Citation Nr: 21003205 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 17-12 700 DATE: January 19, 2021 REMANDED The appeal for service connection for posttraumatic stress disorder (PTSD), is remanded. The appeal for service connection for an acquired psychiatric disorder other than PTSD, to include major depressive disorder, depression not otherwise specified (also claimed as bipolar disorder, a sleep disorder and lost memories), is remanded. The appeal for service connection for a headache disorder is remanded. REASONS FOR REMAND The Veteran had active service from July 1976 to December 1976 and from March 1980 to September 1981. In March 2020, the Veteran testified at a videoconference hearing before the undersigned. A transcript of the hearing is of record. 1. Entitlement to service connection for PTSD. In this case, the Veteran asserts two possible stressors in service that may have resulted in PTSD. First, he reported having personally identified his best friend’s deceased body. See February 2016 VA examination report. Service treatment records dated in July 1980 confirm that he sought treatment during service for “bad nerves” after having had to identify his best friend’s “badly disfigured remains.” The Veteran also reported another stressor in which he and a group of service members were involved in an altercation with nonservice members. During that altercation, he was hit in the head with a pool stick. See e.g. February 2016 VA examination report. He also reported that he did not seek treatment at the time because one of the members of the group was not supposed to be with them at the time. VA treatment records indicate a “history of PTSD.” See e.g. July 2017 VA treatment record. The Veteran was provided with a VA examination to address the claim for PTSD in February 2016. The February 2016 VA examiner determined that the Veteran did not meet the DSM-5 criteria for PTSD. The examiner listed the Veteran’s reported altercation as a qualifying stressor for personal assault but did not appear to consider that the Veteran was presenting two stressors. The examiner noted the Veteran’s report of observing his best friend’s deceased body but did not list it as a stressor. There appeared to be some confusion about the stressor because in the evaluation of the personal assault stressor described above, the examiner noted that the marker listed did not substantiate the Veteran’s claimed stressor of being assaulted in a fight but rather related to identifying a friend’s body, not related to the reported incident. It is unclear as to whether the examiner understood that the two claimed stressors were separate incidents, or considered whether PTSD may be present in relation to both reported stressors. On remand, another assessment should be scheduled. 2. Entitlement to service connection for an acquired psychiatric disorder other than PTSD. As discussed above, the Veteran was provided with a VA examination in February 2016. The examiner noted diagnoses of major depressive disorder with anxious distress as well as opioid use disorder and did not indicate whether either disorder was related to service. Further, VA treatment records indicate diagnoses of depressive disorder not otherwise specified. See e.g. January 2016 VA treatment record. VA treatment records also indicate that the Veteran is on medication for depression, paranoia, and nightmares. See May 2017 VA treatment record. The Board notes that the Veteran initially filed the claim for bipolar disorder as well as for problems sleeping. As the Veteran was provided with a VA examination but no nexus opinion was provided for any of the psychiatric disorders, a remand for a VA addendum opinion is required. Further, the Veteran indicated that he received mental health treatment in confinement in the 1990’s, and from Dr. Sosa in the 1980’s. See February 2016 VA examination report. The agency of original jurisdiction (AOJ) should attempt to obtain any outstanding records regarding mental health treatment during that period. 3. Entitlement to service connection for a headache disorder. The Veteran asserts that he initially experienced headaches in service and has experienced them since service. Transcript pages 3, 16. As noted by the Veteran’s representative during the hearing before the Board, service treatment records confirm complaints of headaches in June 1981. The Veteran also reported being involved in an altercation in which he was hit in the head, in service. See February 2016 VA examination report. To date, he has not been provided with a VA examination, and such should be scheduled on remand. Any outstanding VA treatment records dated since July 2017 should also be obtained. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records dated since July 2017. 2. Take all appropriate steps, to include requesting any assistance or information from the Veteran, to obtain the Veteran’s treatment records during his period of Federal incarceration. Also, ask the Veteran to submit, or authorize VA to obtain on his behalf, private records of care from Dr. Sosa from the 1980s. 3. Schedule the Veteran for a psychiatric examination to assess the nature and etiology of his claimed disability. The content of the entire electronic claims file must be made available to the individual designated to issue the opinion and the examiner should discuss the Veteran’s documented medical history and assertions. The examiner is asked to address the PTSD diagnostic criteria and address both of the Veteran’s asserted stressors. The examiner is also asked to consider the July 1980 service treatment record which confirms treatment for “bad nerves” during service after the Veteran had to identify his best friend’s “badly disfigured remains.” Upon review of the record, interview and examination of the Veteran, the examiner is asked to respond to the following: a) Please identify all diagnosed mental health disorders. If PTSD is diagnosed, the examiner should indicate the stressor or stressors upon which the diagnosis is based. If PTSD is not diagnosed, the examiner should explain how that conclusion was reached. b) For each disability identified, is it at least as likely as not is it at least as likely as not (a 50 percent probability or higher) that the disorder had its onset in service or is otherwise related to service? Consider the Veteran’s reported altercation in service as well as identifying his best friend’s deceased body in service. Complete rationale must be provided for any opinion rendered. 4. Schedule the Veteran for an examination to assess the nature and etiology of his claimed headache disorder. The content of the entire electronic claims file, must be made available to the individual designated to issue the opinion and the examiner should discuss the Veteran’s documented medical history and assertions. The examiner is asked to answer the following questions: (a.) Identify any and all of the Veteran’s disorders manifested by headaches. (b.) Is it at least as likely as not (a 50 percent probability or higher) that the Veteran’s disorder had its onset in service or is otherwise related to service? Consider the Veteran’s competent statements regarding an altercation in service in which he was hit in the head with a pool stick as well as service treatment records which indicate complaints of headaches in June 1981. Consider also the Veteran’s sworn testimony (Transcript page 3) that he has experienced migraine headaches since service. The examiner must provide complete rationale for the conclusions reached. (Continued on Next Page) 5. Then readjudicate the issues on appeal. If the benefits sought remain denied, send the Veteran and his representative a supplemental statement of the case. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Donna D. Ebaugh, 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.