Citation Nr: 18160670
Decision Date: 12/27/18	Archive Date: 12/27/18

DOCKET NO. 17-10 085
DATE:	December 27, 2018
Entitlement to service connection for a psychiatric disorder, to include post-traumatic stress disorder (PTSD) and schizoaffective disorder is remanded.
The Veteran served in the United States Army on active duty from June 1977 to April 1984.
This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO).
Initially, the Board notes the Veteran filed a claim for anxiety and depression related to his service-connected degenerative disc disease.  That issue is not currently before the Board and is not addressed in this decision.
The issue on appeal was characterized by the RO as entitlement to service connection for PTSD.  However, considering the evidence of record, the Board has recharacterized the issue more broadly to include any psychiatric disorder.  See Clemons v. Shinseki, 23 Vet. App. 1, 5-6, 8 (2009).
With reference to the Veteran’s PTSD claim, the RO denied the Veteran’s claim due to a lack of a verified stressor, indicating the Veteran had not provided a valid statement concerning his in-service stressor.  Subsequently, the Veteran provided the statement in which he stated he experienced psychiatric symptoms after observing the condition of a motorcycle driver who was hit by a military tractor.  A January 2017 request and memorandum indicated the stressor could not be verified.  However, the request does not list specifically what event or any of the details provided by the Veteran that need to be verified.  Therefore, the claim is remanded and the AOJ should attempt to verify the Veteran’s claimed stressor (motorcycle driver that was struck by a military tractor in Germany from January 1979 to January 1981).  
Additionally, the Veteran indicated that he received psychiatric evaluation following the incident, including the same day and was prescribed medication.  However, the Veteran reported that the records disappeared.  Therefore, the AOJ should ensure all available service treatment records are associated with the file or make a formal finding of unavailability.  
Moreover, there is conflicting evidence of whether the Veteran has been diagnosed with PTSD.  An August 2016 treatment record indicates the Veteran was currently diagnosed with PTSD.  However, other VA treatment records indicate that his PTSD testing results were negative.  Additionally, an April 2018 VA treatment record contains a diagnosis of schizoaffective disorder, resulting in the Veteran having two prior psychiatric admission and three prior suicide attempts.  The record also states that the Veteran experiences delusions and hallucinations.  Lastly, the record references the Veteran’s observation of the motorcyclist being killed and his dreams related to the incident.  While the Veteran has been afforded a mental health VA examination in September 2016, the examination report did not include a PTSD evaluation nor was it related to the psychiatric symptoms related to this claim.  Rather, the examination was conducted in connection to his secondary service connection claim for anxiety and depression.  Review of the claims file reveals the Veteran has not been afforded a VA examination in connection with his PTSD claim.  
For the reasons stated above, the claim is remanded for further development.
The matter is REMANDED for the following action:
1. The AOJ should contact the Veteran and request the names and addresses of any and all health care providers who have provided treatment for a psychiatric disorder. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. 
The AOJ should also secure any outstanding VA medical records.
2. The AOJ should contact the National Personnel Records Center (NPRC), the Records Management Center (RMC), the Veteran's unit, or any other appropriate location, to request the Veteran’s complete service treatment records for his period of active duty from June 1977 to April 1984.
If the RO already has such records, they should be uploaded to the electronic claims file.
If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile.  The non-existence or unavailability of such records must be verified and this should be documented for the record.  Required notice must be provided to the Veteran and his representative, to include notice of alternative sources of evidence that may substitute for any missing service treatment records.
3. The AOJ should take all appropriate steps to attempt to verify the Veteran’s claimed stressors during his period of active duty (seeing someone on a motorcycle killed and run over by a military tractor between January 1979 to January 1981), to include contacting the Joint Service Records Research Center (JSRRC), National Archives and Records Administration (NARA), or any other appropriate entity.
4. After completing the foregoing development, the Veteran should be afforded a VA examination to determine the nature and etiology of any acquired psychiatric disorder that may be present.
Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed.  The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions.
The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology.  If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation.
The examiner should identify all current psychiatric disorders. 
For each disorder identified other than PTSD, the examiner should state whether it is at least as likely as not that the disorder manifested in service or is otherwise causally or etiologically related to the Veteran’s military service. 
Regarding PTSD, the AOJ should provide the examiner with a summary of any verified in-service stressors, and the examiner must be instructed that only these events and any stressors related to fear of hostile military or terrorist activity may be considered for the purpose of determining whether exposure to an in-service stressor has resulted in PTSD.  The examiner should determine whether the diagnostic criteria to support the diagnosis of PTSD have been satisfied.  If the PTSD diagnosis is deemed appropriate, the examiner should then comment upon the link between the current symptomatology and any verified in-service stressor.
(The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) 
A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review.
5. After completing the above actions, the AOJ should conduct any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs.
Acting Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	K.M. Walker, Associate Counsel

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