190218-5400

• Court: Board of Veterans' Appeals
• Decided: December 31, 2019
• Docket: 190218-5400
• Status: Unpublished

Opinion

Citation Nr: AXXXXXXXX Decision Date: 12/31/19 Archive Date: 12/30/19

DOCKET NO. 190218-5400 DATE: December 31, 2019

REMANDED

Service connection for post-traumatic stress disorder (recharacterized as an acquired psychiatric condition, to include an adjustment disorder) is remanded.

REASONS FOR REMAND

Service connection for an acquired psychiatric condition (to include an adjustment disorder) is remanded.

While the Veteran originally claimed service connection for post-traumatic stress disorder, the evidence reflects a diagnosis for an adjustment disorder. See February 2018 VAMC staff psychologic note. Therefore, to allow VA to more broadly and sympathetically adjudicate the claim, the Veteran’s claim for service connection for PTSD has been recharacterized to include any acquired psychiatric condition (include an adjustment disorder). See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (Board must consider any disability that “may reasonably be encompassed by” a description of the claim, symptoms reported, and other evidence).

In addition, the Board finds that the January 2015 VA psychological examiner’s negative nexus opinion is inadequate. The opinion was based on the inaccurate factual premise that the Veteran does not have a diagnosed psychiatric condition. See Reonal v. Brown, 5 Vet. App. 460, 461 (1993) (an opinion based on an inaccurate factual premise has no probative value).

Based on this finding, upon remand, an addendum opinion must be obtained, and the examiner must consider the whole of the medical evidence of record.

The matters are REMANDED for the following action:

1. In accordance with the provisions of 38 C.F.R. § 3.159(c)(1), contact the Veteran for additional information about treatment for his conditions and make efforts to obtain all VA and private treatment records concerning these claims.

2. Schedule the Veteran for a VA mental health examination, to be conducted by a VA psychologist or psychiatrist, to determine the cause of any acquired psychiatric conditions, to include the previously diagnosed adjustment disorder. Prior to the examination, the claims folder and a copy of this remand must be made available to the examiner for review. A notation to the effect that this record review took place should be included in the report.

The examiner is directed to prepare a report which fully discusses the Veteran’s symptoms as related to any acquired psychiatric conditions, to include a previously diagnosed adjustment disorder.

The examiner MUST OPINE as to whether it is at least as likely as not (a 50 percent or greater probability) that ANY acquired psychiatric conditions, to include the previously diagnosed adjustment disorder, are directly related to active military service.

*The examiner MUST CONSIDER AND DISCUSS the fact that the Veteran has verified exposure to a stressor event that is related to the fear of hostile military or terrorist activity, including directly experiencing the traumatic event. See February 2015 VA examination report.

*In addition, the examiner MUST CONSIDER AND DISCUSS the February 2018 VAMC staff psychologist note which relates the Veteran’s adjustment disorder diagnosis, at least in part, to stressful experiences during service.

3. A detailed explanation (rationale) is requested for all opinions provided. (By law, the Board is not permitted to rely on any conclusion that is not supported by a thorough explanation. Providing an opinion or conclusion without a thorough explanation will delay processing of the claim and may also result in a clarification being requested).

VICTORIA MOSHIASHWILI

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board Department of Veterans Affairs

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.