Citation Nr: 21027515
Decision Date: 05/05/21	Archive Date: 05/05/21

DOCKET NO. 17-37 757
DATE: May 5, 2021

REMANDED

Entitlement to service connection for posttraumatic stress disorder (PTSD) is remanded.

REASONS FOR REMAND

The Veteran served on active duty from January 1963 to August 1971. The Appellant is the Veteran's widow, who has been substituted in his place for this appeal. See September 2016 Notification Letter.  

The Veteran's claim for service connection for PTSD was denied in a January 2020 Board decision. The Veteran appealed that denial to the United States Court of Appeals for Veterans Claims (Court). In December 2020, the Court granted a joint motion for remand (JMR). 

In the JMR, the Court determined that the Board failed to properly weigh medical evidence, and subsequently consider whether a clarifying medical opinion was warranted. Specifically, the Court determined that the Board should address the evidence of hypervigilance, avoidance phenomena, and anxiety noted in the Veteran's February 2013 outpatient treatment record, and reconcile it with the findings noted in the November 2012 VA examination. 

1. Entitlement to service connection for PTSD is remanded.

The Appellant asserts that the Veteran had PTSD which was related to his active service. 

The record shows that the Veteran received outpatient treatment in 1984 and 1985 for psychiatric complaints. At that time, the diagnoses were depression and adjustment disorder.

A VA examination was conducted in November 2012. At that time, the diagnoses were dementia, NOS, and adjustment disorder with depressed mood. The examiner noted that the Veteran did not meet the diagnostic criteria for PTSD. Specifically, it was found that while the Veteran did experience stressors during service to support the diagnosis of PTSD and persistently reexperienced the reported traumatic event, he did not exhibit a sufficient number of persistent avoidance behavior or symptoms of increased arousal to meet the full criteria for the diagnosis.  

A February 2013 VA outpatient treatment record noted that the Veteran did have prominent PTSD symptoms, such as avoidance phenomena and anxiety around crowds, but no diagnosis of PTSD was made at that time.

Considering the above, and with deference to the Court, the Board finds that an addendum opinion should be obtained addressing whether the Veteran had a diagnosis of PTSD. If the examiner is unable to provide such an opinion with the available evidence of record, the examiner should explain that in the opinion. 

The matters are REMANDED for the following action:

1. Obtain an addendum opinion from an appropriate clinician reconciling the conflicting medical evidence regarding whether the Veteran had a diagnosis of PTSD. If it is determined that the Veteran had PTSD, the examiner should opine as to whether it was at least as likely as not that the Veteran's PTSD was related to his active service. The examiner must consider the conflicting medical evidence from November 2012 and February 2013. 

 

 

JENNIFER HWA

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	E. Vosburgh, 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.