Citation Nr: 1124258 Decision Date: 06/27/11 Archive Date: 07/06/11 DOCKET NO. 07-40 070 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. J. In, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1967 to November 1973. This matter comes properly before the Board of Veterans' Appeals (Board) on appeal from an April 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office in St. Louis, Missouri (RO). In January 2006, the Veteran submitted a claim of entitlement to service connection for posttraumatic stress disorder (PTSD). The medical evidence of record includes diagnoses of major depressive disorder and probable PTSD. Although an appellant may only seek service connection for PTSD, a claim "cannot be a claim limited only to that diagnosis, but must rather be considered a claim for any mental disability that may be reasonably encompassed." Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). In essence, an appellant does not file a claim to receive benefits for a particular psychiatric diagnosis that is named on a claims form, such as PTSD, but instead makes a general claim for compensation for the difficulties posed by the appellant's mental condition. Id. As such, the Veteran's January 2006 claim will be addressed herein as captioned above. The appeal is remanded to the RO via the Appeals Management Center in Washington, DC. REMAND The Veteran is seeking service connection for a psychiatric disorder, to include PTSD. The claim has previously been denied on the basis of lack of a verified in-service stressor. During the pendency of this appeal, the criteria for verifying in-service stressors were amended, effective July 13, 2010. Generally, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2010). In addition, service connection may be granted for any disease diagnosed after discharge, when all the evidence including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for PTSD requires (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) a link, established by medical evidence, between current symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. § 3.304(f) (2010). A diagnosis of a mental disorder, including PTSD, must conform to the criteria of DSM-IV. 38 C.F.R. § 4.125 (2010). Effective July 13, 2010, VA amended its regulations governing service connection for PTSD. This amendment eliminated the requirement for corroborating that the claimed in-service stressor occurred if a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and that the Veteran's symptoms are related to the claimed stressor, provided that the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service. 38 C.F.R. § 3.304(f)(3) (2010). The in-service stressors claimed by the Veteran are related to his fear of hostile military activity. The Veteran claims that he served on many combat missions while assigned to a helicopter unit during his tour of duty in Vietnam. Specifically, he claims that it was common during the Vietnam conflict that helicopter units required ground personnel to volunteer for flight duty, which usually involved door gunner duty or retrieving dead and wounded soldiers from the battlefield. In a December 2006 notice of disagreement, the Veteran stated that during the Tet Counter offensive of 1969, his unit came under heavy rocket and mortar attack on a daily basis. The Veteran, as a senior helicopter mechanic, had to man the M-60 machine gun in the door of the aircraft. He also stated that during this tour of duty he was tasked with recovering dead and wounded soldiers from ground units and witnessed many dismembered or badly wounded soldiers. The Veteran reports that he has had nightmares and flashbacks about them ever since that time. The Veteran's service personnel records reveal that he served two tours of duty in the Republic of Vietnam from January 1966 to May 1967, and from January 1969 to August 1970. During the second tour of duty from 1969 to 1970, the Veteran was assigned to the 608th and 79th Transportation Company serving as a Senior Helicopter Repairman. The record also shows that the Veteran participated in the Vietnam Counteroffensive Camp, Phase II, Phase VI, and Phase VII Campaign, as well as in the Tet Counteroffensive of 1969. Therefore, the claimed stressors are consistent with the circumstances, conditions, or hardships of the Veteran's service. However, the medical evidence of record does not show a clear diagnosis of PTSD. A January 2006 VA treatment report noted "[l]ikely dx[(diagnosis)] of PTSD-has occasional reexperience of trauma, increased arousal with 2+ symptoms, but only 1-2 symptoms (needs 3+ for criteria) of avoidance of [stimuli]. Pt[(Patient)] may have had more of these symptoms when he returned from war." There is also no medical opinion as to whether the Veteran's symptoms are related to the claimed stressors. As such, the evidence of record is insufficient to allow the Board to determine whether the criteria under 38 C.F.R. § 3.304(f)(3) have been met. Under these circumstances, a VA examination by a VA psychiatrist or psychologist is warranted to determine whether the claimed stressors are adequate to support a diagnosis of PTSD and whether the Veteran's symptoms are related to the claimed stressors. 38 C.F.R. § 3.304(f)(3). Accordingly, the case is remanded for the following actions: 1. The RO must contact the Veteran to provide him an opportunity to identify all VA and non-VA medical providers who have treated him for his PTSD. The Veteran must be asked to complete a separate VA Form 21-4142 for any private physician or source of treatment he may identify. The RO must then obtain all identified records. Regardless of whether the Veteran responds, the RO must obtain all updated VA treatment records pertaining to the Veteran's PTSD which are not currently associated with the claims file. All attempts to secure this evidence must be documented in the claims file by the RO. If, after making reasonable efforts to obtain the identified records, the RO is unable to secure same, the RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the RO with respect to the claim; and (d) that he is ultimately responsible for providing the evidence. The Veteran and his representative must then be given an opportunity to respond. 2. The Veteran must be afforded a comprehensive VA psychiatric examination to determine the diagnoses of all psychiatric disorders that are present. The examination must be conducted by a psychiatrist or psychologist. All necessary special studies or tests including psychological testing and evaluation must be accomplished. The entire claims file must be made available to the examiner for review in conjunction with this examination. The examiner must integrate the previous psychiatric findings and diagnoses of current findings to obtain a true picture of the nature of the Veteran's psychiatric status. The examination report must include a detailed account of all pathology found to be present. The examiner must state whether any diagnosed psychiatric disorder is related to the Veteran's active duty service. If the diagnosis of PTSD is deemed appropriate, the examiner must explain how the diagnostic criteria of the Diagnostic and Statistical Manual for Mental Disorders are met, to include identification of the specific stressor(s) underlying the diagnosis, and comment upon the link between the current symptomatology and one or more of the stressors. If PTSD is found to be related to an in-service stressor, the examiner must specifically state whether that stressor was related to the Veteran's fear of hostile military activity. If a diagnosis of PTSD is not deemed appropriate, the examiner must specifically explain how the diagnostic criteria for PTSD of the Diagnostic and Statistical Manual for Mental Disorders have not been met. Any opinion provided must include a complete rationale. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The report must be typed. 3. The RO must notify the Veteran that it is his responsibility to report for the scheduled examination and to cooperate in the development of the claim, and that the consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2010). In the event that the Veteran does not report for the scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 4. The examination report must be reviewed to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the RO must implement corrective procedures. 5. After completing the above actions, the RO must readjudicate the Veteran's claim on appeal, taking into consideration any newly acquired evidence. If the benefit on appeal remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). _________________________________________________ JOY A. MCDONALD 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) (2010).