Citation Nr: 18132239
Decision Date: 09/06/18	Archive Date: 09/06/18

DOCKET NO. 16-08 501
DATE:	September 6, 2018
REMANDED
Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depression and an anxiety disorder is remanded.
REASONS FOR REMAND
The Veteran served on active duty from January 2006 to June 2006 and from May 2009 to March 2010.
Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depression and an anxiety disorder is remanded.
The Veteran contends that he has a current psychiatric disorder, including PTSD, which developed as a result of stressful events during active military service in Iraq. See September 2012 statement from the Veteran, December 2012 statement from the Veteran, April 2014 statement from the Veteran
VA and private treatment records show that the Veteran has been diagnosed with PTSD, depression, depressive disorder and anxiety, and that he has reported stressful incidents in service.  
The Veteran was afforded a VA examination in August 2013.  The examiner concluded that the Veteran did not meet the criteria for a diagnosis of PTSD, and opined that his diagnosed adjustment disorder with anxiety and depression were not related to his reported stressful incidents during active military service.  Instead, the examiner found that the Veteran’s psychiatric disorder was a result of stress related to non-military-related family issues.  The examiner did not, however, explain why he believed the Veteran’s disorder was more likely related to family issues than his reported stressful occurrences in service.  Furthermore, the examiner failed to give an opinion on the etiology of the PTSD diagnosed earlier during the appeal period, during VA outpatient treatment.  See McClain v. Nicholson, 21 Vet. App. 319 (2007) (the requirement that a current disability be present is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim...even though the disability resolves prior to the Secretary's adjudication of the claim."). For these reasons, the Board finds that the August 2013 examiner’s opinion is incomplete and therefore, inadequate for evaluation purposes. 
The Board notes that the Veteran also reported during the August 2013 examination that he had been treated for mental illness with medication prior to military service.  See August 2013 VA examination report. However, service treatment records do not show that the Veteran reported a history of mental health problems or mental health treatment at service entrance, and there is no clinical or medical documentation which indicates a diagnosis or treatment for a mental health condition prior to service. A mere self-report of symptoms prior to service does not necessarily constitute clear and unmistakable evidence of a pre-existing condition. In the absence of clear and unmistakable evidence that a disability existed prior to service, the examiner should presume that the Veteran was sound upon entrance into service.
The Board also notes that the Veteran was again diagnosed with PTSD during VA treatment in 2014 and 2015, following the August 2013 VA examination. As such, the Board finds that the evidence of record regarding whether the Veteran has a confirmed diagnosis of PTSD is conflicting and unclear.
Therefore, the Board believes that the Veteran should be afforded another VA psychiatric examination to determine the nature and etiology of all currently present acquired psychiatric disorders. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); 38 U.S.C. § 5103A (d) (2012).
The matter is REMANDED for the following action:
1. Updated treatment records should be obtained and added to the claims folder/efolder.
2. Following completion of the above, afford the Veteran an appropriate VA examination to determine the nature and etiology of his psychiatric disorder(s). The claims folder should be made available to the examiner for review in connection with the examination and the examiner should acknowledge such review in the examination report or in an addendum. Following interview of the Veteran and review of the claims folder, the examiner is requested to provide opinion on the following questions:
a) If the examiner finds that the Veteran meets the criteria for a PTSD diagnosis, he/she should specifically identify which stressors are linked to the PTSD diagnosis, including any stressors prior to or after service.
b) If the examiner finds that the Veteran manifests an acquired psychiatric disorder other than or in addition to PTSD, he/she should provide an opinion as to whether it is at least as likely as not (probability of 50% or greater) that any such currently diagnosed psychiatric disorder was first manifested in service and/or is causally related to event(s) in service.
A complete rationale should be given for all opinions and conclusions expressed. 
The examiner is advised that the Veteran is competent to report injuries as well as symptoms, and that his reports must be considered in formulating the requested opinion. 
The examiner is also advised that the absence of evidence in the service treatment records is an insufficient basis, by itself, for a negative opinion. 
If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made.
(Continued on the next page)
 
3. Readjudicate the claim on appeal. If the benefit on appeal remains denied, an SSOC must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review.
 
KELLI A. KORDICH
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	Fatima Yankey, 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

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