Citation Nr: 1132167 Decision Date: 09/01/11 Archive Date: 09/12/11 DOCKET NO. 08-05 999 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to service connection for an acquired psychiatric disorder. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD James Alsup, Counsel INTRODUCTION The Veteran served on active duty from April 1970 to May 1971. This matter comes before the Board of Veterans' Appeals (the Board) on appeal from a November 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois, which denied the Veteran's claim for service connection for major depression, bipolar disorder and post traumatic stress disorder (PTSD). The Veteran disagreed and perfected an appeal. In February 2007, the Veteran and his representative presented testimony in support of the Veteran's claim at a hearing at the RO before a local hearing officer. In April 2011, the Veteran and his representative presented testimony at a hearing at the RO before the undersigned Veterans Law Judge. Transcripts of those hearings have been associated with the Veteran's VA claims folder. 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 Preliminarily, the Board notes that the Veteran is seeking service connection for an acquired psychiatric disorder and the Board has rephrased the issue on appeal accordingly. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (The Board should consider a claim for a specific psychiatric disorder as a claim for any mental disability that may be reasonably encompassed by the evidence of record). In order to establish service connection or service-connected aggravation for a present disability, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The record evidence includes a September 2004 VA examiner's report that indicates that the Veteran's proper diagnosis is major depression and not PTSD. Other medical evidence indicates other examiners have also evaluated the Veteran with depression during the pendency of the Veteran's claim. No medical examiner has determined whether the diagnosed disorder is related to the disorder diagnosed during service as "passive-aggressive personality," or is related to the events and symptoms reported by the Veteran during service and since service. The Court has held that once VA undertakes the effort to provide an examination, it must provide an adequate one. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Secretary's duty to make reasonable efforts to assist in obtaining evidence necessary to substantiate a claim for benefits pursuant to 38 U.S.C.A. § 5103A(a)(1) includes providing an examination that is adequate for rating purposes. It is incumbent upon the rating official to ensure that a diagnosis or condition is described and supported in sufficient detail for evaluation purposes. See 38 C.F.R. § 4.2 (2010). The issue of whether there is evidence of a nexus between a current psychiatric disorder and the Veteran's active duty service requires a medical opinion before an adequate decision regarding service connection can be provided. For those reasons, the Board remands the claim for a psychiatric examination to determine whether the Veteran's current depression disorder is related to service. Accordingly, the case is REMANDED for the following action: 1. VBA shall ensure that all VA records regarding the Veteran's psychiatric disorder are included in the Veteran's VA claims folder. VBA shall also request in writing that the Veteran identify any treatment received for his psychiatric disorder outside of VA since 2007. If the Veteran responds by identifying such records, VBA shall take appropriate steps to obtain such records and include them in the Veteran's VA claims folder. 2. Following the foregoing, VBA shall provide the Veteran's VA claims folder to an appropriate VA clinical psychologist or psychiatrist who shall review the Veteran's claims folder prior to examining the Veteran. The examiner shall provide a diagnosis of any psychiatric disorder currently manifested by the Veteran and further provide an opinion whether it is at least as likely as not that any diagnosed psychiatric disorder currently manifested by the Veteran was incurred during or aggravated by his active duty military service. The examiner's written narrative report shall include reference to specific clinical or record evidence and state complete rationale supporting any opinion rendered. If the examiner is unable to provide the requested opinion without resort to mere speculation, the examiner shall state the reasons why that is the case. The examiner's report shall be associated with the Veteran's VA claims folder. 3. Following completion of the foregoing, VBA shall readjudicate the Veteran's claim for service connection for an acquired psychiatric disorder. If the benefit sought on appeal remains denied, VBA should provide the Veteran with a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board for further appellate review if otherwise in order. 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. 2010). _________________________________________________ FRANK J. FLOWERS 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).