Citation Nr: 18160167 Decision Date: 12/27/18 Archive Date: 12/26/18 DOCKET NO. 17-06 161 DATE: December 27, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD), anxiety, and major depressive disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from March 1970 to January 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a Department of Veterans Affairs (VA) Regional Office (RO) rating decision in December 2014. The Veteran perfected an appeal. See December 2014 Notice of Disagreement (NOD); January 2017 Statement of the Case (SOC); January 2017 VA Form-9. February 2018 Supplemental Statement of the Case (SSOC). The Veteran's claim for an acquired psychiatric disorder has previously been characterized as a claim of service connection for PTSD and service connection for an acquired psychiatric disorder, to include PTSD. The Board notes that the United States Court of Appeals for Veterans Claims (Court) has held that when a claimant identifies a psychiatric disorder without more, the claim may not be limited to that diagnosis, but rather must be considered a claim for any mental disability that may reasonably be encompassed by several factors including the claimant's description of the claim, the symptoms the claimant describes, and the information the claimant submits or that VA obtains in support of the claim. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (finding that the claimant did not file a claim to receive benefits only for a particular diagnosis, but for the affliction or symptoms that his mental condition, whatever it is, causes him). Treatment records indicate that the Veteran has been treated for symptoms of PTSD, anxiety, and depression, and diagnosed with major depressive disorder. Accordingly, the Veteran's claim is properly characterized broadly as a claim of entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD), anxiety, and major depressive disorder. 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, anxiety, and major depressive disorder Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (West 2012); 38 C.F.R. § 3.159 (2017). The Veteran contends that he has an acquired psychiatric disorder which is related to service, specifically to experiences in combat during his tour of duty in Vietnam from November 1970 to November 1971. While the Veteran’s service treatment records were negative for complaints, treatment, or diagnosis of a psychiatric condition, service personnel records confirm that the Veteran served in the Republic of Vietnam during the Vietnam War. The Board notes that the Veteran is in receipt of the National Defense Service Medal; the Vietnam Service Medal; and the Vietnam Campaign Medal with 60 Device, among other decorations, citations, and honors. See Form DD-214. The Veteran has described an incident in which he was on a three-vehicle mail run convoy from his compound in Da Lat, Vietnam to Cam Ranh Bay. About an hour into the trip, the convoy started receiving gunfire from the tree line about 75 yards away. The Veteran reported hearing bullets whistling by his head and immediately hitting the floor of the truck. He indicated that he had only 60 days left on his combat tour in Vietnam and began to imagine himself “going home in a body bag,” i.e., dying. The Veteran indicated that he gathered himself and returned fire before the convoy finally drove out of range of the shooters. The Veteran further reported that on the journey back to his compound, the convoy had to travel by the same route on which the ambush occurred. The Veteran stated that he had never been so frightened and terrified in his life. While there was no gunfire on the return trip, the Veteran reported that he was not the same person as he was before he went on the convoy, and stated that he continues to have nightmares about the 81-mile trip. See December 2014 Statement in Support of Claim for PTSD. A December 2007 psychology note documents that the Veteran was referred for recent symptoms of stress, including dreams about Vietnam. It was noted that based on a thorough screening of PTSD criteria within the clinical interview, a diagnosis of PTSD did not appear to be warranted. It was found that the Veteran did present with a mild symptomatology of a depressive episode. The examiner noted an initial diagnostic impression of a mild, single episode, major depressive disorder. See December 2007 VA Individual Psychotherapy Note. VA treatment records document positive PTSD screens in May 2012 and March 2013. In April 2013, the Veteran presented for mental health evaluation for PTSD. The clinician rendered diagnoses of depression and anxiety. It was noted that the Veteran had symptoms suggestive of PTSD, however further diagnostic clarification was needed. See April 2013 VA Mental Health Note. In May 2013, the Veteran presented for a mental health diagnostic assessment. It was noted that the Veteran was assessed in 2007 and found not to meet the criteria for PTSD at that time. Further, based on his most recent history, the clinician reported that he also did not diagnose with PTSD. Diagnoses of major depressive disorder and anxiety, not otherwise specified, were noted. See May 2013 VA Mental Health Note. VA treatment records document ongoing outpatient mental health treatment at the Dallas VA Medical Center (VAMC). In particular, the Veteran was regularly seen by L.T., an advanced practice registered nurse (APRN). Notes taken by L.T. note diagnoses of major depressive disorder, anxiety, and PTSD. However, of note, L.T. has variously reported that the Veteran “likely has mild PTSD symptoms” and rendered diagnoses of rule out PTSD, indicating that while the Veteran had symptoms of PTSD, a diagnosis had not been clinically confirmed. See January 2014; February 2014; June 2014 Mental Health Treatment Notes. An initial PTSD examination was performed in August 2014. The VA examiner stated that the Veteran did not meet the criteria for a diagnosis of PTSD under DSM-V criteria, however he noted a diagnosis of moderate, recurrent major depressive disorder. In this regard, the examiner noted that the Veteran reported some characteristics for PTSD. The Veteran was experiencing symptoms of depression, including irritability; poor sleep; lack of motivation; less interest in once preferred activities, mood swings; some crying spells; and self-isolative preferences. The examiner opined that the Veteran’s depressive disorder appeared to be related to post-military life stressors and was less likely as not (less than 50 percent probability) incurred in or caused by combat experiences that occurred while on active duty. See August 2014 Initial PTSD Disability Benefits Questionnaire. In his clinical findings, the examiner noted that in Vietnam, the Veteran’s convoy was ambushed and he was subject to small arms fire. The examiner indicated that this stressor was adequate to support a diagnosis of PTSD, as it was related to the Veteran’s fear of hostile military or terrorist activity. The examiner further noted that the Veteran had recurrent, involuntary, and intrusive distressing memories of the traumatic event, including distressing dreams related to the event. The Veteran also displayed hypervigilance, sleep disturbance, and overall symptoms of depressed mood, anxiety, and chronic sleep impairment. Id. In his December 2014 notice of disagreement, the Veteran reported that he had a diagnosis of PTSD from his mental health professional. He stated that in 2014, he began receiving regular treatment for PTSD approximately every four to six months, including medication as part of his treatment. See December 2014 Notice of Disagreement. While the Board notes the findings of the August 2014 initial PTSD examination, the Board finds that the opinion provided does not adequately address all of the Veteran’s diagnoses. In this regard, the Board notes that establishment of service connection for PTSD requires: (1) medical evidence diagnosing PTSD in accordance with 38 C.F.R. § 4.125 (a) (stating that if a diagnosis of a mental disorder does not conform to DSM or is not supported by findings in the examination report, the rating agency shall return the report to substantiate the diagnosis); (2) medical evidence of a link between current symptomatology and the claimed in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor actually occurred. 38 C.F.R. § 3.304 (f), 4.125(a); see also Cohen v. Brown, 10 Vet. App. 128 (1997). Generally, "[A] clear (that is, unequivocal) PTSD diagnosis by a mental-health professional must be presumed (unless evidence shows to the contrary) to have been made in accordance with the applicable DSM criteria as to both the adequacy of the symptomatology and the sufficiency of the stressor." Id. Here, the August 2014 VA examiner has explicitly found that the Veteran does not meet the applicable DSM criteria for a diagnosis of PTSD. The Board does not question this determination. While VA treatment records contain assessments that include PTSD, and indicate that the Veteran has been treated for PTSD symptomatology, the treatment records do not provide an unequivocal diagnosis of PTSD. However, VA treatment records indicate that the Veteran has also received diagnoses of major depressive disorder and anxiety treated by medication. The August 2014 VA examiner rendered a diagnosis of major depressive disorder and noted the Veteran’s use of psychotropic medications, including sertraline and zolpidem tartrate. The examiner opined that the Veteran’s depressive disorder appeared to be related to post-military life stressors and was less likely as not related to combat experiences while on active duty. However, the examiner, did not provide an adequate rationale beyond this conclusory finding. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (the probative value of a medical opinion is determined by whether the examiner was informed of sufficient facts upon which to base an opinion and whether the report contains data, conclusions, and a complete rationale in support thereof). The Veteran has consistently reported that his acquired psychiatric disorder is related to his reported combat stressor and has endorsed ongoing nightmares about the traumatic event. The August 2014 VA examiner found that the Veteran’s stressor was adequate to support a diagnosis of PTSD and further noted sleep disturbance and recurrent dreams about the traumatic event. Further, in the January 2017 SOC, the RO noted that the Veteran’s reported stressor was considered consistent with the circumstances of his service. In his August 2014 report, the examiner provided no explanation for why the Veteran’s currently diagnosed recurrent, mild major depressive disorder was due to post-military stressors as opposed to his reported combat stressor. Indeed, the examiner provided no description of what the Veteran’s post-military stressors consisted of, nor any explanation or indication as to why they were causative of his current major depressive disorder. Thus, the Board finds that a remand is warranted in order to obtain an addendum opinion as to the nature and etiology of the Veteran’s acquired psychiatric disorder, specifically his diagnosis of major depressive disorder. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Accordingly, the matters are REMANDED for the following action: 1. Provide the Veteran an opportunity to identify and submit any additional pertinent treatment records. The RO/AMC should secure any necessary authorizations. If any requested outstanding records cannot be obtained, the Veteran should be notified of such. Obtain all outstanding records of VA evaluation and/or treatment of the Veteran. 2. Refer the VA claims file to a medical professional with appropriate expertise to provide an opinion as to the claimed acquired psychiatric disorder. The need for an examination is left at the discretion of the medical professional providing the requested opinion. The Veteran's claims file, including a copy of this remand, should be made available for review by the examiner in conjunction with the examination. The examiner should review the claims folder and this fact should be noted in the accompanying medical report. All necessary tests should be conducted. The examiner should then provide an opinion as to the following: Is it at least as likely as not (i.e., at least a 50 percent probability) that the any current psychiatric disorder, to include anxiety and major depressive disorder, is due to or caused by the Veteran’s reported in-service combat stressor; or alternatively is otherwise related to service? Particular attention should be paid to the Veteran’s lay statements concerning continuity of symptoms and his recurrent dreams/nightmares about his reported stressor. To the extent that the Veteran’s current psychiatric disorder is found not to be related to his claimed stressor, if possible, the examiner should report the actual etiology of the Veteran’s disorder, to include any relevant post-service stressors. The examiner is requested to provide a clear rationale and explain in detail the underlying reasoning for any opinions expressed. A discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the examiner cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 3. Following the completion of the foregoing, and any other development deemed necessary, the AOJ should readjudicate the Veteran's claim. If the benefit sought on appeal is denied, supply the Veteran and his representative with a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board for further appellate review, if otherwise in order. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Lewis