Citation Nr: 21063865 Decision Date: 10/18/21 Archive Date: 10/18/21 DOCKET NO. 13-31 281 DATE: October 18, 2021 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 U.S. Army from January 1966 to November 1968. The Veteran's appeal arises pursuant to a decision by the Department of Veterans Affairs (VA) Regional Office (RO) dated February 2010, which denied service connection for PTSD. The Veteran requested a Board hearing that was scheduled in August 2021, but he did not appear for the hearing. Therefore, the Board deems the hearing request withdrawn. 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded. The Veteran seeks entitlement to service connection for PTSD. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). Initially, the Board notes that the VA will not limit the scope of the claim solely to the diagnosis reported by the Veteran, but will consider all diagnoses reasonably encompassed by the symptoms described and evidence obtained. Clemons v. Shinseki, 23 Vet. App. 1 (2009). VA treatment records indicate diagnoses of depression, PTSD, anxiety, and dementia/cognitive disorder. The Board will thus consider the issue as a claim of service connection for an acquired psychiatric disorder, to include depression, PTSD, and anxiety disorder. In connection with his appeal, the Veteran was afforded a VA examination for PTSD in November 2012. The Veteran was diagnosed with PTSD in accordance with the criteria in the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The Veteran was also diagnosed with a cognitive disorder and alcohol abuse (currently in remission). The VA examiner did not provide a medical nexus opinion regarding the etiology of the Veteran's conditions. With regard to his claimed stressor, the Veteran contended he had experienced racial intimidation from an African-American sergeant with whom he worked. The Veteran reported fear of becoming a victim of violence but did not indicate any specific threats. The VA examiner found the claimed stressor was adequate to support a diagnosis of PTSD. The examiner also noted the stressor was not related to the fear of hostile military or terrorist activity. The Board finds that additional development is required before this appeal is decided. The Board must remand this PTSD claim due to the amendments to the VA regulations which removed references to the DSM-IV and replaced them with references to the Fifth Edition of the same treatise (DSM-V). The DSM-V criteria apply to claims certified for appeal to the Board on or after August 4, 2014. See 80 Fed. Reg. 14308, 14309 (March 19, 2015). The Board notes that the Veteran's appeal was certified to the Board in April 2015 and therefore the DSM-V applies. The VA examination report does not address whether the Veteran would qualify for a mental disorder diagnosis under DSM-V, and, if so, whether there is a medical nexus between the claimed in-service event and the Veteran's diagnosis. The Court of Appeals for Veterans Claims has held that the Board should not rely on DSM-IV findings when the DSM-V applies. Golden v. Shulkin, 29 Vet. App. 221, 225 (2018). Therefore, the issue of service connection for an acquired psychiatric disorder, to include PTSD, must be remanded for a medical opinion which applies the legally relevant criteria under the DSM-V to the Veteran's psychiatric symptoms, and which addresses the etiology of any acquired psychiatric disorders. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding VA treatment records. 2. Provide the Veteran's claims file to an appropriate VA medical clinician. After reviewing the Veteran's medical history, the clinician/examiner is asked to provide a medical opinion detailing the Veteran's psychiatric diagnoses during the period on appeal, to include PTSD, in accordance with the American Psychiatric Association's DSM-V criteria. (a.) The Board will not require another examination of the Veteran, and notes that the Veteran may not be available due to incompetency. An additional in-person examination may be unlikely to yield probative information considering the Veteran's condition of dementia. Then, for any diagnosed acquired psychiatric disorder(s), to include PTSD, the clinician/examiner is asked to provide a medical nexus opinion regarding the etiology of the condition. The examiner must opine whether any diagnosed acquired psychiatric disorder, to include PTSD, is at least as likely as not related to an in-service injury, event, or disease. (b.) In offering an opinion, the examiner must consider the full record, to include the lay statements regarding in-service occurrence, and the opinion should reflect such consideration. A clearly stated rationale for any opinion should be provided and must not be based solely on the lack of any in-service records. (c.) If the examiner is unable to provide an opinion without resort to speculation, he or she should explain whether the inability is due to the limits of the examiner's medical knowledge, medical knowledge in general, or if there is evidence that, if obtained, would permit the opinion to be provided. JENNIFER HWA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Medley, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.