Citation Nr: 21065134 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 18-12 854 DATE: October 25, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depression, and substance abuse, is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1973 to March 1974. He appeals a December 2015 rating decision by the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ) denying entitlement to service connection for PTSD. The scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the Veteran's description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Thus, the Board has characterized the claim on appeal to entitlement to service connection for an acquired psychiatric disorder. A Board of Veterans' Appeals (Board) hearing was held in July 2021. A transcript is of record. A veteran is entitled to a VA examination if there is (1) competent evidence of a current disability, and (2) evidence that an injury occurred in service, and (3) an indication that the disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for VA to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The record reflects the Veteran has been treated for various acquired psychiatric conditions during the appeal period, including depression, substance abuse, and PTSD. See May 2016 VA treatment records ("diagnosis: alcohol use disorder, major depression, reported history of PTSD (but no traumatic event)"). In service, the Veteran contends he "could not deal" with the stress of basic training and verbal abuse by his commanding officers. See, e.g., July 2021 Board Hr. Tr. at 5,7. Specifically, the Veteran recalled a traumatic experience during basic training where he was exposed to tear gas in a gas chamber; he stated he was so stressed he ran out of the chamber and away from his training unit. Id. at 4. During basic training, the Veteran also reported he was informed two of his friends died while serving in the Republic of Vietnam. Id. at 5. The Veteran has consistently noted these in-service events traumatized him. See November 2015 VA Form 21-0781; May 2015 VA treatment records; September 2017 VA Form 21-0781; September 2017 VA Form 21-4138. While the Veteran is not competent to opine on the etiology of any acquired psychiatric disorders, satisfying the McLendon elements is a low threshold and the evidence must only 'indicate' that there 'may' be a nexus between a current disability and service. See McLendon, 20 Vet. App. at 83. Thus, as the Veteran has not yet received a VA examination, a remand is required. Additionally, the Board finds the evidentiary record may not be complete. January 2016 Privia treatment records note the Veteran was "to be treated at MedStar Southern Maryland Hospital for behavioral health" after experiencing severe psychiatric symptoms. These private treatment records are not of record and the AOJ should attempt to obtain them on remand. 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(c). The matters are REMANDED for the following action: 1. Obtain any relevant updated private and VA treatment records that have not already been obtained and associate the same with the claims file, including, but not necessarily limited to, any psychiatric treatment records around January 2016 at MedStar Southern Maryland Hospital. If any identified records are not obtainable, or none exist, the Veteran should be notified, and the record clearly documented. 2. Thereafter, schedule the Veteran for an examination by an appropriately qualified clinician to determine the nature and etiology of the Veteran's acquired psychiatric disorder. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. A complete history should be elicited directly from the Veteran and the opinion should include a notation that this record review took place. Following review of the record and examination of the Veteran, the examiner should identify all acquired psychiatric disabilities present. For each identified acquired psychiatric disability, provide an opinion with respect to whether it is at least as likely as not (a 50 percent probability or more) that the Veteran's current acquired psychiatric disability was incurred in or is otherwise related to his time in service, to include his reported traumatic experiences in basic training. If PTSD is diagnosed, the examiner should identify the specific stressors that led to the condition. The examiner is directed to consider the following: (1.) the Veteran's contentions noted in his November 2015 VA Form 21-0781, September 2017 VA Form 21-0781; and July 2021 Board Hearing Transcript at pages 4-7 noting exposure to tear gas, verbal abuse by his commanding officers, and notification that his friends died while serving in the Republic of Vietnam; (2.) May 2016 VA treatment records noting diagnoses of "alcohol use disorder, SIMD, and reported history of PTSD (note no traumatic event);" (3) August 2016 VA treatment records noting symptoms of depression; and (4) September 2017 VA Form 21-4138 wife statement that two of the Veteran's friends died in Vietnam. In rendering this opinion, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. A full and complete rationale for all opinions must be provided, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. After the above has been completed to the extent possible, readjudicate the claim. If any benefit sought remains denied, provide the Veteran and his representative with an SSOC and return the case to the Board. DONNIE R. HACHEY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Bona, Associate 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.