Citation Nr: 1004877 Decision Date: 02/02/10 Archive Date: 02/18/10 DOCKET NO. 08-19 829 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to service connection for a psychiatric disability, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Havelka, Counsel INTRODUCTION The Veteran's active military service extended from March 1976 to January 1978. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, which denied the service connection for PTSD. The record reveals diagnoses of PTSD, depression, and various psychotic disorders. Claims for service connection for PTSD, may encompass claims for service connection for all diagnosed psychiatric disabilities. Clemons v. Shinseki, 23 Vet.App. 1, 5 (2009). Accordingly, the Board has recharacterized that issue. In November 2009, the appellant testified at a hearing at the Department of Veteran Affairs (VA) Regional Office (RO) in Nashville, Tennessee, before the undersigned Veterans Law Judge. Unfortunately, an accurate transcript of the hearing testimony could not be made from the recording of the hearing. 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 record reveals diagnoses of different psychiatric disabilities including PTSD, depression, and psychotic disorders. The Veteran's primary assertion is that he has PTSD as a result of a personal assault during service within the meaning of 38 C.F.R. § 3.304 (f)(4). He asserts two stressors during service. First, he claims that he observed a fellow solider named Nathaniel Fluellen die during service. Second, he claims he was sexually assaulted by a solider named Alex Heard. Additional development with respect to these two stressors is required. The evidence of record reveals that the Veteran is receiving disability benefits from the Social Security Administration (SSA). The evidence of record reveals the presence of severe psychiatric symptoms, accordingly, the SSA records may be relevant to the Veteran's current claim and should be obtained. VA must obtain Social Security Administration decisions and records, which have bearing on the veteran's claim. Waddell v. Brown, 5 Vet. App. 454 (1993). The Veteran needs to be accorded a VA psychiatric Compensation and Pension examination. When the medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Colvin v. Derwinski, 1 Vet. App. 171 (1991). Finally, the Veteran testified at hearing before the undersigned Veterans Law Judge in November 2009. Unfortunately, the recording of that hearing was damaged and an accurate transcript of the hearing testimony could not be made. He should be provided the opportunity to have another hearing if desired. Accordingly, the case is REMANDED for the following action: 1. Obtain from the Social Security Administration the records pertinent to the appellant's claim for Social Security disability benefits as well as the medical records relied upon concerning that claim 2. Develop the Veteran's claim in accordance with M21-1 provisions concerning claims for service connection for PTSD based on personal assault. This includes, but is not limited to, notifying the Veteran of the opportunity to furnish, or to advise VA of the potential source or sources of evidence other than his service records or evidence of behavioral changes that might constitute credible supporting evidence of his purported in-service stressor. Specific examples of corroborating alternative evidence should be provided. In particular, he should be given the opportunity to present statements of friends, family, and former service members attesting to any change in his behavior or events he confided to them. It may also require that the veteran provide another statement containing as much detail as possible regarding the stressors which he claims he was exposed to during active service to include specific details of the claimed stressful events during service, such as dates, places, detailed descriptions of the events, his service units, duty assignments and the names and other identifying information concerning any individuals involved in the events. The veteran should be told that the information is necessary to obtain supportive evidence of the stressful events and that failure to respond may result in adverse action. Specifically, attempt to verify the death of service man Nathaniel Fluellen during the Veteran's period of service and attempt to verify the nature of the discharge of service member Alex Heard. 3. Schedule the Veteran for a VA psychiatric examination with consideration of the criteria for PTSD. The report of examination should include a detailed account of all manifestations of psychiatric pathology found to be present. If there are different psychiatric disorders, attempt to reconcile the diagnoses and specify which symptoms are associated with and which disorders are part of or caused by the service-connected disorder. If certain symptomatology cannot be disassociated from one disorder or another, it should be specified. All necessary special studies or tests including psychological testing are to be accomplished. The examiner should elicit a specific history of the Veteran's stressors, both during and after service, and indicate if any of these stressors are the cause of the psychiatric disabilities diagnosed. The examiner should review the evidence of record with attention to the service treatment records and his long history of post-service psychiatric treatment and provide the following opinion: * Is it at least as likely as not (50 percent or greater probability) that any current psychiatric disorder is related to the Veteran's active military service? Assign a numerical code under the Global Assessment of Functioning Scale (GAF). It is imperative that the examiner include a definition of the numerical code assigned. Thurber v. Brown, 5 Vet. App. 119 (1993). The diagnosis should be in accordance with the DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (4TH ed. 1994). The claims folder and a copy of this remand must be made available and reviewed by the examiner in conjunction with the examination. The examiner should provide a complete rationale for all conclusions reached. 4. Contact the Veteran and inform him that an accurate transcript of the November 2009 hearing testimony could not be made from the recording of the hearing. Offer him the opportunity to have another Travel Board hearing before a member of the Board. 5. Following the above, readjudicate the Veteran's claim for service connection for a psychiatric disability, to include PTSD. If the benefit on appeal remains denied, a Supplemental Statement of the Case should be issued, and the veteran and his representative should be afforded an opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. 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). 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). _________________________________________________ RONALD W. SCHOLZ 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).