Citation Nr: 21029542 Decision Date: 05/13/21 Archive Date: 05/13/21 DOCKET NO. 17-57 645 DATE: May 13, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1974 to July 1980. This matter is on appeal from an August 2016 decision of a Department of Veterans Affairs (VA) Regional Office (RO). In January 2021, a hearing was held before the undersigned. A transcript of the hearing is in the record. The United States Court of Appeals for Veterans Claims (Court) has held that, although a veteran claims service connection for a specified diagnosed disability, it cannot be a claim limited only to that diagnosis, but must rather be considered a claim for any disability that may reasonably be encompassed by several factors, including the veteran's description of the claim, the symptoms the veteran describes, and the information the veteran submits or that VA obtains in support of the claim. The Court reasoned that a veteran does not file a claim to receive benefits only for a particular diagnosis, but for the affliction (symptoms) his condition, however described, causes him. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Here, although the Veteran filed his claim seeking service connection for PTSD, the record indicates he has been diagnosed with other psychiatric disabilities. The Board therefore finds that, pursuant to Clemons, the Veteran's claim seeking service connection for PTSD is more accurately characterized as one for any acquired psychiatric disorder, to include PTSD and has recharacterized the issue accordingly. See Clemons, 23 Vet. App. at 5. The Veteran has alleged that he has a psychiatric disorder due to events that occurred in service. Additionally, the record raises questions as to whether he may have a psychiatric disorder due to his service-connected disabilities. VA treatment records show diagnoses of adjustment disorder with mixed anxiety and depressed mood, unspecified depressive disorder, and unspecified anxiety disorder. In July 2017, the agency of original jurisdiction (AOJ) submitted a request to the Defense Personnel Records Information Retrieval System (DPRIS) to corroborate the details of the Veteran's stressor of the death of a roommate. The request included the tours of duty assignment, unit location, date range, details of the alleged incident, and the roommate's name. In August 2017, DPRIS provided a response which stated that they coordinated their research with the National Archives and Records Administration and were not able to locate any unit records pertaining to the Veteran's battalion for the calendar years 1976 and 1977. The response states that they reviewed other available historical documents and were not able to document the death of an individual by the name provided or any spelling variations thereof. In September 2017, the AOJ contacted the United States Army Combat Readiness Center (USACRC) to obtain copies of an investigation of the death of a U.S. Army Soldier by the name provided by the Veteran. The AOJ provided details regarding the date and duty station. However, the AOJ received a negative response which stated that the request exceeded the 40-year retention period. As such, the AOJ has been unable to obtain records to corroborate the alleged stressor event. Additionally, VA treatment records as recently as March 2020 reflect that the Veteran has reported that his pain affects his mood. The Veteran is service connected for several disabilities, including degenerative disc disease of the lumbar spine, that are shown to cause him pain. Therefore, the record raises questions as to whether the Veteran's service-connected disabilities have caused or aggravated his psychiatric condition. The Board finds that an examination is warranted to assess the etiology of the Veteran's psychiatric condition. 38 C.F.R. § 3.159(c)(4). Furthermore, at the January 2021 hearing, the Veteran testified that he had been seeking treatment with a Dr. C. at VA for about two years and that he had diagnosed him with PTSD. The record contains VA treatment records as recent as November 2020, but they do not reflect a provider by the name of Dr. C. As such, it is unclear whether Dr. C. is a VA provider, a provider with a Vet Center, or a private treatment provider, or if the transcript does not accurately reflect the provider's name. Therefore, further clarification is needed from the Veteran to ensure any outstanding treatment records are obtained. The matter is REMANDED for the following action: 1. Obtain and associate with the claims file updated VA treatment records from November 2020 to the present. 2. Ask the Veteran to complete a VA Form 21-4142 for any provider who has treated him for his psychiatric condition, including Dr. C. (as identified in the January 2020 Hearing Tr. at 3-4), and including if he has received treatment at a Vet Center. Make two requests for any authorized records, unless it is clear after the first request that a second request would be futile. 3. After completing the development requested in items 1 and 2, schedule the Veteran for a VA examination with an appropriate specialist to determine the nature and etiology of all acquired psychiatric disorders. The examiner is asked to respond to the following: A) Based upon a review of the relevant evidence of record and history provided by the Veteran, the VA examiner should identify all acquired psychiatric disorders by diagnosis using the DSM-5 diagnostic criteria. B) If the Veteran is diagnosed with PTSD, the examiner is requested to opine as to whether it is at least as likely as not (50 percent or greater probability) related to any stressor event in his service, to include the alleged death of a roommate. C) As to any acquired psychiatric disorder diagnosed other than PTSD, to include adjustment disorder with mixed anxiety and depressed mood, unspecified depressive disorder, and unspecified anxiety disorder, the examiner is requested to opine as to whether it is at least as likely as not (50 percent or greater probability) related to any event in his service, to include the alleged death of a roommate. D) As to any acquired psychiatric disorder diagnosed other than PTSD, to include adjustment disorder with mixed anxiety and depressed mood, unspecified depressive disorder, and unspecified anxiety disorder, the examiner is requested to opine whether it is at least as likely as not (50 percent or greater probability) caused by any of his service-connected disabilities, to include pain resulting from the disabilities. E) As to any acquired psychiatric disorder diagnosed other than PTSD, to include adjustment disorder with mixed anxiety and depressed mood, unspecified depressive disorder, and unspecified anxiety disorder, the examiner is requested to opine whether it is at least as likely as not (50 percent or greater probability) aggravated by (i.e., any worsening of the condition beyond its natural progression) his service-connected disabilities, to include pain resulting from the disabilities. A complete rationale for any opinion rendered should be provided. If the examiner is unable to provide an opinion without resorting to speculation, an explanation as to why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered should be provided. Merely saying he or she cannot respond will not suffice. M. SORISIO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. H. White, 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.