Citation Nr: 1300890 Decision Date: 01/09/13 Archive Date: 01/16/13 DOCKET NO. 09-16 653 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD R. Dodd, Associate Counsel INTRODUCTION The Veteran had active service from July 1970, to May 1972. This case comes before the Board of Veterans' Appeals (Board) on appeal from an April 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas, which denied the Veteran's claim for service connection for PTSD. The Veteran filed a Notice of Disagreement in August 2008. The Veteran was provided with a Statement of the Case in April 2009 and Supplemental Statements of the Case (SSOC) in February 2011, and June 2011. In a May 2009 VA Form 9, the Veteran perfected his appeal of the issue currently before the Board. In September 2011, a hearing was held before the undersigned Veterans Law Judge making this decision. See 38 U.S.C.A. § 7107(c) (West 2002). A transcript of these proceedings has been associated with the claims file. The Board remanded the claim to the RO via the Appeals Management Center (AMC) for further development in November 2011. That development having been completed, this claim is once again before the Board. It should be noted that the Board has recharacterized the Veteran's claim for service connection for PTSD so that it is clear that it includes a claim for service connection for any acquired psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (finding that a claim for benefits for one psychiatric disability also encompassed benefits based on other psychiatric diagnoses and should be considered by the Board to be within the scope of the filed claim). A review of the Virtual VA paperless claims processing system revealed VA Medical Center treatment records from September 2011 to July 2012. 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 Although the Board regrets the additional delay, remand is necessary to ensure that there is a complete record upon which to decide the Veteran's claim. Remand is required to obtain an addendum opinion. Remand is required to obtain an addendum opinion to the January 2012 VA examination. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311(2007). The opinion regarding the Veteran's PTSD is found to be inadequate. In the January 2012 VA examination, the examiner found that the Veteran did not warrant a diagnosis of PTSD and that his symptoms of depression and chronic sleep impairment could be attributed to a diagnosis of alcohol dependence that was not related to military service. The examiner based his diagnosis on two provided stressors, which included an incident with a roommate from Vietnam and the Veteran having knowledge of the death of his buddies. The examiner found that both stressors did not meet criteria adequate to support a diagnosis of PTSD, but did not provide any further explanation for this. Also, the examiner, although he indicated that the claims file was reviewed, did not address the stressor of the Veteran's exposure to enemy fire on a regular basis. This stressor was previously verified as conceded in an enclosed memorandum. As such, an addendum opinion is required to have the VA examiner consider this additional stressor. Further, although the examiner mentioned the fact that the Veteran had previously carried a diagnosis of PTSD from the VA Medical Center, he did not discuss the discrepancy any further. VA Medical Center treatment records from July 2008 reflect that the Veteran was diagnosed with PTSD. There was no discussion of whether that diagnosis was accurate or if the Veteran's condition had gone into remission. As such, any new opinion must seek to reconcile these disparate findings. Last, the VA examiner found that the Veterans symptoms of depression and chronic sleep impairment were likely caused by his alcohol dependence. However, in a VA treatment record from July 2008, the Veteran reported consuming alcohol as a way of self-medicating his pre-existing sleep impairment. No discussion of this treatment note occurred in the 2012 VA examination report within the context of the Veteran's alcohol dependence. It must be determined if the Veteran's diagnosed alcohol dependence is the cause of his psychiatric symptoms or if it is a result of PTSD or any other acquired psychiatric disorder. Additionally, as this case must be remanded for the foregoing reason, any recent VA treatment records should also be obtained. The Board observes that the Veteran has received VA treatment for his PTSD and records of his VA care, dated since July 2012, have not been associated with the claims file. Under the law, VA must obtain these records. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c) (2012); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). Accordingly, the case is REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. 2. After any additional records are associated with the claims file, obtain an addendum opinion to the January 2012 VA examination in order to determine whether the Veteran has PTSD or any acquired psychiatric disorder and the etiology of such. All pertinent symptomatology and findings must be reported in detail. The entire claims file (i.e., both the paper claims file and any electronic medical records) should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. If the examiner does not have access to electronic medical records, any such relevant treatment records must be printed and associated with the paper claims file so they can be available to the examiner for review. All required testing must be performed. A complete rationale for all opinions must be provided. If the examiner cannot provide the requested opinion without resort to speculation, it must be so stated, and a supporting rationale provided for that opinion. After a review of the examination findings and the entire evidence of record, the examiner must render an opinion regarding whether the Veteran has PTSD or any acquired psychiatric disorder and, if so, whether it is at least as likely as not (a 50% or greater probability) that the PTSD or acquired psychiatric disorder is related to the Veteran's active service, or to any incident therein. The examiner must address the lay statements of record, particularly regarding accounts of being constantly attacked while serving in Vietnam, which for the purpose of this remand, the examiner should find credible. The examiner must also address the VA Medical Center records showing a diagnosis of PTSD and discuss the reasons for any discrepancy in findings. Further, the examiner should address the issue of the Veteran's alcohol dependence and whether it is the cause of or the result of the Veteran's psychiatric disorder. If, and only if, the VA examiner who conducted the Veteran's January 2012 VA examination is not available, then schedule the Veteran for appropriate in-person examination to determine the nature and etiology of his PTSD or any acquired psychiatric disorder. 3. Review the examination report to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the AMC must implement corrective procedures. Stegall v. West, 11 Vet. App. 268, 271 (1998). 4. After completing the above action, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claim must be readjudicated. If the claim remains denied, a supplemental statement of the case must be provided to the Veteran. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate 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). 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. 2012). _________________________________________________ DEBORAH W. SINGLETON 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) (2012).