Citation Nr: 18151755 Decision Date: 11/20/18 Archive Date: 11/20/18 DOCKET NO. 16-12 863 DATE: November 20, 2018 REMANDED Entitlement to service connection for a back disability with sciatica is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depression is remanded. Entitlement to service connection for hypertension, to include as secondary to an acquired psychiatric disorder is remanded. Entitlement to service connection for a gastrointestinal disorder, to include as secondary to an acquired psychiatric disorder is remanded. Entitlement to service connection for erectile dysfunction (ED), to include as secondary to an acquired psychiatric disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1972 to September 1974. This matter is before the Board of Veterans’ Appeals (Board) on appeal of an August 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). As the scope of a mental health disorder 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, the Board has combined the claims related to PTSD and depression into a single claim for service connection for an acquired psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1, 4 (2009). 1. Back disability with sciatica The Veteran asserts he hurt his back during basic training. Service treatment records show a single complaint of low back pain, although this was attributed to an abscess/cellulitis. Since at least August 1994, the Veteran has made complaints of low back pain to medical providers. It is noted the Veteran’s report of symptom onset has varied. For example, in August 1994 a four month history of low back pain was noted, while in November 2010 a history of low back pain since 1980 was reported. The November 2010 VA treatment record noted moderately advanced degenerative changes in the lumbar spine at that time. As there is a current low back disability and a complaint of low back pain during service, a VA medical opinion should be obtained regarding this issue. 2. Psychiatric disorders The Veteran has been diagnosed with depression-related disorders. More recently, in May 2015, he was diagnosed with PTSD. The Veteran received a VA examination in June 2015. Although noting the mental health diagnoses in the medical record, the VA examiner did not render a diagnosis, in part, because of invalid psychological testing results. Another VA examination would assist the Board in deciding this issue. If PTSD or a trauma- or stressor-related disorder is diagnosed, further development to verify the stressors contributing to that diagnosis should be undertaken. The Veteran submitted a May 2015 report from a Readjustment Counseling Therapist at the Vet Center diagnosing PTSD and indicating treatment of the Veteran since 2014. The Vet Center records have not been associated with the file. These records should be sought on remand. 3. Hypertension, gastrointestinal disorder, and ED The Veteran was diagnosed with elevated blood pressure in August 2007 and then hypertension in May 2009. He has also been diagnosed with gastritis and ED. The Veteran believes these disabilities are caused or aggravated by his psychiatric disorder. Thus, the claims are inextricably intertwined with the acquired psychiatric disorder claim. See Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. Ask the Veteran to identify all outstanding treatment records relevant to his claims, to include from the Vet Center. All identified VA records should be added to the claims file. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of the unavailability of the records. 2. After records development is completed, the Veteran should be afforded a VA psychiatric examination to determine if any current psychiatric disorders are present, and if so, their relationship, if any, to service. Psychological testing was deemed invalid at the last VA examination and should be repeated. If it is determined that such testing is not necessary, the examiner should explain why. The examiner should elicit a full history from the Veteran and consider the lay statements of record. It is noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. Following review of the claims file and testing and examination of the Veteran, the examiner should list all appropriate psychiatric diagnoses. If no diagnosis is provided, an explanation as to why that is the case should be provided. For each diagnosed disorder, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the disorder is related to an in-service injury, event, or disease. If PTSD or another trauma- or stressor-related disorder is diagnosed, the examiner should list all stressful incidents contributing to the diagnosis. A rationale for all opinions expressed should be provided as the Board is precluded from making any medical findings. 3. If PTSD or a trauma- or stressor-related disorder is diagnosed by the VA examiner, appropriate development should be undertaken to attempt to verify any stressors upon which the examiner notes the diagnosis is based. 4. If service-connection is ultimately awarded for a psychiatric disorder, appropriate medical opinions should be obtained regarding whether hypertension, a gastrointestinal disorder, and ED are caused or aggravated by the psychiatric disorder. 5. After records development is completed, the Veteran should be afforded a VA spine examination to determine the nature of any current low back disability, and to obtain an opinion as to whether such is related to service. The claim file should be reviewed by the examiner. All necessary tests should be conducted and the results reported. The examiner should elicit a full history from the Veteran and consider the lay statements of record. It is noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current low back disability is related to an in-service injury, event, or disease, to include the abscess/cellulitis noted in the service treatment records. (Continued on the next page) A rationale for all opinions expressed should be provided as the Board is precluded from making any medical findings. Nathan Kroes Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Russell P. Veldenz, Counsel