Citation Nr: 21025438 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 15-39 052A DATE: April 28, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and personality disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1967 to August 1970. This matter comes before the Board of Veterans’ Appeals (Board) from a January 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In the August 2018 decision, the Board denied entitlement to service connection for an acquired psychiatric disorder, to include PTSD and personality disorder, which the Veteran then appealed to the United States Court of Appeals for Veterans Claims (the Court). In June 2020, the Court, based on a Memorandum Decision, vacated the Board’s denial and remanded the issue for further consideration. The Board notes that the PTSD claim has been expanded to include any psychiatric disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23Vet. App.1, 4-5 (2009); Brokowski v. Shinseki, 23Vet. App.79, 86-87 (2009). Therefore, the issue has been restyled accordingly as noted on the title page. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and personality disorder is remanded. Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2020). The Veteran contends that he has PTSD as a result of his active service in Vietnam. Specifically, the Veteran asserts that, while in Vietnam, the woman he was in love with was killed by the Vietnamese and that he experienced mortar attacks. See October 2014 VA Examination Report. In August 2018, the Board reopened the Veteran’s claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD and personality disorder but denied the claim on the merits. In denying the Veteran’s claim, the Board relied on an October 2014 VA examination showing no diagnosis of PTSD conforming to the DSM-5 criteria. In June 2020, the Court, based on a Memorandum Decision, vacated the Board’s denial and remanded the issue. According to the Court, the Board erred when it failed to address both favorable medical evidence showing a diagnosis of PTSD and the Veteran’s contention that the October 2014 VA examination was inadequate. The Board notes that the Veteran was afforded a VA examination in October 2014 wherein the examiner indicated the Veteran did not have a PTSD diagnosis under DSM-5 criteria. However, private treatment records reflect a diagnosis of PTSD as well as treatment. See July 1985 Private Treatment Record. In light of the above, the Board finds that remand is warranted to ensure compliance with the June 2020 Memorandum Decision. Specifically, clarification is needed on whether the Veteran has a PTSD diagnosis under the DSM-5 criteria. As the October 2014 VA examiner did not reconcile the findings of the private treatment record, the opinion is inadequate, and a remand is necessary to provide the Veteran a new VA examination, if possible as he is currently incarcerated. Otherwise, to obtain a medical opinion regarding etiology. As the Veteran is currently incarcerated, the Board notes that although VA’s ability to provide examinations to incarcerated veterans may be limited by the circumstances of the incarceration, VA must “tailor [its] assistance to the peculiar circumstances of confinement. Such individuals are entitled to the same care and consideration given to their fellow veterans.” Bolton v. Brown, 8 Vet. App. 185, 191 (1995) (citing Wood v. Derwinski, 1 Vet. App. 190, 192 (1991)). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA psychiatric examination, with a psychiatrist or psychologist or with a VA contracted psychologist or psychiatrist. If an examination cannot be provided because the Veteran is currently incarcerated, then a VA psychiatrist or psychologist should review the Veteran’s claims file. The clinician is to address the following: (a.) Identify whether PTSD is present under the DSM-5. If no such diagnosis is warranted, please reconcile your findings with the diagnosis of PTSD in the Veteran’s private treatment records dated back to 1985. (b.) If a diagnosis of PTSD under the DSM-5 is warranted, specify whether that diagnosis is related to the Veteran’s reported stressors. (c.) If the Veteran is diagnosed with an acquired psychiatric disorder, other than PTSD, please opine whether the acquired psychiatric disorder is attributable to his military service. A complete rationale should be given for all opinions and conclusions expressed. The AOJ must make reasonable efforts to accommodate the Veteran with respect to his current incarceration when scheduling the VA examination, to the extent possible, in accordance with Bolton v. Brown. See Bolton, 8 Vet. App. at 19; see also VA Adjudication Procedure Manual, Part III, Subpart iv, Chapter 3, Section F.2.d. If the VA examination simply cannot be conducted due to the Veteran’s incarceration, the AOJ should provide documentation of its attempts to obtain the medical examination, including any coordinating efforts with prison authorities. 2. After completing the above, and any other development as many be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran’s claim should be readjudicated based on the entirety of the evidence. If any benefit sought remain denied, furnish the Veteran and his representative a supplemental statement of the case (SSOC) and return the case to the Board. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. C. Slaughter, 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.