Citation Nr: 21076941 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 19-01 779 DATE: December 28, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for traumatic brain injury (TBI) is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1979 to August 1982. These matters come before the Board of Veterans' Appeals (Board) from a September 2018 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). Initially, the Board points out that the Veteran had filed a service connection claim for PTSD. Under Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the Veteran's claim cannot be "limited only to that diagnosis but must rather be considered a claim for any mental disability that may be reasonably encompassed." Id. Therefore, applying the holding in Clemons to the present case, the claim on appeal has been recharacterized as a claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD. The Veteran testified before the undersigned Veterans Law Judge (VLJ) in January 2021, and the transcript of that hearing is of record. 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. Initially, the Board points out that RO previously denied service connection for PTSD by finding no evidence of current disability (i.e., no diagnosis of PTSD) and also by noting a formal finding on a lack of information required to corroborate the stressful events described by the Veteran. However, during the Board hearing, the Veteran testified that he has been diagnosed with PTSD and provided a more detailed account of his multiple in-service stressor events. The Veteran also submitted a photograph of his medications for "PTSD" that he claimed to have received from a private medical provider, prior to his establishing care with the VA. The Board finds that the matter must be remanded for further development. First, the evidence of record does not include any private treatment records. Thus, remand is necessary to obtain any outstanding private treatment records. Second, although the only psychiatric examination of record shows no diagnosis of any psychiatric disorder under the DSM-5 (see August 2018 Disability Benefits Questionnaire), review of his treatment records shows a diagnosis of an acquired psychiatric condition, to include panic disorder without agoraphobia (see i.e., June 2013 VA treatment records), and a subsequent August 2018 mental health outpatient note includes a notation "DSM5 diagnosis: MDD." Therefore, the Board finds it necessary to remand for a medical nexus opinion for his non-PTSD acquired psychiatric disorder. However, it is not entirely clear as to whether the Veteran indeed has a PTSD diagnosis conforming to the DSM-5 standard. While there is a notation for "DSM5 diagnosis: PTSD" (see August 2018 VA treatment records), it is unclear whether the medical provider at the time reviewed all pertinent records in furnishing this diagnosis, and the subsequent October 2018 VA treatment records include only "PTSD/other psych/seizures" and "past medical history: PTSD" (see October 2018 VA treatment records), which do not seem to show whether these were furnished in accordance with the DSM-5 standard. Thus, the Board finds remand is required for determining whether he has a diagnosis of PTSD. Moreover, regarding the PTSD claim, because the Veteran has provided a more detailed (and thus sufficient) information to send a request to JSRRC, RO must take the appropriate steps to corroborate his stressors on remand. Once his PTSD diagnosis and in-service stressors are verified, the medical nexus opinion on whether his PTSD was caused by his service should also be obtained. 2. Entitlement to service connection for traumatic brain injury (TBI) is remanded. The Veteran testified that he incurred a head injury while in service. Specifically, he stated that his head was hit by a chain attached to a truck while he was working on the truck. Despite getting dizzy afterwards, he stated that he did not go to a sick call/seek treatment, but instead, self-treated himself with ice and a bandaid and felt better a couple days later. He further testified that he currently experiences occasional headaches and blurry vision. He reported that he was hospitalized at the Memorial Herman Hospital after having a stroke/seizure last year and was told by a neurologist there that he was bleeding on his brain. When asked whether any doctor has provided a positive medical nexus between his in-service incident and the current head condition, the Veteran denied such, and added that he did not bring it up as he was "fine" until the most recent incident where he fell in the bathroom and hit his head (for which he was hospitalized). The evidence of record does not seem to include hospitalization records from the Memorial Herman Hospital. Thus, the Board finds it necessary to obtain any outstanding treatment/hospitalization records from this facility. These matters are REMANDED for the following action: 1. Ask the Veteran to complete and submit a VA 21-4142 form for VA to obtain any outstanding private treatment records, to include from the Memorial Herman Hospital and from all mental health providers he saw prior to coming to VA. If any records are requested but not received, advise the Veteran of that fact. 2. Obtain VA medical records for treatment from October 2018 to present. 3. Take all appropriate steps to corroborate the Veteran's in-service stressors (see January 2021 Board hearing testimony) to include a JSRRC search request. He provided dates and locations for the alleged events (i.e., see January 2021 Board hearing testimony, (1) claims that he witnessed a suicide of a fellow serviceman at a firing range, around March 1982, while stationed at Camp Pendleton; (2) claims he recovered bodies from an accident around August 1981 at Camp Pendleton, where servicemen were burnt in a car; (3) claims that while at Camp Horno in Camp Pendleton, around August 1982, he witnessed a fellow serviceman commit suicide. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile. 4. DO NOT SCHEDULE the following until the above records are received or it is determined they are not available. 5. Obtain a medical addendum opinion (or if necessary, schedule another VA psychiatric examination and opinion) from the August 2018 examiner, but if not available, from another qualified VA examiner. The examiner must review the complete claims file, including this remand. Then, the examiner must address the following, with full supporting rationales: (a) Diagnose all current psychiatric conditions. (b) For each diagnosed non-PTSD acquired psychiatric disorder: whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease, to include the alleged in-service stressor events. In doing so, the examiner shoulder also consider and address the role of non-military (civilian) traumatic events, to include being robbed at gunpoint while working at the McDonalds and his history of childhood abuse (see June 2013 VA mental health consult note). (c) IF the examiner finds that the Veteran meets the criteria for a PTSD diagnosis in accordance with the DSM-5, s/he should opine as to what claimed stressors are linked to his PTSD diagnosis, including any stressors prior to or after service? If the stressors expressed by the Veteran do not support a DSM-5 diagnosis, please discuss why. The examiner is asked to review and discuss as necessary: "DSM5 diagnosis: PTSD" (see August 2018 VA treatment records) October 2018 VA treatment records include only "PTSD/other psych/seizures" and "past medical history: PTSD" (see October 2018 VA treatment records) Photographs containing prescriptions for "PTSD" Report of the non-military (civilian) traumatic events, to include being robbed at gunpoint while working at the McDonalds and a history of childhood abuse (see June 2013 VA mental health consult note) 4. IF AND ONLY IF the newly obtained records include any pertinent information relating to TBI, obtain a medical opinion. The examiner is requested to review the Veteran's entire electronic claims file, including this remand, prior to examination. The examiner must opine whether the TBI is at least as likely as not related to an in-service injury, event, or disease. In doing so, the examiner should expressly consider and address (1) the Veteran's report of in-service head injury while working on a truck (being hit in his head by a chain attached to a truck while working on the truck and despite getting dizzy afterwards, he did not go to a sick call, but only self-treated himself with ice and bandaid and felt better a couple days later), and (2) the role of the post-service fall from the alleged seizure like symptoms. The examiner must provide a complete rationale for any opinion based on the examiner's medical expertise, medical principles, and the evidence. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Lee, Catherine 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.