Citation Nr: 20026063 Decision Date: 04/15/20 Archive Date: 04/15/20 DOCKET NO. 05-10 231 DATE: April 15, 2020 REMANDED Entitlement to service connection for a psychiatric disability to include posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for coronary artery disease to include as secondary to a psychiatric disability to include (PTSD) is remanded. REASONS FOR REMAND The Veteran had verified periods of active duty for training (ACDUTRA) from June 5, 1980 to August 5, 1980, in the Army National Guard, and from March 21, 1983, to June 23, 1983, with multiple subsequent periods of inactive duty training (INACDUTRA) in the Connecticut and New Mexico Army National Guards and additional unverified periods of ACDUTRA to include (in relevant part for this determination) in February 1991. In a March 2018 Board decision, in pertinent part, denied entitlement to service connection for a psychiatric disability to include PTSD and coronary artery disease. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In May 2019, the Court granted a Joint Motion for Remand (JMR), vacating the Board’s March 2018 decision in pertinent part and remanding the case to the Board for action consistent with the JMR. 1. Entitlement to service connection for a psychiatric disability to include posttraumatic stress disorder (PTSD) is remanded. In the May 2019 JMR, the parties agreed that the Board erred in finding that the duty to assist were satisfied as Veteran, who was incarcerated at the time, did not provide a reason for why he could not attend the examination, but the Board did not explain why an examination could not be conducted at the institution where the Veteran was held. Recent correspondence now shows that the Veteran in no longer incarcerated. Accordingly, the Board finds it necessary to remand these matters for the Veteran to be scheduled for a new VA examination and the examiners must provide opinions with regard to the Veteran’s psychiatric disability. 2. Entitlement to service connection for coronary artery disease is remanded. With regards to the Veteran claim for entitlement to service connection for coronary artery disease, the Veteran has asserted that the condition is caused or aggravated by the psychiatric disability. In the May 2019 JMR, the parties agreed that this matter was inextricably intertwined with the claim for entitlement to service connection for a psychiatric disability. Indeed, an allowance of the psychiatric disability, and PTSD, claim could change the outcome of the coronary artery disease claim. Therefore, this matter is also remanded. The matters are REMANDED for the following action: 1. Schedule the Appellant for a VA psychiatric examination to assist in determining the nature of his psychiatric disability, if any, and a clinical opinion if any diagnosed acquired psychiatric disability is as likely as not (50 percent or greater) causally related to service. Based upon a review of the relevant evidence and history provided by the Veteran, the VA examiner should identify all current acquired psychiatric diagnoses. The VA examiner should, if needed, reconcile his or her opinion with any conflicting medical opinions of record. The VA examiner should then provide the following opinions: a. Did any diagnosed psychiatric disability have its onset during the 1991 verified period of ACDUTRA? b. Is any diagnosed psychiatric disability otherwise related to the 1991 verified period of ACDUTRA? c. If a diagnosis of PTSD is provided, the VA examiner should identify the claimed stressor that serves as the basis for the diagnosis of PTSD. The VA examiner has an independent responsibility to review the entire record for pertinent evidence in conjunction with rendering the requested opinions. In addition to any records that are generated as a result of this Remand, the VA examiner’s attention is drawn to the following: *A June 1980 Army psychiatric evaluation reflects that the Appellant was referred for assessment because he was immature, lacked responsibility, had no remorse for his actions, and attempted to go absent without leave. The service clinician found no disqualifying mental disease and that the Appellant was mentally responsible for his actions. However, the service clinician noted that the Appellant’s rehabilitation potential was very poor and that his motivation to train was completely negative; the service clinician concluded that the Appellant “will likely become a liability to the service.” Additional service records reflect that the Appellant was counseled on several occasions in June and July 1980. As a result, the Appellant was recommended for transfer to the Trainee Discharge Program. *The May 1988 and September 1990 Army Reserve examination reports reflect a normal psychiatric examination. In the accompanying Report of Medical History forms, the Appellant denied “depression of excessive worry,” “nervous trouble of any sort,” and “frequent trouble sleeping.” *A February 1991 Individual Sick Slip reflects a diagnosis of dehydration and that the Appellant was confined to his quarters for 48 hours. The medical officer indicated that the dehydration was incurred in the line of duty. *In the February 1992 VA Form 21-526 (Veteran’s Application for Compensation and/or Pension), the Appellant indicated that he incurred a mental disorder as a result of ACDUTRA in New Mexico between February and March 1991. *Private mental health records dated between May 1991 and April 1992 reflect psychological treatment for symptoms of severe depression, acute anxiety, panic attacks, and insomnia. Diagnoses during this period included adjustment disorder with anxious mood, depression, and alcohol dependence. *In a May 1992 private examination report prepared for in the context of a state disability determination, the psychiatrist noted that the Appellant reported that his symptoms stemmed from an incident that occurred while training in New Mexico in 1991. The Appellant reported that he became dehydrated and had a rapid pulse; he felt like he was going to die. The Appellant reported his primary symptom was insomnia, but the psychiatrist reported additional symptoms indicative of a thought disorder with poor emotional stability. *Upon VA examination in May 1992, the Appellant reported that in February 1991, while training in the desert in New Mexico, he became dehydrated and experienced a “nervous breakdown.” He attributed his primary complaint of insomnia to the February 1991 incident. Following examination, the VA examiner opined that the Appellant demonstrated no significant disease except for complaints of insomnia; however, he noted a personality disorder with passive/aggressive dependent features. *In a September 1992 statement, a private social worker indicated that the Appellant reported depression and panic attacks as beginning following an episode of heat exhaustion and dehydration experienced in 1991 while training in preparation for deployment to the Persian Gulf War. The social worker noted that “the onset of the depression following the training accident in the [S]outhwest desert.” *In an October 1992 private examination report, the psychiatrist indicated that the Appellant presented with a history of sleep disorder, alcohol dependence, and delusional thinking. The Appellant reported an onset of his symptoms following experiencing “heat stroke while training in the desert during the Gulf War somewhere in the Southern USA.” The psychiatrist noted, however, that “there have been unsuccessful attempts to validate the [Appellant’s] claim.” *In April 1993, the Appellant was hospitalized at a VA medical facility due to mental health symptoms. At that time, the Appellant reported “no psychiatric symptoms until 1991 when he was in active duty [for] training for combat in the Persian Gulf. The [Appellant] was training in the desert in New Mexico when he collapsed from dehydration and had ‘convulsions.’“ The VA clinician provided a rule-out diagnosis of major depressive disorder. *An April 1993 private examination report reflects that the Appellant presented with a chief complaint of insomnia, which he attributed to a training accident in New Mexico in preparation for deployment to the Persian Gulf. The Appellant reported experiencing dehydration and was hospitalized. The private psychiatrist diagnosed PTSD; he also provided a rule-out diagnosis of dysthymic disorder and a diagnosis of dependent personality disorder. In a May 1993 statement, the Appellant’s private psychiatrist indicated that the Appellant suffers from PTSD. *The December 1993 Army Reserve examination report reflects a normal psychiatric examination. In the accompanying Report of Medical History form, the Appellant denied “depression of excessive worry,” “nervous trouble of any sort,” and “frequent trouble sleeping.” The Appellant indicated that he was discharged from the Army Reserve in 1991 to the Individual Ready Reserve “because of physical, mental, or other reasons.” *In a February 1994 decision, the Appellant was determined to be “disabled” by the Social Security Administration (SSA). In its decision, SSA determined that the medical evidence established that the Appellant demonstrated severe PTSD, as well as depressive disorder, as a result of “a training incident in early 1991, while the [Appellant] was on military duty.” *The September 1995 Army Reserve examination report reflects a normal psychiatric examination. In the accompanying Report of Medical History form, the Appellant reported “frequent trouble sleeping,” but denied “depression of excessive worry” and “nervous trouble of any sort.” The service physician noted no major medical problems. *Private mental health treatment records dated in November and December 1995 reflect that the Appellant reported mental health symptoms beginning 1991. At that time, he reported being assigned to a classified mission in the desert when he became dehydrated and went into convulsions. The private psychiatrist provided diagnoses of major depression, recurrent, and undifferentiated schizophrenia. *In a November 1996 statement, the Appellant indicated he was training for the Persian Gulf in the Southwestern United States in February 1991. He further indicated that he became dehydrated and was transported to a hospital one hour away and that during the transfer had a rapid pulse and he had an out-of-body experience. He reported that following eight hours of treatment, he returned but was restricted to the barracks for three days, at which time, he began experiencing difficulty sleeping. *VA mental health treatment records dated between November 1996 and January 1998 reflect diagnoses of schizophrenia and chronic depressive symptoms, and a possible diagnosis of PTSD. During this period, the Appellant reported audiovisual hallucinations and nightmares about the Persian Gulf War. *In February 1997, the Appellant was hospitalized at a VA medical facility for mental health symptoms. At that time, the Appellant reported depression since 1991 and being told that he had PTSD and panic attacks. The VA clinician diagnosed psychosis, not otherwise specified, and provided a rule-out diagnosis of substance-induced psychosis. *Upon VA examination in May 1997, the Appellant reported participating in several classified operations that he could not describe in detail; however, he reported two specific stressors. First, he reported “some bad experiences under fire,” for which he received a National Defense Medal and saw men killed. Second, he reported becoming dehydrated requiring hospitalization and resulting in disorientation and an out-of-body experience. Following examination, the VA examiner diagnosed chronic undifferentiated schizophrenia, and indicated a rule-out diagnosis of chronic depression with psychotic features. The VA examiner opined that the Appellant did not meet the diagnostic criteria for PTSD as “there was little evidence that he was exposed to extraordinary events.” However, the VA examiner noted that the Appellant had extreme difficulty coping with the events of the war and was quite fixated about the dehydration incident, but indicated these symptoms were consistent with schizophrenia or psychotic diagnoses. *In September 1998, the Appellant testified before a Decision Review Officer that he was on a classified mission as part of ACDUTRA in New Mexico between February and March 1991, during which he experienced dehydration requiring hospitalization. Following this incident, the Appellant indicated that he began to experience difficulty sleeping, memory loss, panic attacks, and nightmares. He reported not seeking psychological treatment while on ACDUTRA; instead, he initially sought treatment following return home from ACDUTRA. *A February 1999 VA PTSD Biopsychosocial Assessment report reflects that the Appellant reported longstanding and severe insomnia, fatigue, depression, and stress intolerance that “began immediately after an incident that occurred during his 1990-1991 mobilization to active duty from the National Guard.” As described by the Appellant, his unit was assigned to a classified drug interdiction mission along the Mexican border when he became severely dehydrated such that he needed hospitalization. Following examination, the VA psychiatrist indicated that the Appellant appeared to have primary insomnia, but could not rule out breathing-related insomnia or mild neurocognitive disorder. The VA psychiatrist indicated that the Appellant did not meet the diagnostic criteria for PTSD, as he did not endorse symptoms of hyperarousal, intrusive re-experiencing, or avoidance behaviors. *An August 1999 VA treatment record reflects that the Appellant reported being an Army reservist as a combat engineer. He also reported serving in the Persian Gulf War and receiving “shots” before going for training. He described difficulty sleeping and ascribed his symptoms to those “shots.” *An August 1999 mental health treatment record reflects that the Appellant reported insomnia, panic attacks, and paranoid thoughts. He reported being given injections during preparation to ship out to the Gulf War “that he is sure are connected to his mental health symptoms.” He reported not being sent overseas, but instead served on a “highly classified mission” disguised as assisting the United States Border Patrol in Texas. Following treatment, the Appellant returned to the VA psychiatrist’s office and reported that he had embellished his story, including fabricating most of his account of paranoid ideation, in order to improve his chances of receiving service-connected benefits. He further reported that he was advised by other veterans to exaggerate his symptoms in order to advance his case for service connection. The VA psychiatrist diagnosed alcohol dependence, in full sustained remission, and schizotypal personality disorder with borderline and antisocial traits; the psychiatrist also provided rule-out diagnoses of delusional disorder, persecutory type, and schizophrenia, chronic paranoid type. *In an August 2000 statement, the Appellant’s treating VA psychiatrist opined that the onset of the Appellant’s disabling psychiatric disorder began while at Fort Bliss in El Paso, Texas, between 1990 and 1991 while being prepared to be sent into the Gulf War. The psychiatrist opined that the Appellant should be service-connected for an acquired psychiatric disorder. *In an August 2000 statement, the Appellant indicated that he was called to duty in February 1991 for training in preparation of deployment to the Persian Gulf. He indicated that he was under a lot of stress and became so dehydrated that he required hospitalization for treatment. The Appellant reported that he thought he was going to die and had an out-of-body experience. *The September 2000 Individual Ready Reserve examination report reflects a normal psychiatric examination. In the accompanying Report of Medical History form, the Appellant denied “depression of excessive worry,” “nervous trouble of any sort,” and “frequent trouble sleeping.” *A March 2001 VA neuropsychology consultation report reflects that the Appellant reported that his mental health symptoms “started in 1990 when he became severely dehydrated while being trained for Desert Shield. He report[ed] that he thought he was going to die, and report[ed] an out-of-body experience.” The Appellant also reported that his symptoms might also be due to “handling contaminated equipment from Saudi Arabia” or as a result of vaccinations. *A May 2002 private treatment record reflects that the Appellant presented with a chief complaint of PTSD. At that time, he reported that his symptoms of insomnia, memory loss, and difficulty concentrating begin in 1991, and the severity of his symptoms has not changed. Following examination, the internal medicine physician indicated that the Appellant presented with PTSD with anxiety, depression, and insomnia, “as diagnosed by the VA.” However, the physician noted that “there is some question as to his eligibility.” *July 2003 private treatment records reflect that the Appellant was treated for unstable angina and CAD, and noted that the Appellant reported diagnoses of PTSD, anxiety, and chronic insomnia. In one record, the private nurse indicated that the Appellant reported that he had PTSD “since the Persian Gulf War.” *In a May 2005 Stressor Statement, the Appellant reported that his PTSD was due to events that occurred in February 1991 while he was stationed at Fort Bliss in El Paso, Texas. The Appellant described participating in live round exercises in the desert as well as assisting the United States Border Patrol, the Drug Enforcement Agency, and Texas Border Patrol. He reported being stressed out and became dehydrated to such a degree that he required hospitalization and thought he was going to die. *An August 2005 private sleep disorder consultation report reflects that the Appellant reported sleep disturbances as beginning in 1991 “when his military unit was activated for duty in the Persian Gulf War. He recall[ed] training for the activation and received a number of vaccines whose purpose he [did] not know.” The Appellant reported difficulty sleeping since receiving those vaccines, as well as receiving treatment for anxiety, depression, and PTSD. Following examination, the physician opined that the Appellant’s psychiatric disorders were the most likely cause of his insomnia, but the physician could not rule out psychophysiological insomnia, dependent sleep disorder, inadequate sleep hygiene, and obstructive sleep apnea. *In a June 2016 statement, the Appellant reported that his difficulty sleeping and mental health symptoms began following an episode of dehydration that occurred during a period of ACDUTRA in preparation for deployment to the Persian Gulf. He reported that he was hospitalized for treatment of his dehydration and was subsequently placed on restricted duty for two days. He indicated that he sought treatment from a medic for his sleep difficulties during the rest of his ACDUTRA, and sought treatment for his mental health symptoms upon completion of his ACDUTRA. A thorough explanation must be provided for the opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting explanation as to why an opinion cannot be made without resorting to speculation. 2. If, and only if, the clinician determines that it is as likely as not that the Veteran has an acquired psychiatric disability causally related to, or aggravated by, service, obtain a clinical opinion as to whether it is as likely as not (50 percent or greater) that the Veteran’s CAD (which was diagnosed in July 2003) was caused by, or aggravated by, his acquired psychiatric disability. A rationale should be provided for any opinion. If the clinician finds that the Veteran’s CAD is aggravated by the Veteran’s acquired psychiatric disability, the clinician, if reasonably possible, should state the degree of aggravation. T. WISHARD Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Dworkin, 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.