Citation Nr: 18150660
Decision Date: 11/15/18	Archive Date: 11/15/18

DOCKET NO. 15-00 526A
DATE:	November 15, 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 May 1968 to June 1970.
This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2013 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO) in Phoenix, Arizona.
VA treatment records show findings of major depressive disorder.  Accordingly, the Board has widened the scope of the Veteran’s psychiatric claim for PTSD to include all psychiatric diagnoses.  See Clemons v. Shinseki, No. 07-558 (Feb. 17, 2009) (the scope of a mental health disability claim includes any mental disability that may reasonably be encompasses by the claimant’s description of the claim, reported symptoms, and the other information of record).  Thus, the issue has been recharacterized to include all acquired psychiatric disorders, as is listed on the title page of this decision.
The Veteran’s service treatment records show that he was treated for “chronic anxiety state” in December 1969.  His service personnel records also reflect some difficulties with behavior.  He was afforded a VA examination in May 2013; however, the examiner did not provide an opinion as to whether the Veteran’s diagnosed major depressive disorder was related to his military service.  As such, remand is required to obtain an adequate medical opinion.  Further, a new examination is necessary to obtain diagnoses using the updated criteria in the Diagnostic and Statistical Manual (Fifth Edition) (DSM-5) as the Veteran's appeal was certified to the Board after August 4, 2014.  See 79 Fed. Reg. 149, 45094 (August 4, 2014).
As the case must be remanded, the Veteran’s updated VA treatment records should also be obtained.
The matter is REMANDED for the following action:
1. Make arrangements to obtain the Veteran’s VA treatment records, dated from August 2014 forward.
2. Thereafter, arrange for the Veteran to undergo VA examination by a VA psychologist or psychiatrist.  The Veteran’s claims file, including a copy of this REMAND, must be made available to and reviewed by the examiner in conjunction with the examination.  The examiner should elicit a full history from the Veteran. Any medically indicated tests should be conducted.
(a) The examiner must identify all current psychiatric disorders found to be present.  The examiner should clearly indicate whether the Veteran has PTSD or any other psychiatric disorder in accordance with the DSM-5. 
(b) For any diagnosed psychiatric disorder, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that it had its clinical onset during active service or is related to any incident of service.  
In providing this opinion, the examiner should specifically consider and address the Veteran’s service treatment records showing that he was treated for “chronic anxiety state” in December 1969, as well as his service personnel records reflecting some difficulties with behavior.  
The examiner must also address the relationship between any diagnosed PTSD and the Veteran’s asserted claimed in-service stressor(s).  The examiner must specifically address whether each claimed stressor(s) is adequate to support a diagnosis of PTSD and whether the Veteran’s symptoms are related to the claimed stressor(s). 
A supporting rationale for all opinions expressed must be provided.  If the examiner is unable to provide any opinion as requested, the examiner should fully explain the reason why such opinion could not be rendered.

 
P.M. DILORENZO
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	L. Sinckler, Associate Counsel