Citation Nr: 18152468 Decision Date: 11/23/18 Archive Date: 11/23/18 DOCKET NO. 16-22 828 DATE: November 23, 2018 REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1969 to December 1975. This matter is on appeal of an August 2013 rating decision. Once VA undertakes the effort to provide an examination, it must ensure the examination is adequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board finds that the April 2013 VA examiner’s indication that the Veteran did not currently meet the criteria for a diagnosis of PTSD, and the February 2015 VA examiner’s conclusion that the Veteran’s only current psychiatric diagnoses were major depressive disorder (MDD), delusional disorder and anxiety disorder, are inadequate for rating purposes. During the course of the appeal, submitted private treatment records show the Veteran was assessed with PTSD as early as March 2012 and a May 2014 VA treatment record indicates that the Veteran had a positive screening for PTSD. Additionally, in an August 2012 letter, the Veteran’s private treating psychologist indicated that the Veteran was being treated for diagnosed PTSD and depression. In a later, February 2015 letter, the same psychologist opined that the Veteran’s diagnosed Crohn’s disease, diagnosed during service, contributed to his PTSD diagnosis. Service connection has been granted for the Veteran’s diagnosed Crohn’s disease. The Veteran submitted a copy of a December 2010 internet medical article indicating that research suggested that Crohn’s disease and the treatment for it could be perceived as traumatic and that persons with Crohn’s disease might develop PTSD. Research findings suggested a causal relationship between Crohn’s disease and PTSD. Although both VA examiners were unable to diagnose PTSD currently, VA and private treatment records during the course of the Veteran’s appeal clearly show he had been receiving ongoing treatment for diagnosed PTSD in addition to MDD, delusional and anxiety disorders. Service connection may be awarded for a disability if the claimant had the disability at the time the claim was filed or during the pendency of that claim, even if no disability is present at the time of the claim’s adjudication. See McClain v. Nicholson, 21 Vet. App. 319 (2007). The Board finds that the April 2013 VA examiner’s opinion did not contain adequate rationale for the conclusion reached. In this respect, the examiner found that while administered psychiatric testing showed the Veteran exceeded the cutoff for a PTSD diagnosis, there was no evidence of re-experiencing symptoms. The examiner provided an Axis I diagnosis of anxiety disorder, NOS and indicated that the Veteran endorsed avoidance/numbing and hyperarousal symptoms of PTSD, without persistent reexperiencing symptoms. Therefore, although the examiner did not specifically indicate whether the Veteran met the criteria for PTSD, the examiner presumably concluded that his symptoms did not meet the criteria for a diagnosis of PTSD. The February 2015 VA examiner, after noting that the Veteran had previously been diagnosed with PTSD, provided no rationale for the determination that the Veteran had no current psychiatric diagnoses other than MDD, delusional and anxiety disorders. The February 2015 examiner also noted that the Veteran’s electronic claims file was not available for review, and there was only limited access to local treatment records. Therefore, the examinations are inadequate for rating purposes. Further, neither VA examiner addressed the private psychologist’s opinion that the Veteran had a current diagnosis of PTSD, nor the medical article suggesting a causal link between Crohn’s disease and PTSD. The Veteran must be provided another VA psychiatric examination to determine whether he has had a diagnosis of PTSD at any time during the pendency of his appeal, and if so, the etiology of his diagnosis. Regarding the diagnosis of any psychiatric disabilities on examination, a final rulemaking amended § 4.125(a), effective August 4, 2014, to state that diagnosis of a mental disorder must conform to DSM-5, not DSM-IV. 80 Fed. Reg. 14,308 (Mar. 19, 2015). The applicability date of the final rulemaking states that “[t]he Secretary does not intend for the provisions of th[e] final rule to apply to claims that were pending before the Board of Veterans’ Appeals (i.e., certified for appeal to the Board of Veterans’ Appeals on or before August 4, 2014) . . . even if such claims are subsequently remanded to the agency of original jurisdiction.” The Veteran’s case was initially certified for appeal to the Board in January 2018; therefore, DSM-5 is applicable to his case and the examination completed on remand must conform to DSM-5 criteria. A December 2009 private treatment record indicates the Veteran was applying for Social Security Administration (SSA) disability benefits. A review of the record did not find any SSA records had been associated with the claims file, and there is no indication that such records have been sought. SSA records are constructively of record, and the Board is obligated to obtain them when there is a reasonable possibility that they could help the appellant substantiate a claim for VA benefits. Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). Any SSA records could shed additional light on the Veteran’s claim. As such, an attempt should be made to obtain any available SSA determination and any available medical records the determination was based on. Finally, while the appeal is in remand status, all of the Veteran’s contemporaneous and relevant outstanding treatment records should also be obtained and associated with the claims file. 38 U.S.C. § 5103A(b). The matter is REMANDED for the following action: 1. Contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his claim, to include private treatment records from Dr. D.I. Based on his response, attempt to procure copies of all records which have not previously been obtained from identified treatment sources. 2. Obtain the Veteran’s VA treatment records for the period from May 2015 to the present. 3. Secure for the record from the SSA complete records pertaining to any determination regarding SSA disability benefits. All medical evidence considered in connection with the determination must be obtained. If such records are not available, it should be so noted in the record with explanation (e.g., that the records have been lost or destroyed). 4. Afford the Veteran a VA psychiatric examination by an appropriate medical professional to determine the current nature and etiology of diagnosed PTSD, if found to be present. The entire claims file, to include all electronic files, must be reviewed by the examiner. Based on review of all the evidence of record, and the Veteran’s elicited history, the examiner is to: a.) Determine whether the Veteran meets or met DSM-5 criteria for a diagnosis of PTSD at any time during the pendency of the claim (since August 2012). b.) If PTSD is diagnosed in accordance with a.), then opine as to whether it is at least as likely as not (50 percent or greater probability) related or attributable to any incident of the Veteran’s military service, to include any alleged stressor in service, including the in-service diagnosis of Crohn’s disease, and/or treatment for it? c.) If not, is it at least as likely as not (50 percent or better probability) that the Veteran’s current PTSD was caused or aggravated by (where aggravation is any increase in severity beyond the natural progress of the disability) service-connected Crohn’s disease, to include treatment for such disease? A complete rationale for all opinions must be provided that addresses the Veteran’s VA and private treatment records showing assessments of PTSD as early as August 2012, the private psychologist’s August 2012 opinion, and the December 2010 research articles, as well as the April 2013 and February 2015 VA examiners’ opinions. If the examiner cannot provide a requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Wells-Green