Citation Nr: 22011069 Decision Date: 02/25/22 Archive Date: 02/25/22 DOCKET NO. 19-31 864 DATE: February 25, 2022 REMANDED Entitlement to service connection for an acquired psychiatric disorder including but not limited to PTSD is remanded. Entitlement to service connection for residuals of head trauma to include traumatic brain injury (TBI) is remanded. REASONS FOR REMAND The Veteran had active service from July 2005 to July 2009. 1. Entitlement to service connection for an acquired psychiatric disorder including but not limited to PTSD is remanded. The Veteran made a claim for PTSD. The Veteran has been provided a VA examination for PTSD and has submitted a PTSD DBQ dated July 2014 completed by a private practitioner. Although each of these examinations resulted in a diagnosis of PTSD, the RO was unable to verify the Veteran's reported stressors. The Board notes that the Veteran was also diagnosed with depression on the July 2010 VA PTSD examination and that the Veteran's CAPRI records note ongoing issues of anxiety and nightmares. The United States Court of Appeals for Veterans Claims (Court) has held that, although a Veteran claims entitlement to 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). The Board therefore finds that, pursuant to Clemons, the Veteran's PTSD claim is more accurately characterized as service connection for an acquired psychiatric disorder, including but not limited to, PTSD. The RO should schedule the Veteran for a VA general psychiatric examination. 2. Entitlement to service connection for residuals of head trauma to include traumatic brain injury (TBI) is remanded. The Veteran submitted a claim for TBI, either as due to PTSD or to malaria medication. The Veteran's general medical record does not show diagnosis of complaints of head trauma. However, the Veteran is service-connected for a right hip disability that required surgery as a result of a fall from a helicopter. After the incident, the Veteran reported he did not injure his head, but in the August 2021 Board hearing, the Veteran stated that after the fall he felt nauseated, which can be an indication of head trauma. To the extent that the Veteran does not have the medical training to provide etiology opinions or diagnosis of head injury or TBI, it is not competent medical evidence, however, such statements can prompt VA to provide a medical examination. 38 C.F.R. § 3.159; McClendon v. Nicholson, 20 Vet. App. 79 (2006). The RO should provide the Veteran a VA examination for residuals of head trauma to include TBI. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination for general psychiatric conditions. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: a) Direct service connection Is any diagnosed psychiatric condition at least as likely as not related to service, including, but not limited to, the Veteran's lay contentions of witnessing a suicide, witnessing an overdosed Marine, taking of Mefloquine malaria medication, or witnessing a Marine self-inflict a gunshot wound? Provide a rationale to support the opinion(s). b) Secondary service connection i. Is any diagnosed psychiatric condition at least as likely as not proximately due to any service-connected disability? ii. Is any diagnosed psychiatric condition at least as likely as not aggravated, i.e., worsened beyond its natural progression, by service-connected disability? 2. Schedule the Veteran for a VA examination for head injury and residuals of head trauma, to include, TBI. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: a) Direct service connection Is there a head trauma or residuals of head trauma diagnosis or TBI diagnosis that is at least as likely as not related to service, including fall from helicopter, or Mefloquine malaria medication? Provide a rationale to support the opinion(s). b) Secondary service connection i) Is any diagnosed head trauma residuals or TBI at least as likely as not proximately due to any service-connected disability? ii) Is any diagnosed head trauma residuals or TBI at least as likely as not aggravated, i.e., worsened beyond its natural progression, by any service-connected disability? DAVID L. WIGHT Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Miller, 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.