Citation Nr: 21021447 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 15-14 543A DATE: April 13, 2021 REMANDED Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD) and major depressive disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from July 8, 1970 to August 20, 1980. The Veteran had an additional period of active duty service from August 21, 1980 to March 15, 1989; however, a March 2011 administrative decision determined that his discharge for this period of service was not under honorable conditions and is considered to be a bar to VA benefits. This matter is before the Board of Veterans Appeals (Board) on appeal from an August 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). On the May 2015 VA Form 9, Appeal to the Board of Veterans’ Appeals, the Veteran requested to appear at a hearing before the Board. In subsequent correspondence received in May 2019, he withdrew his hearing request. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and major depressive disorder, is remanded. The Board finds further development is required before a decision can be made regarding the Veteran’s claim. A review of the record shows the Veteran underwent a VA PTSD examination in April 2011. The examiner noted that the Veteran reported several stressors, including seeing someone lose fingers as a result of getting his hand stuck in a breech, seeing ships on fire, and being court marshalled, but found the Veteran did not meet the criteria for a PTSD diagnosis. In June 2013, the Veteran underwent another VA examination in which he reported undergoing mortar attacks while aboard ship at sea. The examiner indicated that the stressor was related to the fear of hostile military or terrorist activity but found the Veteran did not meet criteria for a PTSD diagnosis. However, the Veteran submitted several private opinions, including opinions received in October 2011 and April 2013, which indicate he was diagnosed with PTSD. In addition, a May 2014 VA treatment record indicates the Veteran was diagnosed with PTSD, in accordance with the DSM-V, by history, but an April 2018 VA treatment record reflects that the Veteran denied a history of PTSD. As the record is unclear as to whether the Veteran has a PTSD diagnosis, the Board finds remand is required. The record also shows that the Veteran was diagnosed with major depressive disorder, as noted in private treatment records and April 2011 and June 2013 VA examination reports. However, these diagnoses were in accordance with the DSM-IV. As interim rulemaking amended § 4.125(a) to state that a diagnosis of a mental disorder must conform to DSM-5, not DSM-IV, where a case was certified to or pending before the Board on or after August 4, 2014, and the Veteran’s claim was certified to the Board in March 2016, the DSM-5 is applicable. See 79 Fed. Reg. 45,093 (Aug. 4, 2014). Thus, remand for an examination is necessary to determine whether the Veteran meets DSM-V criteria for major depressive disorder. In addition, the Board also notes that, in a September 2012 opinion, Dr. M.S. opined that the Veteran’s major depressive disorder was related to his active service. However, in June 2013, a VA examiner opined that the Veteran’s condition was less likely than not caused by his active service. As neither physician provided an adequate rationale to support the opinions, the Board finds a medical opinion addressing the etiology of the Veteran’s major depressive disorder should also be obtained on remand. In sum, on remand the Veteran should be provided a new VA examination with medical opinion by a VA psychiatrist or psychologist to address any relationship between any psychiatric disability diagnosed, including PTSD and major depressive disorder, and any incident of the Veteran’s military service. The matters are REMANDED for the following action: Schedule the Veteran for an examination by an appropriate examiner to determine the nature and possible relationship to service of any current psychiatric disability. The Veteran’s claims file must be made available to the examiner for review in conjunction with the examination. All necessary tests should be performed, and the results reported. The examiner is asked to respond to the following questions: (a) Does the Veteran have a diagnosis of PTSD in accordance with the DSM-V? (b) If the Veteran has a diagnosis of PTSD, then is it at least as likely as not (a 50 percent or greater probability) that PTSD is caused by stressors related to his fear of hostile military or terrorist activity during service? (c) For any psychiatric diagnosis other than PTSD, to include major depressive disorder, is it at least as likely as not (a 50 percent or greater probability) that such disability began during the Veteran’s active service or is otherwise related to any incident of his military service, taking into account in-service events related to fear of hostile military or terrorist activity during service? A complete rationale for all opinions must be provided. If the examiner cannot provide a requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. Evan M. Deichert Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Jiggetts 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.