Citation Nr: 21022164 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 17-57 819 DATE: April 14, 2021 REMANDED The claim of entitlement to an initial disability rating higher than 50 percent for posttraumatic stress disorder (PTSD) with major depression, opiate dependency in remission, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1983 to June 1986. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a July 2015 rating decision by a U.S. Department of Veterans Affairs (VA) Regional Office (RO). In February 2021, the Veteran testified in a hearing before the Board. A transcript of the hearing is included in the electronic claims file and has been reviewed. A remand is warranted for medical inquiry into the claim of entitlement to a higher initial rating. The Veteran underwent VA examination into her psychiatric illness most recently in July 2015. Her testimony before the Board indicates a worsening of the disorder since then. See Green v. Derwinski, 1 Vet. App. 121 (1991). The matters are REMANDED for the following action: 1. Undertake appropriate development to obtain any outstanding records pertinent to the claim. Include in the claims file any outstanding VA treatment records. All records/responses received must be associated with the claims file. See 38 C.F.R. § 3.159. 2. Schedule an examination to determine the nature and severity of PTSD with major depression. After reviewing the claims folder, interviewing the Veteran, and examining her, the examiner should address the following question. (a). Does the Veteran experience occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships? (b). If so, does PTSD also cause total social and occupational impairment? Please explain in detail any opinion provided and the supporting rationale. In rendering the requested opinion, the examiner should note that the Veteran is competent to attest to matters of which she has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran and any other lay witnesses, the examiner should indicate this in the examination report and provide a rationale for that determination. In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Christopher McEntee, 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.