Citation Nr: 21016148 Decision Date: 03/19/21 Archive Date: 03/19/21 DOCKET NO. 19-09 060A DATE: March 19, 2021 REMANDED Entitlement to service connection for a psychiatric disability, to include posttraumatic stress disorder, anxiety and depression, is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1961 to January 1966, to include service in the Republic of Vietnam. He testified at a virtual Board hearing before the undersigned in March 2021. At the hearing, the Veteran and his representative agreed to waive initial Agency of Original Jurisdiction consideration of additional VA treatment records that were added to the claims file after the issuance of the March 2019 Statement of the Case. As a result of these additional records, remand is required to determine if there is a current psychiatric disability. A March 2017 VA examiner opined that the Veteran’s symptoms did not meet the diagnostic criteria for a mental disorder, to include PTSD. However, at the March 2021 Board hearing the Veteran provided testimony that he did suffer from psychiatric symptoms as a result of his military service and had been given a diagnosis of PTSD. Review of the record shows the Veteran was referred for VA mental health treatment in April 2019 by his Veterans Service Organizations (VSO) representative as he wanted to file a claim for disability. At that time, the Veteran screened negative for PTSD and he was given a diagnosis of an adjustment disorder with mixed mood by a VA Licensed Master Social Worker. Subsequently, in May 2019 and August 2019, he was given a diagnosis of PTSD by a VA PTSD Licensed Specialist Clinical Social Worker. As the evidence shows there may now be a current psychiatric disability, remand is required for a current examination. The matter is REMANDED for the following action: Afford the Veteran an appropriate VA examination by a psychologist or psychiatrist to determine the nature and etiology of any acquired psychiatric disability present during the appeal period. The entire claims file should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. a) The examiner should provide a diagnosis for any acquired psychiatric disorder. The examiner should specifically consider the diagnosis of PTSD which is noted in May and August 2019 VA treatment records, and the diagnosis of adjustment disorder with mixed mood which is noted in April 2019 VA treatment records. b) If PTSD is found, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that PTSD had its onset during service or is otherwise related to service. c) For any other acquired psychiatric disorder found, provide an opinion as to whether it as least as likely as not (50 percent probability or greater) had its onset during service or is otherwise related to service. The examiner is advised that the Veteran is competent to report his symptoms/history and that such reports must be acknowledged and considered in formulating any opinion. If his reports are discounted, the examiner should provide a reason for doing so. A rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Fletcher, Kathleen 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.