Citation Nr: 21007872 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 17-12 848 DATE: February 11, 2021 REMANDED Entitlement to an initial rating in excess of 30 percent for service-connected posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran had active service in the United States Army from July 2006 to November 2007 and from May 2009 to June 2010. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2017 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. The Veteran submitted a notice of disagreement (NOD) in February 2017. A statement of the case was issued in March 2017. The Veteran perfected a timely substantive appeal via VA Form 9 in March 2017. The Veteran and his representative appeared at a virtual Board hearing before the undersigned Veterans Law Judge in August 2020. A transcript of the proceeding is associated with the claims file. 1. Entitlement to an initial rating in excess of 30 percent for service-connected PTSD is remanded. The Veteran initially underwent VA examination in December 2016. The examiner reported occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The Veteran’s symptoms included anxiety, suspiciousness, and impaired impulse control. In his February 2017 NOD, the Veteran reported symptoms including weekly anxiety attacks, disturbances of mood and motivation, and difficulty maintaining personal and work relationships. In his March 2017 VA Form 9, the Veteran reported depression, frequent panic attacks, and the inability to sleep. He stated that he often missed work and struggled with isolation. He also stated that he resorted to violence when the anxiety builds up. An October 2018 VA treatment note contained the Veteran’s report of a high stress level at his current job as a train conductor. He also reported altered sleep, flashbacks, and getting angry and yelling a lot at work. The Veteran declined a referral to the mental health clinic. He and the medical professional agreed that once the Veteran was able to leave his current work situation, he would feel much less anxious. The claims file includes a January 2019 PTSD Disability Benefits Questionnaire completed by a private psychologist. She reported occupational and social impairment with deficiencies in most areas. The Veteran’s symptoms included depressed mood, anxiety, suspiciousness, panic attacks weekly or less often, chronic sleep impairment, flattened affect, impaired judgment, disturbances of motivation and mood, difficulty in establishing relationships, difficulty adapting to stressful environments, inability to establish and maintain effective relationships, impaired impulse control, and disorientation to time and place. A June 2020 VA treatment note indicated a negative PTSD screening. During the August 2020 Board hearing, the Veteran described PTSD symptoms including panic attacks, impaired sleep, nightmares, memory problems, violent confrontations, isolation, and poor judgement. After review, the Board finds that a remand is necessary to obtain updated treatment records and afford the Veteran an opportunity to report for an updated VA psychiatric examination to ascertain the current severity and manifestations of the service-connected PTSD. Although a VA examination was conducted in December 2016, the Veteran submitted a January 2019 DBQ from a private psychologist which suggests that there may have been a material change in the Veteran's disability. The Board notes that the January 2019 DBQ does not indicate whether the private psychologist reviewed the Veteran’s claims file and medical history. Thus, a remand is necessary to obtain updated treatment records and allow the Veteran to undergo an appropriate VA examination based on a review of the claims file in order to assess the current nature and severity of his service-connected PTSD. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Ask the Veteran to complete a VA Form 21-4142/21-4142a for any relevant private treatment records pertaining to his psychiatric disability. Make two requests for any identified authorized records, unless it is clear after the first request that a second request would be futile. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected PTSD. (a.) The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. (b.) The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. (c.) To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to the service-connected PTSD alone. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Jamison, E. 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.