Citation Nr: 1216640 Decision Date: 05/09/12 Archive Date: 05/16/12 DOCKET NO. 09-19 040 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES Entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia and posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Maryland Department of Veterans Affairs ATTORNEY FOR THE BOARD Dan Brook, Counsel INTRODUCTION The Veteran served on active duty from September 1963 to September 1967. This appeal to the Board of Veterans' Appeals (Board) arises from rating decisions of the Baltimore, Maryland and Columbia, South Carolina Regional Offices (ROs) of the Department of Veterans' Affairs (VA). The case was certified to the Board by the Baltimore, RO. In his May 2009 Form 9, the Veteran requested a Board hearing in Washington D.C., however, in March 2012 correspondence the Veteran indicated that he could not attend a hearing. Consequently, he wanted the Board to go ahead and review his case. VA initially adjudicated this matter as separate claims of entitlement to service connection for PTSD and schizophrenia. The Board has consolidated the appeal into one issue, as shown on the title page above. The Veteran is not prejudiced by this consolidation. The Board and the agency of original jurisdiction will be specifically considering whether service-connected compensation is warranted for PTSD and/or schizophrenia when it readjudicates the question of entitlement to service connection for an acquired psychiatric disorder. Clemons v. Shinseki, 23 Vet. App. 1 (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 service treatment records do not contain any findings, diagnoses or complaints related to psychiatric disorder. During a September 1998 VA general medical examination, the examiner noted that the Veteran was currently being seen in the VA mental hygiene clinic for symptoms of PTSD. The examiner also noted that the Veteran was currently taking olanzapine, an antipsychotic medication, for dreams and hallucinations. Subsequent VA records associated with the claims file indicate that the Veteran received mental health treatment from 2000 to 2007. Diagnoses included schizophrenia, psychotic disorder not otherwise specified, delusional disorder and depressive disorder, not otherwise specified. In February 2008, the Veteran submitted a letter from his wife, which included her recollections of his behavior prior to service, during service and thereafter. In a June 2008 letter, a treating VA psychologist indicated that the Veteran had been receiving psychological services from him since early July 2006. He also indicated that in early 1998, the Veteran was seen by a VA psychiatrist, Dr. H. At that time, Dr. H diagnosed the Veteran with delusional disorder, a less severe diagnosis than schizophrenia. The psychologist noted that it was common for psychiatric disorders to wax and wane in severity over time and that this had occurred in the Veteran's case. In the spring of 2007, both the psychologist and a treating psychiatrist, Dr. M, concluded that the Veteran was suffering from schizophrenia. The psychologist also noted that schizophrenia typically first clearly manifests in young adulthood and that the descriptions of behavior during service provided by the Veteran and his wife were consistent with him having symptoms of schizophrenia during that time. Thus, the psychologist opined that the Veteran suffered from schizophrenia while serving in the Navy. The Veteran was subsequently afforded a VA psychological evaluation in February 2011. The psychologist found that the Veteran's symptomatology did not meet the criteria in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM -IV) for a diagnosis of posttraumatic stress disorder. She diagnosed the Veteran as having a psychotic disorder, not otherwise specified. She did not provide an opinion, however, addressing the likelihood that this disorder is related to the Veteran's military service. Given that the June 2008 opinion provided by the VA psychologist suggests a possible nexus between current psychiatric disability and military service, and given that the February 2011 VA psychologist did not provide an opinion addressing the etiology of any diagnosed psychiatric disorder, the Board finds that a further VA examination is necessary. 38 C.F.R. § 3.159c(c)(4) (2011); McClendon v. Nicholson, 20 Vet. App. 79 (2006). On remand, the Veteran should be afforded a VA examination by a psychiatrist to determine the likelihood that any current psychiatric disability is related to service. In conjunction with the examination, the examiner should review all the pertinent information contained in the claims file to include the service treatment records, service personnel records, post-service VA mental health treatment records, the June 2008 letter from the VA psychologist, the recollections provided by the Veteran's wife in February 2008, the assertions of the Veteran, the assertions of the Veteran's representative and the non-treating VA psychologist's February 2011 report. Prior to arranging for the VA examination, the AMC/RO should ask the Veteran whether he received any post-service mental health treatment prior to 1998. If so, the Veteran should identify the source of the treatment and when he was treated. The AMC/RO should then ensure that all available post- service VA and private mental health treatment records are associated with the claims file. In particular, the AMC/RO should attempt to obtain records of the mental health treatment for "symptoms of PTSD" alluded to in the September 1998 VA examination report. The AMC/RO should also attempt to obtain more recent VA treatment records, as it is unclear whether the records submitted by the Veteran for the time frame from 2000 to 2007 include all documentation of mental health treatment for that time frame. Additionally, the AMC/RO should ensure to obtain all additional records of VA mental health treatment the Veteran may have received from 2008 to the present. Accordingly, the case is REMANDED for the following action: 1. The AMC/RO should ask the Veteran whether he received any post-service mental health treatment prior to 1998. If so, the Veteran should identify the source of the treatment and the approximate time frame in which he was treated. The AMC/RO should then ensure that all available post-service VA and private mental health treatment records are associated with the claims file. In particular, the AMC/RO should obtain all available records of VA mental health treatment from 1998 to the present, including the records of treatment for "symptoms of PTSD" alluded to in the September 1998 VA general medical examination report. If the AMC/RO is unable to locate any records, it must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The AMC/RO must then: (a) notify the Veteran and his representative of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claim. The Veteran must then be given an opportunity to respond. 2. Thereafter, the Veteran should be afforded a new VA examination by a psychiatrist to determine the likely etiology of any diagnosed psychiatric disability. Any indicated tests should be performed. The examiner is to be provided access to the claims folder, a copy of this remand, and Virtual VA. The examiner should be sure to review the service treatment records, service personnel records, post service VA mental health treatment records, the June 2008 letter from the VA psychologist, the recollections provided by the Veteran's wife in February 2008, the assertions of the Veteran, the assertions of the Veteran's representative, the non-treating VA psychologist's February 2011 report and any other pertinent information. The examiner must specify in the report that the claims file and Virtual VA records have been reviewed. The examiner must also specify the range of dates of the records reviewed on Virtual VA. The Board takes this opportunity to note that as of the date of this remand there is absolutely no evidence that the appellant served in Vietnam as he has claimed, there is no evidence that he ever attended basic underwater demolition school (BUDS) let alone served as a Navy SEAL as he has claimed during some psychiatric examinations; and there is no evidence that he was trained by any member of a special forces group. The Board, however, takes administrative notice of the fact that the USS AMERICA, on which the appellant did serve, did support the USS LIBERTY in evacuating its dead and wounded after that ship was attacked in June 1967 by Israeli torpedo boats. After the examination, claims file review and Virtual VA review, the examiner must provide an opinion as to whether it is at least as likely as not (i.e., is there a 50% chance or greater) that any current psychiatric disability is related to service. The examiner should explain the rationale for any opinion provided. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, he or she should specifically explain the reason for this conclusion. The Veteran is to be notified that it is his responsibility to report for the examination and to cooperate in the development of the claim. 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. In the event that the Veteran does not report for the aforementioned examination, documentation should be obtained which shows that notice scheduling the examination was sent to the last known address. It should also be indicated whether any notice that was sent was returned as undeliverable. 3. After the development requested has been completed, the AMC/RO should review the examination report to ensure that it is in complete compliance with the directives of this REMAND. The AMC/RO must ensure that the examiner documented his or her consideration of Virtual VA, to include identifying the date range of Virtual VA records reviewed. If the report is deficient in any manner, the AMC/RO must implement corrective procedures at once. 4. After undertaking any other development deemed appropriate, the AMC/RO should readjudicate the issue on appeal. If the benefit sought is not granted, the Veteran should be furnished with a supplemental statement of the case and afforded an opportunity to respond before the record is returned to the Board for further review. 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). _________________________________________________ DEREK R. BROWN 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) (2011).