Citation Nr: 21031992 Decision Date: 05/25/21 Archive Date: 05/25/21 DOCKET NO. 19-19 815 DATE: May 25, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for coronary artery disease, to include on a secondary basis, is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1961 to January 1966. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In February 2021, the Veteran testified at a Board videoconference hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. Lastly, the Board has re-characterized the claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD, anxiety disorder not otherwise specified, depression not otherwise specified, dysthymic disorder, major depressive disorder, and insomnia. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (The scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record.). 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded. During his February 2021 hearing, the Veteran testified that his acquired psychiatric disorder manifested while he was serving on active duty. To this end, the Board notes that the Veteran has described four significant in-service stressor events. Initially, the Veteran reported that he was stationed at Malmstrom Air Force Base and worked in close proximity to a highly secret and secure nuclear weapons storage area during the Cuban Missile Crisis. To this end, the Veteran stated that he lived in fear of hostile military activity throughout his tenure at the base because he believed nuclear war to be imminent. In addition, the Veteran stated that there were multiple near accidents while he was stationed at Malmstrom Air Force Base. In this regard, he described an incident during which a nuclear warhead did not "check out properly," which led to an immediate evacuation. The Veteran also described multiple "alerts," during which he was called into work in the middle of the night and indicated that such occurred extremely often during the Cuban Missile Crisis. He also stated that his commanders would show movies of World War II explosions to "drill" the nuclear effects of the war into the Veteran and other airmen. The Veteran reported that he believed that the constant state of danger associated with working in proximity to nuclear weapons, and prohibition against confiding in others, to include his wife, due to the confidential nature of his work, forced him to live in a constant state of stress and anticipation, and indicated that he has continued to experience such symptoms since service. In addition, the Veteran indicated that he felt so severely overwhelmed and uncomfortable working in a nuclear weapons storage facility that he spoke to his commanding officer and was transferred from the area. See September 2011 VA Form 21-4138 Statement in Support of Claim; July 2013 Correspondence; February 2021 Hearing Transcript, pages 2-5. As noted above, the Veteran described three additional in-service stressor events. First, he reported that the Governor of Montana and a Sergeant he knew and thought highly of were killed in a helicopter crash. The Veteran further indicated that the crash was closely followed by the assassination of President Kennedy in November 1963, which occurred shortly after he took his family on a visit to see the President. In this regard, the Veteran reported that he found the helicopter crash, assassination of President Kennedy, and his experiences during the Cuban Missile Crisis, taken together, to be extremely troubling and indicated that such had a huge impact on his life. Notably, the Veteran has not stated that he witnessed the helicopter crash or assassination but rather has reported that he found out about them after they occurred. See July 2013 Correspondence; February 2021 Hearing Transcript, pages 5-6. In addition, the Veteran reported that a dog attempted to attack him in or around 1963. In this regard, the Veteran stated that the dog lunged as he rounded the corner of an air police building but was caught by a chain approximately one foot away from the Veteran after he arrived on base during an alert. In a July 2013 statement, the Veteran stated that he reported the attack to the branch of military police in charge of guard dogs and to his supervisor, but indicated that he was not sure whether the incident had been officially recorded. See September 2011 Correspondence; July 2013 Correspondence; February 2021 Hearing Transcript, pages 5-6. Lastly, the Veteran testified that his house flooded in June 1964. He noted that the flood, which destroyed bridges and killed people, forced him to relocate to a new house. In the July 2013 statement, the Veteran indicated that he, his wife who was eight months pregnant at the time, and his two year old daughter got out of their home as the flood waters came in. See July 2013 Correspondence; February 2021 Hearing Transcript, pages 5-7. A review of the Veteran's service personnel records (SPRs) reveals that he was stationed at Malmstrom Air Force Base in Montana and was assigned to the 29th Training Systems Squadron, from August 1961 to January 1966. See June 2014 Military Personnel Record. The Veteran's service treatment records (STRs) are silent for any findings or diagnoses of psychiatric disorders, to include PTSD, anxiety disorder not otherwise specified, depression not otherwise specified, dysthymic disorder, major depressive disorder, and insomnia. See April 2015 STR Medical. A review of the post-service treatment records shows that the Veteran has been diagnosed with multiple psychiatric disorders, to include PTSD, anxiety disorder not otherwise specified, depression not otherwise specified, dysthymic disorder, major depressive disorder, and insomnia. See, e.g., December 2012 Medical Treatment Record Non-Government Facility; March 2013 Medical Treatment Record Non-Government Facility; April 2019 CAPRI. A private treatment record shows that the Veteran underwent a psychiatric diagnostic interview examination with a psychiatric nurse in December 2012. During the interview, the Veteran reported that he worked with nuclear weapons in a high security area during the Cuban Missile Crisis. He further stated that he was constantly on alert and would get called into work at two in the morning. In addition, the Veteran reported that guard dogs lunged at him as he walked by. Notably, the nurse indicated that the Veteran was only able to provide "sparse" details of his in-service stressor events because he had "blocked out" most memories of his active duty service. Following the interview examination, the nurse diagnosed the Veteran with PTSD, dysthymic disorder, major depressive disorder, and rule-out avoidant personality disorder. See March 2013 Medical Treatment Record Non-Government Facility. In support of his claim, the Veteran submitted a private medical opinion from the same psychiatric nurse, dated in July 2013. The nurse opined that in-service stressor events caused the Veteran's PTSD. In support of her opinion, she noted that the Veteran had been under her care for emotional difficulties that manifested while he was serving on active duty since December 2012 and reported that the Veteran had been diagnosed with PTSD. See July 2013 Medical Treatment Record Non-Government Facility. The Veteran also submitted a private medical opinion from Dr. Eric Levensky, dated in November 2019. Dr. Levensky noted that he evaluated the Veteran in June 2013 for the purpose of mental health diagnosis and treatment planning and stated that he diagnosed the Veteran with moderate chronic PTSD. In this regard, Dr. Levensky opined that it was more likely than not that the Veteran's diagnosed PTSD was the result of ongoing and acute in-service combat-related stressors, to include fear of hostile military activity (nuclear attack) during the Cuban Missile Crisis and fear of nuclear exposure while working with nuclear weapons related to several "near accidents" that occurred at his place of work. See August 2020 Medical Treatment Record Government Facility. After a review of the evidence of record, the Board finds that a remand for further development is necessary. Initially, the Board notes that the Veteran reported four significant stressor events during his active duty service. However, there is no indication in the record that the RO attempted to contact any appropriate repositories to verify his reported stressors. In addition, the Board finds the private medical opinions, dated in July 2013 and November 2019, speculative and therefore currently inadequate to adjudicate the claim on appeal. The Board finds that the Veteran should be afforded a VA examination with respect to his claim for entitlement to service connection for an acquired psychiatric disorder. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). As VA and private treatment records confirm that the Veteran has been diagnosed with multiple acquired psychiatric disorders, to include PTSD, anxiety disorder not otherwise specified, depression not otherwise specified, dysthymic disorder, major depressive disorder, and insomnia, which he relates to multiple in-service stressor events, the Board finds that a VA examination is required in order to obtain an opinion addressing the nature and etiology of any diagnosed acquired psychiatric disorder. 2. Entitlement to service connection for coronary artery disease, to include on a secondary basis, is remanded. During his February 2021 hearing, the Veteran testified that his diagnosed coronary artery disease was caused or aggravated by his acquired psychiatric disorder. See February 2021 Hearing Transcript, pages 4, 9-11; see also November 2012 Correspondence. The Veteran's STRs are silent for any findings or diagnoses of cardiac disorders, to include coronary artery disease. See April 2015 STR Medical. A review of the post-service treatment records shows that the Veteran had myocardial infarctions in 1994 and 2000 and that he was subsequently diagnosed with atherosclerotic coronary artery disease. See, e.g., February 2013 Medical Treatment Record Non-Government Facility. In support of his claim, the Veteran submitted a private medical opinion from Dr. Todd Whitsitt, dated in July 2013. Dr. Whitsitt noted that he treated the Veteran for heart attacks in 1994 and 2000. In this regard, Dr. Whitsitt reported that, while PTSD was not the only factor in the Veteran's premature coronary artery disease, stress was a known contributor to myocardial infarction. See July 2013 Medical Treatment Record Non-Government Facility. The Veteran submitted a private Disability Benefits Questionnaire (DBQ), from Dr. Pedro Ortiz, dated in September 2015. Dr. Ortiz noted that the Veteran had been diagnosed with coronary artery disease, old myocardial infarction, and cardiomyopathy. Dr. Ortiz further noted that the Veteran had a history of percutaneous coronary intervention and myocardial infarction and that he required continuous medications for his cardiac disorders. See September 2015 VA Form 21-0960A-1 Ischemic Heart Disease Disability Benefits Questionnaire. However, Dr. Ortiz did not proffer an opinion as to the etiology of the Veteran's cardiac disorders. The Veteran also submitted a private medical opinion from Dr. Robert Taylor, dated in July 2020. Dr. Taylor noted that he began treating the Veteran in September 2019 and that he had a history of two prior myocardial infarctions. In this regard, Dr. Taylor noted that there was recent evidence to support that PTSD could be one of several contributing factors in the development of atherosclerotic heart disease in veterans and stated that it could be that heightened activity in the amygdala region of the brain, which plays a role in processing emotions, especially fear, triggers inflammation and leads to cardiovascular disease. Dr. Taylor further noted that the Veteran stated that he had been suffering from PTSD since 1964. As such, Dr. Taylor opined that it was more likely than not that the Veteran's heart disorder was a result of his PTSD. See August 2020 Medical Treatment Record Non-Government Facility. After a review of the evidence of record, the Board finds that a remand for further development is necessary. The Board finds the July 2013 private medical opinion to be inadequate as it is speculative in nature. In addition, the Board finds the July 2020 private medical opinion from Dr. Taylor, to be speculative as it appears to be based upon the Veteran's lay statements. The Board further notes that there are no other medical opinions of record as to whether the Veteran's diagnosed coronary artery disease was caused or aggravated beyond its natural progression by his acquired psychiatric disorder. Thus, as VA treatment records confirm that the Veteran has been diagnosed with coronary artery disease, which he relates to his acquired psychiatric disorder, the Board finds that a VA examination is required in order to obtain an opinion addressing the nature and etiology of his diagnosed coronary artery disease. See 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). In addition, the Board notes that the Veteran reported that he received treatment from Dr. McGuire, a private cardiologist at Albuquerque Health Partners from 2007 to 2011 and that he had been receiving treatment from Dr. Sopko, a private cardiologist at the New Mexico Heart Institute, since 2013. See March 2013 VA Form 21-4142 Authorization for Release of Information. The Board further notes that, in the July 2020 private medical opinion, Dr. Taylor noted that he had been treating the Veteran since September 2019. See August 2020 Medical Treatment Record Non-Government Facility. However, the Board notes that none of these private treatment records have been associated with the Veteran's claims file. As such, the Board finds that a remand is also required to obtain these records. The matters are REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran's VA treatment facilities, and all private treatment records from the Veteran not already associated with the file, to include any medical records from Dr. McGuire, a private cardiologist at Albuquerque Health Partners, dated from 2007 to 2011; Dr. Sopko, a private cardiologist at the New Mexico Heart Institute, dated from 2013; and Dr. Robert Taylor, dated from September 2019. 2. The AOJ should request any records needed to corroborate the Veteran's claimed stressor events, to include verification of all in-service incidents, as described by the Veteran over the course of the appeal. The evidence of record shows that the Veteran has endorsed the following stressor events: (a.) He reported that he was stationed at Malmstrom Air Force Base and worked in close proximity to a highly secret and secure nuclear weapons storage area during the Cuban Missile Crisis. He also stated that there were multiple near accidents while he was stationed at Malmstrom Air Force Base, to include an incident during which a nuclear warhead did not "check out properly," which led to an immediate evacuation. See September 2011 VA Form 21-4138 Statement in Support of Claim; July 2013 Correspondence; February 2021 Hearing Transcript, pages 2-5. (b.) He reported that the Governor of Montana and a Sergeant he knew and thought highly of were killed in a helicopter crash, which was closely followed by the assassination of President Kennedy in November 1963. See July 2013 Correspondence; February 2021 Hearing Transcript, pages 5-6. (c.) He reported that a dog attempted to attack him in or around 1963. See September 2011 Correspondence; July 2013 Correspondence; February 2021 Hearing Transcript, pages 5-6. (d.) He testified that his house flooded in June 1964 and indicated that he, his wife who was eight months pregnant at the time, and his two year old daughter got out of their home as the flood waters entered the dwelling. See July 2013 Correspondence; February 2021 Hearing Transcript, pages 5-7. If any records cannot be located, the AOJ must specifically document the attempts made to locate them and explain in writing why further attempts to locate or obtain any government records would be futile. 3. After completion of the above development, schedule the Veteran for a VA examination by an appropriately qualified examiner to determine the nature and etiology of his diagnosed acquired psychiatric disorder. The examiner should provide the following opinion: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's claimed acquired psychiatric disorder is etiologically related to his period of service? (b) If a diagnosis of PTSD is made, the examiner should identify the stressor(s) on which the diagnosis is based. The examiner should review pertinent documents in the Veteran's claims file in connection with the examination. The examiner should specifically consider the diagnoses of PTSD, anxiety disorder not otherwise specified, depression not otherwise specified, dysthymic disorder, major depressive disorder, and insomnia, which are noted in the Veteran's post-service treatment records, the private medical opinions from a psychiatric nurse and Dr. Levensky, respectively dated in July 2013 and November 2019, and any conflicting medical evidence of record, to include the records identified in the body of this Remand. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. 4. After completion of the development in 1-3, schedule the Veteran for a VA examination by an appropriately qualified examiner to determine the nature and etiology of his diagnosed atherosclerotic coronary artery disease. The examiner should provide the following opinion: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's diagnosed disability is etiologically related to his military service? (b) Is it at least as likely as not (50 percent or greater probability) that the Veteran's diagnosed atherosclerotic coronary artery disease was (a) caused or (b) aggravated by his acquired psychiatric disorder, to include as due to psychiatric symptoms and side effects of the Veteran's psychiatric medications? If aggravation is found, the examiner should identify, to the extent possible, the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to the Veteran's acquired psychiatric disorder. (Continued on the next page) The examiner should review pertinent documents in the Veteran's claims file in connection with the examination. The examiner should specifically consider the private medical opinions from Dr. Whitsitt and Dr. Taylor, respectively dated in July 2013 and July 2020, and any conflicting medical evidence of record, to include the records identified in the body of this Remand. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Justis, 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.