Citation Nr: 21026142 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 11-26 187 DATE: April 29, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD) and depressive disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1981 to November 1984 and from April 1986 to September 1987. This matter comes before the Board on appeal from a March 2009 Regional Office (RO) rating decision. In May 2018, the Veteran testified at a hearing before the undersigned Veterans Law Judge. 1. Entitlement to service connection for an acquired psychiatric disability, to include PTSD and depressive disorder, is remanded. The Veteran has claimed entitlement to service connection for an acquired psychiatric disability, to include PTSD and depressive disorder. The Veteran has cited two potential stressors. First, he has attributed PTSD to a training exercise involving a gas chamber. (See Board hearing transcript, pages 4-6.) The Board notes that this is a common basic training exercise and thus presumes that this event occurred. Second, the Veteran has also described an in-service automobile accident in which his vehicle was struck from the passenger side and he struck his head on the window. (See May 2018 personal statement.) The Veteran’s service treatment records reflect that he was in an automobile accident in May 1987, and that stressor is thus considered to have been verified. In March 2019, VA obtained an etiology opinion in which it was opined that the Veteran does not satisfy the criteria for a PTSD diagnosis under the American Psychiatric Association: Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5). The Board notes, however, that the DSM-5 is relevant to claims certified to the Board on and after August 4, 2014. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). As the Veteran’s claim was originally certified to the Board before August 4, 2014, the DSM-IV applies in this case. Thus, a remand is required to obtain an opinion with respect to whether a PTSD diagnosis under the DSM-IV is warranted. The Board further notes that an April 2020 VA medical record notes that the Veteran “is being treated at clinic for Depression and Chronic PTSD” and notes a diagnostic impression of “Depression and Chronic PTSD.” February 2020, March 2020, and May 2020 VA medical records note that the Veteran has a history of PTSD. A November 2020 VA medical record notes that the Veteran is being “followed for recurrent depressive episodes, unspecified PTSD….” In addition, a January 2021 VA medical record contains a diagnostic impression of PTSD. On remand, with respect to the March 2019 VA examiner’s finding that the Veteran does not have PTSD, an opinion should be obtained addressing whether the examiner’s opinion on a lack of PTSD diagnosis would change in light of these new medical records. The matters are REMANDED for the following action: 1. Obtain all relevant VA and private treatment records not currently associated with the claims file, to include any VA medical records that were created since the Veteran’s records were last obtained. 2. Send the claims file to the author of the March 2019 examination report, or another qualified examiner, to obtain an opinion with respect to whether a PTSD diagnosis is warranted under the DSM-IV criteria. If such a diagnosis is made, is it at least as likely as not (a 50 percent probability or greater) that such a diagnosis is related to service? The examiner is instructed to consider the Veteran’s two reported in-service stressors, involving a training exercise involving a gas chamber and an in-service automobile accident, to be verified. In giving this opinion, the examiner should review, in particular, the Veteran’s May 2018 Board hearing testimony in which he described his reported stressors. In regard to the March 2019 VA examiner’s finding that the Veteran does not have a PTSD diagnosis under the DSM-5, does this opinion change in light of the additional VA medical records noting diagnostic impressions of PTSD? In forming this opinion, please review the VA medical records dated in February 2020, March 2020, April 2020, May 2020, November 2020, and January 2021. A complete rationale should be provided for any opinion, including discussion of the facts of the case and pertinent medical principles. (continued on next page) TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Elizabeth Jalley, 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.