Citation Nr: 21027832 Decision Date: 05/06/21 Archive Date: 05/06/21 DOCKET NO. 18-30 583 DATE: May 6, 2021 REMANDED Entitlement to service connection for acquired psychiatric disorder, to include anxiety disorder NOS and posttraumatic stress disorder (PTSD), claimed as adjustment disorder with depression is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disability is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1974 to April 1980 and from September 1981 to September 1995. These matters come before the Board of Veterans' Appeals (Board) on appeal of a September 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a virtual hearing before the undersigned Veterans Law Judge (VLJ) in May 2021. As there appear to be multiple acquired psychiatric disorders of record, including anxiety disorder NOS and depression, the Board has recharacterized the Veteran's claim for entitlement to service connection for adjustment disorder with depression, to a claim for entitlement to service connection for any acquired psychiatric disorder, however diagnosed. See Clemons v. Shinseki, 23 Vet. App. 1,5 (2009). Entitlement to service connection for PTSD and anxiety disorder NOS are remanded. The Veteran contends that he has PTSD and anxiety disorder NOS that are related to his active service. The Veteran currently receives medical treatment from the VA Medical Center; however, the most recent VA treatment records of record are from January 2018. Upon remand, updated VA treatment records must be obtained. Although in September 2012 and October 2012 Deferred rating decisions, the RO noted that they must attempt to verify the Veteran's claimed in-service stressors and that they had not verified any of his stressors, no development to verify his in-service stressors was undertaken. On remand, the RO must attempt to verify the Veteran's in-service stressors. However, the Board notes that the stressor regarding the Veteran killing an intruder and the subsequent charges are verified by Court documents. Pursuant to 38 C.F.R. § 3.304 (f)(3), if a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of posttraumatic stress disorder and that the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. The Board observes that the Veteran served in Southwest Asia from January 1991 to April 1991. The Veteran had a VA examination for PTSD in June 2012. The Veteran had VA examinations for mental disorders other than PTSD in August 2013 and March 2018. In the August 2013 and March 2018 mental disorders examination, the examiner did not provide a direct service connection opinion. The August 2013 VA examiner provided an opinion that the Veteran's anxiety/depression is not connected to his service-connected disabilities. The Veteran has not asserted that his anxiety NOS is secondary to service-connected disabilities. The March 2018 examiner opined only as to whether the Veteran's anxiety disorder NOS is at least as likely as not incurred in or caused by the stressor of helping to contain a fire in-service. A remand is necessary to obtain an opinion as to whether any acquired psychiatric disorder is causally related to the Veteran's active service, to include any verified stressor fear of hostile military or terrorist activity. The duty to assist requires that when a VA examination is conducted it must be adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As the Veteran's VA treatment records have not been updated in over two years, the VA examiners do not appear to have addressed all of the Veteran's psychiatric disorders of record, and there is an additional PTSD diagnosis of record which was received in October 2019, the Board finds the previous VA examinations of record are incomplete and new examinations for PTSD and mental disorders must be obtained. In October 2019, the Veteran submitted a document from a Social Security Administration decision which states that N.H., Ph.D. evaluated him in May 2012 for complaints of PTSD, lack of sleep, major depression and adjustment disorder and that Dr. N.H. diagnosed the Veteran with PTSD. VA is obligated to obtain Social Security Administration records if there is a reasonable possibility that the records could help substantiate the claim. See Golz v. Shinseki, 590 F.3d 1317, 1322 (2010). Thus, upon remand, an attempt should be made to obtain the Veteran's Social Security Administration disability benefits claim supporting documents. Entitlement to a TDIU due to service-connected disability is remanded. Because the TDIU and PTSD claims are inextricably intertwined, TDIU must be remanded concurrently. See Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records. 2. Attempt to obtain the Veteran's outstanding Social Security Administration disability benefits records in accordance with VA regulation. 3. Attempt to corroborate the Veteran's in-service stressors, including seeing a car hit his friend's truck, seeing his friend's injured head and the other driver's body in pieces; seeing a bus crash into a dump truck head on, seeing occupants blinded by broken window glass, seeing the dead truck driver bloodied and dead; helping contain a fire and being transported to the hospital due to smoke inhalation and any other indications of stressors in the record. If more details are needed, contact the Veteran to request additional information. 4. After the above development is completed, schedule the Veteran for a psychiatric examination. The examiner must: Identify all current psychiatric diagnoses. In identifying all current psychiatric diagnoses, please consider medical and lay evidence dated both prior to and since the filing of the claim for service connection for an acquired psychiatric disability, to include PTSD. Please note that although the Veteran may not meet the criteria for a diagnosis at the present time, diagnoses made prior to and since the date of claim filing meet the criteria for a "current" diagnosis. For any diagnosis of record which cannot be validated or confirmed, please explain why such diagnosis cannot be confirmed. The examiner should provide an opinion as to the following: a) Whether the Veteran currently suffers from PTSD or any other acquired psychiatric disorder related to his fear of hostile military or terrorist activity while on active duty. b) Whether the Veteran has PTSD or any other acquired psychiatric disorder due to a corroborated stressor; to specifically consider the Veteran shooting and killing a young man while on active duty in 1979. c) For any psychiatric diagnosis rendered other than PTSD the examiner is requested to render an opinion as to whether it is at least as likely as not (i.e., a likelihood of 50 percent or more) that any diagnosed psychiatric disorder began in service or is related to an in-service incident. (Continued on the next page) d) A comprehensive rationale for all opinions expressed must be provided. The copy of the examination report and all completed test reports should thereafter be associated with the claims folder. If any opinion cannot be rendered without resorting to speculation, the examiner must explain in detail why an opinion cannot be offered. Jennifer White Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Susan Leary 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.