Citation Nr: 21028986 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 16-34 294 DATE: May 12, 2021 REMANDED Entitlement to service connection for any acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and unspecified depressive disorder (UDD) is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1979 to July 1987 and November 1990 to August 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2014 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). To provide the broadest and most sympathetic review, the claim for service connection for PTSD has been recharacterized to include any acquired psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Entitlement to service connection for any acquired psychiatric disorder, to include PTSD, MDD, and UDD is remanded. The Veteran contends service connection is warranted for his psychiatric disability, to include PTSD, MDD, and UDD. The Veteran submitted his claim in January 2014 and identified three stressors: his spouse's infidelity, severe depression while stationed in South Korea from June 1985 to 1986, and a personal assault in January 1987. The Veteran's medical treatment records show he has been diagnosed with PTSD and MDD. A May 2014 VA examiner diagnosed the Veteran with UDD and opined that his psychiatric disability was not caused or aggravated by service because there was no evidence showing a chronic condition developed or was treated since 1985. The examiner then opined that the Veteran's depression during his time in South Korea was homesickness and difficulty adjusting being separated from his spouse and infant son, essentially a situational reaction. The examiner did not believe the Veteran suffered from PTSD. Rather, she believed he suffered from post-concussion syndrome as a result of the personal assault and found no evidence linking the Veteran's current symptoms to his psychiatric disability. The Veteran's treating psychiatrist diagnosed PTSD based on the DSM-IV on July 24, 2014. The Veteran submitted a police report showing he was attacked on October 27, 1986, suffered memory loss, was checked by police officers, and transported to Halifax Hospital Medical Center for treatment. Medical notes show the Veteran was admitted at 5:45 pm and discharged the next morning on October 28, 1986. As a result of this new diagnosis and verifying information of a personal assault during active service, the RO afforded the Veteran VA examinations in April 2016 and December 2016. Both VA examiners opined that the Veteran did not suffer from PTSD. They opined that the Veteran suffered from UDD and did not meet the criteria for PTSD pursuant to the DSM-V. Based on the April 2016 and December 2016 VA examination report, it appears the Veteran's three stressors were not considered nor addressed by the VA examiners as none of them are mentioned anywhere. Furthermore, both examiner's failed to discuss whether the Veteran's UDD and/or MDD was related to the reported stressors and lay statements. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Importantly, the Board notes that the April 2016 and December 2016 examiners did not provide sufficient detail for the Board to fairly adjudicate the claim. As a result of these errors, remand is required. When VA provides an examination or obtains an opinion, the examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The matters are REMANDED for the following action: 1. Associate updated VA treatment records. 2. Schedule the Veteran for an examination. The examiner is to be provided access to/ the Veteran's entire claims file, and must specify in the report that these records have been reviewed. The examiner should then address the following and MUST answer all questions: (a.) Identify any acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), major depressive disorder (MDD), or unspecified depressive order (UDD), that presently exists or that has existed since January 2014, the date of the Veteran's claim. (b.) For any acquired psychiatric disorder, to include MDD and UDD, other than PTSD, state whether state whether it is as least as likely as not that the disability had its onset in service or is otherwise etiologically related to his active service to include his in-service stressors. (c.) State whether it is at least as likely as not that PTSD had its onset in service or is otherwise etiologically related to an in-service stressor. A complete and fully explanatory rationale must be provided for any opinion offered. If any opinion cannot be rendered without resorting to speculation, the examiner/ must provide an explanation for this finding./ If it is found that the Veteran's lay assertions are not credible, the examiner must explain why. Jennifer White Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mohammad Mahmoudi, 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.