Citation Nr: 21071580 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 18-20 165 DATE: November 30, 2021 REMANDED Entitlement to service connection for a psychiatric condition, to include other specified trauma and stressor related disorder, alcohol use disorder, and alcohol induced mood disorder (claimed as PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1976 to January 1986. The Veteran had additional periods of reserve service. These matters come to the Board of Veterans' Appeals (Board) on appeal from a June 2017 rating decision issued by the Department of Veterans Affairs (VA) regional office (RO). The Veteran was afforded a hearing before the undersigned Veterans Law Judge in July 2021. 1. Entitlement to service connection for other specified trauma and stressor related disorder, to include posttraumatic stress disorder (PTSD), alcohol use disorder, or alcohol induced mood disorder (claimed as PTSD) is remanded. The Veteran contends his stressor related disorder is due to service. Specifically, the Veteran contends that he was ejected out of a plane while in service and he was afraid that he was going to die. An October 1994 service treatment record (STR) notes that the Veteran was ejected from an F-16 while on duty in Alaska two and a half years prior. The Veteran is service connected for a neck condition and shoulder condition due to this in-service event. The Veteran's STRs do not show any diagnosis or treatment for alcohol abuse, or any stressor related disorder or mental health condition. A February 2015 private treatment record notes the Veteran reported he began drinking alcohol when he was four or five years old but did not have a first period of significant intoxication until he was in college. The Veteran reported he first recognized a problem with alcohol in the late 1990s. He also stated an airplane incident caused some health problems and PTSD. The examiner noted the Veteran's mood was dysphoric and depressed. The examiner noted discharge diagnoses as alcohol dependence continuous, depression versus substance-induced mood disorder, and possible anxiety. In a January 2017 statement the Veteran reported that in May 1992 on a normal training mission he was ejected from an F-16 due to an engine malfunction at 1,800 feet above the ground. After three attempts to correct the problem he ejected at 220 feet above the ground. While in ejection and his seat facing straight down, he knew he was about to die. The Veteran stated the nightmares began within days, and after six months of nightly dreams he began to numb the dreams with alcohol. He also stated the dreams continue to this day, though they are not as frequent. In June 2017, the Veteran was afforded a VA examination. The examiner stated the Veteran's alcohol use predates the event, and there is no evidence of onset of symptoms. The examiner opined the Veteran's condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner stated the Veteran's medical records do not support that his other specified trauma and stressor related disorder was incurred in service. There is clear evidence that the Veteran was ejected in May 1992. However, there is no evidence of onset of symptoms following this event. There is clear evidence of problematic alcohol use which predates this event. The examiner did not offer an aggravation opinion. The examiner stated that the Veteran does not have a diagnosis of PTSD that conforms to DSM-5 criteria. The examiner noted diagnoses of other specified trauma and stressor related disorder, alcohol use disorder, severe and alcohol induced mood disorder. The examiner stated nightmares, sleep impairment, and anxiety are partially due to an other specified trauma and stressor related disorder. The alcohol induced mood disorder causes some sleep impairment and anxiety. Delineation of each disorder would require the Veteran to maintain sobriety. The examiner stated the alcohol use disorder is caused by alcohol use. The examiner also stated there is no empirical support for trauma related disorder causing alcohol use. There is consistent evidence that prolonged alcohol use causes mood disorders. The examiner also stated the Veteran reported upon discharge, he sought work for six months. He was eventually hired by the commander of the reserve unit in Bergstrom, AFB where he remained for three years. The Veteran then took a position with an American Airline, and other airlines but stated that he lost his flight status in 2014 due to PTSD. Additionally, the Veteran stated he reported PTSD in an FAA physical in 2014. However, the Veteran denies reporting similar symptoms in previous FAA physicals. In 2015, the Veteran was diagnosed with PTSD in his inpatient alcohol use rehabilitation, and records indicate that the Veteran self-reported a diagnosis of PTSD in his inpatient rehabilitation in 2015. There are no records of formal diagnosis by healthcare providers in the course of this treatment. The examiner noted the Veteran reported that he began drinking alcohol after his ejection. There has been a reported period of sobriety of seven years. In 2015, the Veteran sought inpatient treatment through Texas Star at the behest of his daughter. He states that he continues to drink to intoxication on a regular basis. Records indicate that the Veteran began drinking alcohol at four to five years of age with problematic usage beginning in college. In a 1981 report of medical examination, the Veteran reported daily usage of three beers. The examiner also stated there is no empirical evidence that trauma related disorders cause alcohol use. Theoretically, the hypothesis of self-medication offered by Khantzian has not found empirical support following the direction indicated by the hypothesis. According to the empirical literature, there is no causative association between PTSD and alcohol abuse in individuals who are not trait vulnerable to alcohol abuse. In individuals who are trait vulnerable, there appears to be an association between state anxiety and alcohol consumption. Conversely, there appears to be some evidence that indicates that continued usage of alcohol can cause increased anxiety. Problematic alcohol use predates military service and his stated stressor. At the July 2021 Board hearing, the Veteran stated his drinking began six months after the incident, and he drank to get a full night's sleep, and by 1996 he was an alcoholic. In addition, the Veteran reported nightly dreams of the event itself over and over again, including waking up in the middle of the night with sweats, and experiencing anxiety to fly the airplane again. He stated he was taken off of flight status due to anxiety that he experienced going to fly. The Veteran's representative stated he thinks the examiner more or less focused on the alcohol that the Veteran was actually using. As stated above, the examiner noted that with individuals who are trait vulnerable, there appears to be an association between state anxiety and alcohol consumption but did not address the February 2015 private treatment note from Texas Star, that the Veteran had a possible diagnosis of anxiety nor did the examiner indicate whether the Veteran is considered "trait vulnerable." In addition, the examiner did not address whether the Veteran's pre-existing alcohol use was aggravated beyond its natural progression by his military service. Furthermore, the examiner stated there is no empirical evidence that trauma related disorders causes alcohol use. However, the examiner did not address whether the Veteran's other diagnosed condition of "depression versus substance-induced mood disorder," and possible anxiety noted in the February 2015 treatment report was caused by the Veteran's service. The matters are REMANDED for the following action: 1. Update the electronic file with any new VA treatment records and private treatment records. 2. Obtain an addendum opinion regarding the Veteran's alcohol use disorder, severe and alcohol induced mood disorder. The examiner must provide an opinion as to whether: a) there is clear and unmistakable evidence that an alcohol use disorder pre-existed service? *If there is clear and unmistakable evidence that an alcohol use disorder pre-existed service, the examiner is asked to opine as to whether there is clear and unmistakable evidence that the pre-existing alcohol use disorder DID NOT undergo an increase in severity during service, to include as a result of being ejected from an F-16 plane and believing he was going to die. *If there was an increase in the severity of the Veteran's alcohol use disorder during service, please offer an opinion as to whether such increase was clearly and unmistakably due to the natural progress of the disease. b) If the Veteran's alcohol use disorder did not pre-exist service, please opine as to whether it is at least as likely as not that the Veteran's alcohol use disorder was causally or etiologically due to service, to include as a result of being ejected from a plane in service. *The examiner is asked to specifically consider and discuss the Veteran's statements regarding his time in service and contentions that the Veteran's in-service experience being ejected from the F-16 led to nightmares and after six months of nightly dreams he began to numb the dreams with alcohol. *Please offer comments and a discussion on the theory that "alcohol use disorder is caused by alcohol use" as stated by the June 2017 examiner. 3. Obtain an addendum opinion regarding the Veteran's psychiatric disorders, to include, other specified trauma and stressor related disorder noted in his June 2017 examination, and "depression versus substance-induced mood disorder," and "possible anxiety" noted in the February 2015 treatment report. The electronic claims file must be reviewed by the examiner, and a note that it was reviewed should be included in the report. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's psychiatric condition(s) are related to his active service. A detailed rationale for all opinions must be provided. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. (continued on next page) TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Daley, 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.