Citation Nr: 19150697 Decision Date: 06/28/19 Archive Date: 06/28/19 DOCKET NO. 18-37 517 DATE: June 28, 2019 REMANDED Entitlement to service connection for an acquired psychiatric disorder, claimed as posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1969 to February 1979, including service in the Republic of Vietnam. This matter is before the Board following his appeal of a September 2016 rating decision. In his February 2015 claim, the Veteran stated he is seeking entitlement to service connection for PTSD. The medical evidence of record includes diagnoses of an unspecified depressive disorder, anxiety disorder not otherwise specified (NOS), mood disorder, and insomnia. The United States Court of Appeals for Veterans Claims has held that the scope of a mental health disability 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. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Accordingly, the Board has recharacterized the claim on appeal to entitlement to service connection for an acquired psychiatric disorder. The Veteran’s service personnel records confirm that during his Vietnam service, he participated in a counterinsurgency against the VietCong. See Combat History Expeditions. A January 2003 Huntington VA Medical Center (VAMC) mental health initial evaluation note includes the Veteran’s report that when he first returned from Vietnam, he was placed on Librium for anxiety and anger by the Clarksburg VAMC. On remand, the Agency of Original Jurisdiction (AOJ) should obtain any outstanding treatment records from the Clarksburg VAMC. During a June 2015 VA Initial PTSD examination, the Veteran indicated he had undergone three alcohol treament programs at non-VA facilities. A remand is required to allow VA to obtain authorization and request these records. The Veteran was last afforded a VA mental health examination in June 2015. The VA examiner diagnosed alcohol use disorder as a primary condition, as well as unspecified depressive disorder. However, the examiner’s opinion appears to contradict itself, as the examiner opined the Veteran’s depressive symptoms were due to a combination of years of alcohol dependence and the Veteran’s combat exposure in Vietnam, but then stated alcohol use better accounted for the onset of his depressive symptoms. Further, the VA examiner did not address the January 2003 Huntington VAMC initial mental health evaluation note, in which both anxiety disorder NOS and alcohol dependence were assessed following the Veteran’s description of combat events during his service in Vietnam, as well as his past history of alcohol use. Further, since the June 2015 VA examination, treatment records from Edward’s Comprehensive Cancer Center dated between January 2016 and September 2017 include notations of anxiety and insomnia symptoms, as well as assessments of insomnia. Accordingly, a remand is required to afford the Veteran a new VA examination to determine the nature and etiology of any current acquired psychiatric disorder. The matter is REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for the alcohol treatment centers in Charleston; Ripley, West Virginia; and Friendship Hall in North Carolina, as noted upon his June 2015 VA examination. Also ask the Veteran to complete a VA Form 21-4142 for any other non-VA mental health treatment. Make two requests for the authorized records from each identified provider, unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s outstanding VA treatment records from the Clarksburg VAMC, as well as any updated treatment records from the Huntington VAMC from June 2015 to the present. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any current acquired psychiatric disorder. After a review of the claims file, and interview and examination of the Veteran, the examiner is asked to respond to the following inquiries: a) Identify with specificity all acquired psychiatric disorders that are currently manifested, or that have been manifested at any time since February 2015. The examiner should specifically address the diagnoses of unspecified depressive disorder, anxiety disorder NOS, mood disorder, and insomnia of record. b) For each acquired psychiatric disorder, the examiner should opine whether it is at least as likely as not (i.e. probability of 50 percent or greater) that such disability was either incurred in, or is otherwise related to, the Veteran’s active military service, to include his combat experiences in Vietnam. The examiner should specifically address the Veteran’s reports that his psychological symptoms, including depression, began during service after his return from Vietnam, that he drank to cope with these symptoms, and that his symptoms have continued since service and after he stopped drinking. See, e.g., October 2018 Veteran affidavit. L. STEPANICK Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Delhauer, Counsel 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.