Citation Nr: 18123932
Decision Date: 08/03/18	Archive Date: 08/03/18

DOCKET NO. 15-34 633
DATE:	August 3, 2018
REMANDED
Entitlement to service connection for an acquired psychiatric disorder, to include adjustment disorder, major depressive disorder, depression, anxiety, sleep disturbances, with alcohol use disorder, is remanded.
REASONS FOR REMAND
The Veteran served on active duty from October 1989 to May 1990, and November 1990 to May 1997.  
This matter is before the Board of Veterans’ Appeals (Board) on appeal of April and July 2015 rating decisions of the St. Paul, Minnesota, Regional Office (RO) of the Department of Veterans Affairs (VA). 
The Veteran has submitted an October 2017 written request to withdraw his prior hearing request.  The Board deems the hearing request properly withdrawn.  38 C.F.R. § 20.704(d). 
1. Entitlement to service connection for an acquired psychiatric disorder, to include adjustment disorder, major depressive disorder, depression, anxiety, sleep disturbances, with alcohol use disorder, is remanded.
Service treatment records (STRs) reflect psychiatric symptoms present during service.  In March 1995, the Veteran reported frequent trouble sleeping, depression or excessive worry, loss of memory or amnesia, and nervous trouble.  An April 1995 report found no psychiatric diagnosis.  In July 1996, the Veteran reported loss of memory.  An April 1998 report notes memory deficits and depressive symptoms.
A March 1998 VA examination reflects adjustment reaction to the loss of his son with mild depressive features.  Psychosocial stressors included problems adjusting to his new civilian role.
In a May 2015 VA treatment record, the Veteran reported being depressed since his deployment.
An August 2015 VA treatment record diagnosed depression, anxiety, and alcohol use disorder.  The examining psychologist stated there is little evidence for a diagnosis of PTSD, although the Veteran’s symptoms do appear related to his deployment.  
The Veteran appeared for a VA examination in February 2015.  Alcohol use disorder was diagnosed.  The examiner stated it is unlikely the alcohol use is related to service.  The reliability of the Veteran's self-report was found to be questionable.  However, given his self-report and information from his treatment records, it is unlikely that the Veteran's alcohol use disorder stems from military experiences.  He has significant pre-military stressors, pre-military substance abuse, and post-military records do not support his current claims.
The Veteran appeared for a VA examination in October 2015.  The examiner diagnosed major depressive disorder and alcohol use disorder.  The examiner stated that it is less likely as not that the Veteran's current mental health problems are related to the anxiety/depression noted in the service.  The examiner noted that the service treatment records do not reflect chronic mental health problems.  He self-reported concerns on the Report of Medical History in 1995, including anxiety, worry, sleep, memory, and other concerns.  The same areas were not marked as concerns in 1996 and a note by a Psychiatrist in 1996 made no diagnosis on Axis I.  Therefore, the examiner stated that there is no evidence of a chronic mental health condition that can be traced to the time in the service.  Treatment records since the service reflect mental health symptoms in reaction to various life stressors.  For example, he was diagnosed with Adjustment disorder in 2004 by Dr. L in context of marital distress, a DWI, and a discovery that he was the father of a child.  He was diagnosed with Adjustment disorder in 2014 by Dr. G in the context of work stress and how he was treated at work.  Alcohol has been labeled as a problem as far back as 2004, as well.  More recent treatment records indicate issues related to anxiety and depression, both, as well as Alcohol use disorder. Again, the examiner stated that the context appears to be mostly related to life stressors.
An addendum VA examiner’s opinion is required, as the medical evidence indicating the Veteran’s psychiatric disorder was caused or aggravated by his deployment must be addressed.
Further, in a February 2018 statement, the Veteran noted that his claims file lacks his military personnel records, which he states contain relevant information.  Upon remand, these records must be obtained.  It is also not clear if the full STRs are associated with the claims file.
The matter is REMANDED for the following action:
1. Please associate all VA treatment records with the claims file and allow the Veteran the opportunity to request any private treatment records be associated with the claims file.  All records/responses received must be associated with the electronic claims file.  
2. Please associate all Military Personnel Records with the claims file, to include records relating to anger management sessions and depression diagnosis.  All records/responses received must be associated with the electronic claims file.  
3. Please ensure all STRs are associated with the claims file, to include the earlier portion of the Veteran’s service, from October 1989, and all entrance exams.
4. Then, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any acquired psychiatric condition to include adjustment disorder, major depressive disorder, depression, anxiety, sleep disturbances, with alcohol use disorder.  The examiner must opine whether the diagnoses, made from January 2014 to present, are at least as likely as not related to an in-service injury, event, or disease, including in-service recorded psychiatric symptoms.  
Please address the medical treatment records and lay statements indicating psychiatric symptoms are related to the Veteran’s deployment.  
Please consider whether the in-service psychiatric symptoms may indicate the onset of mental disorder, regardless of whether a diagnosis was made at the time.
If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor.  Verify all reported stressors to the fullest extent possible.
5. Then, after completing any additional development needed, the AOJ should readjudicate the issue on appeal.  If the benefits sought on appeal are not granted to the Veteran’s satisfaction, the AOJ should furnish to him and his representative a supplemental statement of the case (SSOC) and afford them the requisite opportunity to respond before the case is returned to the Board.
 
KRISTI L. GUNN
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	K. M. Georgiev

 For A Complete Guide To VA Disability Claims and to find out more about your potential VA disability case and how to obtain favorable VA Rating Decision! Visit: VA-Claims.org

For More Information on Veterans Disability Compensation Benefits! Visit: DisableVeteran.org ~ A Non-Profit Non Governmental Agency

Advertisements

Leave a Reply

Please log in using one of these methods to post your comment:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.