Citation Nr: 18156464 Decision Date: 12/10/18 Archive Date: 12/10/18 DOCKET NO. 14-41 498 DATE: December 10, 2018 REMANDED Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder with secondary depression (PTSD) from December 8, 2010, to August 29, 2016, and in excess of 50 percent thereafter is remanded. REASONS FOR REMAND The Veteran served in the United States Air Force from October 1951 to June 1972. This case comes before the Board of Veterans' Appeals (Board) on appeal from a June 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). Entitlement to an initial rating in excess of 30 percent for PTSD prior to August 29, 2016, and in excess of 50 percent thereafter is remanded. The Veteran underwent a VA examination on August 29, 2016. At the examination, it was reported that the Veteran’s PTSD symptoms were exhibited through: depressed mood, anxiety, suspiciousness, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting. The Veteran reported to the examiner that he had been seeing a psychologist contracted through the VA, Dr. C.C., for the past year, every other week. However, it is not clear that the Veteran’s medical records from these bi-weekly treatments were considered by the VA psychologist in her determination that the Veteran’s current occupational and social impairment was with reduced reliability and productivity. In her remarks, the VA psychologist referred to the Veteran’s previous examination report from March 2011 and mental health notes from December 2010, but she did not go into detail about the Veteran’s bi-weekly psychotherapy sessions since March 2015. We received correspondence from the Veteran's psychologist, Dr. C.C., in August 2018, reporting that the Veteran had been seeing her bi-weekly since March 2015. The focus of his therapy was initially centered around reducing symptoms of depression including, irritability, social isolation, poor frustration, poor tolerance, apathy and anticipation of negative outcomes. The Veteran’s depression also exhibited symptoms of poor self-esteem, reduced interpersonal interactions, difficulty trusting others, feelings of hopelessness, decreased appetite, insomnia, difficulties with concentration, not feeling able to complete day to day tasks, and anhedonia. The psychologist reported that PTSD symptoms included a significant startled response, environmental and interpersonal hypervigilance, intrusive ideations and attempts at avoiding anything reminiscent of stress, which included avoiding socializing with other veterans to avoid talking about war-time experiences. It was also noted that the Veteran restricts his reading and TV/video exposure because it increases his agitation. Moreover, it was reported that he had impaired appetite, social withdrawal and avoidance, and feeling judged by others and being uncomfortable and easily irritated around groups of people. The psychologist also reported that the Veteran has been unable to maintain full-time employment and had impaired interpersonal relationships. He also has had conflict with authority figures, poor frustration and tolerance and avoidance of others due to becoming irritated with very minor annoyances. It was also reported that he has had period of impulsivity and poor judgment leading to poor decisions of substance and abuse. At his Board hearing, the Veteran reported that he suffered from night sweats and hypervigilance. He reported that he had problems in crowds. Also, loud noises startled him, and he could not go to a restaurant or public places with loud noises because he jerked around in response to the loud noises. Moreover, while in public places, he did not like to sit with his back to doors. As far as his occupational impairment, the Veteran reported that he worked on a part time basis for the census bureau up until five years ago (from his August 2018 hearing). However, he stopped working after having traumatic census interviews with persons. Moreover, he reported, that he could no longer work due to his PTSD symptoms. He stated that he tried to do volunteer work, but was not successful because of his PTSD symptoms. In summary, his PTSD kept him from leaving his house. He did not want to leave his house because he did not want to engage with people or encounter the anxiety and stressful situations. It was reported, that even at this August 2018 Board hearing, the Veteran’s anxiety made it hard for him to answer the undersigned Veteran’s Law Judge’s (VLJ) questions. The undersigned VLJ found the Veteran’s testimony at his hearing truthful and credible. The Board finds that a remand is required to obtain the Veteran’s medical records for his bi-weekly individual therapy sessions with a VA contracted psychologist, Dr. C.C. Additionally, a new examination is needed. As stated by the Veteran at his August 2018 Board hearing and demonstrated by the record, his PTSD symptoms may have worsened since his last VA examination in August 2016. However, there is not enough medical evidence to determine the duration and frequency to which his PTSD and depression symptoms impair him socially and occupationally. Accordingly, after his records from his bi-weekly sessions for individual treatment have been associated with the record, the Veteran should undergo a VA examination that evaluates the current severity of his PTSD. The matter is REMANDED for the following action: 1. Obtain updated medical records, particularly, the records from the Veteran’s bi-weekly sessions with his psychologist, Dr. C.C. 2. After the development in paragraph one has been completed, the Veteran should be afforded a VA examination to evaluate the current severity of his service-connected PTSD with depression using the most recent DBQ form. The claims folder, including a copy of this remand, should be made available to the examiner for review prior to the examination. The examiner should acknowledge such review in the examination report. Any medically indicated tests should be conducted. G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Wade, Associate Counsel