Citation Nr: 18158767 Decision Date: 12/17/18 Archive Date: 12/17/18 DOCKET NO. 09-34 248 DATE: December 17, 2018 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from February 1968 to December 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In July 2012, August 2014, and December 2017, the Board remanded the claim for further development. 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded. The August 2018 VA examination report is inadequate, as the examiner utilized the DSM-5 and did not provide sufficient rationale for his opinion. See 80 Fed. Reg. 14,308 (March 19, 2015) (DSM-5 does not apply to claims that have been certified for appeal to the Board or are pending before the Board on or before August 4, 2014, even if such claims are subsequently remanded). Additionally, there is indication that the Veteran’s psychiatric disorder may have pre-existed service. Specifically, the Veteran was discharged from the military as a result of his chronic schizophrenic reaction, which was noted to exist prior to entry and not aggravated by service. See May 1970 Medical Board Report. The record also lacks an opinion regarding whether any psychiatric disorders were superimposed on his diagnosed personality disorder during service. Therefore, a new examination and opinion is needed on remand. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Any outstanding VA and private treatment records should also be secured. The matter is REMANDED for the following action: 1. Obtain all outstanding VA treatment records. 2. With any necessary assistance from the Veteran, obtain any outstanding relevant private treatment records. 3. Then schedule the Veteran for a VA examination to determine the nature and etiology of his psychiatric disorder. The entire claims file should be made available to the examiner. All indicated tests and studies should be performed and all findings reported in detail. Following a review of the claims file, the examiner is asked to address the following: (a) A diagnosis of PTSD per the DSM-IV should be explicitly ruled in or excluded, and if diagnosed, the stressor(s) upon which that diagnosis is based should be identified. If the Veteran does not meet the criteria for a diagnosis of PTSD, the examiner must reconcile this finding with the diagnosis of the same in the August 2012 and May 2017 VA examination reports. (b) Identify all psychiatric disorders other than PTSD diagnosed under the DSM-IV since January 2008, to include adjustment disorder with depressed mood, dysthymic disorder, and intercurrent major depression. If any of the diagnoses are not warranted, please reconcile these findings with the diagnoses of the same in the March 2008 private treatment record and April 2008 VA treatment record. (c) Is there clear and unmistakable (obvious, manifest, and undebatable) evidence that any psychiatric disorder diagnosed since January 2008 existed prior to active service? Please discuss the May 1970 Medical Board Report and other medical evidence supporting your conclusion. (d) If the answer to question (c) is yes, is there clear and unmistakable (obvious, manifest, and undebatable) evidence that the pre-existing psychiatric disorder WAS NOT aggravated (worsened beyond natural progress) during service? (e) If the answer to question (c) is no or the answer to question (c) is yes and question (d) is no, is it at least as likely as not (50 percent or greater probability) that the Veteran’s diagnosed psychiatric disorder: (1) had its onset in service; (2) was superimposed upon his diagnosed personality disorder during service; or (3) is otherwise related to the circumstances of his service, to include as a result of the documented November 1968 diagnosis of “passive dependent personality disorder” and April 1970 diagnosis of schizophrenic reaction. If the criteria for a diagnosis of a psychotic disorder are met, please state, to the best of your ability, whether the prodromal period for such disorder as likely as not had its onset during the Veteran’s period of active service. (f) If the Veteran is diagnosed with brief psychotic disorder, delusional disorder, psychotic disorder due to another medical condition, other specified schizophrenia spectrum and other psychotic disorder, schizoaffective disorder, schizophrenia, schizophreniform disorder, or substance/medication-induced psychotic disorder, please indicate whether it is at least as likely as not (50 percent probability or more) that the psychiatric disability was present within one year after separation of service. (g) Did the Veteran exhibit any symptoms in service that were an early manifestation of schizophrenia or any other psychiatric disorder? Please address the May 1970 Medical Board Report in answering this question. (h) If a psychiatric disorder other than substance abuse is attributed to service, please also opine as to whether it is at least as likely as not (50 percent probability or greater) any diagnosed substance abuse disorder, including alcohol dependence, is (1) proximately due to or (2) aggravated (worsened beyond natural progress) by that disorder. If the alcohol dependence, early remission, diagnosis is not warranted, please reconcile this finding with the diagnosis of the same in the April 2008 VA treatment record. A complete rationale should be given for all opinions and conclusions expressed. If unable to opine without resorting to speculation, please provide a rationale for this conclusion. S. BUSH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S.S. Mahoney, Associate Counsel