Citation Nr: 18146774 Decision Date: 11/01/18 Archive Date: 11/01/18 DOCKET NO. 15-02 671 DATE: November 1, 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 on active duty from September 1967 to September 1969. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a December 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran testified at a hearing before the undersigned Veterans Law Judge in July 2018. A transcript of that proceeding is associated with the record. The Veteran has contended that he has an acquired psychiatric disorder due to service. During the July 2018 hearing, the Veteran reported that, while he was serving on a detail in Vietnam, an individual with whom he was working began to fire a weapon at children that had gathered around them. The Veteran also reported that he had memories of shooting at enemy forces. His wife and son reported that the Veteran had angry outbursts and would get upset easily. In November 2011, the Veteran was afforded a VA examination. The examiner found that the Veteran did not have a diagnosis of PTSD or of any other mental condition. During the July 2018 hearing, the Veteran reported that he had been receiving treatment for PTSD since 2011 from Dr. P and from Dr. G (initials used to protect privacy) and that he had been diagnosed with PTSD. At the time of the hearing, these records had not been submitted or associated with the claims file. In August 2018, the Veteran submitted VA treatment records from December 2011 through August 2018. These VA treatment records documented the Veteran’s diagnosis of PTSD, and the treatment he had been receiving. Given this evidence of a diagnosis of PTSD, a remand is necessary to obtain an additional VA examination and opinion which addresses the nature and etiology of the Veteran’s acquired psychiatric disorder. The Board also notes that the November 2011 VA examiner relied upon the Fourth Edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), in diagnosing the Veteran. Effective August 4, 2014, VA amended the portion of the rating schedule dealing with mental disorders and its adjudication regulations to incorporate the Fifth Edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) rather than the Fourth Edition (DSM-IV). As this issue was certified to the Board after that time, the regulations pertaining to the DSM-5 are for application. See 79 Fed. Reg. 45093 (Aug. 4, 2014) and 80 Fed. Reg. 14,308 (March 19, 2015) (adopting interim final rule as final). The matter is REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for any psychiatric disorder. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure all VA treatment records, including any records from Dr. P and from Dr. G (initials used to protect privacy). 2. After completing the foregoing development, the Veteran should be afforded a VA examination to determine the nature and etiology of any acquired psychiatric disorder(s), including PTSD, that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should identify all current psychiatric disorders under the DSM-5 criteria. If any previously diagnosed psychiatric disorders are not found on examination, the examiner should address whether such disorders were misdiagnosed or have resolved. For each diagnosis identified other than PTSD, the examiner should discuss whether it is at least as likely as not that the disorder manifested in service or is otherwise causally or etiologically related to the Veteran’s military service. Regarding PTSD, the AOJ should provide the examiner with a summary of any verified in-service stressors. The examiner must be instructed that only these events, as well as any stressors related to fear of hostile military or terrorist activity, may be considered for the purpose of determining whether exposure to an in-service stressor has resulted in PTSD. The examiner should determine whether the diagnostic criteria to support the diagnosis of PTSD have been satisfied. If the PTSD diagnosis is deemed appropriate, the examiner should then comment upon the link between the current symptomatology and any in-service stressor. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find favor of conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history[,]” 38 C.F.R. § 4.1, copies of all pertinent records in the Veteran’s claims file, or in the alternative, the claim file, must be made available to the examiner for review. 3. After obtaining the requested medical opinions, the AOJ should review the examination report to ensure that it is in compliance with this remand. If it is deficient in any manner, the AOJ should implement corrective procedures. 4. After completing these actions, the AOJ should conduct any other development as may be indicated by a response received as a consequence of the actions taken in the preceding paragraphs. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Saikh, Associate Counsel