Citation Nr: 1002953 Decision Date: 01/20/10 Archive Date: 02/01/10 DOCKET NO. 03-10 089 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), mood disorder, and schizoid personality disorder. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Robert J. Burriesci, Associate Counsel INTRODUCTION The Veteran had active service from June 1965 until May 1968. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a March 2002 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in St. Petersburg, Florida. In July 2004, the veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of this hearing is associated with the claims folder. The issue on appeal was previously denied by the Board in a February 2005 decision. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In an October 2006 Order, the Court vacated the February 2005 Board decision and remanded the matter back to the Board for development consistent with the parties' Joint Motion for Order Vacating Board's Decision and Incorporating the Terms of this Remand (Joint Motion). Subsequently, this case was before the Board again in June 2007 when it was remanded for further development. The Veteran originally filed a claim of entitlement to service connection for PTSD. Although not claimed by the Veteran, the Board has recharacterized the issue on appeal as indicated above to include mood disorder and schizoid personality disorder. See Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009). The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran seeks entitlement to service connection for an acquired psychiatric disorder. The Veteran contends that incidents during his service on the border between East and West Germany during the Cold War caused his PTSD. The Veteran's service treatment records do not reveal any complaint, diagnosis, or treatment for any psychiatric condition. Upon examination at separation from service in February 1968 the Veteran was not noted to have any psychiatric condition. The Veteran's post service treatment records reveal that the Veteran was treated by the Vet Center in St. Petersburg, Florida for PTSD. In a letter dated in August 2001 a social worker at the Vet Center indicated that the Veteran's reported symptoms, including hypervigilence, sleep disturbance, avoidance, and intrusive thoughts, were consistent with a diagnosis of PTSD. The social worker noted that the Veteran's PTSD symptoms significantly hindered the Veteran's ability to function in an effective manner and his ability to tolerate the normal stresses involved in social and work interactions. In May 2008 the Veteran was afforded a VA Compensation and Pension (C&P) PTSD examination. The Veteran reported that in service he felt harassed by the East German soldiers because he would hear gunfire at night and felt that he was being fired at. After examination the Veteran was diagnosed with PTSD and assigned a GAF score of 65. The examiner noted that it would be mere speculation to differentiate between the Veteran's Axis I diagnosis of PTSD and the Veteran's Axis II diagnosis of schizoid personality disorder. The examiner did not render an opinion regarding whether the Veteran's conditions were related to the Veteran's active service or to the Veteran's reported stressors in active service. In May 2009 the Veteran was afforded another VA C&P PTSD examination. After examination the Veteran was afforded an Axis I diagnosis of mood disorder and an Axis II diagnosis of schizoid personality disorder and assigned a GAF score of 70. The examiner rendered the opinion that the Veteran did not meet the criteria for a diagnosis of PTSD and that the Veteran had limited disability primarily due to his chronic schizoid traits. The examiner did not render an opinion regarding whether the Veteran's diagnosed mood disorder or schizoid personality disorder are due to the Veteran's active service. As stated above, the Board notes that the Court has held that claims for service connection for PTSD encompass claims for service connection for all psychiatric disabilities. Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009) (the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). As such, the Veteran's initial claim of entitlement to service connection for PTSD has been recharacterized as a claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD, mood disorder, and schizoid personality disorder. The Board notes that once VA undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). As the examiner in May 2008, while diagnosing PTSD, failed to render an opinion regarding the etiology of the Veteran's condition and the examiner in May 2009, while diagnosing a mood disorder and schizoid personality disorder and excluding a diagnosis of PTSD, failed to render an opinion regarding whether the Veteran's mood disorder and/or schizoid personality disorder was related to the Veteran's active service, the claim must be remanded for the Veteran to be afforded a VA medical examination and for an opinion to be rendered regarding the etiology of any and all acquired psychiatric disorders found to be present. Accordingly, the case is REMANDED for the following action: 1. Afford the Veteran a VA psychiatric examination to determine the nature, extent and etiology of any and all psychiatric disability found to be present. The claims folder should be made available to and reviewed by the examiner. All necessary tests should be conducted, and the examiner should rule in or exclude a diagnosis of PTSD. The report of examination should note all psychiatric disabilities found to be present, and the examiner must acknowledge and comment on the Veteran's reports of a continuity of psychiatric symptoms since service. Thereafter, he or she must opine as to whether it is at least as likely as not that any psychiatric disability found to be present is related to or had its onset during service. If the examiner diagnoses the Veteran as having PTSD, the examiner should indicate the stressor(s) underlying that diagnosis. The rationale for any opinion expressed should be provided in a legible report. 2. Thereafter, adjudicate the Veteran's claim. If the benefit sought on appeal is not granted, the RO should issue the Veteran and his representative a supplemental statement of the case and provide the Veteran an opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). (CONTINUED ON NEXT PAGE) This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). _________________________________________________ JOAQUIN AGUAYO-PERELES Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2009).