Citation Nr: 21030673 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 14-34 031 DATE: May 19, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD), depression, and sleep disturbances, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from June 1968 to July 1972, and from March 1973 to March 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a March 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The Board notes that the Veteran previously requested a hearing before the Board. As noted by the Veteran through his representative in an April 2018 Appellant's Brief, the hearing was scheduled for December 1, 2017, and the Veteran failed to appear. The hearing request is deemed withdrawn because he failed to report for this hearing, and no request for postponement has been received. See 38 C.F.R. §§ 20.703, 20.704 (2017). The evidence of record indicates diagnoses of both PTSD with a superimposed sleep disorder, as well as depression. Therefore, the Board broadens the scope of the Veteran's claim for entitlement to service connection for PTSD to encompass any confirmed psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009) (holding that although a claim identifies only a single diagnosed disorder, it must be considered a claim for any disability that may reasonably be encompassed by that claim). Service Connection The Board finds that additional development is required before the claim on appeal may be decided. Acquired Psychiatric Disorder The Veteran asserts that he has an acquired psychiatric disorder that is related to his periods of active service. Specifically, the Veteran reported that his acquired psychiatric disorder is as a result of taking part in an in-service cleanup around Charleston Naval Base in approximately 1967 or 1968, in which he believes he was exposed to herbicide agents. By way of background, the Veteran's claim for service connection for an acquired psychiatric disorder was previously remanded by the Board in May 2018, in order to verify a PTSD stressor, to verify exposure to herbicides, and to administer a VA psychiatric examination. In May 2019, the Veteran was afforded a VA examination. At that time, and the examiner concluded that the Veteran did not have an acquired psychiatric disorder related to his periods of active service. In support of this conclusion, the examiner commented that the Veteran's service treatment records were absent complaints or treatment of a mental health disorder and stated "I only found that he attributed his PTSD (specifically his nightmares) to his fear that he will die by Agent Orange when he received a psychiatric evaluation later in 2014." The Board finds that it is unable to decide the claim based on the findings contained within the May 2019 VA medical opinion report. In this regard, the examiner relied heavily on the absence of complaints for a mental health disorder in the Veteran's service treatment records as the rationale for the negative nexus opinion. Moreover, the examiner did not address the significance of the Veteran's report, if any, that the Veteran feared for his health as a result of his belief that he was exposed to herbicide agents. Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007) (an examination was inadequate where the examiner did not comment on a Veteran's reports of in-service injury and instead relied on the absence of evidence in a Veteran's service treatment records to provide a negative opinion). Additionally, this opinion is wholly silent as to a 2009 positive PTSD screening. See Medical Treatment Records (Sept. 8, 2019). Therefore, the Board finds that new VA medical opinion are warranted to address the nature and etiology of the Veteran's acquired psychiatric disorder. Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are 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 claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records from January 2019 to present. 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 his 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, obtain an etiology opinion from an appropriate examiner to determine the nature and etiology of any currently present acquired psychiatric disorders, to include PTSD with superimposed sleep disturbances, and persistent depressive disorder. The need for a physical examination is left to the discretion of the medical professional offering the medical opinion. The record must be made available to the examiner for review, and the examiner should indicate that the record was reviewed in connection with the examination. All indicated tests and studies should be accomplished and the findings then reported in detail. Based on the examination results and review of the record, the examiner should first identify all psychiatric disabilities present during the pendency of the appeal, or proximate thereto. Then, for each acquired psychiatric disorders identified, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any identified disability is had its onset during the Veteran's active service, or is otherwise etiologically related to such service. The examiner must specifically address the Veteran's alleged exposure to or perceived exposure to Agent Orange while serving at Charleston Naval Base in 1968. The examiner must also address a 2010 statement from fellow service-member, A. L. R., a December 2014 VA treatment record, and a September 2009 PTSD screening result that was not discussed in the May 2019 examinations. If PTSD, or a trauma- or stressor-related disorder is diagnosed, the examiner should list all traumatic events contributing to that diagnosis. A complete rationale should be given for each opinion expressed. In this regard, a discussion of the facts and medical principles involved would be considerable assistance to the Board. CHRISTOPHER J. O'DONNELL Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Michael B. Engle, 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.