Citation Nr: 0810589 Decision Date: 03/31/08 Archive Date: 04/09/08 DOCKET NO. 99-08 497A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUE Entitlement to service connection for post-traumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Kathy Lieberman, Attorney ATTORNEY FOR THE BOARD S. B. Mays, Counsel INTRODUCTION The veteran served on active duty from June 1968 to June 1970. This appeal originally came before the Board of Veterans' Appeals (Board) from a December 1998 rating decision of the Department of Veterans Affairs (VA), San Juan, Puerto Rico, regional office (RO). In February 2005, the Board remanded the issue on appeal for additional development. Subsequently, a December 2005 rating action continued the prior denial. In April 2006, the Board denied the veteran's service connection claim for PTSD. The veteran filed a timely appeal of that decision to the United States Court of Appeals for Veterans Claims (Court). While the case was pending at the Court, the VA Office of General Counsel and the veteran's representative filed a Joint Motion for Remand, received in July 2007, requesting that the Court vacate the Board's April 2006 denial, and remand the claim for further development. In August 2007, the Court granted the motion and vacated the April 2006 decision. In 2008, the veteran submitted additional medical evidence along with a waiver of initial RO consideration. 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 Pursuant to the Court's August 2007 order, the Board finds that further development is necessary. The veteran is seeking service connection for PTSD. His DD Form 214 indicates that he was exposed to combat during his service in the Republic of Vietnam. The veteran has indicated that he suffers from nightmares and intrusive thoughts of his combat experiences in Vietnam. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. §4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f) (2007). See Cohen v. Brown, 10 Vet. App. 128 (1997). If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f). As noted in the Joint Motion for Remand, the evidence of record suggests the existence of additional treatment records from the VA Medical Center (VAMC) in San Juan and the Vet Center. The veteran was referred to the PTSD clinic at the San Juan VA Medical Center (VAMC) in October 2000, and has received treatment thereafter. The Board finds that all outstanding VA records should be obtained and associated with the claims folder. Further, the Joint Motion indicates that the Board failed to address the incorrect standard applied by VA examiners to diagnose PTSD. In this regard, the VA examiners who conducted the December 2002 examination opined that the veteran was unable to specify and describe in detail a "severe and horribly traumatic event experienced in combat," and therefore his stressors were insufficient to satisfy the diagnostic criteria under the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, (DSM- IV), published by the American Psychiatric Association. However, as noted in the Joint Motion, a stressor does not need to be a "severe and horribly traumatic event experienced in combat," to satisfy the DSM-IV criteria. Rather, the DSM-IV requires that a person's response to the stressor involve intense fear, helplessness, or horror. Two requirements as to the sufficiency of a stressor are: 1) a person must have been "exposed to a traumatic event" in which "the person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others," and 2) "the person's response [must have] involved intense fear, helplessness or horror." DSM-IV at 427-28. Here, the Joint Motion indicates that it is unclear whether the December 2002 VA examiners understood or considered the fact that a stressor need not be "life threatening" to satisfy the DSM-IV. Thus, the Board finds that another VA examination should be afforded the veteran in order to determine whether he meets the diagnostic criteria for PTSD when the correct definition of a stressor, pursuant to the DSM-IV, is applied. Accordingly, the case is REMANDED for the following action: 1. The RO should request and associate with the claims folder all outstanding treatment records from the VA Medical Center in San Juan and the San Juan Vet Center. 2. The veteran should be scheduled for a psychiatric examination by a board of two psychiatrists who have not previously addressed whether the veteran meets the DSM-IV criteria for PTSD. The examination report should reflect review of the entire claims folder. If a diagnosis of PTSD is made, the examiners should specify (1) whether each alleged stressor found to be established by the record by the RO was sufficient to produce PTSD; and (2) whether the remaining diagnostic criteria to support the diagnosis of PTSD have been satisfied; and (3) whether there is a link between the current symptomatology and one or more of the in-service stressors found to be established by the record by the RO and found to be sufficient to produce PTSD by the examiners. The examiners should be reminded that a sufficient stressor is one in which the veteran was exposed to a traumatic event in which he experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others, and 2) the veteran's response must have involved intense fear, helplessness or horror. No other definition of a "stressor" should be used. The examiners should reconcile any opinions with all evidence of record, to include a VA psychiatric examination report dated in November 1977; VA hospitalization report covering treatment from September and October 1997; a November 1997 assessment of PTSD by J.A.J.O., M.D; a December 1999 VA examination report; a March 2000 assessment of PTSD by J.R.C., M.D; a September 2000 VA examination report; a December 2002 VA examination report; a VA outpatient report dated in December 2004; and a February 2008 evaluation report provided by C.R., Ph.D. The examination report should include the complete rationale for all opinions expressed. All necessary special studies or tests, to include psychological testing and evaluation, such as the Minnesota Multiphasic Personality Inventory, and the Mississippi Scale for Combat-Related PTSD, should be accomplished. The entire claims folder and a copy of this REMAND must be made available to the examiner prior to the examination. 3. Upon completion of the above- requested development, the RO should readjudicate the veteran's service connection claim for PTSD, taking into account any newly obtained evidence. All applicable laws and regulations should be considered. If the benefit sought on appeal remains denied, the veteran and his representative should be provided with a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, the case should be returned to the Board if in order. The Board intimates no opinion as to the ultimate outcome of this case. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). 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. 2007). _________________________________________________ THOMAS J. DANNAHER 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) (2007).