Citation Nr: 18142339
Decision Date: 10/15/18	Archive Date: 10/15/18

DOCKET NO. 16-33 263
DATE:	October 15, 2018
REMANDED
The issue of an initial rating in excess of 30 percent for adjustment disorder with anxiety is remanded.
REASONS FOR REMAND
The Veteran served on active duty from February 1971 to February 1973 and from December 1990 to May 1991.
This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2014 rating decision issued by RO. 
This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system.
1. Entitlement to an initial rating in excess of 30 percent for adjustment disorder with anxiety is remanded.
Remand is required to afford the Veteran VA examination to determine the current severity of the service-connected adjustment disorder with anxiety. 
The matter is REMANDED for the following action:
1. Schedule the Veteran for a VA examination to evaluate the current severity and manifestations of his adjustment disorder with anxiety. The entire claims file should be made available to, and be reviewed by, the VA psychologist or psychiatrist. All appropriate tests, studies, and consultation should be accomplished and all clinical findings should be reported in detail with a full description of the Veteran’s adjustment disorder with anxiety, including the level of social and occupational impairment attributable to the Veteran’s adjustment disorder with anxiety.
If the psychologist or psychiatrist is unable to render the requested opinion without resort to speculation, he or she must so state. However, a complete explanation for such a finding must be provided. 
The examiner’s attention is drawn to the following:
*Private psychological evaluation documents that on mental status examination, the Veteran was casually dressed and appeared to relate well. He maintained good eye contact and there was no psychomotor agitation or retardation. His speech was regular rhythm and delivery and there was no dysarthria. His mood was depressed and his affect was congruent with his mood. Thought process and thought content were within normal limits. There was no evidence of paranoia or delusions. He denied suicidal or homicidal ideation. He was oriented but had problems focusing and concentrating. He had fair insight into his issues and had fair judgment.  
*VA examination report of February 2014 documents that the Veteran’s adjustment disorder was productive of occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress or symptoms controlled by medication. Documented symptoms of the Veteran’s adjustment disorder included anxiety and suspiciousness. 
*December 2013 to July 2015 private treatment records document the treatment the Veteran received for his acquired psychiatric disorder. The July 2015 private psychiatric record reflects that the Veteran continued to have active symptoms of his psychiatric disorder. He reported that he left his job in February 2015 and has not worked since that time. He complained of problems at night, namely hyperarousal and alertness. On mental status examination, he was anxious. He had a blunted affect with psychomotor retardation. He was cooperative and answered the questions appropriately without being spontaneous. There was no pressured speech. He complained of anxiety, depression and hyperarousal symptoms. His affect was congruent with his mood. He had no flight ideas, looseness of association or circumstantial thought. He denied any auditory, visual and tactile hallucinations. He had a general mistrust of people and a general discomfort when he was in a crowd. He had obsessive thought about being safe. He denied suicidal or homicidal thought or any self-injurious behavior; there was no evidence of delusions.  
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THE EXAMINER IS ADVISED THAT BY LAW, THE MERE STATEMENT THAT THE CLAIMS FOLDER WAS REVIEWED AND/OR THE EXAMINER HAS EXPERTISE IS NOT SUFFICIENT TO FIND THAT THE EXAMINATION IS SUFFICIENT.
 
Vito A. Clementi
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	G. Jackson, Counsel