Citation Nr: 21029252 Decision Date: 05/13/21 Archive Date: 05/13/21 DOCKET NO. 16-11 484A DATE: May 13, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, including posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1988 to July 1991. In June 2020, the Veteran testified at a videoconference hearing before the undersigned VLJ. A copy of the transcript is of record. During the hearing, the VLJ clarified the issue on appeal, elicited relevant testimony from the Veteran, identified potential evidentiary defects, and held the file open for 60 days to allow the Veteran to submit additional evidence. These actions complied with the duties owed during a hearing set forth in 38 C.F.R. § 3.103. 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded. The Veteran seeks service connection for an acquired psychiatric disorder, including posttraumatic stress disorder (PTSD). Remand is required to obtain outstanding VA medical records and to provide a new VA examination. The Veteran was provided a VA disability benefits questionnaire examination for PTSD in October 2013. The examiner noted only a diagnosis of an adjustment disorder and determined the Veteran did not meet the diagnostic criteria for PTSD under the DSM-IV. No PTSD stressors are documented on the examination report. VA treatment records available at the time of the 2013 examination reflect the Veteran was seen for depression in December 2000. A diagnosis of "adjustment disorder with mixed disturbance of emotions and conduct" was first documented in July 2010 treatment notes while incarcerated. We note that the most recent VA treatment records associated with the claims file are from July 2014 and do not show PTSD. The Veteran reported that he now had a diagnosis of PTSD in the March 2016 VA Form 9, and in an accompanying statement reported that he was only receiving treatments at VA medical centers. At the February 2021 Board hearing, the Veteran testified that he had received mental health treatment in the 1990's at the VA medical center in Nashville, Tennessee, and that he was diagnosed with and currently being treated for PTSD at the same VA medical center. The Veteran also reported two stressors during 1991 when he was serving onboard the USS Eisenhower involving a helicopter that was taking pictures of the ship and an aircraft that flew low over his head. As noted, the most recent VA treatment records available date from July 2014 and make no reference to PTSD. Given the Veteran's testimony, potentially relevant VA treatment records are no included in the Veteran's claims file. Additionally, the October 2013 VA examination is not adequate. The Veteran has indicated that he told the examiner about his in-service stressors, but that the examiner did not record them. See, e.g., May 2014 Statement in Support of Claim. No such stressors are documented on the October 2013 examination report. As noted above, the Veteran reported at least two potential stressors at the February 2021 Board hearing. In addition, no nexus opinion was provided as to whether the Veteran's diagnosed adjustment disorder was at least as likely as not related to service. Regardless, if the Veteran's VA treatment records show a current diagnosis of PTSD, a new VA examination and nexus opinion will be required. Given the Veteran's testimony, a remand is warranted to obtain any outstanding VA treatment records and, once those records are obtained, to provide the Veteran with a new VA examination. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period since July 2014. 2. Attempt to corroborate the Veteran's in-service stressors. See Veteran's February 2021 Board hearing testimony. If more details are needed, contact the Veteran to request the information. 3. Once the Veteran's updated VA treatment records have been obtained and his reported stressors have been developed, schedule the Veteran for a psychiatric examination to determine the nature and etiology of any currently diagnosed psychiatric disorder, including PTSD. If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor. If any other acquired psychiatric disorders are diagnosed, the examiner must opine whether each diagnosed disorder is at least as likely as not related to service. 4. After the above development, and any additionally indicated development, readjudicate the claim for entitlement to service connection for an acquired psychiatric disorder, to include PTSD. If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. H. N. SCHWARTZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Morse 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.