Citation Nr: 18156070 Decision Date: 12/06/18 Archive Date: 12/06/18 DOCKET NO. 16-22 294 DATE: December 6, 2018 REMANDED The issue of entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran had a period of active duty for training (ACDUTRA) from July 1976 to November 1976. The Veteran served on active duty in the U.S. Army National Guard from December 2003 to June 2004, to include service in Southwest Asia, and in the U.S. Army from May 2007 to May 2009. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2013 rating decision of the San Juan, Puerto Rico Regional Office (RO). PTSD The record contains a VA PTSD examination and VA treatment records that all used the DSM-IV criteria. Remand is necessary to determine whether the Veteran has a PTSD diagnosis under the DSM-V criteria. Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities (Rating Schedule) to remove outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and replace them with references to the updated Fifth Edition (DSM-V). 79 Fed. Reg. 45,093, 45,094. However, the DSM-IV governs all applications for benefits certified to the Board prior to August 4, 2014. The RO certified the Appellant’s appeal to the Board on May 19, 2016; therefore, the claim is governed by the DSM-V. The matter is REMANDED for the following actions: 1. Return the file to the VA examiner who conducted the March 2012 VA PTSD examination. If the examiner is not available, have the file reviewed by a similarly-qualified examiner for an addendum opinion. IF APPROPRIATE, conduct any new examinations. If the VA examiner indicates that he or she cannot respond to the Board’s questions without examination of the Veteran, another examination should be afforded to the Veteran. All relevant medical and non-medical records must be made available to the examiner for review of pertinent documents. The examination report should specifically state that such a review was conducted. The examiner must provide a comprehensive explanation for all opinions provided. Based upon a review of the relevant evidence and history provided by the Veteran, the VA examiner should determine whether the Veteran has a diagnosis of PTSD under the DSM-V diagnostic criteria. The examiner must respond to the following inquiries: Does the Veteran have a current diagnosis of PTSD under the DSM-V diagnostic criteria? If the Veteran has a current diagnosis of PTSD, is the Veteran’s claimed stressor adequate to support a diagnosis of PTSD? If the Veteran has a current diagnosis of PTSD, are the Veteran’s symptoms related to his claimed stressor? Although the examiner must review the VBMS file, his or her attention is drawn to the following: • The Veteran’s DD Form 214 reflects that he served in Kuwait, an imminent danger pay area, as a military police officer from February 2004 to April 2004. • In a July 2004 VA psychiatric treatment record, the Veteran reported experiencing trouble with his wife, sleeping and adjusting to civilian life after his deployment in Southwest Asia. The VA medical doctor did not diagnose the Veteran with a psychiatric disorder. • A July 2004 VA treatment record reflects the Veteran’s positive PTSD screen pertaining to his service in Southwest Asia. • In a March 2005 VA treatment record, the Veteran reported experiencing episodes where he was back in Southwest Asia. • In a March 2005 VA general medical examination, the Veteran reported experiencing stress due to his wife’s psychiatric hospitalization. The examiner noted that the Veteran had no psychiatric symptoms. • In a June 2005 service initial medical review, the service medical examiner noted no psychiatric symptoms. • In a September 2005 post-deployment health assessment, the Veteran reported experiencing depression and hopelessness in the preceding two weeks. • A September 2007 VA treatment record reflects the Veteran’s negative PTSD screen pertaining to his service in Southwest Asia. • In an August 2008 service treatment record, no psychiatric symptoms were noted. • In an October 2009 statement of medical examination and duty status, the service medical examiner indicated that the Veteran was mentally sound. • In the March 2012 VA PTSD examination, the examiner indicated that the Veteran’s stressor – service in Southwest Asia – was adequate to support a diagnosis of PTSD and it was related to the Veteran’s fear of hostile military or terrorist activity. The examiner indicated that the Veteran did not have a diagnosis of PTSD under the DSM-IV. • In a November 2013 VA treatment record, the Veteran reported that during his service in Southwest Asia, he underwent attacks while providing escort services to VIPs. He also reported experiencing tension as a military police officer in Southwest Asia. • A November 2013 VA treatment record reflects the Veteran’s diagnosis of PTSD under the DSM-IV. • In a May 2014 VA treatment record, the Veteran reported that during his service in Southwest Asia, he was a military police officer and an escort to political persons and supplies. He also reported experiencing anxiety, depression, flashbacks and hypervigilance upon his return from Southwest Asia. • A May 2014 VA treatment record reflects the Veteran’s diagnosis of PTSD under DSM-IV. 2. Readjudicate the issue on appeal. If the benefit sought on appeal remains denied, the Veteran should be provided a supplemental statement of the case (SSOC). An appropriate period should be allowed for response before the case is returned to the Board. Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Cohen, Associate Counsel