Citation Nr: 21031763
Decision Date: 05/24/21	Archive Date: 05/24/21

DOCKET NO. 16-32 732
DATE: May 24, 2021

REMANDED

Entitlement to service connection for post-traumatic stress disorder (PTSD) is remanded. 

REASONS FOR REMAND

The Veteran served on active duty from September 1989 to May 2001.  He is a recipient of the Combat Action Ribbon.

Entitlement to service connection for PTSD is remanded. 

The Veteran seeks entitlement to service connection for PTSD. The Board notes that the Veteran is already service connected for a psychiatric disorder other than PTSD, identified as persistent depressive disorder.

As an initial matter, the January 2013 rating decision made a favorable finding that a stressor is conceded based on the Veteran's receipt of the Combat Action Ribbon.

The Veteran was last afforded an Initial Post Traumatic Stress Disorder (PTSD) DBQ in December 2016, at which time the VA examiner noted diagnoses of alcohol use disorder; unspecified personality disorder; and substance induced depressive disorder.  The examiner determined that the Veteran's symptoms did not meet the diagnostic criteria for PTSD under the DSM-5 criteria.

The Veteran's VA treatment records indicate a medical diagnosis of PTSD.  See February 2019 VA Treatment Record.  Months later, a clinician noted an unspecified anxiety disorder, ruling out PTSD.  See July 2019 VA Treatment Record.  As it is unclear whether the Veteran currently meets the criteria for a DSM-5 PTSD diagnosis, a remand is needed to provide the Veteran with a new psychiatric examination and to obtain any outstanding treatment records.

The matters are REMANDED for the following action:

1. Obtain all updated VA treatment records (dated July 2019 to Present) and any private medical records identified by the Veteran as pertinent to the claim.

2. Then, schedule the Veteran for a psychiatric examination to determine the nature and etiology of his claimed PTSD.  

The claims file, including a copy of this Remand, must be made available and reviewed by the examiner.  The examiner should note such review in the report.

(a)	Determine whether the Veteran has a current diagnosis of PTSD that meets the DSM-5 criteria.  If so, the examiner must explain how the diagnostic criteria are met.

**In doing so, the examiner is reminded that the stressor has been conceded.

**The examiner should also consider and comment upon the February 2020 VA Treatment Record, which indicated a diagnosis of PTSD.

(b)	Opine as to whether it is at least as likely as not (i.e. 50 percent or greater probability) that the Veteran's PTSD is causally or etiologically due to service, to include his conceded in-service combat stressor(s).

A detailed rationale is requested for the opinion provided.  If an opinion cannot be provided without resorting to speculation, provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made.

 

 

GAYLE STROMMEN

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	T. Hanson, 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.