Citation Nr: 21071347 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 16-32 639 DATE: November 30, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from April 2002 to September 2003. This matter comes before the Board of Veterans' Appeals (Board) from a May 2014 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran appeared for a hearing before the undersigned Veterans Law Judge in May 2020. A transcript of the proceeding is associated with the claims file. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD is remanded. The Board notes that the Veteran's psychiatric disability was initially claimed as PTSD; however, given the various psychiatric diagnoses of record, the Board has broadened the issue on appeal to include any diagnosed psychiatric disability. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran contends he has PTSD caused by several in-service stressors. In a January 2016 statement, the Veteran reported an in-service stressor involving frequent SCUD missile attacks on his base. In a February 2014 statement, the Veteran reported another in-service stressor involving an attack by civilians on his convoy. The Veteran further contends that his psychiatric symptoms upon discharge led him to abuse alcohol and other substances as a coping mechanism. The Board regrets further delay, but more information is needed to allow the Board to make a fully-informed decision. It is unclear whether the Veteran has a current diagnosis of PTSD under the DSM-5. The May 2014 VA examiner declined to give a PTSD diagnosis due to objective testing indicating exaggeration of symptoms or malingering. The examiner also declined to opine on any connection between the Veteran's claimed in-service stressors and current symptoms, and noted that the Veteran had no other mental health diagnoses and that his substance abuse predated his service. However, private treatment records dated November 2008, August 2012, and October 2012 indicate the Veteran was diagnosed with PTSD, anxiety disorder, depressive disorder, panic disorder, and polysubstance abuse and dependence prior to the May 2014 examination. Further, in his May 2015 notice of disagreement, the Veteran stated that he was under the influence of substances at the VA examination, and thus his statements during the examination are not reliable. Accordingly, remand is required to obtain a VA examination and opinion regarding the nature and etiology of the Veteran's psychiatric disability. Additionally, the Veteran identified relevant outstanding private treatment records at the May 2020 hearing, and an October 2012 private treatment note indicates that there may be outstanding and relevant Social Security Administration records. A remand is required to allow VA to obtain authorization and request these records. This matter is REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Ask the Veteran to complete a VA Form 21-4142 for any identified private treatment facilities that have provided treatment for the Veteran's psychiatric disabilities for the relevant period on appeal. See June 2020 Correspondence from the Veteran's representative. Make two requests for the authorized records from any identified facilities unless it is clear after the first request that a second request would be futile. 3. Ask the Veteran to clarify whether he is in receipt of Social Security Administration benefits. If so, obtain the Veteran's federal records from the Social Security Administration. Document all requests for information as well as all responses in the claims file. 4. After completing directives #1-3, schedule the Veteran for a psychiatric examination to determine the nature and etiology of any acquired psychiatric disorder. If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not (a 50 percent or greater probability) related to a verified in-service stressor. If the Veteran is not diagnosed with PTSD, the examiner is asked to reconcile his or her assessment with the private and VA treatment records that reflect a PTSD diagnosis. If any other acquired psychiatric disorders are diagnosed, the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease. The Veteran stated that he started drinking alcohol heavily in service. He stated that after he was separated from service, he abused alcohol and substances as a mechanism to cope with his psychiatric symptoms. The Veteran also stated that his responses in the May 2014 VA examination are not reliable because he was under the influence of substances during the examination. The examiner is asked to consider the Veteran's statements. A complete rationale must be provided for all opinions expressed. Nathaniel J. Doan Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.L. Blevins, 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.