Citation Nr: 21077535 Decision Date: 12/30/21 Archive Date: 12/30/21 DOCKET NO. 16-35 187 DATE: December 30, 2021 REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1981 to June 1984. This matter is before the Board of Veterans' Appeals (Board) on appeal from a July 2015 rating decision by a Department of Veterans Affairs Regional Office (RO). In September 2021, the Veteran testified at a hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. TDIU At the September 2021 Board hearing, the Veteran testified that he previously worked as a psychologist, and that he last worked in 2013. Prior to his employment as a psychologist, he reported working as a physical education teacher for approximately 20 years. He reported that he stopped working due to memory issues, depression, anxiety and an inability to sleep. He also reported that his VA treating psychiatrist, Dr. Sanz, established his psychiatric diagnosis and indicated he was unable to work. At the time he filed his TDIU claim on appeal, the Veteran asserted that he was unable to work due to his service-connected lumbar spine and bilateral shoulder disabilities. See March 2016 Claim. He was not service connected for a psychiatric disorder at that time. However, he did file a service connection claim for a psychiatric disorder in October 2015, which was granted following a January 2016 VA examination. That examination report noted a diagnosis for a mood disorder, depressive type due to back and shoulder pain. The psychiatric disorder was manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The Veteran reported that he stopped working due to his back problems. The following symptoms were noted: depressed mood; anxiety; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; disturbances of motivation and mood; difficulty in adapting to stressful circumstances, including work or a worklike setting; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. Other symptoms including feeling hopeless and worthless since he stopped working. In July 2017, the Veteran submitted a mental disorder disability benefits questionnaire (DBQ), which was issued by Dr. Sanz. Dr. Sanz noted a diagnosis for recurrent moderate major depressive disorder (MDD) with psychosocial problems including chronic pain and cognitive deterioration. The psychiatric disorder was manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The following symptoms were noted: depressed mood; anxiety; chronic sleep impairment; mild memory loss; impairment of short and long term memory; memory loss for names of close relatives, own occupation or own name; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work like setting; and disorientation to time or place. The psychiatrist also noted the Veteran had low energy, cognitive decline, problems with decision making, and more recent problems with orientation and memory. VA treatment records show that following the July 2017 DBQ, Dr. Sanz referred the Veteran for a neuropsychology assessment. That assessment occurred in October 2017. At that time, the Veteran reported having memory problems and episodes of disorientation. He also reported irritability, less motivation to do things he used to do, that he felt sadder because he was no longer able to do things he used to be able to do, sleep problems, and prior suicidal ideation. He further reported needing assistance with activities of daily living, including assistance with bathing and getting dressed due to physical limitations. A cognitive test revealed average to above average ranges which were not compatible with early symptoms of a major neurocognitive disorder or dementia. The Veteran performed well in memory tasks. Some concentration problems were noted. He was alert and generally attentive, oriented to time, but somewhat disoriented to place. He was able to easily understand and follow instructions, and repetition was never required. He had adequate speed problem solving, and was persistent and challenged by harder tasks. See VA Medical Records Received February 2018. Thereafter, a November 2017 VA psychiatric treatment record shows Dr. Sanz had reviewed the neuropsychology assessment which was discussed with the Veteran. A mental status examination was conducted, and Dr. Sanz noted preserved cognition. A December 2017 VA medical record noted the Veteran was oriented to time, place and person. See VA Medical Records Received February 2018. After a review of the evidence of record, the Board finds that another VA psychiatric examination is necessary. In this regard, although the Veteran's VA treating psychiatrist issued a DBQ in July 2017 documenting severe memory problems, a subsequent VA neuropsychology assessment noted he performed well in memory tasks. Cognitive testing also showed the Veteran to be average to above average in that area. Moreover, following the neuropsychology assessment, a November 2017 VA mental status examination conducted by Dr. Sanz did not note any memory problems, and his cognition was found preserved at that time. Later VA medical records also show the Veteran was assessed as fully oriented. Accordingly, the July 2017 DBQ does not appear to accurately reflect the current severity of the service-connected psychiatric disorder and another VA examination is necessary. The Board additionally finds that efforts should made to obtain updated VA treatment records. In this regard, the Veteran receives treatment for his service-connected psychiatric disorder at his VA medical center, but the most recent record contained in the claims file is dated February 2018. The matter is REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file, including all records dating from February 2018, and all private treatment records not already associated with the file. 2. Then, schedule the Veteran for a VA examination to determine the current severity of his service-connected psychiatric disorder. The examiner should indicate the functional impact of the service-connected psychiatric disorder on the Veteran's ability to work. The examiner should identify the nature, frequency, and severity of all current manifestations of the Veteran's psychiatric disorder and specify the degree of occupational or social impairment. (Continued on the next page) 3. Thereafter, the RO should readjudicate the claim for TDIU. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Lamb, 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.