Citation Nr: 21013066 Decision Date: 03/08/21 Archive Date: 03/08/21 DOCKET NO. 17-27 484 DATE: March 8, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for residuals of traumatic brain injury (TBI) is remanded. REASONS FOR REMAND The Veteran had honorable active duty service with the United States Army from August 1982 to September 1992. These matters are before the Board of Veteran’s Appeals (Board) from September 2013 decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran provided sworn testimony in support of his appeal during a hearing before the undersigned Veterans Law Judge in December 2020; the hearing transcript has been associated with the file and has been reviewed. 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) is remanded. The Veteran underwent a VA examination in April 2017. The examiner was unable to make a psychiatric assessment, because he said an assessment of psychiatric conditions is heavily reliant on self-reporting, and the examiner found the Veteran’s self-report to be invalid for diagnostic purposes. The examiner said that his inability to diagnose the Veteran did not mean that he was free of psychopathology, but merely indicated that an assessment of his true psychological condition could not be obtained at that time. Because the examiner was unable to diagnose the Veteran a determination as to etiology was also impossible at that time. The Veteran during the December 2020 Board hearing expressed the opinion that the 2017 PTSD exam was invalid because the examiner asked to see physical scars from the Veteran’s claimed PTSD stressor as corroboration, and the facts the examiner attributed to the Veteran in his report were not made by him and were factually wrong. For these reasons the Veteran believes the 2017 PTSD examination is invalid. The Veteran had a prior VA contract mental health examination in June 2013, which diagnosed the Veteran with PTSD and dysthymic disorder and provided a positive nexus opinion. This examination, however, was based upon the DSM-IV and also did not consider all of the reported stressors. Rather, it focused on his duties on the gravedigging team. The following is an excerpt from the Veteran’s May 2014 statement describing the claimed in-service stressor for PTSD: On February 25th, 1990 I [REDACTED] was ordered to return to port and sign for two 10,000-gallon water bladders and bring them forward so that our water purification teams would be able to stockpile water. I arrived at Dhahran the Aujan compound close to Al Khobar around 10 00 hours. I signed for the equipment and awaited movement orders. I was able to get ready to leave that afternoon when the alarms sounded that scuds were inbound. We were told to go into MOPP 4 and to take our PB tablets. It seemed like there were more than one, but I could only see that a warehouse there was hit. I took cover and only remember feeling like I was going to die. The explosion was loud, and I couldn’t move. It felt as if the whole compound was going to be destroyed. I have never been so afraid for my life. To this day I can see those people with burns and screaming for help. The 2013 examination was based upon the DSM-IV, not the DSM-V and the 2017 examination did not discuss the prior diagnoses of record. As such, another examination is necessary to determine the nature and etiology of the Veteran’s mental health condition. 2. Entitlement to service connection for residuals of traumatic brain injury (TBI) is remanded. The Veteran was afforded A VA contract TBI examination in November 2017. The examiner determined that the Veteran does not currently have residuals and did not sustain a TBI in service as described. Instead the 2017 examiner offers as rationale the alternative theory that the Veteran may be suffering from dementia. The June 2013 contract mental health examiner was of a different opinion but deferred making a TBI diagnosis to a general medical examiner. The following is an excerpt from the Veteran’s May 2014 statement describing the claimed in-service injury that caused his TBI: On or about February of 1991 I [REDACTED] was on top of a 20ft high platform and the unit was notified that our chemical detection alarms were going off. At that time a crane carrying a 4000-pound bladder struck me in the head and ejected me several feet from the tower. The next thing I know I was unable to move and sometime later awoke being loaded onto a Medivac helicopter headed for 12th EVAC Hospital. Upon arrival I was semi-conscious and only remember waking up a few days later. The doctors their told me that I had a severe concussion. I was told that I was allowed to go back to my unit until I Improved. To the best of my knowledge I was unconscious for about five days. Upon waking I asked if I could return to my unit, I was proscribed many medications for pain and the severe headache that seem to never quit. I had severe pain throughout my entire body and head but managed to keep it at bay with the large bottles of Motrin and pain killers that was' given to me by the Medics from Company C 26th support battalion medical staff. To this day I have headaches 2 hours a day with no rest from it. Because of the discrepancy between the 2017 and 2013 TBI examination results, and neither opinion being convincing, the Board feels another examination is needed, one that reconciles the prior opinions and provides an adequate rationale. Also, the examiner should be made aware of the Formal Finding, dated May 29, 2013, indicating that service treatment records for the Veteran’s entire active service period from August 24, 1982 to September 10, 1992 are unavailable for review, and the lack of corroborating medical records from that period should not be construed as negative evidence against the Veteran’s claims. Furthermore, the Veteran has testified that he was hospitalized as a base hospital in Frankfurt, Germany and he also reported being sent to the 12th EVAC Hospital. Records from these facilities have not yet been requested or associated with the file. On remand, attempts to obtain these records should be made. Although the Board regrets the additional delay, a remand is required in this case to ensure that there is a complete record upon which to decide the issues of PTSD and TBI, so that the Veteran is afforded every possible consideration. The matters are REMANDED for the following action: 1. Any missing medical treatment records should be located and added to the claims file, along with this remand decision, and the examiner(s) should be made aware that the Veteran’s service treatment records from August 24, 1982 to September 10, 1992 are unavailable for review. 2. Request the Veteran’s records from Army Base Hospital in Frankfurt, Germany and the 12th EVAC Hospital and associate them with the claims file. 3. Obtain an addendum PTSD opinion from a qualified medical VA examiner different from the June 2013 and April 2017 examiners. A new examination is required to give the new examiner firsthand access to the Veteran for assessment. The examiner is asked to opine as to the following (a.) Clarify all diagnosed psychiatric disorders, to include PTSD. The examiner must specifically discuss prior diagnoses noted in treatment records including PTSD, dysthymic disorder, major depressive disorder and r/o dissociative disorder. (b.) For each diagnosed disorder, opine as to whether it is at least as likely as not that the condition onset in service or is causally related to service, to include as due to the stressor events the Veteran has reported experiencing in service. The examiner should comment on the Veteran’s report of SCUD attacks during his deployment. In formulating the above opinions, the examiner must consider and discuss all lay statements and assertions provided by the Veteran. A complete rationale must be provided for all opinions offered. 4. Obtain an addendum, residuals of TBI opinion from a qualified medical VA examiner different from the June 2013 and November 2017 examiners. A new examination is required to give the new examiner firsthand access to the Veteran. The examiner is asked to opine as to the following for any residuals of TBI if diagnosed: (a.) Whether it is at least as likely as not that the condition onset in service or is causally related to service, to include as due to the events the Veteran reported experiencing in service. In formulating the above opinions, the examiner must consider and discuss all lay statements and assertions provided by the Veteran. A complete rationale must be provided for all opinions offered. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Black, 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.