Citation Nr: 19124158 Decision Date: 04/02/19 Archive Date: 03/30/19 DOCKET NO. 16-05 502 DATE: April 2, 2019 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include post traumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty for training in the U.S. Army from May 1988 to August 1988 and on active duty from February 1989 to November 1995 as an administrative specialist with service in Southwest Asia. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD First, although the Veteran has expressly claimed service connection for PTSD, the scope of a claim may include other diagnoses that could reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Notably, in this case, the record also reflects other psychiatric diagnoses and symptoms including depressive disorder, unspecified psychosis, insomnia and post traumatic stress disorder. Thus, the issue has been modified broadly as a claim for an acquired psychiatric disorder, to include PTSD, rather than solely as a claim for PTSD. Next, during the course of the appeal it appears the Veteran was released from incarceration and his current address has not been updated. Correspondence indicates the Veteran post-incarceration was residing in Salina, Kansas and as such his address of record should be updated. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for an acquired psychiatric disorder, to include PTSD because no VA examiner has fully opined as to direct service connection relating to the broadened scope of the claim to include an acquired psychiatric disorder. Treatment records note ongoing treatment for PTSD, depression and insomnia. Records of court-ordered mental health assessments in December 2012 and state department of corrections assessments in November 2013, all associated with post-service offenses and incarceration, contain diagnoses of multiple mental health disorders including PTSD, depression, substance abuse, and personality disorders arising from a variety of causes and experiences. However, a VA examination in June 2015 (presumably after release from incarceration) noted it was less likely than not that the Veteran had a diagnosis of PTSD that was incurred in or caused by an in-service injury, event or illness. The examiner noted the Veteran did not meet the full DSM V criteria for PTSD and attributed his ongoing symptoms of anger and aggression to his antisocial personality disorder. Further, additional lay statements regarding the Veteran’s ongoing symptomology of depressed mood, difficulty sleeping, regular nightmares, avoidant behaviors and self-medicating since service should be addressed. As such a remand is warranted for a supplemental VA examination. The matter is REMANDED for the following action: Schedule the Veteran for a psychiatric examination to determine the nature and etiology of any acquired psychiatric disorder, to include post traumatic stress disorder, depressive disorder, insomnia and unspecified psychosis. The examiner must opine whether: (a.) Identify all current acquired psychiatric disorders, under DSM V criteria. (b.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s PTSD is caused by traumatic events in active service to include an in-service injury or disease, including service in Southwest Asia? If PTSD is diagnosed, the examiner must identify the stressor(s) supporting the diagnosis. The examiner should provide an opinion as to whether the Veteran’s diagnosis of PTSD is supportable solely by the stressor(s) that has (have) been verified or established in the record. Note that the Veteran did perform service in Southwest Asia but was not in a combat occupation. (c.) If the Veteran is diagnosed with any other acquired psychiatric disorder, is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s identified acquired psychiatric disorder is caused by active service to include an in-service injury or disease, including service in Southwest Asia? Review of the entire claims file is required. The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Attention is invited to treatment records noting ongoing treatment for depression, PTSD and difficulty sleeping and nightmares. Further, the Veteran reports current ongoing nightmares, difficulty sleeping, anger, avoidant behaviors and mood difficulties and symptomology relating to an incident in Southwest Asia where he saw a fellow soldier killed after stepping on an unexploded bomb. The Veteran reports ongoing mental health symptomology and the use of alcohol and drugs to self-medicate and avoid events since service, specifically since serving in Southwest Asia. In addition, attention is invited to the court ordered and prison treatment records from 2012 and the June 2015 VA examination noting a diagnosis of antisocial personality disorder, alcohol use disorder, and cannabis use disorder. The VA examination noted it was less likely than not that the Veteran had a diagnosis of PTSD that was incurred in or caused by an in-service injury, event or illness. The examiner noted the Veteran did not meet the full DSM V criteria for PTSD and attributed his ongoing symptoms of anger and aggression to his antisocial personality disorder. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Kardian