’s competent statements as a mental health professional. Moreover, the Veteran has also asserted that she has PTSD symptoms. However, none of the VA examinations have addressed whether the Veteran has PTSD due to serving in a combat area in the Gulf War, to include a fear of hostile military or terrorist activity. In light of the above, the Board finds that another VA examination is necessary to address the etiology of any current psychiatric disorder. There is also some indication that the Veteran received mental health treatment while in service. It does not appear that the Veteran’s service mental health records have been specifically requested. Likewise, as the Veteran is claiming PTSD, her service personnel records should also be obtained. As such, the National Personnel Records Center (NPRC) should be contacted to obtain service personnel records and any service mental health clinical records. See 38 C.F.R. § 3.159(c). Further, the Veteran reported treatment at Camp Pendleton Naval Hospital. The record shows that a CD with her records was sent to VA. However, it appears that the documents on the CD were not able to be downloaded. Nevertheless, no further attempts were made to obtain these records. The Board finds that further steps are necessary, to include obtaining appropriate authorization to obtain such records. Moreover, any other private treatment records should also be obtained. Lastly, additional VA clinical records dated from January 2017 to the present should also be obtained. The matters are REMANDED for the following action: 1. Obtain from the NPRC or any other appropriate repository the Veteran’s service personnel records and any service mental health clinical records for the Veteran. 2. Ask the Veteran to complete a VA Form 21-4142 for any private treatment records not already of record as well for treatment records from Camp Pendleton Naval Hospital. Make two requests for the authorized records from all identified facilities, unless it is clear after the first request that a second request would be futile. 3. Obtain the Veteran’s VA treatment records from January 2017 to the present. 4. Afford a VA examination to the Veteran conducted by a psychologist or psychiatrist in order to determine the current nature and etiology of her acquired psychiatric disorder. The record should be made available. The examiner should respond to the following: A) Clearly delineate all currently diagnosed psychiatric disorders and specifically indicate whether the Veteran meets the diagnostic criteria for PTSD. B) Whether any diagnosed PTSD is at least as likely as not due to fear of hostile military or terrorist activity while serving in a combat area in the Gulf War. C) With respect to each diagnosed psychiatric disorder, is there clear and unmistakable evidence that the disorder pre-existed service? If there is clear and unmistakable evidence that the disorder pre-existed service, the examiner is asked to opine as to whether there is clear and unmistakable evidence that the pre-existing disorder did not undergo an increase in the underlying pathology during service, i.e., was not aggravated during service. If there was an increase in the severity of the Veteran’s disorder, the examiner should offer an opinion as to whether such increase was clearly and unmistakably due to the natural progress of the disease. D) For each currently diagnosed acquired psychiatric disorder other than PTSD that did not preexist service, whether it is at least as likely as not that any such disorder is related to the Veteran’s service. A rationale for all opinions expressed should be provided. The examiner much address the service treatment and personnel records, post-service medical records and statements and hearing testimony from the Veteran. The Board notes that the Veteran is competent and credible to report her in-service and post-service symptoms and attribute such symptoms to in-service incidents. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J.N. Moats 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.