Citation Nr: 21025522 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 16-22 294 DATE: April 28, 2021 REMANDED Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD) and unspecified depressive disorder, is remanded. REASONS FOR REMAND The Veteran had a period of active duty for training (ACDUTRA) from July 1976 to November 1976. The Veteran served on active duty in the U.S. Army National Guard from December 2003 to June 2004, to include service in Southwest Asia, and in the U.S. Army from May 2007 to May 2009. This case is before the Board of Veterans’ Appeals (Board) on appeal from a February 2013 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. In that rating decision, the RO denied entitlement to service connection for PTSD. The Veteran’s notice of disagreement was received in April 2013. The RO issued a statement of the case in December 2015. The Veteran’s VA Form 9, substantive appeal to the Board, was received in February 2016. In December 2018, the Board remanded the case to the RO for further development and adjudicative action.   In February 2020, the Board denied the claim. The Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In a November 2020 Order, the Court vacated the Board’s February 2020 decision and remanded the matter pursuant to a November 2020 Joint Motion for Remand (JMR). In the November 2020 JMR, the Board was directed to consider and discuss evidence favorable to the Veteran’s claim, specifically, the February 2, 2020 VA psychiatry admission evaluation note which reflects a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) diagnosis for PTSD. In this regard, the Board notes the record contains additional reports by VA medical staff referring to PTSD diagnoses, to include an October 30, 2020 psychiatry telephone intervention note stating, “Initial DSM-V diagnosis: PTSD; adjustment disorder.” Nonetheless, the aforementioned records do not include sufficient details for the Board to make a fully informed decision in this case. In particular, the records do not provide adequate opinions addressing the etiology of the Veteran’s PTSD. Moreover, although the Veteran underwent additional psychological examination in January 2021, such examination was designed to address mental disorders other than PTSD. To comply with the Court’s JMR, therefore, a remand is warranted for an appropriate examination and opinion that considers all the relevant evidence of record and addresses whether the Veteran has a current diagnosis of PTSD related to a verified in-service stressor. The matter is REMANDED for the following action: Schedule the Veteran for a VA PTSD examination with an examiner who has not previously participated in this case in order to determine the nature and etiology of any acquired psychiatric disorder, to include PTSD and unspecified depressive disorder.   The examiner should note review of this remand and the entire claims file. The examiner’s attention is directed to: (a) the February 2, 2020 VA psychiatry admission evaluation note DSM-V diagnosis of PTSD, and (b) the October 30, 2020 psychiatry telephone intervention note DSM-V diagnoses of PTSD and adjustment disorder. The examiner then should address the following inquiries: (A) Identify all current acquired psychiatric disorders that have been present at any point pertinent to the Veteran’s claim, even if such is asymptomatic or has since resolved, that meet the DSM-V. In this regard, the examiner should address the evidence reflecting diagnoses of adjustment disorder, unspecified depressive disorder, and PTSD. (B) If a diagnosis of PTSD is rendered, the examiner should state the stressor on which such is based, to include whether such is the result of a fear of hostile military activity. (C) For each currently diagnosed psychiatric disorder other than PTSD, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that any such disorder is related to the Veteran’s military service. In rendering his or her opinion, the examiner is advised that the sole basis of a negative opinion cannot be the fact that the Veteran’s service treatment records are silent as to any complaints, treatment, or diagnosis referable to an acquired psychiatric disorder.   A rationale for any opinion offered should be provided. MARTIN B. PETERS Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Ardalan, 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.