Citation Nr: 18143786 Decision Date: 10/22/18 Archive Date: 10/22/18 DOCKET NO. 06-04 209 DATE: October 22, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder other than posttraumatic stress disorder (PTSD) to include major depressive disorder, dysthymia, and adjustment disorder is remanded. Entitlement to service connection for PTSD is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1965 through February 1967. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2005 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In May 2017, the Court of Appeals for Veterans Claims (Court) remanded the case for further development upon a Joint Motion for Remand (JMR). The Board thereafter remanded the claims in August 2017 for compliance with the JMR. The case has returned to the Board for further appellate proceedings. The issue of TDIU was previously remanded and remains at the AOJ stage. Service connection for an acquired psychiatric disorder other than PTSD as well as service connection for PTSD The Board previously remanded these claims in August 2017 for the AOJ to provide the Veteran with a VA examination to determine whether he met the DSM-IV criteria for a diagnosis of PTSD or any other acquired psychiatric disorder and whether such disorder is related to his service, to include his reported stressor of being in fear of enemy fire during service in Vietnam. Pursuant to the August 2017 Board remand, the Veteran was provided a VA psychological examination in October 2017. After examination of the Veteran and consideration of his medical history, the VA examiner diagnosed the Veteran with PTSD. Although he opined that the Veteran meets the criteria for PTSD and that it is at least as likely as not related to his service in Vietnam, she could not opine as to when the PTSD originated without resort to speculation. Moreover, the VA examiner’s diagnosis of PTSD was in accordance with the DSM-5 criteria, not the DSM-IV as instructed in the August 2017 remand. She also diagnosed the Veteran with depressive disorder and while she opined that such disability is related to the Veteran’s fear of outcome with medical issues pertaining to his bladder cancer, she did not provide a rationale for her opinion. Further, the diagnosis of depressive disorder was not in accordance with the DSM-IV but rather the DSM-5, and she did not comment on the etiology of the Veteran’s previously diagnosed dysthymia and adjustment disorder as was instructed in the previous remand. Additionally, as to the Veteran’s alcohol abuse, the VA examiner did not address whether the Veteran’s diagnosed alcohol use disorder is a symptom of, or the result of, any diagnosed mental health disorders. In light of the inadequacies of the VA examination discussed above, the Board finds that remand is warranted for compliance with the August 2017 Board remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are REMANDED for the following action: 1. Forward the claims file to the VA examiner who provided the VA psychological examination for the Veteran’s acquired psychiatric disorder in October 2017. If that examiner is not available, then forward the claims file to another appropriate medical professional. The examiner is requested to review all pertinent records associated with the claims folder, including the Veteran’s service treatment records, post-service medical records, and lay statements. If the clinician determines that another examination is needed, the Veteran should be scheduled for a new examination. Based on the review of the Veteran’s claims file, the examiner is asked to provide a multi-axis diagnosis for the Veteran, including Axis I diagnoses of any psychiatric disorders. In expressing the diagnosis(es), the examiner should state with specificity how the Veteran’s current and previous symptomatology, as reported by the Veteran and noted in the other evidence in the claims file, meets the DSM-IV criteria for each diagnosed psychiatric disorder. The examiner’s explanation should also take into account and address the symptoms, findings, and diagnoses expressed in the Veteran’s lay statements; service treatment records; post-service treatment records, to include the Veteran’s VA treatment records, prior May 2005 VA examination, and social security records. If the examiner finds that the Veteran does not demonstrate a current psychiatric disorder, then the examiner should provide an explanation as to how the Veteran’s current and previous symptomatology do not meet the DSM-IV criteria for PTSD. Please also address whether the Veteran could have had any other acquired psychiatric condition other than PTSD, to include major depressive disorder, dysthymia, and adjustment disorder, based on the earlier diagnoses that occurred within the appeals period. See McClain, 21 Vet. App. at 321. The examiner should also address whether the Veteran’s diagnosed alcohol use disorder is a symptom of, or the result of, any diagnosed mental health disorders. If the Veteran is diagnosed with PTSD under DSM-IV criteria specifically, the examiner should then offer opinions as to whether it is at least as likely as not (that is, a 50 percent or greater probability) that the Veteran’s reported stressors are adequate to support a diagnosis of PTSD and whether the Veteran’s symptoms are related to those reported stressors. If the Veteran is diagnosed with any psychiatric disorder other than PTSD, then the examiner should specifically offer an opinion as to whether it is at least as likely as not that the diagnosed psychiatric disorder was sustained during service, or, is etiologically related to his combat experience or any injury or illness sustained by the Veteran during his active duty service. A complete rationale must be given for all opinions and conclusions. Such rationale must include a discussion of all relevant evidence in the claims file and supporting medical principles, and, must be expressed in a typewritten report. If the examiner is unable to reach any of the requested opinions without resort to speculation, he or she should explain the reasons for this inability and comment on whether any further tests, evidence or information would be useful in rendering an opinion. 2. Review the claims file to ensure that all the foregoing requested development is completed, and arrange for any additional development indicated. Then readjudicate the claims on appeal. If the benefits sought remain denied, issue an appropriate supplemental statement of the case and provide the Veteran and his representative with the requisite period of time to respond. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Arif Syed, Counsel