Citation Nr: 25005156 Decision Date: 04/16/25 Archive Date: 04/16/25 DOCKET NO. 19-10 438 DATE: April 16, 2025 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 duty from April 1970 until December 1971. This matter is on appeal from a December 2014 rating decision. In March 2023, the Board reopened the claim for service connection for an acquired psychiatric disorder and denied service connection. In a September 2024 joint motion for partial remand (JMPR), the parties to the March 2023 Board decision agreed that there had been inadequate reasons and bases in that Board decision, to include failure to address a July 2018 VA medical record indicating a diagnosis of depression and PTSD, an inadequate statement of reasons and bases for finding that the Veteran was not credible, whether the Veteran's lay statements triggered VA's duty to assist and verify the claimed stressors, and failure to address psychiatric diagnoses other than PTSD. 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded. Per the September 2024 JMPR, the Veteran contends that he has PTSD due to service at Tommy Hawk and Fire Base Birmingham, due to being constantly under fire at those bases from September 1970 through September 1971 (reported in a July 2008 statement). During his September 2014 VA examination, he alternatively claimed an incident in which his base was overrun in a huge firefight and they had to kill all 250 attackers. The JMPR raised the question of whether the Veteran's lay statements triggered VA's duty to assist and verify the claimed stressors. Given the Veteran's reports, the Board finds that the Veteran should be given another opportunity to provide additional information regarding his stressors and additional stressor verification should be performed, to include whether the Veteran served in combat, as he claimed in the September 2014 VA examination and in a February 2025 lay statement. Additionally, although the Veteran underwent a VA examination in September 2014, the VA examiner did not address other diagnoses of record, such as an April 2008 VA medical records indicating diagnoses of mild depression and paranoid personality disorder, a February 2019 diagnosis of irritability and anger (rule out PTSD), and the September 2014 VA examination diagnosis of adjustment disorder with depressed mood. The VA examiner also had not addressed the diagnosis of PTSD of record, such as one from a June 2019 VA medical record or the October 2015 private medical opinion of A.E.C., Ph.D., M.D. A new VA medical opinion is thus necessary. Furthermore, the Board notes that the Veteran has also indicated private treatment, including in a February 2008 VA medical record wherein he reported previously being prescribed Xanax for anxiety from his retiring private doctor. In an April 2008 VA medical record, he identified treatment from New Iberia and by Dr. P.L. at Adiana Family Physicians, but was unclear as to whether that provider(s) provided psychiatric treatment. Also, in an October 2018 VA medical record, the Veteran reported prior psychological treatment from a Dr. B., but the record is unclear as to where such treatment was received. The Board notes that at that time, the Veteran had also reported prior psychological treatment from a different Dr. B. and those records are already associated with the claims file as they are VA medical records. A remand is required to allow VA to obtain authorization and request these records. As this matter is being remanded, any unassociated VA medical records should also be obtained and associated with the claims file. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for private medical provider(s), including those he reported in a February 2008 VA medical record prescribing him Xanax for anxiety, in an April 2008 VA medical record from New Iberia and by Dr. P.L. at Adiana Family Physicians (if acquired psychiatric disorder treatment was provided), from Dr. B., psychologist, reported in an October 2018 VA medical record, and any other pertinent private medical provider(s). Make two requests for the authorized records from identified private medical provider(s), unless it is clear after the first request that a second request would be futile. 2. Obtain and associate any unassociated VA medical records with the claims file. 3. Attempt to corroborate the Veteran's in-service stressor[s], including (per the September 2024 JMPR) that during service at Tommy Hawk and Fire Base Birmingham he was under constant fire from September 1970 through September 1971 (reported in a July 2008 statement) and an incident in which his base was overrun in a huge firefight, and they had to kill all 250 attackers (per the September 2014 VA examination). Also, VA should attempt to corroborate whether the Veteran served in combat, as he claimed in the September 2014 VA examination and in a February 2025 lay statement. If more details are needed, contact the Veteran to request the information. 4. After the above record development is accomplished, schedule the Veteran for a psychiatric examination to determine the nature and etiology of any posttraumatic stress disorder (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 the Veteran is diagnosed with a personality disorder and PTSD, the examiner must opine whether the PTSD was at least as likely as not superimposed on a personality disorder during active service and resulted in additional disability. Please note consideration of the Veteran's previous diagnosis of paranoid personality disorder in an April 2008 VA medical record. 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 an in-service injury, event, or disease, to include any verified stressor. Please note consideration of previously diagnosed acquired psychiatric disorders associated with the claims file, to include, but not limited to, an adjustment disorder with depressed mood (September 2014 VA examination), depression (April 2008 VA medical record), and Irritability and Anger Insomnia, Unspecified (Rule Out PTSD) (October 2018 VA medical record). A fully articulated medical rationale for any opinion expressed must be set forth in the medical report. The VA medical opinion provider should discuss the particulars of this Veteran's medical history (such as prior diagnoses of record, the September 2014 VA examination, and the September 2015 private medical opinion of Dr. A.M.C.) and relevant medical science as applicable to this case, which may reasonably explain the medical guidance in the study of this case. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Lindio 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.