Citation Nr: 18141629 Decision Date: 10/11/18 Archive Date: 10/11/18 DOCKET NO. 13-02 570 DATE: October 11, 2018 REMANDED Entitlement to service connection for a psychiatric disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from November 1969 to June 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for PTSD, hearing loss and tinnitus. Service connection for hearing loss and tinnitus was granted in a January 2017 rating decision. As this award represented a full grant of the benefits sought on appeal, the claims are not before the Board. In July 2018, the Veteran testified at a hearing before the undersigned Veterans’ Law Judge (VLJ); a transcript is of record. During the hearing, the undersigned agreed to hold the record open for a period of 60 days to allow for the submission of additional evidence. However, no further evidence was received.   1. Entitlement to service connection for a psychiatric disorder is remanded. The Veteran contends he has a psychiatric disorder, to include PTSD, that is related to his service in Vietnam. A December 2013 VA treatment record shows a diagnosis of unspecified anxiety disorder by a clinical psychologist. As such, the claim is recharacterized as service connection for a psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran reports that he witnessed deaths and injuries, and experienced incoming fire, during combat his service. See October 2011 notice of disagreement (NOD); July 2018 Hearing Transcript. His personnel records show receipt of the Bronze Star Medal for meritorious achievement in connection with military operations against a hostile force in Vietnam from January 1971 to April 1971 and a military occupational specialty (MOS) of 13B40 (field artillery crewman/cannoneer). The Board thus resolves any reasonable doubt in the Veteran’s favor and finds that he engaged in combat with the enemy during his service in Vietnam. Accordingly, his accounts of in-service stressor events during combat are presumed credible and consistent with the types and circumstances of his service, and are conceded. The appeal must be remanded for a new VA examination and to obtain relevant medical records. At an August 2011 VA examination, an examiner opined the Veteran did not meet the criteria for a PTSD diagnosis per DSM-IV. During the course of this appeal, VA promulgated a final rule which mandates the use of the DSM 5 for all PTSD claims that are certified to the Board on and after August 4, 2014. 70 Fed. Reg. 45,093 (Aug. 4, 2014). The Veteran’s claim was not certified to the Board until February 2018; thus, the DSM 5 is applicable. Remand is necessary to determine if he meets the diagnostic criteria for PTSD under the DSM 5. An opinion is also needed to determine whether the Veteran’s current unspecified anxiety disorder is related to service. The Veteran also has generally reported that he experienced psychiatric symptoms, including issues with speaking, getting along with others, and being around large crowds, since returning from service. See July 2018 Hearing Transcript. Additionally, there may be outstanding relevant VA treatment records. The most recent VA treatment records associated with the Veteran’s claims file are from February 2018. However, during the July 2018 hearing, the Veteran reported treatment since February 2018. Any VA treatment records are within VA’s constructive possession, and are considered potentially relevant to the issues on appeal. Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016). A remand is required to obtain them. Finally, during the hearing, the Veteran testified that he received treatment at a Vet Center from approximately 2011 to 2016. While treatment records from 2011 to 2016 from the Vet Center located on Richmond Avenue are associated with the claims file, hearing testimony indicates that the Veteran may have gone to a second location. Any additional records should be sought on remand. The matter is REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records from February 2018 to the present. 2. Ask the Veteran to complete a VA Form 21-4142 for all Vet Centers he sought treatment at, other than the one previously located on Richmond Avenue. Make two requests for the authorized records from identified Vet Center(s), unless it is clear after the first request that a second request would be futile. 3. Schedule the Veteran for an examination to determine the nature and etiology of his current psychiatric disorders. The examiner must review the record, including a copy of this remand, and then address the following: If the Veteran is diagnosed with PTSD, 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. The examiner should note that in evaluating the Veteran for PTSD, he or she must apply the diagnostic criteria set forth in the DSM-5 and not that set forth in the DSM-IV. For any diagnosed acquired psychiatric disorder other than PTSD, to include unspecified anxiety disorder, the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease, to include the combat experiences the Veteran describes in his October 2011 NOD and July 2018 hearing transcript. A complete rationale must be provided for all opinions. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD E. Mortimer, Associate Counsel