Citation Nr: 18155604 Decision Date: 12/04/18 Archive Date: 12/04/18 DOCKET NO. 16-38 466 DATE: December 4, 2018 REMANDED The claim of entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1969 to September 1971 and served in Vietnam from June 1969 to June 1970. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). Entitlement to service connection for a psychiatric disorder, to include PTSD. Initially, the Board notes that the claim of entitlement to service connection for PTSD has been broadened to include any psychiatric disorders diagnosed during the appeal period. A claim for service connection for a disability encompasses all relevant symptoms, regardless of how that symptomatology is diagnosed. Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009). This is because a claimant generally is not competent to diagnose his or her specific condition where such a diagnosis requires medical expertise; he is only competent to identify and explain the symptoms that he observes and experiences. Clemons, 23 Vet. App. at 4-5. Accordingly, because there are other diagnoses of record, on remand, the issue is broadened to a claim of entitlement to service connection for a psychiatric disorder, to include PTSD. Next, effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders to remove outdated references to the DSM-IV and replace them with references to the updated Diagnostic and Statistical Manual (Fifth Edition), the DSM-5. See 79 Fed. Reg. 45,094 (August 4, 2014). VA adopted this interim rule without change and clarified that the provisions of this rule did not apply to claims that have been certified for appeal to the Board or were pending before the Board on or before August 4, 2014. 80 Fed. Reg. 14,308 (March 19, 2015). In this case the RO initially certified the Veteran’s appeal to the Board in 2015. Thus, the DSM-5, not the DSM-IV, is the applicable edition for consideration. The Veteran claims he has PTSD as a result of exposure to combat during his verified service in the Republic of Vietnam during the Vietnam War. See July 2010 claim and September 2010 statement. VA provided an examination in December 2010. Using the DSM-IV criteria, the examiner found that the Veteran did not have PTSD, explaining that the psychometric testing revealed scores that were not consistent with PTSD. The examiner did not discuss whether the Veteran had any other psychiatric disorders. The Veteran submitted a December 2011 note from Dr. DR, who had performed a history and physical examination of the Veteran in July 2011. The doctor had utilized a PTSD screening tool and found that it was at least as likely as not that the Veteran currently has PTSD. VA treatment records show diagnoses of anxiety disorder in August 2011, an adjustment disorder with anxiety and depression, rule out PTSD, in October 2011. An addendum to the October 2011 VA treatment record indicates that the diagnosis was amended to PTSD, chronic, delayed onset. The record contains several psychiatric diagnoses. On the issue of whether PTSD is present, the record is also in conflict. The Board finds that a new examination should be provided to reconcile the various findings of record. As noted by the Veteran’s representative in the November 2018 Informal Hearing Presentation, the December 2010 VA examination made use of the DSM-IV, and so the new examination on remand should use DSM-5 criteria. The matter is REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his or her representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his psychiatric disorder. The entire claims file should be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. a. The examiner must determine what psychiatric disorders the Veteran has. If any previous diagnosis is not found, including PTSD, anxiety disorder, and adjustment disorder with anxiety and depression, the examiner should address the prior diagnoses of record. b. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that each diagnosed psychiatric disorder, to include PTSD, had its onset in, or is otherwise caused by, the Veteran’s military service. The examiner must address the following: 1) a December 2011 letter from Dr. DR that diagnoses the Veteran with PTSD; 2) VA treatment records from 2011 diagnosing anxiety disorder and adjustment disorder with anxiety and depression; 3) the 2010 VA examination; and 4) the Veteran’s statements regarding rocket attacks on his base while Vietnam from June 1969 to June 1970. 4. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claim, and that the consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2017). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Department of Veterans Affairs