Citation Nr: 18158264 Decision Date: 12/14/18 Archive Date: 12/14/18 DOCKET NO. 09-07 914 DATE: December 14, 2018 REMANDED Entitlement to service connection for hypertension, to include as due to exposure to herbicide agents or as secondary to ischemic heart disease, is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depression, and anxiety, is remanded. REASONS FOR REMAND The Veteran had active duty from February 1968 to February 1976. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in January 2009 by a Department of Veterans Affairs (VA) Regional Office (RO). In June 2012, March 2015, June 2016, and October 2017, the Board remanded the issues for additional development and they now return for further appellate review. 1. Entitlement to service connection for hypertension, to include as due to exposure to herbicide agents or as secondary to ischemic heart disease. The Veteran contends that he has hypertension as a result of his military service, to include his acknowledged exposure to herbicide agents coincident with his service in Vietnam, or as secondary to his service-connected ischemic heart disease. In the June 2016 remand, the Board requested an opinion as to (i) whether the Veteran’s hypertension had its onset during active service, was related to any in-service disease, event, or injury, including exposure to herbicide agents, in service, or manifested within the first year of separation from service; and (ii) whether such was caused or aggravated by his service-connected ischemic heart disease. In an October 2016, a VA examiner opined in the negative as to all inquiries. In support of his opinions, he noted that hypertension was not on the list of diseases that VA associated with herbicide exposure, and there was no evidence in the medical literature that hypertension was aggravated by ischemic heart disease; rather, the reverse was often the case. However, the October 2016 VA examiner did not provide a rationale for his opinion that the Veteran’s hypertension was not caused by his service-connected ischemic heart disease. Furthermore, in October 2017, the Board requested an addendum opinion as whether his hypertension was related to his acknowledged in-service exposure to herbicide agents despite the fact that it was not on the list of presumptive diseases. In this regard, the examiner was requested to consider the National Academy of Science (NAS) Institute of Medicine’s Veterans and Agent Orange: Update 2010 that concluded that there was limited or suggestive evidence of an association between exposure to Agent Orange and hypertension. In November 2017, the October 2016 VA examiner noted the Update, but found that the Veteran’s hypertension was more likely related to known risk factors such as advancing age, obesity, excessive alcohol consumption, physical inactivity, smoking, and depression. However, since such time, NAS has upgraded hypertension from its previous classification in the category of “limited or suggestive” evidence of an association between exposure to Agent Orange and hypertension to the category of “sufficient” evidence of an association in Update 11 (2018). According to NAS, “[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. Consequently, the Board finds that a remand is necessary in order to obtain an addendum opinion addressing whether the Veteran’s service-connected ischemic heart disease caused his hypertension or whether such is related to his acknowledged in-service exposure to herbicide agents. 2. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, depression, and anxiety. In October 2017, the Board remanded the Veteran’s claim for service connection for an acquired psychiatric disorder for an addendum opinion. In this regard, the Board observed that an October 2016 VA examiner found that the Veteran did not meet the diagnostic criteria for any psychiatric disorder under the Fifth Edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), but found that, as his claim was governed by the DSM-IV, an addendum opinion was necessary to determine whether he met the diagnostic criteria for a psychiatric disorder under such authority and, if so, whether such was related to his military service. In November 2017, a VA examiner indicated that she was unable to provide the requested diagnoses under the DSM-IV as such was outdated and, thus, an inaccurate assessment of psychopathology. While such may be true, the Board is bound by the legal authority governing the adjudication of the instant claim. Consequently, a remand for an addendum opinion addressing whether the Veteran has a diagnosis of a psychiatric disorder under the DSM-IV and, if so, whether such is related to his military service, is necessary to decide the claim. The matters are REMANDED for the following actions: 1. Return the record to the VA examiner who offered the November 2017 opinion regarding the etiology of the Veteran’s hypertension. The record and a copy of this Remand must be made available to the examiner. If the November 2017 VA examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. Following a review of the record, please address the following inquiries: (A) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s hypertension is caused by his ischemic heart disease? (B) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s hypertension is related to his military service, to include his acknowledged exposure to herbicide agents (notwithstanding the fact that it may not be a presumed association)? In offering such opinion, the examiner must address the NAS Institute of Medicine’s Veterans and Agent Orange: Update 11 (2018) that upgraded hypertension from its previous classification in the category of “limited or suggestive” evidence of an association between exposure to Agent Orange and hypertension to the category of “sufficient” evidence of an association. According to NAS, “[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. A rationale for any opinion offered should be provided. 2. Forward the record an appropriate examiner other than the psychologist who offered the November 2017 opinion regarding the nature and etiology of the Veteran’s claimed acquired psychiatric disorder. The record and a copy of this Remand must be made available to the examiner. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. Following a review of the record, please address the following inquiries: (A) The examiner should identify any psychiatric disorders for which the Veteran meets the diagnostic criteria under the DSM-IV. The examiner should also address any prior diagnoses of record, including memory loss, PTSD, depression, and anxiety, and indicate whether the Veteran met the diagnostic criteria for the disorder during the appeal period (since August 2008). (B) For each psychiatric disorder identified, the examiner should state whether it is at least as likely as not (i.e., at least a 50 percent probability or greater) that the disorder had its clinical onset during active service or is related to any in-service disease, event, or injury, including service in Vietnam and/or exposure to herbicides in service, or psychoses manifested within the first year after separation from military service. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Brennae L. Brooks, Associate Counsel