Citation Nr: 18144574 Decision Date: 10/25/18 Archive Date: 10/24/18 DOCKET NO. 16-37 955 DATE: October 25, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress (PTSD) disorder, is remanded. REASONS FOR REMAND The Veteran had active duty service from July1968 to April 1970 and is a Purple Heart recipient. After review of the record, the Board finds that further development is necessary before the Board can properly adjudicate the Veteran’s claim. The Veteran is seeking service connection for PTSD. Generally, service connection requires competent evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). To establish entitlement to service connection for PTSD the evidence must satisfy three basic elements. There must be 1) medical evidence diagnosing PTSD; 2) a link, established by medical evidence, between current symptoms of PTSD and an in-service stressor; and 3) credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304 (f). A diagnosis of PTSD must be established in accordance with 38 C.F.R. § 4.125 (a), which simply mandates that, for VA purposes, all mental disorder diagnoses must conform to the criteria of the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders (DSM). During the appeal period, the criteria of DSM-IV initially applied but, following a revision to the DSM, VA now recognizes the application of DSM-V. See 79 Fed. Reg. 45099 (August 4, 2014). In the Veteran’s case, military personnel records confirm receipt of a Combat Infantryman’s Badge and Purple Heart as a result of active duty service in Vietnam; therefore, the Veteran’s in-service stressor is conceded. With regard to a current disability, the Veteran has received VA examinations to determine the nature and etiology of his psychiatric disorder; however, no diagnosis of PTSD was made. Particularly, in his May 2011 PTSD examination, the examiner found that the Veteran did not meet the full criteria for PTSD. Instead, the examiner diagnosed the Veteran with primary insomnia. Similarly, in his July 2014 examination, the examiner found that the Veteran did not meet the criteria for PTSD under DSM IV or DSM V. Alternatively, the examiner diagnosed the Veteran with unspecified anxiety disorder. Despite the above findings, the Board notes that the United States Court of Appeals for Veterans Claims (Court) in Clemons v. Shinseki, 23 Vet. App. 1 (2009), has held that an initial claim of entitlement to service connection for PTSD should be read as including other psychiatric disorder diagnoses reasonably raised by the symptoms described and all information obtained in support of the claim. A review of the Veteran’s claims file shows that the Veteran was diagnosed with anxiety disorder as early as March 2013. Additionally, the May 2011 examiner noted that the Veteran was being treated for anti-anxiety and has been taking Lorazepam for sleep for 15 to 20 years. Given the holding in Clemons, the Board has recharacterized the Veteran’s psychiatric claim to include all diagnosed psychiatric disorders, and finds that any and all of the Veteran’s diagnosed psychiatric disorders should be considered when determining service connection. As such, a new examination and opinion is warranted to determine the nature and etiology of the Veteran’s psychiatric disorder throughout the entirety of the appeal period. Further, VA treatment records show that the Veteran was diagnosed with PTSD in March 2013 and July 2015. The Veteran has also been treated for this condition. Therefore, an opinion should be obtained reconciling the opinions from the May 2011 and July 2014 examiners who found that the Veteran did not meet the criteria for a PTSD diagnosis. Lastly, although the above-referenced examiners found that the Veteran lacked certain criteria for a PTSD diagnosis, the Board notes that the Veteran and his spouse have submitted several detailed statements describing the effects of his PTSD, and the impairments it causes. The Board finds the Veteran and his spouse competent to report observable symptoms, as doing so requires only personal knowledge. Layno v. Brown, 6 Vet. App. 465 (1994). The Board also finds the Veteran and his spouse credible in this regard. On remand, these lay statements must be considered by the examiner in formulating his or her medical opinion; otherwise, the examination will be deemed inadequate. Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006). Accordingly, the matter is REMANDED for the following action: 1. Obtain all of the Veteran’s outstanding VA treatment records from July 2015 to present. All efforts to obtain these records must be documented in the Veteran’s claim file. 2. Schedule the Veteran for a retrospective examination with different examiners than those in the Veteran’s May 2011 and July 2014 examinations. The examiner should address the current and past nature and etiology of the Veteran’s psychiatric disorder(s) over the entire claim period. The claims file, including this Remand, must be made available to and reviewed by the examiner. Any indicated studies should be performed. The record shows that the Veteran lives in Costa Rica; therefore, if the Veteran is unable to attend an examination, provide a medical opinion based upon a review of the Veteran’s entire claim file. 3. The examiner should first identify all psychiatric disabilities present during the pendency of the claim. If the examiner determines that any prior diagnoses are incorrect, he or she should provide an explanation for why the diagnosis was in error. 4. Then, for each identified psychiatric condition, the examiner should provide an opinion as to whether it is at least as likely as not (a degree of probability of 50 percent or greater) that any diagnosed psychiatric disorder is etiologically related to service. The examiner should set forth all examination findings and a complete rationale for any opinions expressed should be provided. All necessary special studies or tests, to include psychological testing and evaluation, should be accomplished. If the examiner determines that he or she is unable to provide the requested opinion without resort to speculation, the examiner must provide a reasoned explanation for such conclusion. 5. Then, readjudicate the claim. If any benefit sought remains denied, the AOJ should issue an appropriate supplemental statement of the case and afford the Veteran and his representative the opportunity to respond. The case should then be returned to the Board for further review. Gayle E. Strommen Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Laffitte, Associate Counsel