Citation Nr: 21031609 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 18-03 869 DATE: May 24, 2021 REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD), also claimed as mental health disease to include claustrophobia, is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1990 to September 1994. This case comes before the Board of Veterans' Appeals (Board) on appeal from a December 2015 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). In February 2021, the Veteran provided sworn testimony before the undersigned Veterans Law Judge (VLJ) at a Board hearing. A copy of the hearing transcript has been associated with the electronic claims file. The Veteran is claiming service connection for a mental health disorder which he asserts began while he was in the military. Specifically, he has contended that his claustrophobia and mental health problems began while he was deployed in Desert Storm and was in small spaces, such as vehicles and tents. He further asserted he did not complain of his mental health issues in service due to not wanting to bother his fellow military servicemembers. The Board notes that his service treatment records (STRs) and military personnel records do indicate that he served in Saudi Arabia between January and June 1991. It is also shown that in July 1993, he was arrested for drunk driving; was issued an Article 15 in August 1993 for being AWOL; and in May 1994, he was discharged after another Article 15 for testing positive for marijuana usage. The STRs also note that in November 1993, he had a CT scan of his head after an episode of psychosis that was noted to be improved with medication, but in the June 1994 report of medical history, the Veteran indicated his health was good and that he marked "no" to depression or excessive worry or nervous trouble of any sort. The 2015 VA examiner opined that there was no record of psychiatric complaints or treatment in service and that in May 1994, the Veteran was seen by behavioral health for the purposes of evaluating his mental status in light of his recent Article 15 for drug use, but, no evidence of a significant psychiatric disease/disorder was found. However, the Veteran did undergo counseling between August 1993 and December 1993, and, as noted above, in November 1993, he had a CT scan of his head after an episode of psychosis. This was not considered. Additionally, the examiner stated the Veteran had not been formally evaluated or treated for mental health, but the VA medical records from December 2015 through January 2017 show mental health consultations. As such, another examination and medical opinion to consider the above is warranted. Further, during the 2021 Board hearing, the Veteran reported that he had been seeing Dr. C. at VAMC through 2019, but the only records available are up to January 2017. In addition, it is unclear from the Veteran's testimony whether he receives private medical care, or if all of his medical care is through VA; specifically, he mentioned that he works in healthcare and he sees his primary doctor all the time. He also stated that he receives care for his anxiety and panic attacks from his primary care doctor, and that there are "not that many reasons where I have to go to the VA." As such, on remand, a request as to whether he has outstanding private medical records is warranted. The matters are REMANDED for the following action: 1. Obtain the VA Medical Center records from January 2017 to present, and associate them with the Veteran's file. 2. Contact the Veteran and ask him to identify the names and addresses and approximate dates of treatment from any private provider who has or is currently treating him for mental health symptoms, to include the primary care doctor who prescribed him anti-anxiety medication and treats him for panic attacks, and ask him to complete releases authorizing VA to obtain those records. If any private records identified by the Veteran are not obtained, notify him and his representative of such and give him an opportunity to obtain the records himself and submit them. 3. DO NOT SCHEDULE THE FOLLOWING EXAMINATION UNTIL AFTER THE ABOVE RECORDS HAVE BEEN OBTAINED TO THE EXTENT POSSIBLE. 4. Schedule the Veteran for an examination to determine the nature and etiology of his mental health disorder. The entire claims file must be made available to and be reviewed by the examiner, and it must be confirmed that such records were available for review. The examiner is asked to determine: (a.) Whether the Veteran has a diagnosis for PTSD? If so, is it at least as likely as not (50 percent probability or greater) related to service? (b.) Whether any of the Veteran's diagnosed mental health disorders, to include previously diagnosed anxiety and claustrophobia/phobia, are at least as likely as not (50 percent probability or greater) related to service. In providing this opinion, the examiner must consider the following: August 1993 Article 15 for being AWOL; Between August 1993 and December 1993, he attended counseling; November 1993, he had a CT scan of his head after an episode of psychosis that was noted to be improved with medication; May 1994 psychiatric evaluation noted he had an occupational problem and that he had misuse of alcohol and drugs; The June 1994 report of medical history showed his health was good and that he marked "no" to trouble sleeping, depression or excessive worry, or nervous trouble of any sort and his June 1994 separation examination marked that he was psychiatrically normal; In the December 2015 VA examination, he was diagnosed with situational specific phobia, but his symptoms did not meet the diagnostic criteria for PTSD; December 2015 VA medical record, the Veteran reports that he did not have phobias or anxiety until after the Gulf War and noted some unease with closed spaces. He stated the feeling has grown worse over the years and he now alters his personal and work behavior to deal with the fears; December 2015 VA medical note, the Veteran stated that his symptoms spontaneously started during his military service and have continued; January 2017 mental health consultation discussed treatment for his triggers for anxiety. He reported a recent private MRI caused him to have a panic attack. His doctor marked that he has ongoing claustrophobia that is stable; The 2021 Board hearing where he testified that he feels his diagnosed claustrophobia is related to several instances when he was in Desert Storm when he was in enclosed areas and vehicles and being in tents; and if retrieved, the VA medical documents, the private doctor records from the primary care doctor, and other private medical records as indicated above. Rationale must be provided for the opinions proffered. If the examiner determines a requested opinion is not possible without resort to mere speculation, then the examiner must explain why. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G.Hoy, 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.