Citation Nr: 22012889 Decision Date: 03/07/22 Archive Date: 03/07/22 DOCKET NO. 18-18 139 DATE: March 7, 2022 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran had active service from March 1966 to March 1968, to include service in the Republic of Vietnam. This appeal comes before the Board of Veterans' Appeals (Board) from an October 2017 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). During the current appeal, and specifically in October 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. As the record indicates that the Veteran may have a range of symptoms related to his mental health, the Board has recharacterized the claim as one for service connection for an acquired psychiatric disorder, to include PTSD. Clemons v. Shinseki, 23 Vet. App. 1 (2009). This appeal is advanced on the docket pursuant to 38 C.F.R. § 20.902(c). The Veteran contends that service connection is warranted for PTSD due to combat stressors during his active service in Vietnam. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred (unless the evidence shows that the Veteran engaged in combat and the claimed stressor is related to combat). 38 C.F.R. § 3.304 (f). Here, the Veteran's military personnel records indicate that he served in combat in Vietnam from approximately June 1967 to March 1968. His DD Form 214 shows that he was awarded the Vietnam Service Medal. At the October 2021 Board hearing, the Veteran testified about one of his stressors that is related to experiencing a mortar attack while serving in combat in Vietnam, in January 1968. See Board Hearing Transcript at 3. His combat-related stressors were conceded in a March 2018 statement of the case. The Veteran was afforded a VA examination in September 2017, during which the examiner concluded that the Veteran does not have PTSD or any other mental disorder. No PTSD symptoms were noted on the examination report. The examiner remarked that, while the Veteran was exposed to traumatic events during his active service and these events have contributed to the presence of mental health symptoms, these symptoms have not caused clinically significant impairment, warranted treatment, and have not negatively impacting the Veteran's current functioning. However, in his February 2018 notice of disagreement lay statement, the Veteran reported that he felt the examiner rushed the examination because she was double-booked. He explained that the examiner spent less than 15 minutes to evaluate him, and that the time was not sufficient to elicit responses that would warrant a PTSD diagnosis. The Veteran is requesting another PTSD examination with a different examiner. He reiterated these sentiments in his April 2018 VA Form 9 lay statement. At the Board hearing, the Veteran testified that he experiences frequent symptoms related to his claimed PTSD, to include problems with loud noises, crowds, sleep disturbances (difficulty falling asleep or staying asleep), startle responses, intrusive thoughts/distressing memories, recurrent distressing dreams, and irritability. See Board Hearing Transcript, pp. 3-7. He also stated that he sleeps with a loaded weapon by his bed every night and that he has intrusive distressing memories of close friends who were killed in Vietnam. Id. The Board finds that the Veteran's reports regarding his mental health symptoms are competent and credible. The Board also resolves reasonable doubt in the Veteran's favor and finds that another VA examination is warranted to determine whether he has a current diagnosis of an acquired psychiatric disorder, to include PTSD. He has maintained that he felt he was not adequately examined for his PTSD symptoms. A review of the September 2017 VA examination report for PTSD also shows that no symptoms were documented, despite the examiner's remarks that the Veteran was exposed to traumatic events during his active service, which have contributed to the presence of mental health symptoms. Thus, a remand is required to afford the Veteran another VA examination to determine whether he has PTSD or another mental disorder that directly resulted from his conceded in-service stressors. The matter is REMANDED for the following action: Schedule the Veteran for a VA psychiatric examination with a different examiner to determine the nature and etiology of any mental disorder, to include PTSD. The examiner should review the claims file and note such review on the examination report, conduct all necessary tests and studies, and elicit a complete history from the Veteran. All findings should be reported in detail. The examiner is asked to determine whether the Veteran has a current diagnosis of PTSD or any other mental disorder. If the Veteran is diagnosed with PTSD or another mental disorder, the examiner must opine whether each diagnosed disability at least as likely as not (50 percent or greater probability) began during service or was caused or aggravated by his active duty, to include any verified/conceded stressors (i.e., combat). The examiner is advised that the Veteran is competent to report his symptoms and history pertaining to his claimed disability and that such reports must be acknowledged and considered in formulating any opinion. The examiner must provide a complete rationale for any opinion expressed. If the examiner is unable to reach an opinion without resort to speculation, he or she should explain the reasons for this inability and comment on whether any further tests, evidence or information would be useful in rendering an opinion. A. J. Spector Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Trowers, 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.