Citation Nr: 21025095 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 15-22 305 DATE: April 27, 2021 REMANDED Service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. Service connection for a sleep disorder, to include insomnia and sleep apnea, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1970 to April 1972. These matters come before the Board of Veterans’ Appeals (Board) on appeal from December 2013 and October 2015 rating decisions. The case was previously before the Board in April 2019 when it was remanded for further development. The Veteran seeks service connection for insomnia. Currently, the claims file appears to be negative for diagnosis of the condition but positive for evidence of sleep apnea and complaints of sleep disturbance. In order to more accurately reflect the nature of the Veteran’s disability, the Board has expanded the claim, per Clemons, to entitlement to service connection for a sleep disorder, to include sleep apnea. These changes are reflected on the title page and provide the most favorable review of the Veteran’s claim in keeping with the holding in Clemons. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). 1. Service connection for an acquired psychiatric disorder, to include PTSD, is remanded. A December 2019 VA medical opinion states the Veteran reports symptoms sufficient to meet the diagnostic criteria for PTSD. However, the examiner notes that no service records of the remembered traumatic stressor were discovered within the claims file. Thus, the examiner provided a negative opinion. The Board notes the Veteran has provided statements relating to his PTSD stressor. For example, in a December 2013 statement, the Veteran recalls going down a mountain in a convoy, and a truck overturned. He states a head rolled out in front of him next to his door. He further recalls a fellow soldier, D.D. began to yell in excitement over the incident. He states his lieutenant grabbed his arm and delegated him to be the shooter. The Veteran recalls being left in a position on the mountain and was ordered to shoot anything coming through the valley. However, this asserted stressor has not been developed or verified by the RO. Thus, on remand, the Agency of Original Jurisdiction (AOJ) should take the appropriate steps to develop and verify the Veteran’s claimed in-service PTSD stressor. See 38 C.F.R. § 3.304 (f). Furthermore, an August 2020 Mental Health Note states past psychiatric diagnoses include depression, PTSD, and a generalized anxiety disorder. However, the December 2019 VA opinion notes there is no diagnosis of an acquired psychiatric disorder. Considering the Veteran’s additional psychiatric diagnoses of record, the Board finds that clarification is required. Furthermore, in an October 2015 correspondence, the Veteran states he was treated for a nervous condition in 1970 during basic training at Fort Polk, Louisiana. He further states that in 1970 he was in “Delta Company D-I-T Training group.” He asserts his nervous condition from basic training was further exacerbated by his active service. A review of the Veteran’s available service medical records does not show treatment for a nervous condition. As a result, on remand, the AOJ should verify whether all the Veteran’s service medical records have been obtained. Finally, the Veteran reported that he was released to the National Guard on an early release program from Germany. See VA Form 21-526, received in March 2005. Accordingly, all records associated with his National Guard service should be obtained. 2. Service connection for a sleep disorder, to include insomnia and sleep apnea, is remanded. In December 2019, a VA examiner found the Veteran’s insomnia is a symptom of his PTSD. As noted, the Veteran’s claim has been broadly expanded and recharacterized as one for a sleep disorder, to include sleep apnea. If the Veteran is service connected for a psychiatric condition on remand, an opinion should be obtained as to causation and aggravation or whether any relationship exists between any separate diagnosis of sleep apnea and any service-connected psychiatric condition. The matters are REMANDED for the following action: 1. Undertake appropriate action to ensure the Veteran’s complete service treatment records are obtained, to include any mental health treatment records dated in 1970 while the Veteran was at basic training at Fort Polk, Louisiana. Follow the procedures set forth in 38 C.F.R. § 3.159(c) with respect to requesting records from Federal facilities. All records/responses received should be associated with the claims file. 2. As noted above, the Veteran reported that he was released to the National Guard on an early release program from Germany. Undertake appropriate action to ensure the Veteran’s complete treatment records associated with his National Guard service are obtained. Follow the procedures set forth in 38 C.F.R. § 3.159(c) with respect to requesting records from Federal facilities. All records/responses received should be associated with the claims file. 3. Ensure that the Veteran’s complete service personnel records have been obtained, to include all records concerning his going AWOL. See VA examination report, dated December 9, 2019, showing that the Veteran stated that he had two AWOLS while he was in basic training “to come home to see my wife.” 4. Obtain any outstanding VA treatment records and any outstanding private medical records, to include all records from the Tupelo Medical Clinic, as pertinent to the Veteran’s claim. 5. After obtaining any additional necessary details/information from the Veteran, take all appropriate steps to verify his claimed stressors, to include the following: • While going down a mountain in a convoy, seeing a truck overturned and a head roll out in front of him next to his door, after which his lieutenant grabbed his arm and delegated him to be the shooter. The Veteran recalled being left alone in a position on the mountain and was ordered to shoot anything coming through the valley (see VA Form 21-0781, dated November 26, 2013); • After having his ID taken from him, being left in Germany in 1971 to keep the enemy away from an operation for 15-20 minutes; • Being threatened with a knife by other service members (see VA examination report, dated December 9, 2019); and • Seeing a helicopter crash (see VA Form 21-4138, received December 3, 2012). 6. After the above development is completed, schedule the Veteran for a Mental Disorders examination. The Veteran’s claims file, including a copy of this remand, must be made available to and reviewed by the examiner. The examination report must reflect that such a review had been undertaken. The examination should include any necessary diagnostic testing or evaluation. The examiner should identify all current psychiatric disorders found to be present, i.e., PTSD, depression, generalized anxiety disorder, etc. The examiner should note the diagnosis of PTSD on VA examination in December 2019, as well as the diagnoses of depression and a generalized anxiety disorder in the VA outpatient treatment records. As to each diagnosed psychiatric disorder, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) it had its clinical onset during active service or is related to any incident of service, to include the Veteran’s claimed stressors. A complete rationale must be offered for all opinions expressed, including a discussion of the evidence and medical principles which led to the conclusions reached. 7. If, and only if, the Veteran becomes service connected for PTSD or another psychiatric condition, obtain a VA examination and opinion for the Veteran’s claimed sleep disorder, to include sleep apnea. The claims file and a copy of this Remand must be made available to and reviewed by the examiner in conjunction with the opinion. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) any current sleep disorder, to include sleep apnea, was caused by any diagnosed service-connected psychiatric condition. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) any current sleep disorder, to include sleep apnea, was aggravated (i.e., worsened) by any diagnosed service-connected psychiatric condition. The examiner is advised that aggravation may include temporary worsening of a disability. The examiner must provide a comprehensive report that includes a complete rationale for all opinions and conclusions reached. P. M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Denton, Buck 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.