Citation Nr: 1311745 Decision Date: 04/09/13 Archive Date: 04/19/13 DOCKET NO. 08-07 519 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include, but not limited to, posttraumatic stress disorder (PTSD) and depression. 2. Entitlement to service connection for paroxysmal tachycardia (PAT), claimed as a heart disorder, to include as secondary to an acquired psychiatric disorder. 3. Entitlement to service connection for hypertension, to include as secondary to an acquired psychiatric disorder REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. J. Houbeck, Counsel INTRODUCTION The Veteran had active service from September 1987 to November 1991, including service in Saudi Arabia from October 1990 to April 1991. This case is before the Board of Veterans' Appeals (Board) on appeal from March 2006 and January 2008 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The Veteran testified at a video conference at the RO before the undersigned Veterans Law Judge. A transcript of the testimony is associated with the claims file. In a September 2011 decision, the Board reopened the Veteran's claim for entitlement to service connection for PTSD and combined that claim with his claim for service connection for an acquired psychiatric disorder and remanded all claims on appeal for additional development. The matter again is before the Board. 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 Veteran is seeking entitlement to service connection for an acquired psychiatric disorder, to include PTSD and depression, as well as for a heart disorder and hypertension, both claimed as secondary to the psychiatric disorder. After a complete review of the record, the Board finds that despite the extensive development already undertaken the claims must again be remanded. In that regard, the Board notes that the September 2011 remand directed that the Appeals Management Center (AMC), "Ask that the Veteran either submit relevant medical records or provide sufficient information to allow VA to request records pertaining to assessment and/or treatment for all acquired psychiatric disorders, including PTSD, since discharge from service, that have not been previously secured." The AMC sent a letter to the Veteran in October 2011 with the request and in October 2011 the Veteran returned a completed VA Form 21-4142 for the Regional Medical Center in Anniston, Alabama. In the 21-4142, however, he only noted treatment for his heart from 2006 to 2011. The AMC sent a request to the Regional Medical Center for "all treatment records, hospital summaries, findings and/or diagnoses" relating to the Veteran. The Northeast Alabama Regional Medical Center responded in December 2011, indicating the provision of records from 2006 to 2011. The Board notes that on multiple occasions the Veteran has reported hospitalization for at least two suicide attempts. During the October 2011 VA psychiatric examination, for example, the Veteran reported a suicide attempt in 1992 when he was taken to the Northeast Alabama Regional Medical Center and later transferred to the Tuscaloosa, Alabama VA Medical Center (VAMC). In addition, he reported a suicide attempt in the 1990s, possibly in 1998, for which he was hospitalized at Stringfellow Hospital in Anniston, Alabama. In February 2006, by contrast, the Veteran reported three hospitalizations for psychiatric problems, including two hospitalizations in 1996 (one at the Tuscaloosa VAMC) and another hospitalization in February 2002 at the Regional Medical Center. Treatment records from the Tuscaloosa VAMC confirm hospitalization for about two weeks in May and June 1996 for alcohol dependence and a suicide attempt by overdose of Klonopin. The discharge summary also confirms that he was transferred to the Tuscaloosa VAMC from the Northeast Alabama Regional Medical Center. Thus, there is evidence of hospitalization for psychiatric problems, including possible suicide attempts, at the Northeast Alabama Regional Medical Center in 1996 and possibly in 1992 and/or 2002. As the December 2011 response from the Northeast Alabama Regional Medical Center explicitly included only medical records from 2006 to 2011, possibly because the Veteran's VA Form 21-4142 only indicated treatment (for his heart) during that time period, the Board concludes that a remand is required to attempt to obtain records prior to 2006 from the Northeast Alabama Regional Medical Center or directly from the Veteran. In addition, the Board recognizes that the Veteran has reported hospitalization for a suicide attempt in the 1990s, possibly in 1998, at the Stringfellow Memorial Hospital in Anniston, Alabama. As such, the AMC is directed to contact the Veteran and ask him either to submit directly to VA relevant hospitalization and other treatment records from Stringfellow Hospital or to provide authorization for VA to seek those records directly from Stringfellow Hospital. The Veteran also reported during a February 2006 VA mental health clinic appointment that he was treated by Dr. Sinusi. An April 2010 VA mental health note indicates the Veteran was triaged in a local emergency room for heart palpitations and told to follow up with his cardiologist. The Veteran should also be asked to provide or authorize the release of these records on remand. The Veteran also has reported that he received multiple Article 15s during military service, which he claims are relevant to his psychiatric disorder claim. To that end, the AMC should attempt to associate the Veteran's personnel file, to include any Article 15s, with the claims file. The September 2011 Board remand also directed that the Veteran be afforded a VA examination to determine the current nature and etiology of any acquired psychiatric disorder, including, but not limited to PTSD and depression. The resulting October 2011 VA examination report diagnosed personality disorder not otherwise specified, depressive disorder not otherwise specified, and alcohol abuse reportedly in full sustained remission. In addition, the examiner noted numerous psychiatric diagnoses over time, including substance abuse and dependence, bipolar disorder, major depressive disorder with psychotic symptoms, personality disorder, PTSD, rule out PTSD, and rule out bipolar disorder. The examiner provided an extensive discussion on why, although the Veteran met the criteria for a diagnosis of PTSD, his reported symptoms were not credible and why a diagnosis of PTSD was not warranted. In addition, the examiner provided specific rationale as to the etiology of the Veteran's diagnosed depressive disorder, substance abuse disorder, and psychotic symptomatology. Finally, the examiner concluded, "it is less likely than not that any current psychiatric disorder, other than possibly his history of alcohol abuse, began during service or is the result of any event or incident in service." Despite the overarching conclusion, the Board notes that the examiner did not provide a specific rationale as to the etiology of any anxiety or bipolar disorder, unless such symptomatology was attributed to the psychotic symptoms. Given the Veteran's past diagnoses of anxiety and bipolar disorders and the Court's holding in McLain v. Nicholson, 21 Vet. App. 319 (2007) that the requirement that a claimant have a current disability before service connection may be awarded for that disability is also satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even if no disability is present at the time of the claim's adjudication, the Board concludes that an addendum opinion is necessary. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that an examination that provides an etiology opinion without a rationale is inadequate). The AMC also should take this opportunity to obtain and associate with the claims file any VA treatment records from January 2012 to the present. Consideration of the Veteran's claims for entitlement to service connection for a heart disorder and hypertension remain deferred pending resolution of the Veteran's claim for service connection for an acquired psychiatric disorder, as the heart and hypertension claims are inextricably intertwined with this claim. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, the case is REMANDED for the following action: 1. Obtain all medical records and hospitalization records for the Veteran's conditions from all appropriate VA facilities from January 2012 to the present. 2. Request a complete copy of the Veteran's service personnel records. 3. Ask that the Veteran either submit relevant medical records directly to VA or provide authorization for VA to seek records from the Northeast Alabama Regional Medical Center (for records prior to 2006), Stringfellow Memorial Hospital, and Dr. Sinusi, all in Anniston, Alabama. He should also be asked to authorize the release of hospital records pertaining to assessment/treatment for heart palpitations in 2010. Should authorization be received, all reasonable attempts should be made to obtain such records. If, after making reasonable efforts to obtain named records the AMC is unable to secure same, the AMC must notify the Veteran and (a) identify the specific records the AMC is unable to obtain; (b) briefly explain the efforts that the AMC made to obtain those records; (c) describe any further action to be taken by the AMC with respect to the claim; and (d) inform the Veteran that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. 4. After the above evidence is obtained, to the extent available, obtain a supplemental opinion from the examiner who conducted the October 2011 examination. If the examiner is not available, obtain an opinion from another appropriate medical professional. If the reviewer determines that additional examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled. However, the Veteran should not be required to report for another examination as a matter of course, if it is not found to be necessary. The claims file must be made available to and reviewed by the reviewer/examiner. The reviewer/examiner is asked to provide an opinion regarding whether it is as least as likely as not (50 percent probability or more) that any previously diagnosed anxiety or bipolar disorder was incurred in or is otherwise related to the Veteran's military service. As noted above, the Veteran's other previously diagnosed psychiatric disorders were fully addressed in the October 2011 VA examination report, however, as additional evidence may be added to the claims folder on remand, the examiner should also address whether it is at least as likely as not that the other acquired diagnosed disorders are at least as likely as not related to service. The examiner/reviewer's attention is directed to the May 2012 opinion of the Veteran's VA treating psychiatrist that he has PTSD and bipolar disorder, both of which are at least as likely as not a result of his experiences on active duty. It would be helpful if the examiner/reviewer would use the following language, as may be appropriate: "more likely than not" (meaning likelihood greater than 50%), "at least as likely as not" (meaning likelihood of at least 50%), or "less likely than not" or "unlikely" (meaning that there is a less than 50% likelihood). The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. The examiner/reviewer should provide a complete rationale for any opinion provided. 5. After the above is complete, readjudicate the Veteran's claims. If one or more of the claims remains denied, issue a supplemental statement of the case (SSOC) to the Veteran and his representative, and they should be given an opportunity to respond, before the case is returned to the Board. 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). _________________________________________________ S. S. TOTH 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).