Citation Nr: 21007288 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 17-39 962 DATE: February 9, 2021 REMANDED Entitlement to service connection for a posttraumatic stress disorder (PTSD) disability is REMANDED. REASONS FOR REMAND The Veteran served honorably in the United States Navy from April 1969 to December 1970. Upon review of the record, the Board concludes that further evidentiary development is necessary. Although the Board sincerely regrets this delay and is appreciative of the Veteran’s service to his country, a remand is necessary to ensure VA provides the Veteran with appropriate assistance in developing his claim prior to final adjudication. Entitlement to service connection for a posttraumatic stress disorder (PTSD) disability is remanded. In June 2010, the Veteran submitted a VA Form 21-4138. Thereby, the Veteran initiated a claim for service connection for PTSD. In April 2019, correspondence from a VA provider was associated with the claims file. Therein, the provider noted a diagnosis for PTSD. The VA provider relayed that the PTSD stressors were abuse as a child AND while in the military. The VA provider relayed the following description of the in-service stressor: “he had been coerced into volunteering for a project that was taking place on post. He was then transported to a place and told to participate. He states that he was then placed in a situation in which he was exposed to some type of gas and assessed afterward. He states that he did report to sick call the next day. He states he was told not to speak about this incident.” In February 2020, the Veteran supplied sworn testimony to the undersigned Veteran’s Law Judge (VLJ). The Veteran testified that, “I had PTSD when I went in the service because I was molested.” The Veteran testified that he had not undergone any psychiatric treatment prior to entering the military. The Veteran testified that the claimed in-service stressor incident occurred in January 1970, but he did not seek psychiatric treatment until 2006. The Veteran relayed that, “there was a little bus that pulls up, we got on it and the side windows were all blacked out and we couldn’t see, and we were on that bus. We went down a logging trail, we got off base and went down a logging trail. It dead ended. On that dead end, there was a 4 x 4 with a showerhead on it and there was a (inaudible) had no windows in it and I kind of put it together when I was getting off. I told them, I said, I’m not going to do this (), you know. I was the only one out of the bunch raising () and I couldn’t believe it. Finally, the guy said, I’ll go in with you, my boss. Okay, I said, I’ll go because you they do it, you have to do it. That was the rule back then. I don’t know how it is now, but he shut the door behind me, and he didn’t come in with me. So, we walked around in circles and gas came out and we didn’t have a mask on but in that cabin, you could see where it had been used a lot because it was like a . . . you know how the animals travel on a trail and it digs down in the dirt, well that’s what it was in there. It had a mound that high in there at least, poor people walked around in circles. We came out and everybody, I was the last one to come out and I washed my face. I was the last one to do that in the shower and everybody was signing a statement saying they wouldn’t talk about it ever; you know one of those (inaudible) things and that they volunteered. I am standing over there and I said I didn’t volunteer, and I didn’t. I said I’m not signing it. He said, ‘are you going to walk back to the barracks?’ I didn’t know where I was at, I signed it.” When questioned by the undersigned, the Veteran confirmed that the claimed in-service stressor incident was not associated with Project 112. In April 2020, the Board addressed the Veteran’s claim for service connection for PTSD. At that time, the Board remanded the Veteran’s claim to the agency of original jurisdiction (AOJ) for additional development. The Board directed the AOJ to schedule a VA examination that addressed whether any current PTSD was either directly related to the Veteran’s service, or whether the he had PTSD that was aggravated during his active military service. The Board specifically directed that, “(i)f the examiner finds that any current PTSD did not pre-exist the Veteran’s period of active service, is it at least as likely as not (50 percent or greater probability) that the disability was initially manifested during service or within one year of his separation from service.” In May 2020, the Veteran underwent a VA examination that addressed the nature and etiology of any currently endured PTSD. The VA examiner noted a diagnosis for substance / medication-induced psychotic disorder with delusions. The VA examiner noted a history of LSD use since September 1970 and utilization of speed, marijuana, and amphetamines at various times. After reviewing the evidence, the VA examiner noted that previous providers had diagnosed the Veteran with PTSD. The VA examiner reported that there was nothing to support a current PTSD diagnosis; however, he VA examiner noted that the Veteran satisfied Criterion A – H for a PTSD diagnosis under the DSM-V. The VA examiner opined that, “(t)he Veteran does not have a diagnosis of (a) posttraumatic stress disorder that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) Active duty service during service. Dr. Motts on 4/16/10 dx Veteran with back pain, depression, and PTSD. However, there is nothing to support a dx of PTSD.” The VA examiner also opined that, “there is no current PTSD which clearly and unmistakably pre-existed the Veteran's entry into active duty in April 1969.” The VA examiner noted that the Veteran was hospitalized in April 1971 after hearing voices due to polysubstance abuse. The VA examiner opined that, “(t)here is not clear and unmistakable evidence to support PTSD pre-existed active duty service. Therefore, no pre-existing disorder could or did undergo a worsening in service to a permanent degree beyond that which would be due to the natural progression of the disease as a result of active duty in the United States Navy. There is no clear trauma in the Navy, rather LSD drug use is clear and unmistakable.” The VA examiner relayed that, “Veteran was exposed to LSD around 9/1970 while in the military. He has continued his substance abuse since this time. As a result, he appears to be very delusional. He is dx with Substance/Medication-Induced Psychotic Disorder with delusions. Historically, he has used LSD since 9/1970. He has used speed, marijuana, and amphetamines. He noted hearing voices from drug use.” The VA examiner relayed that, “(the Veteran) noted he was under project 112, which reportedly occurred within the dates of his military service. He noted he saw a news piece on the TV and is convinced that this is what he experienced in his reported stressor. Further, he believes he has been secretly monitored. This is best understood as a delusion resulting from substance abuse, in particular a hallucinogen, LSD.” The VA examiner opined that the acquired psychiatric disability, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. In July 2020, the Veteran’s treatment records from the Birmingham VAMC were associated with the claims file. After review, the Board notes that a clinical psychologist reported a diagnosis for chronic PTSD in August 2019. The Board finds fault with the conclusions of the VA examiner in May 2020. First, the VA examiner reported that the Veteran has abused LSD since 1970. After review of the claims file, the Board finds that, even though ongoing substance abuse is reported, continuous use of LSD is not supported by the clear evidence of record. Second, the VA examiner did not list a current diagnosis for PTSD, but the examiner noted that all the criteria under DSM-V were satisfied for a diagnosis. This stands counter to the VA examiner’s report and the PTSD diagnosis rendered by the VA provider in April 2019. As the VA examiner’s negative opinions were based on the fact that there was no current PTSD diagnosis, the Board finds that it was appears to have been based on an inaccurate factual premise, which renders the opinion inadequate. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (holding that medical opinions based on incomplete or inaccurate factual premise are not probative). Accordingly, on remand, an addendum opinion regarding the nature and etiology of any PTSD currently endured by the Veteran must be obtained. Barr v. Nicholson, 21 Vet. App. 303, 31 (2007). Consequently, the matter is REMANDED to the AOJ for the following action: 1. If available, the AOJ must obtain an addendum opinion from the May 2020 VA examiner to determine the nature and etiology of any current posttraumatic stress disorder (PTSD) endured by the Veteran. The VA examiner must opine whether any current PTSD clearly and unmistakably pre-existed the Veteran’s entry into active duty in April 1969. If yes, the examiner must cite to the evidence of record to support that conclusion and state whether the evidence is clear and unmistakable (undebatable) as to show that PTSD pre-existed any period of active duty. If the examiner finds that PTSD pre-existed active duty service, can it be concluded with clear and unmistakable (undebatable) certainty that the pre-existing disorder DID NOT undergo a worsening in service to a permanent degree beyond that which would be due to the natural progression of the disease as a result of active duty in the United States Navy? If the examiner finds that any current PTSD did not pre-exist the Veteran’s period of active service, is it at least as likely as not (50 percent or greater probability) that the disability was initially manifested during service or within one year of his separation from service. The VA examiner must address all the DSM-IV and V PTSD diagnoses found in the claims file during the appellate period, June 2010 to present. An explanation for all opinions expressed must be provided. All opinions must take into account the Veteran’s own history and contentions. 2. After completing the above, and any other development as may be indicated by any response received as a consequence of the action taken in the preceding paragraphs, the Veteran’s claim should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board RLBJ, 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.