Citation Nr: 21021563 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 14-43 777 DATE: April 13, 2021 REMANDED Entitlement to service connection for an acquired psychological disorder, to include PTSD and major depressive disorder is remanded. REASONS FOR REMAND The Veteran had active military service from April 1973 to December 1975. This matter comes before the Board of Veterans Appeals (Board) on appeal from a March 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In May 2017, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript has been associated with the electronic claims file. The Board previously considered this appeal in May 2018 and remanded this issue for further development including scheduling a VA examination. The case returned to the Board for further appellate review. After reviewing the evidence of record, and in light of Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the Board has recharacterized the issue of service connection for PTSD to encompass any acquired psychological disorder, to include PTSD and major depressive disorder. 1. Entitlement to service connection for an acquired psychological disorder, to include PTSD and major depressive disorder is remanded. The Veteran is seeking service connection for an acquired psychological disorder, to include PTSD and major depressive disorder, related to Military Sexual Trauma (MST). Although the Board regrets the additional delay, the Board finds that further development is required before the claim on appeal can be decided. Unfortunately, there has not been substantial compliance with the Board's previous remand directives regarding the issue of entitlement to service connection for an acquired psychological disorder, to include PTSD and major depressive disorder. In a July 2011 VA examination, the Veteran was assessed with major depressive disorder and not PTSD. In a January 2012 MH outpatient treatment plan note, the examiner assessed the Veteran with panic disorder with agoraphobia, PTSD (MST) and major depression, recurrent, moderate. In an April 2012 VA examination, the examiner noted the Veteran does not meet DSM-IV for PTSD. In January 2020, the Veteran underwent an examination where she was diagnosed with PTSD and adjustment disorder with depressed mood. Lastly, in February 2021, the Veteran underwent a VA examination in connection with her claim. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In rendering the opinion, the examiner found that the Veteran does not have a mental disorder that conforms with DSM-5 criteria and specifically indicated that she does not meet the diagnostic criteria for PTSD. However, as previously noted, there is evidence of a diagnosis and treatment for psychiatric disorders during the appeal period, which the examiner did not reconcile in his opinion. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (noting that the requirement of a current disability is satisfied when the claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim and that a claimant may be granted service connection even though the disability resolves prior to the Secretary's adjudication of the claim). Based on the foregoing, the Board finds that another VA examination and medical opinion are needed to decide the claim. The matters are REMANDED for the following action: 1. Obtain any outstanding VA medical records. 2. After completing the foregoing development, the Veteran should be afforded a VA examination to determine the nature and etiology of any acquired psychiatric disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed, but should include psychological testing, including PTSD sub scales. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and lay assertions. The Board notes that the VA treatment records indicate that the Veteran has been previously diagnosed with PTSD, an adjustment disorder with depressed mood, panic disorder with agoraphobia, major depression, and MST. The examiner should identify any current psychiatric disorders that have been present since the Veteran filed her claim in November 2010 or within close proximity thereto (even if they have resolved). If any previously diagnosed psychiatric disorders are not found on examination, the examiner should address whether they were misdiagnosed or have resolved. Regardless of if the condition is not diagnosed or resolved, for any psychiatric disorder identified other than PTSD since 2010, to include but not limited to the PTSD, an adjustment disorder with depressed mood, panic disorder with agoraphobia, major depression, and MST, the examiner should state whether it is at least as likely as not that the disorder manifested in service or is otherwise causally or etiologically related to the Veteran's military service. In providing this opinion the examiner must comment on and reconcile the January 2012 Mental Health outpatient treatment plan note, VA treatment records, and January 2020 examination that provided a diagnosis of PTSD. Regarding PTSD, the AOJ should provide the examiner with a summary of any verified in-service stressors, and the examiner must be instructed that only these events and any personal assault he or she determines to have occurred in service may be considered for the purpose of determining whether exposure to an in-service stressor has resulted in PTSD. The examiner should comment on whether the Veteran exhibited any behavioral changes during service (after the alleged incident) that are reflective of the occurrence of an in-service physical assault. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Romero-Sanchez, 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.