Citation Nr: 21008829 Decision Date: 02/18/21 Archive Date: 02/18/21 DOCKET NO. 17-27 987 DATE: February 18, 2021 REMANDED A claim for service connection for an acquired psychiatric disability, to include post-traumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran honorably served on active duty from January 1968 to January 1970, to include his tour of duty in the Republic of Vietnam. In a July 2013 rating decision, the Region Office (RO) denied his claim for service connection for PTSD. The Veteran appealed. In March 2020, the Veteran testified via a Board’s video conference hearing, a transcript of which is of record. At the hearing, the Veteran stated under oath that he has been “self-medicating” with excessive amounts of alcohol for many years to cope with the memories and flashbacks of his Vietnam combat experiences which he described at some length. Upon considering the Veteran’s testimony, the Board finds that construing the claim more broadly as an acquired psychiatric disorder, to include PTSD, is appropriate. Of note, a March 2017 VA mental health evaluation report reflects a medical opinion that the Veteran meets the full DSM-V diagnostic criteria for alcohol use disorder, moderate, in early remission. The examiner further opines that it is less likely as not that the Veteran’s alcohol use disorder is etiologically related to his service. However, the examiner has not offered any rationale in support of this conclusion. Moreover, the examiner has not considered the Veteran’s statement made at his hearing that his alcohol use was prompted by the memories and flashbacks of his Vietnam combat experiences. Further, it is unclear whether the Veteran does or does not have a PTSD. For example, an August 2007 psychiatric note reflects an annotation of “currently mild and stable PTSD.” The August 2008 and August 2009 primary care notes reflect a history of PTSD. A May 2014 Vet Center PTSD program intake report (received in April 2017) reflects an opinion that the Veteran does meet the diagnostic criteria for PTSD, albeit not entirely clear why. Yet, a July 2013 VA mental health evaluation report reflects a medical opinion that the Veteran does not meet the full DSM-IV diagnostic criteria for PTSD. In considering the PTSD DSM-IV diagnostic criteria referred to as Criteria A-F, the examiner noted that the Veteran meets Criteria A-D, but not E or F. It is, however, unclear why under Criterion E the examiner indicated that the duration of the Veteran’s symptoms is from 0 to less than 1 month, which is diametrically opposite to the evidence of record. For example, a January 2007 psychiatry note reflects the Veteran’s report that he has been having nightmares, flashbacks, and intrusive memories of his Vietnam combat experiences, while also having been combative in his sleep and easily startled, all of which have persisted for at least six months. It is further unclear why the examiner indicated that the Veteran does not meet the Criterion F pertaining to the functional impairment due to the clinically significant symptoms, while noting under Criterion A that the Veteran does meet the in-service stressor requirement and under Criteria B-D he does exhibit clinically significant symptoms, to include depressed mood, anxiety, hypervigilance, avoidance, and recurrent distressing memories, flashbacks, and dreams. However, the boxes listed under Criterion F pertaining to whether or not the PTSD symptoms result in any clinically significant distress or impairment in social, occupational, or other important areas of functioning are unchecked. Instead, the examiner noted that the Veteran does not meet the full diagnostic criteria for PTSD. The only explanation provided is that the Veteran’s symptomatology is very mild. However mild symptomatology might be, from analytical perspective, it appears to have caused distressing memories, flashback, and dreams resulting in, for example, sleep impairment. The record further suggests an impaired social functioning evidenced, for example, in the Veteran’s three failed marriages, or poor judgment evidenced in defaulting on two properties shortly after the purchases. The Board, however, may not substitute its own judgement for a medical opinion which is required for diagnosis of a mental disorder. As such, although the evidence of record suggests, from analytical perspective, that the Veteran may have PTSD, it remains unclear whether, from a medical perspective, the Veteran does or does not have a PTSD and why. Further, a January 2007 VA psychiatric note reflects the Veteran report that, in 1979, his ex-wife recommended marriage counseling. In 1981, per Veteran, following a psychological evaluation, he was diagnosed with PTSD and enrolled in Texas VA PTSD group for a year. However, the record is devoid of any indicia that the RO has attempted to obtain these VA medical records or otherwise assist the Veteran in obtaining those VA medical records potentially relevant to his claim. Accordingly, the matters are REMANDED for the following action: 1. Contact the Veteran for any information he may have regarding the specific VA facility in Texas where he may have undergone the diagnostic evaluation and counseling approximately between 1979 and 1981, and then attempt to obtain those records. 2. Then, schedule the Veteran for a mental health evaluation with a psychiatric or psychologist as to the nature and etiology of his psychiatric disorder(s). The examiner is asked to review the Veteran’s entire claims file, to include the January, February, and August 2007 VA psychiatry notes, August 2008 and August 2009 primary care notes, July 2013 and March 2017 VA mental health evaluations, the May 2014 Vet Center PTSD program intake report, and the Veteran’s statements in support of his claim including his March 2020 testimony. The examiner is then asked to answer the following questions: a) Does the Veteran have, or ever had, any psychiatric disorder, to include PTSD? Why or why not? b) Is it at least as likely as not (meaning probability of 50 percent or greater) that the Veteran’s mental disorder, however diagnosed (if so diagnosed), is etiologically related to his service? Why or why not? MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Alex Bardin, 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.