Citation Nr: 21041490 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 20-29 930A DATE: July 9, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), major depressive disorder, and alcohol use disorder, to include as secondary to service-connected right knee disability is remanded. REASONS FOR REMAND The Veteran had active military service from June 1973 to June 1977. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2018 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that the Veteran filed an untimely substantive appeal in October 2020. However, as the Veteran represented good cause, the Veteran's claim has been perfected and is now before the Board. 1. Entitlement to service connection for an acquired psychiatric disability, to include PTSD, major depressive disorder, and alcohol use disorder, to include as secondary to service-connected right knee disability is remanded. At the outset, the Board notes that in a February 2018 VA treatment record the Veteran was diagnosed with PTSD, major depressive disorder, and alcohol use disorder. See May 2018 CAPRI. In an October 2017 VA treatment record, the Veteran reported that he drinks alcohol to cope with his PTSD symptoms. A review of the service treatment records shows normal psychiatric condition in his April 1974 entrance examination and April 1977 separation examination. See September 2014 STR Medical. In the April 1977 report of medical history, the Veteran denied having frequent trouble sleeping, depression or excessive worry, or nervous trouble of any sort. The Veteran claims that his psychiatric disability manifested as a result of his service, or in the alternative as secondary to his service-connected right knee disability. Specifically, the Veteran stated that a missile misfired while he was scoring a tank at Fort Stewart. See February 2018 VA 21-0781 Statement in Support of Claim for PTSD. The tank elevated off the ground, knocking the Veteran down onto the ground. He stated that he feared for his life as the missile came back toward the tank before he passed out. In a September 2017 VA treatment record, the Veteran stated that he has had flashbacks and nightmares regarding a tank missile misfiring. He stated that his symptoms began about a year ago around the time he was experiencing unstable living condition. See May 2018 CAPRI. In a February 2018 VA mental health consultation, it was noted that based on the various psychological assessments, the Veteran was diagnosed with PTSD, major depressive disorder, and alcohol use disorder. In the alternative, the Veteran claims that his psychiatric disability is caused as a result of his right knee pain. See February 2020 VA 27-0820 Report of General Information. The earlier medical records show that in an April 2008 VA treatment record the Veteran reported that uncontrolled low back pain and knee pain is depressing. See May 2008 Medical Treatment Record Government Facility. The Veteran also endorsed depression due to his financial and marital situation. See March 2014 CAPRI. The June 2018 DPRIS Response stated that a coordinated research with the National Archives and Records Administration was completed but they were unable to locate copies of unit records submitted by the 4th Battalion 68th Armor for January to December 1975 time period. Other historical documents that are available to the agency were reviewed but there was no evidence of the incident described by the Veteran pertaining to a missile that misfired in 1975 at Fort Stewart, Georgia. See June 2018 DPRIS Response. Then, in a January 2020 PIES response, it was noted that the Veteran's allegation was investigated but no records were found. See January 2020 VA 21-3101 Request for Information. The Board finds that there is sufficient evidence to demonstrate that the Veteran has a current psychiatric disability, to also include anxiety and depression, which may be related to an illness or event incurred in service or as secondary to his service-connected right knee disability. Here, while PTSD requires a confirmed inservice stressor, the Board finds that the medical evidence also has demonstrated evidence of other psychiatric disabilities, to include anxiety which the Board is obligated to infer into the Veteran's claim for PTSD. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Accordingly, the Board finds that the VA's duty to assist has been triggered and as such a VA examination should be afforded to the Veteran. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Based on the foregoing, the Board finds that a remand is necessary to obtain a nexus opinion. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination by an appropriately qualified examiner to determine the nature and etiology of any current psychiatric disorder, to include PTSD, anxiety, major depressive disorder, and alcohol use disorder. The claims file, including a copy of this remand, must be made available to the examiner. A record of the review of the claims file should be documented in the examination report. Following the examination of the Veteran and a review of the record, the examiner must, first, identify each current psychiatric diagnosis found to be present since 2018. If PTSD is diagnosed, the examiner should identify the stressor(s) upon which such diagnosis is based. The examiner should consider that VA treatment records have shown diagnoses for PTSD, major depressive disorder, anxiety, and alcohol use disorder. See May 2018 CAPRI. In an October 2017 VA treatment record, the Veteran reported that he drinks alcohol to cope with his PTSD symptoms. The examiner is asked to consider the following unverifiable stressful event: The Veteran stated that a missile misfired while he was scoring a tank at Fort Stewart. See February 2018 VA 21-0781 Statement in Support of Claim for PTSD. The tank elevated off the ground, knocking the Veteran down onto the ground. He stated that he feared for his life as the missile came back toward the tank before he passed out. For each diagnosed psychiatric disorder, provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that the disorder had its onset in service or is otherwise etiologically related to service. The examiner must state whether it is at least as likely as not (a fifty percent probability or greater) that the Veteran's acquired psychiatric disability was (a) caused by or has been (b) aggravated (worsened beyond the natural progress of the disorder) by his service-connected right knee disability. The examiner should consider that in an April 2008 VA treatment record the Veteran reported that uncontrolled low back pain and knee pain is depressing. See May 2008 Medical Treatment Record Government Facility. In a February 2020 correspondence, the Veteran again stated that his psychiatric disability is caused by his service-connected right knee disability. See February 2020 VA 27-0820 Report of General Information. A detailed rationale for all opinions must be provided. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. Zi-Heng Zhu Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Noh, 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.