Citation Nr: 21032354 Decision Date: 05/26/21 Archive Date: 05/26/21 DOCKET NO. 16-05 502 DATE: May 26, 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 for training in the U.S. Army from May 1988 to August 1988 and on active duty from February 1989 to November 1995, with service in Southwest Asia. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a June 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO or AOJ). This case was most recently before the Board in April 2019, at which time it was remanded for further development. The case has since been returned to the Board. Unfortunately, remand is warranted for additional medical inquiry into the service connection claim for an acquired psychiatric disorder, to include PTSD. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In the April 2019 Remand, the Board deemed a May 2015 VA medical opinion inadequate for purposes of adjudicating the Veteran's claim as the examiner did not opine as to direct service connection relating to the broadened scope of the Veteran's claim to include any acquired psychiatric disorder. On remand, the Veteran was afforded a new VA mental health examination in November 2019. In this report, the examiner noted diagnoses of antisocial personality disorder, alcohol use disorder, and cannabis use disorder. He indicated the Veteran did not have a diagnosis of PTSD that conforms to DSM-5 criteria. With regards to non-PTSD psychiatric disorders, the examiner stated the Veteran does not struggle with depression. However, he did not adequately explain the premise behind this conclusion. The examiner also stated that there were treatment records suggesting some mental health symptoms and diagnoses recognized during the Veteran's incarceration, however, they were not currently present at the time of the evaluation. The report does not provide an opinion regarding whether the mental health symptoms and diagnoses were related to service. Such an opinion should be included in the record. Furthermore, VA treatment records document diagnoses of insomnia, and DSM-5 impressions of PTSD and depression. See November 2017 and January 2020 VA treatment records. More importantly, the Veteran's service treatment records document his in-service report of complaints of nightmares "from Saudi duty." See March 1992 service treatment record. However, this service treatment record was not addressed in the November 2019 report. Additionally, there was no discussion of the Veteran's lay report of ongoing symptomatology of depressed mood, difficulty sleeping, regular nightmares, avoidant behavior, and self-medicating service, as directed by the Board in its April 2019 Remand. Therefore, the November 2019 VA report is not of probative value here, and an opinion addressing whether the PTSD, depression, insomnia, and any other mental health symptoms and diagnoses that were diagnosed during the appeal period relates to service, to include the Veteran's in-service complaints of nightmares "from Saudi duty," should be provided. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (noting that the requirement of a current disability is satisfied when the claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim). Additionally, the record indicates the Veteran sought private treatment through SandStonebridge Counselling Services. See January 2020 VA treatment record. However, there is no indication in the record that the AOJ sought to obtain these records. The matters are REMANDED for the following action: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran's claim, to include any outstanding private treatment records. In this regard, ask the Veteran to complete a VA Form 21-4142 and VA Form 21-4142a for any private treatment records associated with his claim for service connection for an acquired psychiatric disorder, to include PTSD, to include from SandStonebridge Counselling Services. In the event the Veteran returns a VA Form 21-4142 and VA Form 21-4142a, make two requests for the authorized records from the clinicians or facilities identified by the Veteran, unless it is clear after the first request that a second request would be futile. 2. Obtain an addendum opinion from a qualified examiner to determine the nature and etiology of any current psychiatric disorders. If the examiner deems a physical examination necessary one should be scheduled and conducted. The claims file should be made available to and reviewed by the examiner. The examiner is asked to: (a.) Identify all of the Veteran's psychiatric disorders experienced during the claim period (since October 2014), to include whether he meets the criteria for PTSD. If PTSD is not diagnosed, it should be explained why this diagnosis is not appropriate. (b.) If the examiner finds that the Veteran meets the diagnostic criteria for PTSD, provide an opinion whether it is at least as likely as not the result of an in-service stressor, to include an incident in Southwest Asia where he saw a fellow soldier killed after stepping on an unexploded bomb. (c.) For any diagnosed psychiatric disorder other than PTSD, the examiner should offer an opinion as to whether it is at least as likely as not that the disorder had its onset during service or is otherwise related to service. In addressing the above, the examiner must consider and discuss the VA evidence of record indicating diagnoses of PTSD, depression, insomnia, and other mental health symptoms and diagnoses as noted by the November 2019 VA examiner. (Continued on the next page) The examiner must consider and discuss the March 1992 service treatment record indicating the Veteran complained of nightmares "from Saudi duty" during his active service. In addition, the examiner must also consider and discuss the Veteran's lay report of ongoing mental health symptomatology to include regular nightmares, and the use of alcohol and drugs to self-medicate, and avoid events since service, specifically since serving in Southwest Asia. In all conclusions, the examiner must identify and explain the medical basis or bases, with identification of the evidence of record. If an opinion cannot be offered without resorting to mere speculation, the examiner should explain why this is the case and identify any additional evidence that may allow for a more definitive opinion. DUSTIN L. WARE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Smith, 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.