Citation Nr: 21074032 Decision Date: 12/14/21 Archive Date: 12/14/21 DOCKET NO. 18-12 262 DATE: December 14, 2021 REMANDED Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1977 to September 1978. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) which, inter alia, denied reopening the Veteran's claim for service connection for PTSD. In March 2015, the Veteran filed his notice of disagreement, was issued a statement of the case in January 2018, and in February 2018 perfected his appeal to the Board. In April 2019, the Board, among one other thing, denied reopening the Veteran's claim for service connection for PTSD. The Veteran appealed the Board decision to the Court of Appeals for Veteran's Claims (Court) which in March 2020 granted a Joint Motion for Partial Remand (JMPR) filed by the parties, vacating, and remanding part of the Board's April 2019 decision, finding that the Board failed to consider evidence of an eye injury in the Veteran's medical report which contributed to the decision to deny reopening the claim. In September 2020, the Board reopened the claim of entitlement to service connection for PTSD, and remanded the claim to the RO for a VA examination to determine the nature and etiology of any PTSD. In October 2020, the RO continued its denial of the Veteran's claim for service connection for PTSD, notifying the Veteran in a supplemental statement of the case. In December 2020, the Board denied the Veteran's claim for service connection for PTSD, finding that the Veteran did not have a diagnosis of PTSD. The Veteran appealed the Board decision to the Court which in August 2021 granted a Joint Motion for Remand (JMR) filed by the parties, vacating, and remanding the Board's December 2020 decision, finding that the October 2020 VA examination upon which the Board relied in making its decision was inadequate. The Board notes that the Veteran has filed a VA Form 10182 notice of disagreement, appealing the issues of entitlement to service connection for hypertension, a back disability, and a mental/stress disorder under the Appeals Modernization Act (AMA). However, as the current claims have been appealed under the legacy system, and the claims for hypertension, a back disability, and a mental/stress disorder have been appealed under the AMA, the claims for service connection for hypertension, a back disability, and a mental/stress disorder will be addressed in a separate Board decision. PTSD In an undated statement, the Veteran reported witnessing a close friend die after suffering from heat stroke during a training exercise in service. The Veteran stated that since witnessing the incident, he has difficulty sleeping and has bad dreams. A Defense Personnel Records Information Retrieval System report indicated that the Veteran's reported stressor of witnessing a friend's death during service could not be verified. An August 2009 disability examination report reflects that the Veteran reported being involved in a motor vehicle accident during service which caused blunt trauma to his left eye and abdomen. He reported a history of "posttraumatic stress and anxiety" with onset of symptoms following discharge in approximately 1980. He complained of difficulty sleeping and dreams of the accident. June 1978 service treatment records indicate that the Veteran was treated for pain and swelling of the right eye, with the Veteran reporting that he was hit in the eye a week prior. A February 2009 VA psychiatry consult indicates that the Veteran has PTSD from an accident involving heavy military equipment during service. August 2010 VA treatment records reflect that the Veteran reported witnessing children being bitten by snakes, fearing for his life from explosions, and seeing deaths while in the infantry from 1968 to 1969 leading to PTSD symptoms and self-medicating. July 2014 VA treatment records indicate that the Veteran reported witnessing a fellow servicemember dying from heat exhaustion during basic training. November 2016 VA treatment records reflect a diagnosis of PTSD by a registered nurse, while January 2017 VA psychiatrist notes indicate that the Veteran's PTSD diagnosis is by history. In a June 2018 letter, the Veteran's personal care provider stated that the Veteran suffers with PTSD. She stated that the Veteran is afraid of noise and has nightmares. The care provider reported that the Veteran has seen an incomparable amount of death, has flash backs, and self-medicates to cope with his PTSD. An October 2020 disability benefits questionnaire (DBQ) indicates that the Veteran does not have a diagnosis of PTSD that conforms to DSM-5 criteria. The psychologist opined that the Veteran's PTSD was less likely than not (less than a 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness, stating that Veteran was not diagnosed with PTSD. The psychologist reported that the Veteran did not report a traumatic response to his eye injury, but mentioned feeling frustrated and depressed that the surgery did not work. The psychologist also noted that the Veteran did not report the necessary symptoms for a PTSD diagnosis related to the death of a fellow servicemember. Pursuant to the previously discussed August 2021 JMR, the parties agreed that the Board failed to provide the Veteran with an adequate examination prior to its adjudication of the claim for service connection for PTSD. The parties found the October 2020 DBQ inadequate as the psychologist's opinion presents an inconsistency. Specifically, the psychologist noted that the Veteran tends to "become angry and yell", yet did not find that the Veteran exhibited "irritable behavior and angry outburst (with little or no provocation) typically expressed as verbal or physical aggression toward people or object". Thus, the parties to the JMR agree that a remand is warranted for a new VA examination to determine whether the Veteran meets the criteria for PTSD. Accordingly, the case is REMANDED for the following actions: 1. Obtain an opinion from a psychologist/psychiatrist to determine whether the Veteran meets the criteria for a diagnosis of PTSD. If an examination is deemed necessary, one should be conducted, to include via telehealth if feasible. 2. If the psychologist/psychiatrist determines that the Veteran has a diagnosis of PTSD, the psychologist/ psychiatrist should opine as to whether the Veteran's PTSD is at least as likely as not (at least a 50 percent probability) related to an in-service stressor, to include the Veteran's reports of being involved in a motor vehicle accident during service which caused an injury to his eye. The psychologist/psychiatrist is advised that the Veteran is competent to report symptoms and treatment, and these reports must be considered when formulating the requested opinion. A negative opinion should not be based on a lack of treatment records. All opinions expressed must be accompanied by a complete rationale. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Maddox, 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.