Citation Nr: 18100552
Decision Date: 04/17/18	Archive Date: 04/17/18

DOCKET NO. 17-12 773
DATE:	April 17, 2018
ISSUES DECIDED:	0	ISSUES REMANDED:	1
 
REMANDED ISSUE
 
The Veteran’s service connection claim for PTSD is remanded for additional development.  The Veteran asserts that his PTSD is due to his experiences in the Republic of Vietnam.  Specifically, he has reported several stressors, including learning of his uncle being killed in Vietnam, and coming under repeated rocket attack and Viet Cong attacks while stationed at An Khe. 
The Veteran’s service treatment records (STRs) do not show any complaints, symptoms, treatment, or diagnosis for an acquired psychiatric disorder.
In February 2016, the Veteran was afforded a VA examination for his acquired psychiatric disorder.  The examiner found that that Veteran did not meet the criteria for a diagnosis of PTSD.
However, in March 2016, Louise Glogau, MA, diagnosed the Veteran with PTSD based on stressors experienced during his service in Vietnam, essentially based on the fear of hostile military or terrorist activity.
VA regulations provide that:
If a stressor claimed by a veteran is related to the Veteran’s fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and that the Veteran’s symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran’s service, the Veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor.  For purposes of this paragraph, “fear of hostile military or terrorist activity” means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran’s response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror.
However, the revised regulations are very clear that a diagnosis of PTSD based on these regulations must be made by a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted.
Here, the VA examiner did not diagnose PTSD, but since that time a private medical professional did, but based on fear of hostile military or terrorist activity.
This triggers the need to obtain an additional medical opinion.
 
The matter is REMANDED for the following action:
1. Schedule the Veteran for a VA psychiatric examination, with a psychiatrist or psychologist.  The examiner should diagnose any current psychiatric disability and should answer the following questions:
Is it at least as likely as not (50 percent or greater) that any current acquired psychiatric disorder, to include PTSD (pursuant to DSM-5) either began during or was otherwise caused by the Veteran’s active service.  Why or why not? 
In so doing, the examiner should review the examination report of Ms. Glogau.
If a diagnosis of PTSD is not found to be warranted, the examiner should specifically explain what criteria are not met, and should explain why the diagnosis of PTSD that was rendered by Ms. Glogau is not considered to be accurate.
If PTSD is diagnosed, the examiner should indicate what stressor or stressors the diagnosis was based on, to include whether it was the result of fear of hostile military or terrorist activity.
2. Then, readjudicate the appeal.  If the claim remains denied, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate time for response.
 
 
MATTHEW W. BLACKWELDER
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	T. Berryman, Associate Counsel