Citation Nr: 1307192 Decision Date: 03/04/13 Archive Date: 03/11/13 DOCKET NO. 10-20 486 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Virginia Girard-Brady, Attorney at Law ATTORNEY FOR THE BOARD A. Haddock, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1965 to October 1967, with service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2008 rating decision of the Cleveland, Ohio Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that the Veteran filed a timely notice of disagreement with the issue of entitlement to service connection for bilateral hearing loss; however, in his May 2010 substantive appeal, the Veteran specifically limited his appeal to the issue of entitlement to service connection for PTSD. The Board has limited its consideration accordingly. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. 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 Board finds that additional development is required before the Veteran's claim on appeal can be decided. A review of the record shows that in February 2009 the Veteran was diagnosed with PTSD at the Dayton, Ohio VA Medical Center. At that time, the Veteran reported symptoms including frequent flashbacks of his time in the Republic of Vietnam with occasional nightmares, efforts to avoid thoughts, feelings or conversations associated with the trauma experienced in Republic of Vietnam, difficulty maintaining sleep, irritability or outbursts of anger, and exaggerated startle response. The Veteran was assigned a GAF score of 59. The Veteran was afforded a VA examination in November 2011. At that time the Veteran reported symptoms similar to those he reported during his February 2009 treatment at the VA Medical Center; however, the VA examiner found that the Veteran's symptoms did not warrant a diagnosis of PTSD as his social and occupational functioning was not significantly effected. The Board finds that this rationale is inadequate. According the DSM-IV a diagnosis of PTSD is warranted when the "disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning." While the Board notes that the November 2011 VA examiner found that the Veteran was not experiencing significant impairment to his social or occupational functioning, she did not discuss whether his symptoms had caused a level of clinical distress sufficient to warrant a diagnosis in accordance with the DSM-IV. Additionally, while the examiner did acknowledge that the Veteran had a previous diagnosis of PTSD, she did not offer an opinion as to whether the February 2009 PTSD diagnosis was causally related to his active service. Therefore, the Board finds that a new VA examination is necessary to determine whether the Veteran currently has, or has had at any time during the pendency of this appeal, a diagnosis of PTSD that is causally related to his active service. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be afforded a VA examination by a psychiatrist or a psychologist (different from the November 2011 examiner) with sufficient expertise to determine the nature and etiology of any currently present PTSD. The claims file must be made available to and reviewed by the examiner. All indicated studies should be performed. Based on the examination results and the review of the record, the examiner should provide an opinion as to whether the Veteran currently has, or has had, a diagnosis of PTSD that is consistent with the criteria outlined in the DSM-IV, during the pendency of the appeal. If so, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's PTSD is etiologically related to one or more in-service stressors reported by the Veteran. The examiner must specifically state whether the claimed stressor(s), if not involving combat, is related to the Veteran's fear of hostile military activity or terrorist activity of the type contemplated by the recent revision to 38 C.F.R. § 3.304(f)(3). The complete rationale for all opinions expressed must be provided. Specifically, the examiner's rationale should address, and explain, the February 2009 VA treatment record which notes the Veteran was given a diagnosis of PTSD at that time and the November 2011 VA examination report which noted that the Veteran did not meet the criteria for a PTSD diagnosis. 2. Then, the RO should readjudicate the issue on appeal. If the benefits sought remain denied, the Veteran and his representative should be furnished an appropriate Supplemental Statement of the Case and afforded a reasonable 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). 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). _________________________________________________ T. D. JONES Acting 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).