Citation Nr: 21065570 Decision Date: 10/26/21 Archive Date: 10/26/21 DOCKET NO. 19-03 428 DATE: October 26, 2021 ORDER Service connection for unspecified depressive disorder and unspecified anxiety disorder is granted. REMANDED Entitlement to service connection for migraines is remanded. Entitlement to service connection for a back disability is remanded. Entitlement to service connection for keloids is remanded. Entitlement to service connection for a dental condition for compensation purposes is remanded. FINDING OF FACT The Veteran's unspecified depressive disorder and unspecified anxiety disorder have been shown to be related to service by competent medical evidence; the Veteran does not have a diagnosis of PTSD. CONCLUSION OF LAW The criteria for service connection for unspecified depressive disorder and unspecified anxiety disorder have been met. 38 U.S.C. §§ 1110, 1154(a), 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304(f). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1970 to December 1971, with service in Republic of Vietnam. These matters are before the Board of Veterans' Appeals (Board) on appeal from an October 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In June 2021, the Veteran testified before the undersigned Veterans Law Judge at a virtual hearing. A copy of the transcript is associated with the claims file. 1. Service connection for unspecified depressive disorder and unspecified anxiety disorder The Veteran seeks service connection for PTSD. The Board has recharacterized the original claim based on the evidence of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Based on the following, the Board concludes that unspecified depressive disorder and unspecified anxiety disorder are related to service. 38 U.S.C. §§ 1110, 5107; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304 (f). In a written statement received in July 2015, the Veteran reported that in service in Vietnam he endured the stress of policing in Bien Hoa, New Port Vietnam. He indicated stressful events as the unfortunate dismemberments of American and Vietnamese soldiers in 24th Evac Hospital; stress of orphans while escorting medical teams to orphanages; the experience of death of fellow soldiers in my platoon and company; fellow soldiers coming back from combat experiences; and the stressful responsibility of protecting high military officers and classified communication center. The Veteran served in Vietnam and as a military policeman. He was awarded the Vietnam Service Medal with Two Stars and the Vietnam Campaign Medal with 60 Device. The Veteran's circumstances of service are consistent with his report of stressful incidents. Therefore, the question for the Board is whether he has PTSD or a current mental health disability that has a causal relationship to service. Service treatment records do not reflect a chronic psychiatric disorder or treatment for psychiatric complaints. On VA examination in October 2015, the examiner determined that the Veteran did not meet the criteria for a diagnosis of PTSD. Rather, the examiner diagnosed him with unspecified depressive disorder and unspecified anxiety disorder and determined that it was at least as likely as not these conditions were related to service. The rationale was that the "onset of his symptoms occurred as the result of trauma experiences in Vietnam." At the outset, the Board finds that service connection for PTSD is not warranted, after a review of the evidence. A clinician has not provided a PTSD diagnosis in accordance with 38 C.F.R. § 4.125 (a). The Veteran is not competent, as a lay person without medical training, to self-diagnose PTSD. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Since the first element has not been met, service connection may not be granted for PTSD. See 38 C.F.R. § 3.304 (f); Brammer v. Derwinski, 3 Vet. App. 223 (1992). However, the October 2015 VA examination report shows that the Veteran has current diagnoses of unspecified depressive disorder and unspecified anxiety disorder which the examiner concludes are at least as likely as not due to military service. The examiner's nexus opinion is considered adequate and probative because it was based on review of the relevant evidence in the file and the Veteran's contentions and was supported with cogent rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There is no opinion to the contrary. Accordingly, service connection for unspecified depressive disorder and unspecified anxiety disorder is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for migraines is remanded. 2. Entitlement to service connection for a back disability is remanded. 3. Entitlement to service connection for keloids is remanded. 4. Entitlement to service connection for a dental condition for compensation purposes is remanded. Additional development is required before the Board adjudicates the remaining claims. The Veteran contends that his migraines and back disability had onset during service and/or are secondary to his psychiatric disability. The Veteran has not been afforded a VA examination for these claims. Now that service connection has been granted for unspecified depressive disorder and unspecified anxiety disorder, a medical examination is necessary to determine whether the Veteran has migraines and a back disability that are related to service or to a service-connected disability. See 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Veteran testified that he had received private medical treatment for his claimed back disability, migraines, keloids, and fractured tooth. The undersigned held the record open for 90 days after the hearing for him to submit additional evidence in support of these claims. The Veteran submitted seven pages of private treatment records; however, it is clear that additional identified records have not been associated with the claims folder. On remand, the Veteran will have another opportunity to identify non-VA providers to authorize VA to obtain them and/or submit additional medical records. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for any non-VA health provider, to include Kaiser Permanente and any private dentist who has treated his fractured tooth. Make two requests for the authorized records, unless it is clear after the first request that a second request would be futile. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of his claimed migraines and back disabilities. The examiner should review the claims file and a copy of this Remand. The examiner is asked to provide responses to the following: a) Is any current migraine and/or back disability at least as likely as not related to service? In providing the requested opinion, consider the Veteran's description of his in-service symptoms as well as his post-service symptoms, to specially include the Veteran's assertions that he had headaches and back pain during service. If there is any medical reason to accept or reject the proposition that the Veteran's reported symptoms in service and thereafter represented the onset of a current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? b) Is the migraine and/or back disorder at least as likely as not proximately due to the service-connected psychiatric disability? c) Is the migraine and/or back disorder at least as likely as not aggravated, i.e., worsened beyond its natural progression by the service-connected psychiatric disability? In answering these questions, the examiner must consider the Veteran's assertions that his psychiatric disability contributes to his headaches and back disability. A rationale for the requested opinions must be provided. D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. G. Mazzucchelli, 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.