Citation Nr: 1752512 Decision Date: 11/16/17 Archive Date: 11/22/17 DOCKET NO. 13-31 819 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Detroit, Michigan THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), adjustment disorder, depressive disorder and major depression. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD B. Cohen, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Army from August 2000 to April 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2009 and April 2012 rating decision of the Detroit, Michigan Regional Office (RO). The Board has recharacterized the issue on appeal to include the Veteran's reported diagnoses during service and post-service. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The record contains several VA psychiatric examinations and VA treatment records that all used the DSM-IV criteria. Remand is necessary to determine whether the Veteran has a PTSD diagnosis or any other acquired psychiatric diagnoses under the DSM-V criteria. Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities (Rating Schedule) to remove outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and replace them with references to the updated Fifth Edition (DSM-V). 79 Fed. Reg. 45,093, 45,094 However, the DSM-IV governs all applications for benefits certified to the Board prior to August 4, 2014. The RO certified the Veteran's appeal to the Board on August 28, 2014; therefore, the claim is governed by the DSM-V. The case is REMANDED for the following actions: 1. Return the file to the VA examiner who conducted the April 2012 VA psychiatric examination. If the examiner is not available, have the file reviewed by a similarly-qualified examiner. Another examination is not required; however, if the VA examiner indicates that he or she cannot respond to the Board's questions without examination of the Veteran, another examination should be afforded to the Veteran. All relevant medical and non-medical records must be made available to the examiner for review of pertinent documents. The examination report should specifically state that such a review was conducted. The examiner must provide a comprehensive explanation for all opinions provided. Based upon a review of the relevant evidence and history provided by the Veteran, the VA examiner should identify all current acquired psychiatric disorders diagnosed under the DSM-V diagnostic criteria. The examiner must respond to the following inquiries: Does the Veteran have a current diagnosis of PTSD under the DSM-V diagnostic criteria? If the Veteran has a current diagnosis of PTSD, is the Veteran's claimed stressor related to fear of hostile military or terrorist activity? If the Veteran has a current diagnosis of PTSD, is the Veteran's claimed stressor adequate to support a diagnosis of PTSD? If the Veteran has a current diagnosis of PTSD, are the Veteran's symptoms related to his claimed stressor? Does the Veteran have a current diagnosis of adjustment disorder, depressive disorder, major depression or any other acquired psychiatric disorder under the DSM-V diagnostic criteria? If the Veteran has a current diagnosis of adjustment disorder, depressive disorder, major depression or any other acquired psychiatric disorder, is the Veteran's acquired psychiatric disorder(s) caused by his active service? Although the examiner must review the VBMS file, his or her attention is drawn to the following: * March 2000 pre-entrance medical examination report that indicates no psychiatric abnormalities noted and the Veteran reported no psychiatric medical history. * December 2001 mental status evaluation report that indicated the Veteran was treated for depression and suicidal ideations, and had his ammunition removed. * In a March 2003 pre-deployment health assessment, the Veteran indicated that during the past year, he sought counseling or care for his mental health. * In a March 2003 VA treatment progress note, the examiner noted PTSD. * In an August 2003 pre-deployment health assessment, the Veteran indicated that during the past year, he did not seek counseling or care for his mental health. * December 2003 letter from the Veteran's commanding officer that indicated the Veteran be placed on unit watch. * In a March 2004 mental status evaluation report that suggested service separation, the service clinical psychologist noted the Veteran as having depression, adjustment disorder, and previously treated for emotional difficulties. * In a March 2004 pre-separation medical history report that diagnosed the Veteran as anti-social, the Veteran indicated anxiety or panic attacks, habitual stutters, frequent trouble sleeping post-Iraq, received counseling, depression or excessive worry, evaluated and treated for a mental condition, and attempted suicide. * In a March 2004 pre-separation medical examination report, the "summary of defects and diagnoses" section indicated the Veteran has a history of anti-social behavior. * In an October 2004 post-deployment health assessment, the Veteran indicated that he entered or closely inspected destroyed military vehicles while in Iraq, felt in great danger of being killed in Iraq, is not interested in receiving help for stress and emotional problems, and has no concerns about possible exposures or events during his deployment that the Veteran feels may affect his health. * In a September 2004 VA progress note, the Veteran was diagnosed with major depression. * In a November 2004 VA progress note that diagnosed him with major depression and adjustment disorder, the Veteran stated he has PTSD because his father had it, never saw direct military combat, never had military sexual trauma, lost friends and feels guilty, trouble sleeping with occasional nightmares, lost his job at Hilltop RV, lives with parents and harbors feelings of mistreatment during service. * In an April 2004 VA psychiatric progress note that did not provide a psychiatric diagnosis, the Veteran stated he saw limited combat during deployment, has no nightmares, flashbacks, and sleeps well. * In a March 2009 VA progress note that diagnosed him with major depressive disorder and PTSD, the Veteran indicated he is fearful his life will not improve and believes an injustice was done to him during service. * In a March 2009 VA progress note that diagnosed him with major depression, depressive disorder, and chronic PTSD, the note indicated that the Veteran has eight years of failed experiences during service. * In an April 2009 VA progress note that diagnosed him with major depression and chronic PTSD, the Veteran stated he has financial burdens and is jealous of his brother who is on total disability. * In an August 2009 discharge summary that provided no diagnosis, the Veteran reported depression, irritability, nightmares, social isolation and intrusive thoughts related to mortar attacks he experienced in Iraq. * September 2009 VA examination that diagnosed the Veteran with depression, not PTSD, under DSM-IV. * VA progress notes dated February 2009 to August 2010, where the Veteran received treatment for PTSD, major depressive disorder, and depression. * October 2010 VA examination that diagnosed the Veteran with a personality disorder related to his pre-service difficulties and possibly exacerbated by service. * October 2011 Veteran Center mental status evaluation that noted the Veteran displays symptoms of PTSD. * Veteran Center treatment records dated October 2011 to November 2011 and September 2015 to September 2016, that indicate the Veteran received treatment for PTSD and depression. * April 2012 VA examination that diagnosed the Veteran with malingering, depressive disorder and personality disorder, under DSM-IV, but no PTSD diagnosis. * November 2013 letter from the Veteran's counselor at the Veteran Center that indicates the Veteran has PTSD. * VA treatment dated July 2013 to March 2016 that diagnosed the Veteran with PTSD and major depressive disorder. * July 2014 written statement from the Veteran's mother indicating the Veteran is depressed. * March 2015 psychiatric/psychological impairment questionnaire from the Veteran Center that indicates the Veteran has PTSD. * October 2016 written statement from the Veteran indicating his failed employment was due to his PTSD. * October 2016 letter from the Veteran's counselor at the Veteran Center that indicates the Veteran has PTSD under DSM-V. 2. Readjudicate the issue on appeal. If the benefit sought on appeal remains denied, the Veteran should be provided a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2016).