Citation Nr: 21069909 Decision Date: 11/22/21 Archive Date: 11/22/21 DOCKET NO. 08-38 038 DATE: November 22, 2021 REMANDED Entitlement to service connection for a psychiatric disorder is remanded. REASONS FOR REMAND The Veteran had active service in the U.S. Army from October 1952 to September 1954. Unfortunately, the Veteran died in February 2011. The appellant is his surviving spouse. Initially, the Board extends its sincere condolences to the appellant for the loss of her husband and recognizes the valuable service that he provided to this country in the United States Army. An August 2016 letter reflects that the Veteran's wife has been accepted as substitution for purposes of processing the Veteran's appeal to completion. See 38 U.S.C. § 5121A; 38 C.F.R. § 3.1010; see also 79 Fed. Reg. 52,977-52,985 (Sept. 5, 2014). This matter comes to the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating decision issued by the Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). The appellant testified at a travel Board hearing before the undersigned Veterans Law Judge in February 2018. A transcript of that proceeding is associated with the claims file. The Board regrets any additional delay, but for reasons explained below, additional development is necessary so that the Appellant is afforded every possible consideration. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. Entitlement to service connection for a psychiatric disability is remanded. Pursuant to a July 2018 remand, a medical opinion was obtained in March 2020 to determine the nature and etiology of the Veteran's claimed psychiatric disorder. At this time, the VA examiner found no link between the Veteran's active service and his previously documented neuropsychiatric symptoms. Instead, the examiner concluded that the Veteran's symptomatology is related solely to a diagnosis of alcohol abuse. The examiner further concluded that this condition was caused by the Veteran's willful misconduct and not by military service. In July 2021, the Board concluded that this opinion was inadequate and remanded the claim for an addendum opinion. The same VA examiner concluded again in September 2021 that the Veteran's neuropsychiatric symptomatology are not related to service. In support of his opinion, the examiner noted that service treatment records (STRs) are silent for any psychiatric complaints, psychiatric assessments, or neuropsychiatric treatment recommendations with the exception of a notation in February 1953 that the Veteran "feels nervous." Additionally, the examiner concluded that the Veteran's psychiatric symptoms were attributed solely to his alcohol abuse. In support of this conclusion, the examiner noted that the Veteran was treated for psychiatric symptoms in November 1995, at which point the Veteran reported weekend alcohol use. The examiner also noted that the Veteran's primary care physician documented a diagnosis of ETOH abuse in February 2002 and the Veteran's last psychiatric intervention was with a substance abuse dependence treatment program in April 2008. The examiner further dismissed the Veteran's diagnosis of PTSD from a June 2003 psychiatric evaluation, noting that the evidence did not establish that the diagnostic criteria was satisfied for PTSD under the DSM-5. The Board finds that this opinion is inadequate. First, the Board notes that a formal finding was made in March 2009 that the Veteran's STRs were unavailable for review because a fire destroyed a major portion of records for Army military personnel for the period from 1912 through 1959. While some STRs have been added to the record, there is no indication that this is a complete record. Nevertheless, post-service treatment records reveal that the Veteran sought psychiatric care for symptoms attributed to his service in Korea in June 2003, which was more than six years before he filed his claim for service connection. At this time, the Veteran reported that his past history of mental or physical illness stemmed from what happened to him in Korea. He elaborated that he was seeing corpses and dreaming of blood slaughter. With regard to his symptoms, he complained of anger, poor impulse control, self-isolation, nightmares, and sleep disturbances. The Board notes that the Veteran is competent to report symptoms and observable events within the realm of his personal knowledge. Layno v. Brown, 6 Vet. App. 465, 470-471 (1994); Jandreau, 492 F.3d at 1377. Furthermore, the Board finds no reason to doubt the credibility of these statements, as they were made during the course of treatment and resulted in a diagnosis of PTSD under the DSM-IV six years before he even filed a claim for service connection. Second, there is no indication in the record that alcohol use is the sole cause of the Veteran's psychiatric symptoms. In March 1988, the Veteran was assessed with anxiety during a physical examination and there is no mention of alcohol abuse at this time. Although the Veteran was informed of an abnormal liver biopsy several months later, it was noted that the Veteran had no preceding or subsequent history of alcoholism. Additionally, the Veteran was treated for depressive symptoms and insomnia in 1995 and 1996, at which point he reported weekend alcohol use but did not exhibit any symptoms of alcohol dependence or withdrawal. Furthermore, as noted, the Veteran reported in June 2003 that he was having nightmares related to his experience in Korea. Given that the examiner did not consider all of the relevant evidence of record prior to rendering an opinion, including the Veteran's competent and credible reports of symptoms related to his experience in Korea, the Board finds that the opinion is inadequate. While the Board regrets additional delay, a remand is necessary in order to obtain an addendum opinion. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate examiner who has not participated in this case regarding the nature and etiology of the Veteran's psychiatric symptoms. The claims file must be provided to the examiner for review. (a) The examiner is asked to indicate whether the Veteran had a diagnosis for PTSD in accordance with the DSM-5. In reaching a conclusion, the examiner must address the PTSD diagnosis made under the DSM-IV in June 2003. (b) The examiner is also asked to identify any other psychological diagnoses supported by the record. In reaching a conclusion, the examiner must address the Veteran's competent and credible reports about having nightmares of his experience in Korea, and other symptoms, including anger, poor impulse control, self-isolation, and sleep disturbances. The examiner must also address whether the Veteran's alcohol use was a symptom of an underlying mental condition. (c) The examiner is then asked to provide an opinion on the following: (i) Whether it is at least as likely as not (a 50 percent or greater probability) that a verified stressor supports a diagnosis of PTSD. (ii) Whether it is at least as likely as not (a 50 percent or greater probability) that any psychiatric diagnosis is related to, or had its onset during, the Veteran's active service. 2. After ensuring that the opinions comply with the terms of this remand, the AOJ should re-adjudicate the claim. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Beech, 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.