Citation Nr: 21008177 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 17-28 754 DATE: February 11, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder to include posttraumatic stress disorder (PTSD), depressive disorder, and alcohol dependence disorder, is remanded. REASONS FOR REMAND The Veteran had active service from June 1976 to March 1983. This matter comes to the Board of Veterans’ Appeals (Board) on an appeal from a September 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), the Agency of Original Jurisdiction (AOJ). In the rating decision, the AOJ denied service connection for an acquired psychiatric disorder (also claimed to include posttraumatic stress disorder and any mental health disorder NOS). The Veteran appealed this determination and the present appeal ensued. The Veteran recently testified during a videoconference hearing before the undersigned Veterans Law Judge in August 2020. A transcript of the hearing has been associated with the Veteran's claims file. 1. Entitlement to service connection for an acquired psychiatric disorder to include PTSD, depressive disorder, and alcohol dependence disorder is remanded. The Veteran filed a claim for PTSD and any mental health disorder NOS that was received on February 23, 2016. The Veteran claimed he experienced symptoms of PTSD, depression and anxiety secondary to an incident during service that led to court martial proceedings. The Veteran’s service treatment records note that he checked off “depression or excessive worry.” An April 2016 VAMC behavior note indicates symptoms reported by the Veteran included depressive symptoms, anger, and anxiety. The health care provider noted that the Veteran’s symptoms do not meet the DSM-5 or VA criteria for a diagnosis of PTSD. In July 2016, VAMC records indicate that the Veteran was diagnosed with depression and alcohol dependence disorder. The Veteran was afforded a VA examination for mental disorders in August 2016. The examiner noted only a diagnosis of alcohol use disorder and symptoms of depressed mood and anxiety, chronic sleep impairment, difficulty in establishing and maintaining effective work and social relationships, irritability, and difficulty trusting others. The examiner noted no history of mental health treatment prior to service and that the Veteran began receiving mental health treatment in 2011 or 2012, with complaints of sleep difficulties, depression, and labile mood. He was prescribed citalopram, an anti-depressant. He began receiving treatment at a VAMC in March 2016 when he checked into a behavioral health ward. The Veteran saw a psychologist every other month. The Veteran reported he began drinking heavily after an incident in service in 1982. He was involved in an argument with his first wife when two men assaulted him. A Major then approached him after the altercation and cursed at him and poked him in the chest. The Veteran responded by shoving him and he was arrested and “brought up on summary court martial charges.” He was ultimately found not guilty. The examiner found that it was less likely than not (less than 50 percent probability) that the Veteran’s claimed condition was incurred in or caused by service. The rationale was that “[t]he medical record does not support a history of treatment for substance use issues or mental health problems. The Veteran's report of PTSD symptoms related to military court martial do not meet DSM5 criteria for a diagnosis of PTSD. The Veteran self-reported a history of excessive alcohol use, starting in 1982, with intermittent periods of sobriety. It could not be substantiated that the Veteran's use of alcohol was predicated by his reported alteration, that led to his court martial proceedings and eventual discharge from the Army.” The VA examiner also provided an opinion that the Veteran did not have a diagnosis of any mental health NOS that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) Veteran’s noted depression on his separation exam. The rationale provided was that “[t]he medical record does not provided documentation of services at VA. There is a Department of Veteran Affairs Memorandum dated July 27, 2016 with a Formal Finding on a lack of evidence to verify stressors.” Medical records documenting VA treatment were associated with the file in September 2016. A PTSD screen in September 2016 was negative. The Board notes that the Veteran was found not guilty of the charges brought in the court martial and he was honorably discharged in March 1983. In addition, military records documenting the claimed incident as it was reported by the Veteran were associated with the file in March 2017. Social Security Administration records were associated with the file in September 2016, including a benefits letter indicating that the Veteran was disabled from conditions including depression and generalized anxiety disorder as of March 19, 2014. It was noted that the Veteran was sober but his anxiety and depression have continued. It was noted that the Veteran was voluntarily hospitalized in March 2016 with an increased difficulty dealing with people. He had a history of altercations with superiors. He described himself as antisocial. Outpatient treatment records documented complaints of being short tempered, difficulty sleeping, racing thoughts hopelessness, helplessness, lack of energy, feeling jittery and heart palpitations. In December 2015, the reviewing psychologist for the agency opined that the Veteran has “severe affective disorder” resulting in no restrictions in his ability to perform activities of daily living, moderate difficulties in maintaining social functioning, no difficulties in maintaining concentration, persistence, or pace, and no episodes of decompensation of extended duration. The doctor opined that the Veteran could carry out short and simple instructions but had moderate limitations in his ability to get along with coworkers or peers without distracting them or exhibiting behavioral extremes, in accepting instructions, in responding appropriately to criticism from superiors or interacting with the public. The letter noted that significant weight was given to this opinion as it was “well supported by treatment records from the VA.” The Veteran also testified during a hearing before the undersigned Veterans Law Judge in August 2020. He testified that he was diagnosed with PTSD in 2017 at a VAMC and that his symptoms began in 1982. He stated that his symptoms included anger and hypervigilance. He reported mood swings, anxiety, and intolerance. He stated he had an aggressive personality and was always in an irritable state. This affected his family life and work life. At work his symptoms affected his ability to be promoted and there were disciplinary actions for job performance and irritability until he was ultimately terminated from employment. He related the incident that led to his court martial and stated that he was angry and scared. He stated that not a day goes by that he doesn’t think about the incident. He stated that he never sleeps soundly, has nightmares, and feels betrayed. He decided not to continue his military career due to the incident and court martial and that it “stayed with me the rest of my life.” He stated that he self-medicated with alcohol for many years. As a result of the above history, the Board finds that a remand is required to afford the Veteran a new examination and opinion as new evidence, hearing testimony, and medical records have been associated with the Veteran’s file that were not available to the 2016 examiner. Thus, the examination and opinion do not accurately reflect the evidence of record. In addition, the file indicates that the Veteran is receiving Social Security Administration disability benefits, but his medical records from that agency are not of record. A remand is therefore also required to obtain such records and associate them with the Veteran’s file. The matters are REMANDED for the following action: 1. The Veteran’s Social Security Administration medical records and any additional records identified by the Veteran should be obtained, following the receipt of any necessary authorizations from the Veteran, and associated with the claims file. 2. The AOJ should schedule an examination and obtain a medical opinion regarding the nature and etiology of any acquired psychological disorder, including but not limited to PTSD, depressive disorder, and alcohol dependence disorder. The examiner should review the entire claims file, including this remand. The examiner should conduct all necessary tests and studies, and provide the requested opinions. a. Identify all acquired psychiatric disorders present during the pendency of the Veteran’s claim. b. Provide an opinion as to whether it is at least as likely as not (i.e., probability of 50 percent or more) that any identified acquired psychiatric disorder had its onset in service, including PTSD, depressive disorder, alcohol dependence disorder. The examiner should provide a complete rationale for any opinions offered. Michael J. Skaltsounis Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Debra B. McLoughlin, 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.