Citation Nr: 21028391 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 13-25 276 DATE: May 11, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder to include posttraumatic stress disorder (PTSD) and an anxiety disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty with the United States Air Force from September 1964 to September 1968, to include service in the Republic of Vietnam from March 1967 to March 1968. This matter comes before the Board of Veterans' Appeals (Board) from a March 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The case was last remanded in June 2020 and has since been returned to the Board for appellate review. 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and an anxiety disorder, is remanded. The Veteran contends that he suffers from PTSD as a result of his service in Vietnam. Specifically, in the December 2016 VA Form 21-0781, the Veteran explained that his duty was to guard various locations on base to include the bomb dump, and the perimeter was surrounded by trees and bushes which appeared to be like people to him during his shifts. In May 2018 VA Form 21-0781, the Veteran explained that during an unknown date and time, the gate guard called for help, and the strike team arrived and shot M-16, M-60, and pop flares in the area while he was on a patrol jeep. The Veteran also reported that there was a mortar attack in either March or April 1968, when he had checked out of the squadron and was preparing to leave Vietnam for the United States soon. A May 2018 VA examination diagnosed the Veteran with PTSD and opined that it was at least as likely as not (more than 50/50 probability) caused by or a result of or due to service connection based the Veteran's service in Vietnam based on the Veteran's self-report, a diagnosis of PTSD by a VA mental health professional and that the Veteran's stressor recall is absent direct trauma. In a June 2018 addendum opinion, this same examiner states that the Veteran's reported stressor that involved a mortar attack by the enemy in Vietnam was not sufficient to relate to a fear of hostile military activity and that the Veteran was adamant that he suffered from PTSD and that he suffered from occupational and social impairment sufficient for a 70 percent rating. The examiner further noted that a mental condition has been formally diagnosed but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. However, this examiner did not explain how the Veteran's reported stressor involving a mortar attack in Vietnam was insufficient to relate to a fear of hostile military activity and did not provide an adequate rationale for the opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); see, e.g., Dalton v. Nicholson, 21 Vet. App. 23 (2007). The examiner appears to conflate the diagnosis of an acquired psychiatric disorder with the level of social and occupational functioning associated with such condition. Moreover, the examiner did not address other diagnosed acquired psychiatric disorders when rendering an etiology opinion. A December 2016 VA treatment note contained a provisional diagnosis of anxiety rule-out PTSD and an April 2017 VA treatment note contained a diagnosis of an unspecified anxiety disorder. Clemons v. Shinseki, 23 Vet. App. 1 (2009). On remand, an addendum opinion should be obtained that adequately addresses the relevant evidence of record. The matter is REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in their possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, schedule the Veteran for a VA psychiatric examination by an appropriate clinician who has not previously examined the Veteran to confirm all of the Veteran's applicable acquired psychiatric diagnoses, and to determine the etiology of same. The claims file, including a copy of this remand, must be made available to and reviewed by the examiner. The need for an in-person examination is left to the discretion of the examiner. After a review of the record, an examination and interview of the Veteran, the examiner should address each of the following: (A) Identify all of the Veteran's acquired psychiatric disorders that meet, or have met, the Diagnostic and Statistical Manual of Mental Disorders criteria of the American Psychiatric Association (DSM-5) diagnostic criteria any time since October 2012. If it is determined that PTSD or an unspecified anxiety disorder has not been present during the period of the claim, the examiner should clearly explain why the diagnosis is not warranted. (B) With respect to any currently diagnosed PTSD, is it at least as likely as not (50 percent probability or greater) related to a verified in-service stressor. The examiner should note that the Veteran's service in Vietnam is established by the record. (C) For any diagnosed acquired psychiatric disorder other than PTSD, is it at least as likely as not (50 percent probability or greater) that the disorder had its onset in service or is otherwise etiologically related to service, to include any incident thereof? A rationale should be provided for any opinion offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinion must support the conclusions reached with an analysis that is adequate to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. J. Kim, 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.