Citation Nr: 18123972
Decision Date: 08/03/18	Archive Date: 08/03/18

DOCKET NO. 15-13 493
DATE:	August 3, 2018
REMANDED
Service connection for an acquired psychiatric disorder, to include major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) is remanded.
REASONS FOR REMAND
The Veteran had active service from October 1963 to November 1967.
This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota.
In June 2018, the Veteran and his spouse testified at a video conference hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is of record.
The Board has recharacterized the Veteran’s claims for MDD and PTSD as a claim for an acquired psychiatric disorder, to include MDD and PTSD.  Clemons v. Shinseki, 23 Vet. App. 1 (2009) (stating that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record).
Service connection for an acquired psychiatric disorder to include MDD and PTSD is remanded
The Veteran contends that he has an acquired psychiatric condition because of stressors he experienced while in service.  In an August 2012 statement, the Veteran stated that while serving aboard his ship, in service, in and around the waters of Vietnam, the ship was attacked by sniper fire.  Additionally, he was tasked with transporting wounded and dead soldiers back to the ship.  At his June 2018 hearing he again reported that he was subjected to sniper fire while serving aboard the USS Whitfield County and having had to carry body bags back to his ship.  
The Veteran’s wife also testified at the hearing.  She cited that at the beginning of their marriage, she realized that her husband had problems.  He was often depressed and pulled his hair out, leaving bald spots.  For the past 38 years, she has “woken up from him violently yelling and twitching in his sleep.”  She also testified that the Veteran reported having recurring nightmares of people hiding behind trees and shooting at him and of his being aboard a ship with body bags.  When the body bags are turned over and opened, he sees himself inside of bags. 
The evidence of record also contains a series of Family Grams that were sent to the soldiers aboard the USS Whitfield County.  In a December 14, 1965 Family Gram, the commanding officer, R. D. G., wrote:  
On 7 September, Whitfield County participated in “Operation Piranha” by launching the first wave of assault against the enemy-held beaches at Cape Batangan, South Vietnam. This operation resulted in many substantial dead and wounded Viet Cong forces… Five of the past six months have found us in the combat zone and half of this time has been duty subject to hostile fire.
The Veteran’s personnel record shows that he served aboard the USS Whitfield County from May 1965 to September 1967.  Therefore, the Board concedes that the Veteran participated in Operation Piranha in September 1965 and as such, his in-service stressors are related to a fear of hostile military or terrorist activity.
Per 38 C.F.R. § 4.125 (a), establishing service connection for PTSD requires (1) medical evidence diagnosing PTSD; (2) a link, established by medical evidence, between a veteran’s present symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304 (f) (2017); Cohen v. Brown, 10 Vet. App. 128, 139 (1997). 
The evidentiary burden of establishing a stressor is reduced when it is related to a fear of hostile military or terrorist activity. If a stressor is related to the Veteran’s fear of hostile military or terrorist activity, as in this case, and a VA psychiatrist or psychologist confirms that the stressor is adequate to support a diagnosis of PTSD and that the Veteran’s symptoms are related to the stressor, in the absence of clear and convincing evidence to the contrary, and provided that the stressor is consistent with the places, types, and circumstances of his service, his lay testimony alone may establish the occurrence of the claimed stressor. 38 C.F.R. § 3.304 (f)(3) (2017).
The Veteran was afforded a VA examination in July 2013. The examiner did not diagnose PTSD nor MDD.  Regarding the stressor for PTSD, the examiner noted that the Veteran “generally described being on shore, … and having body bags on board [and] was not specific about having a specific stressor but did not describe feeling traumatized by any particular incident.”  The examiner concluded that the Veteran did not meet Criterion A stressor and, therefore, his stressor was not adequate to support the diagnosis of PTSD.  Considering the evidence of record, including the recent hearing testimonies from the Veteran and his wife, the Board finds the July 2013 VA examination inadequate for adjudication purposes.  A new examination is warranted.  
Accordingly, the matter is REMANDED for the following action:
1. Schedule the Veteran for VA examination with an appropriate clinician his acquired psychiatric disorder. 
The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. 
The examiner must take a detailed history from the Veteran. If there is any clinical or medical basis for corroborating or discounting the reliability of the history provided by the Veteran, the examiner must so state, with a complete explanation in support of such a finding. 
Although an independent review of the claims file is required, the Board calls the examiner’s attention to the following: 
a.	A June 3, 2013 neuropsychological assessment conducted by Dr. M. J. W. at the St. Cloud VA.
b.	The Veteran and his wife’s June 2018 hearing testimonies. 
The examiner must provide a diagnosis for each psychiatric disability. The examiner must specifically determine whether the Veteran has PTSD. If the examiner diagnoses PTSD, he or she must specify the stressor or stressors underlying the diagnosis.
The examiner is advised that the Board concedes the Veteran’s reported stressors regarding transporting body bags and wounded soldiers, and being exposed to sniper fire as part of Operation Piranha.  
For each psychiatric disorder, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that it began during active service or is related to an incident of service. 
The examiner must provide all findings, along with a complete rationale for his or her opinion(s), in the examination report. If any of the above-requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion, as well as specifically explain whether there is any potentially available information that, if obtained, would allow for a non-speculative opinion to be provided.
2. Then, readjudicate the claim.  If any decision is adverse to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response.  Then, return the case to the Board.

 
D. Martz Ames
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	N. Stevens, Associate Counsel 

For A Complete Guide To VA Disability Claims and to find out more about your potential VA disability case and how to obtain favorable VA Rating Decision! Visit: VA-Claims.org

For More Information on Veterans Disability Compensation Benefits! Visit: DisableVeteran.org ~ A Non-Profit Non Governmental Agency


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