Citation Nr: 1307079 Decision Date: 03/01/13 Archive Date: 03/11/13 DOCKET NO. 07-22 249 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to service connection for a variously diagnosed psychiatric disability, to include anxiety reaction and posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K.S. Hughes, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from July 1997 to July 2000. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2006 rating decision of the Houston, Texas Department of Veterans Affairs (VA) Regional Office (RO). In October 2010, the Board denied service connection for left shoulder and low back disorders and remanded for additional development the matter of service connection for a psychiatric disability. 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 As was noted in the Board's October 2010 remand, the Veteran's July 2005 claim specifically sought service connection for anxiety reaction, and that was the specific claim adjudicated by the RO and developed for appellate review. However, as the evidence showed a diagnosis of PTSD, in accordance with the United States Court of Appeals for Veterans Claims (Court) decision in Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Board recharacterized the issue to encompass other psychiatric diagnoses (including PTSD) and remanded the matter for due process considerations. The RO was to provide Veterans Claims Assistance Act of 2000 (VCAA) mandated notice, secure (with the Veteran's assistance) complete records of all psychiatric treatment, and readjudicate the matter of service connection for a variously diagnosed psychiatric disability (to include anxiety reaction and PTSD). A November 2010 letter from the RO asked the Veteran to complete and return a questionnaire providing specific details of the stressful incident(s) in service that resulted in his PTSD, identify all VA and private psychiatric treatment he had received, and submit records of private treatment or authorize VA to obtain such records on his behalf. The Veteran did not provide the information requested. San Antonio VA Medical Center treatment records were obtained; in October 2011 a supplemental statement of the case (SSOC) noting that the Veteran did not respond to the request for additional evidence and PTSD stressor information was issued. In January 2012 (after the issuance of the October 2011 SSOC), VA received additional evidence from the Veteran (forwarded to the Board by his representative), including a December 2010 statement from the Veteran's physician at the Laredo Veterans Outpatient Clinic stating that the Veteran has PTSD. The most recent records of treatment at the Laredo Outpatient Clinic in the claims file are dated in January 2011. Updated treatment records are pertinent evidence, and must be secured; notably, any VA treatment records are constructively of record. Further, the additional evidence received in January 2012 also included statements from the Veteran's fellow service members, recalling the Veteran being singled out for threats, indimidation, and harassement by a superior in service, and statements from the Veteran's family and friends, regarding changes in his behavior noted after military service. The Veteran has not been afforded a VA examination in connection with this claim. As the record shows diagnoses of various psychiatric entities and because there is medical evidence suggesting a connection between the Veteran's psychiatric disability and his military service, an examination to secure a nexus opinion is necessary. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the case is REMANDED for the following action: 1. The RO should ask the Veteran to identify all providers of psychiatric treatment he has received since his discharge from active duty, and to provide authorizations for VA to obtain records of any such private treatment. The RO should secure for the record copies of complete clinical records of the treatment identified. The Veteran should be notified if any records identified are not received pursuant to the RO's request. Whether or not he responds, the RO should secure complete records of all VA psychiatric treatment he has received from January 2011 to the present. 2. When the development sought above is completed, the RO should arrange for a psychiatric examination of the Veteran to determine the nature and likely etiology of his psychiatric disability(ies). The Veteran's claims file (to include this remand) must be reviewed by the examiner in conjunction with the examination. The examiner must be advised of the Veteran's alleged stressors in service, and further advised which stressors are corroborated by credible supporting evidence. Based on examination of the Veteran and review of the record, the examiner should provide an opinion that responds to the following: (a) Please identify (by medical diagnosis) each of the Veteran's psychiatric disabilities found. (b) Specifically, does the Veteran warrant a diagnosis of PTSD based on a corroborated stressor event in service? If not, please identify what is needed for such diagnosis that is lacking. Please discuss sufficiency of the stressors described (to support a diagnosis of PTSD) and identify the symptoms that support any diagnosis of PTSD. (c) As to each (and every) psychiatric diagnosis other than PTSD, please indicate whether such disability entity is at least as likely as not (a 50 percent or better probability) related to the Veteran's military service. The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data, as appropriate. 3. Following completion of the above and any further development deemed necessary, the RO should readjudicate the claim seeking service connection for a variously diagnosed psychiatric disability (to include anxiety reaction and PTSD). If it remains denied, the RO should issue an SSOC and afford the Veteran and his representative the opportunity to respond. The case should be returned to the Board for further 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 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). _________________________________________________ George R. Senyk 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).