Citation Nr: 21022321 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 14-02 838 DATE: April 15, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. Entitlement to a total rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1958 to August 1962. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a December 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO), which, inter alia, denied re-opening the Veteran’s previously denied service connection claim for an acquired psychiatric disorder, to include PTSD. The RO also denied entitlement to a TDIU. This appeal has been advanced on the Board’s docket pursuant to 38 U.S.C. § 7107(a)(2) and 38 C.F.R. § 20.900(c). In a July 2014 decision, the Board found that the Veteran had submitted new and material evidence to warrant readjudication of his service connection claim and remanded that claim and entitlement to a TDIU for further development. Most recently, in December 2020, the claims were remanded by the Board to the agency of original jurisdiction (AOJ) for further development. After accomplishing the above, the AOJ continued to deny the Veteran’s claims (as reflected in a February 2021 supplemental statement of the case (SSOC)). 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD In March 2015, the Secretary updated VA mental health regulations to require claims certified for appeal to the Board after August 4, 2014, to be rated under the DSM-5 criteria. See 580 Fed. Reg. 14,308-01 (Mar. 19, 2015); see also 38 C.F.R. § 4.125(a). The rule specified that claims certified on or before this date, as in the instant case, would continue to be rated under DSM-IV criteria. See 80 Fed. Reg. 14,308-01; see also 38 C.F.R. § 4.125(a). In the December 2020 remand, the Board found that the prior February 2019 VA examination was inadequate because it only included an PTSD evaluation under DSM-5, but contained no discussion as to whether the Veteran met the criteria for a PTSD diagnosis under DSM-IV. On remand, the examiner was also directed to address the symptoms described in a September 2012 letter from Dr. Ortiz-Valentin, the Veteran’s private physician, which opined that the Veteran’s in-service motor vehicle accident (MVA) caused him excessive worry and anxiety. The Veteran underwent VA PTSD examination in February 2021. The examiner indicated that the Veteran’s symptoms do not meet the diagnostic criteria for PTSD under DSM-5. However, she failed to discuss whether the Veteran met the diagnostic criteria for PTSD under DSM-IV, as directed. Moreover, in the February 2021 VA disabilities benefits questionnaire (DBQ), the examiner stated that since Dr. Ortiz-Valentin was the Veteran’s primary physician and not a trained or certified psychologist or psychiatrist, she lacked the expertise and qualifications necessary to render a mental disorder diagnosis. However, the examiner did not address the substantive symptoms identified in the September 2012 letter, as directed in the remand. Dr. Ortiz-Valentin’s letter asserted that as a result of the in-service MVA, the Veteran witnessed other passengers incur serious bodily injuries that cause him symptoms such as excessive anxiety, nightmares, flashbacks, and episodes of irritability. As such, the Board finds that substantial compliance with the December 2020 remand directives has not been achieved. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Therefore, the Board finds that a remand is warranted for a new VA examination and medical opinion as to the nature and etiology of the Veteran’s acquired psychiatric disorder, to include whether the Veteran meets the criteria for a PTSD diagnosis pursuant to the DSM-IV and whether the Veteran has any other diagnosed acquired psychiatric disorder that was caused by or otherwise related to service. 2. Entitlement to a TDIU In addition, the Veteran’s entitlement to a TDIU is inextricably intertwined with his service connection claim for an acquired psychiatric disorder, to include PTSD; therefore, the TDIU claim must be remanded with it. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Schedule the Veteran for a psychiatric examination to determine the nature and etiology of any acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). The examination must be performed using the diagnostic criteria set forth in DSM-IV. 2. If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor. 3. The examiner must identify any other psychiatric disorder(s). For each diagnosed disorder, the examiner must opine whether each diagnosed disorder is at least as likely as not related to service, to include any verified in-service stressor. In addressing the above, the examiner should also consider and discuss the September 2012 letter from Dr. Ortiz-Valentin regarding an in-service motor vehicle accident (MVA), and the symptoms noted therein. 4. After the above development and any other development deemed necessary is completed, readjudicate the Veteran’s service connection claim and adjudicate entitlement to a TDIU. If the claim(s) remain denied, the Veteran should be issued a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. K. Parakkal Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Kovacs, Associate 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.