Citation Nr: 18142888 Decision Date: 10/17/18 Archive Date: 10/16/18 DOCKET NO. 16-31 498 DATE: October 17, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served with the United States Army from May 27, 1981 to August 28, 1987, October 8, 2001 to October 4, 2002, March 26, 2006 to April 24, 2007 and July 30, 2009 to March 20, 2010. As the record reflects potential diagnosis for an anxiety disorder in addition to the claimed PTSD, the Board has recharacterized the claim to include acquired psychiatric disorders generally. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). 1. Entitlement to service connection for an acquired psychiatric disorder to include, PTSD. The Veteran seeks service connection for PTSD. He has confirmed service in Iraq and is in receipt of combat medals for duties fulfilled therein. Considering the record, in-service stressors are conceded. That said, the record remains unclear as to the existence of a current disability. See April 2015 Rating Decision. VA records contain notations of a PTSD diagnosis provided by a VA general care provider. See Atlanta VAMC Records. However, this diagnosis does not appear to have been predicated on DSM criteria. Additionally, in March 2015 a VA examiner opined that the Veteran did not have sufficiently severe psychological symptomatology to warrant a PTSD or anxiety disorder diagnosis. Nevertheless, the examiner essentially indicated that the Veteran’s psychological state was dynamic in nature and it is possible that his symptoms at an earlier date would have warranted psychiatric diagnosis. The Board finds that a remand is required. First, 2015 VA treatment records reflect that at the time of VA examination the Veteran was being prescribed Lorazepam for anxiety by a private care physician. Treatment records from this physician are not in evidence. Correspondingly, the effects of this anxiety medication on the Veteran’s symptomatology/diagnosis were not discussed by the 2015 examiner. Second, throughout the record the Veteran has reported being diagnosed with PTSD in between his periods of service by a private physician. These records are not in evidence and should also be obtained. Finally, given the need for clarification as to the effects of his psychiatric medication, and the noted dynamic nature of his psychological state, a new VA examination should be obtained. The matter is REMANDED for the following action: 1. Contact the Veteran and provide him with a VA Form 21-4142, Authorization and Consent to Release Information to VA, in order to obtain any private treatment psychiatric records. Advise the Veteran that he may submit his private treatment records if he so chooses. If a negative response is received from the Veteran, or any private treatment provider, the claims file should be properly documented in this regard. NOTE: The Board is particularly interested in counseling records prepared in between his periods of service, records prepared by the private treating physician who prescribed the Veteran Lorazepam, and any records discussing his diagnosis of PTSD. Associate all records of the Veteran’s VA treatment medical records with his electronic claims file (VBMS). If a review of these records discloses the existence of other pertinent records under federal control (i.e., VA or military facility as a retiree), such records should be obtained as well. 2. Schedule the Veteran for a new examination with the 2015 examiner, or if unavailable, an appropriate clinician to determine the nature and etiology of any acquired psychiatric disorder. Following review of the claims file, interview, and examination, with any necessary testing, the examiner should address the following: (a.) Identify/diagnose any acquired psychiatric disorder that presently exists or that has existed during the appeal period. State whether the Veteran meets the criteria for a diagnosis of PTSD or anxiety disorder. If a diagnosis of PTSD or anxiety disorder is not made, the examiner should reconcile such a finding against the diagnoses of record and his prescription for Lorazepam. (b.) If a diagnosis of PTSD is made, the stressor(s) relied on should be identified. Note: The Veteran’s reported wartime stressors have been conceded. (c.) For each psychiatric diagnosis, state whether it is as likely as not that the disorder had its onset in service or is otherwise etiologically related to the Veteran’s active service, to include being the result of an incident or stressor during service. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. L. Burroughs, Associate Counsel