Citation Nr: 22018771
Decision Date: 03/30/22	Archive Date: 03/30/22

DOCKET NO. 17-59 110
DATE: March 30, 2022

REMANDED

Entitlement to service connection for a psychiatric disability, to include posttraumatic stress disorder (PTSD), is remanded.

REASONS FOR REMAND

The Veteran served in the United States Army on active duty from May 1968 to March 1970, including service in the Republic of Vietnam.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO).

This case was previously before the Board in March 2020, at which time the issue currently before the Board was remanded for additional development. The case has now been returned to the Board for appellate review.

The Veteran asserts that he has a psychiatric disability, to include PTSD, that is related to his active service.  He served in the Republic of Vietnam; hence, his stressors are conceded.

Post-service medical evidence of record shows that the Veteran was diagnosed with unspecified anxiety disorder in June 2014 and major depressive disorder (MDD) in December 2020.

At a December 2020 VA examination, the examiner opined that the Veteran's psychiatric disability was less likely than not incurred in or caused by his active service.  In support of this opinion, the examiner noted that the Veteran made no complaints and received no treatment or diagnoses for any psychiatric disability during his time in service. Additionally, the examiner noted that the Veteran did not meet the DSM-5 criteria for posttraumatic stress disorder (PTSD) and his MDD developed many years post-service due in part to his chronic physical issues and other factors.

The Board finds that the December 2020 VA medical opinion is inadequate for adjudication purposes.  In this regard, the examiner did not address the Veteran's combat service in the Republic of Vietnam.  Further, the examiner did not explain the "other factors" related to the Veteran's MDD.  Therefore, an additional VA examination is warranted.     

The matter is REMANDED for the following action:

1. Identify and obtain any pertinent, outstanding VA and private treatment records and associate them with the claims file.

2. Then, schedule the Veteran for a VA examination by a psychiatrist or psychologist with sufficient expertise to determine the nature and etiology of any currently present psychiatric disability, to include PTSD.  The claims file must be made available to and reviewed by the examiner.  Any indicated studies should be performed.

Based on the examination results and the review of the record, the examiner should first identify all psychiatric disabilities present during the pendency of the claim, or proximate thereto.

Then, for each psychiatric disability identified, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or better probability) that the psychiatric disability had its onset during the Veteran's active service or is otherwise etiologically related to such service, to include the Veteran's combat-related stressors conceded on the record.  

A rationale for all opinions expressed must be provided.

3. Confirm that the VA examination report and all medical opinions provided comport with this remand and undertake any other development determined to be warranted.

4. Then, readjudicate the appeal.  If the decision remains adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response.  Then, return the case to the Board.

 

 

D. Ware

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	I. Umez-Eronini, 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.