Citation Nr: 21000904 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 20-15 146A DATE: January 6, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depression, and anxiety, is remanded. REASONS FOR REMAND The Veteran served on active duty as a U.S. Navy SEAL from March 1966 to January 1995. During his long period of service, the Veteran was awarded decorations including the Silver Star, a Bronze Star Medal with a “V” device, and two Gold Stars (in lieu of additional Bronze Star Medals), among numerous other honors. This case is before the Board of Veterans’ Appeals (Board) on appeal from a January 2018 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. In that decision, the RO, inter alia, denied entitlement to service connection for PTSD. In April 2018, VA received the Veteran’s Notice of Disagreement (NOD). In February 2020, the RO issued a Statement of the Case (SOC). In April 2020, VA received the Veteran’s VA Form 9 appeal to the Board, which only listed the issue of entitlement to service connection for PTSD. The Veteran’s psychiatric disorder has been variously diagnosed, and therefore the issue on appeal is characterized as noted on the title page of this decision. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (holding 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). Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, depression, and anxiety. During his Vietnam service, the Veteran was deployed on four separate six-month combat deployments as a Navy SEAL operator. See April 2020 Veteran statement. He was responsible for “many kills” and witnessed the deaths of “several friends” and Vietnamese civilians. January 2018 VA examination report. The Veteran’s citations for his Silver Star, Bronze Star Medal with a “V” device, and two Gold Stars, reflect extreme courage under fire; his accomplishments include evacuation of injured comrades under heavy enemy barrages. His first Gold Star citation indicates that he participated in “over 60 combat operations” while embedded with a paramilitary force of Vietnamese combatants. See list of citations uploaded on April 18, 2020. In December 2017, the Veteran reported “insomnia, PTSD, daily feelings of depression, [and] occasional memory loss.” He received assessments of depression and anxiety. See annual examination dated December 15, 2017. Notwithstanding, there are also negative screenings for PTSD and depression of record. See, e.g. nursing outpatient note dated August 12, 2015. The Veteran has also previously declined mental health treatment through the VA. See annual examination dated December 15, 2017. The Veteran received an initial VA examination for PTSD in January 2018. The VA examiner did not provide a diagnosis of PTSD or any other psychiatric disorder under the DSM-5. He recorded symptoms of anger and irritability, “startle,” anxiety, “sits w/back in corner or to wall in social settings,” and emotional numbing. The examiner also indicated that the Veteran “did not report nightmares.” Furthermore, he noted that, according to the Veteran’s wife, the Veteran would jump up with fists raised when woken up, has a low frustration tolerance, and experiences “sadness/[depression] 2-3 times per month which goes away after a few hours.” Regarding his claimed stressor (among others), the Veteran indicated that, while embedded with Vietnamese combatants, he witnessed the deaths of a family of Vietnamese civilians due to a grenade detonation. He reported taking a surviving child back to his village elders.” Furthermore, he indicated that, during one operation, “he and his men killed 26 enemy (N. Vietnamese) soldiers.” Notably, the Veteran’s DD Form 214s and personnel file show that the Veteran served in combat in the Republic of Vietnam. Although concluding that the Veteran’s claimed stressor(s) were adequate to support a diagnosis of PTSD and the Veteran’s symptoms of startle, anger, and anxiety met some of the PTSD criteria, the examiner found that the Veteran did experience intrusion symptoms associated with the traumatic event(s) and did not persistently avoid stimuli associated with the traumatic event(s). Finally, he noted that the Veteran “did not complain of mental health symptoms during the military and has never gone to mental health counseling.” In an April 2020 correspondence submitted with his VA Form 9, the Veteran provided additional information about his symptoms. Specifically, he reported that he becomes “extremely agitated upon being abruptly awakened from sleep or suddenly being spooked and frightened by unexpected noises, strangers from behind or even while exiting a vehicle.” Moreover, the Veteran indicated that he becomes startled even when in his garage, “when a car suddenly pulls up behind me, that I didn’t immediately recognize.” When startled, the Veteran stated that he can “become violent by openly displaying his fists, thinking someone was about to get aggressive with me.” Additionally, he indicated that he becomes “rather paranoid while being exposed to large crowds and very untrusting among strangers” and “never like[s] being left alone for extended periods of time.” The Veteran also reported that it is “hard for me to focus, relax and at times sleep well,” “difficult to concentrate and my memory isn’t what it used to be,” and has “experienced flashbacks, sudden nightmares and other mental unpleasant thoughts.” In essence, the Veteran described having emotional outbursts, exaggerated startle response, extreme agitation, aggression, and paranoia in large crowds. He also reported that he is moody and anxious and has difficulty focusing and relaxing. Notably, he also explained that he avoids discussing or confronting his symptoms, and he tries to cope as best as he can with his nightmares, unpleasant thoughts and flashbacks of his combat experiences in Vietnam. Finally, he indicated extreme difficulty talking about his feelings about his wartime service. The Veteran explained that he was not accustomed to discussing personal and sensitive issues with others, and he found that being subjected to questioning at a VA examination was rather difficult and awkward. He stated that his hesitancy in discussing personal and sensitive dire events parallels the discipline of most U.S. Navy Seals. Notably, the Veteran stated, “In short, I felt embarrassed and uncomfortable to be succumbed to such sensitive and personal questioning that was totally foreign to me.” See April 2020 VA Form 9 and attached statement. In light of the above lay evidence, another VA examination is warranted for the Veteran’s PTSD. Furthermore, given prior assessments of depression and anxiety, the Veteran’s claim for PTSD is expanded to include all acquired psychiatric disorders. Clemons v. Shinseki, 23 Vet. App. 1 (2009). On remand, the VA examiner should, in particular, address the Veteran’s April 2020 statement, in which the Veteran competently described symptoms including anger, violence, and nervousness in response to certain stimuli, paranoia and avoidance of crowds, as well as the Veteran’s reported difficulty communicating his feelings about his wartime service. The matters are REMANDED for the following action: 1. Obtain a VA examination and opinion regarding the nature and etiology of any acquired psychiatric disorder, to include PTSD. The claims file and a copy of this Remand must be made available to the reviewing examiner, and the examiner shall indicate in the addendum report that the claims file was reviewed. After a complete review of the claims file, including a copy of this Remand, the examiner should opine whether it is at least as likely as not (a 50 percent probability or greater) that any acquired psychiatric disorder, to include PTSD, is related to the Veteran’s numerous combat experiences, or any other disease or injury during the Veteran’s 30-year period of active duty. In particular, the examiner should discuss the symptoms reported in the April 2020 VA Form 9 and attached statement, including anger, violence, and nervousness in response to certain stimuli (such as being woken up suddenly and people exiting nearby vehicles), paranoia and avoidance of crowds, as well as the Veteran’s reported difficulty communicating his feelings about his wartime service. L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Small, Attorney advisor 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.