Citation Nr: 18146121 Decision Date: 10/30/18 Archive Date: 10/30/18 DOCKET NO. 16-35 660A DATE: October 30, 2018 REMANDED Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1981 to June 1987 and from September 1999 to July 2013. This matter is on appeal from a September 2013 rating decision, which granted entitlement to service connection for PTSD with a disability rating of 30 percent, effective August 1, 2013. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is remanded. A review of the claims file reveals that a remand is necessary before a decision on the merits of the claim can be reached. The Veteran was afforded a PTSD VA examination in March 2016. Based on the clinical evaluation, the examiner diagnosed the Veteran with PTSD under DSM-5 criteria, and opined that he has symptoms resulting in “[o]ccupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication.” The examiner reported that the Veteran had the following symptoms for VA rating purposes: anxiety, panic attacks that occur weekly or less often, and chronic sleep impairment In July 2016, the Veteran submitted a VA Form 9, in which he reported that he had lost his job as an emergency room nurse due to internal stress and turmoil. He contended that a 30 percent disability rating did not adequately address his symptoms. In February 2018, the Veteran’s representative submitted a Review PTSD Disability Benefits Questionnaire (DBQ) that was completed in January 2018 by Dr. B.L.S., the Veteran’s treating psychologist. The DBQ examination was completed without a review of the Veteran’s records as the examiner reported “[r]ecords are not available at this time.” She diagnosed the Veteran with PTSD and severe major depression with anxious distress and reported that it was possible to differentiate what symptoms are attributable to each diaganosis. The examiner reported that the Veteran’s level of occupational and social impairment was occupational and social impairment with reduced reliability and productivity. She indicated that it was not possible to differentiate what portion of the occupational and social impairment was caused by each of the Veteran’s mental disorders. The examiner reported on the January 2018 DBQ that the Veteran had the following symptoms for VA rating purposes: depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; chronic sleep impairment; impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks; flattened affect; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work like setting; inability to establish and maintain effective relationships; and neglect of personal appearance and hygiene. In June 2018, the Veteran’s representative submitted a Review PTSD DBQ that was completed in May 2018 by Dr. B.L.S., the Veteran’s treating psychologist. The DBQ does not reflect that the examiner reviewed the Veteran’s claims file as she specified that the records reviewed were “TRIWEST records.” The examiner diagnosed the Veteran with PTSD and severe major depression with anxious distress but failed to report the Veteran’s level of occupational and social impairment. However, despite failing to report a level of impairment, she curiously indicated that it was possible to differentiate what portion of the occupational and social impairment was caused by each of the Veteran’s mental disorders. In response to the DBQ’s instruction to list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis, the examiner reported the following: “Depression – little interest in any activity; depressed mood most everyday; insomnia; fatigue, problems with concentration; feelings of worthlessness.” The examiner reported on the May 2018 DBQ that the Veteran had the following symptoms for VA rating purposes: depressed mood; anxiety; suspiciousness; panic attacks more than once a week; chronic sleep impairment; impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks; flattened affect; impaired judgment; gross impairment in thought processes or communication; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work like setting; inability to establish and maintain effective relationships; suicidal ideation; and impaired impulse control, such as unprovoked irritability with periods of violence. Considering the Veteran’s report in July 2016 that he had lost his job as a nurse and the extensive number of symptoms listed in the PTSD DBQs completed in January 2018 and May 2018, the Board notes that it appears that the Veteran’s impairment level became worse in the period following the March 2016 VA examination. However, both PTSD DBQs completed in 2018 are inadequate to assess the Veteran’s level of occupational and social impairment. The January 2018 DBQ is inadequate because the examiner’s findings are equivocal. The examiner diagnosed the Veteran with PTSD and severe major depression with anxious distress, and she indicated that it was possible to differentiate the symptoms attributable to each diagnosis. However, the examiner provided the following non-sensical response to the DBQ’s instruction to list which symptoms are attributable to each diagnosis: “His depression, though severe, is somewhat separated from his wife.” This response by the examiner fails to describe which symptoms are attributable to PTSD and major depressive disorder. A medical opinion must “support its conclusions with an analysis that the Board can consider and weigh against contrary opinion.” Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The January 2018 examiner reported that the Veteran’s level of occupational and social impairment was occupational and social impairment with reduced reliability and productivity. She indicated that it was not possible to differentiate what portion of the occupational and social impairment was caused by each of the Veteran’s mental disorders because “many of the symptoms overshadow the others.” However, a little more than four months later, the examiner completed another DBQ in May 2018 in which she indicated that it was possible to differentiate what portion of the occupational and social impairment was caused by each of the Veteran’s mental disorders. Furthermore, the examination was based upon the Veteran’s testimony without a review of the Veteran's claims file, as the examiner reported “[r]ecords are not available at this time.” For the foregoing reasons, the Board affords little probative weight to the January 2018 DBQ. The May 2018 DBQ is inadequate because the examiner indicated that it was possible to differentiate what portion of the occupational and social impairment was caused by each of the Veteran’s mental disorders yet failed to report a level of impairment. Furthermore, in response to the DBQ’s instruction to list which portion of the indicated level of occupational and social impairment is attributable to each diagnosis, the examiner reported the following: “Depression – little interest in any activity; depressed mood most everyday; insomnia; fatigue, problems with concentration; feelings of worthlessness.” This response by the examiner fails to describe which portion of the indicated level of occupational and social impairment is attributable to PTSD and major depressive disorder. See Stefl, 21 Vet. App. at 124; see also Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (noting that factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). Moreover, it not clear whether the examiner reviewed the Veteran’s claims file as she specified that the records reviewed were “TRIWEST records.” For the foregoing reasons, the Board affords little probative weight to the May 2018 DBQ. In view of the foregoing, the Board finds that a remand for a medical examination to assess the current severity of the Veteran’s PTSD is necessary. The matter is REMANDED for the following action: 1. Obtain any outstanding pertinent VA and private treatment records not evidenced by the current record and associate with the claims file. 2. Schedule the Veteran for a VA psychiatric examination to assess the current severity of his PTSD. The examiner must review the claims file and must note that review in the examination report. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The examiner must consider the Veteran’s statements regarding the severity of his symptomatology. The examiner should make specific findings as to the presence, extent, and frequency of all symptoms of his PTSD. The examiner should provide an assessment of the severity of PTSD, specifically commenting on the functional effects of the Veteran’s PTSD. The examiner is advised that the Veteran is competent to report history and symptoms and that his or her reports must be considered in formulating any requested opinion. If the examiner rejects the Veteran’s reports, the examiner must provide a rationale for doing so. 3. After completing the requested actions, and any additional development deemed warranted, readjudicate the claims in light of all pertinent evidence and legal authority. If the claims remain denied, a supplemental statement of the case must be provided to the Veteran. After the Veteran and any representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans’ Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Moore, Associate Counsel