Citation Nr: 1315080 Decision Date: 05/07/13 Archive Date: 05/15/13 DOCKET NO. 11-21 584 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, claimed as posttraumatic stress disorder. REPRESENTATION Appellant represented by: Florida Division of Veterans Affairs WITNESS AT HEARINGS ON APPEAL The appellant ATTORNEY FOR THE BOARD Stephen F. Sylvester, Counsel INTRODUCTION The Veteran served on active duty from December 1980 to December 1983. This case comes before the Board of Veterans' Appeals (Board) on appeal of a September 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York. The Veteran subsequently relocated, and jurisdiction of his claim was transferred to the RO in St. Petersburg, Florida. Good or sufficient cause having been shown, the Veteran's appeal has been advanced on the Board's docket under the provisions of 38 U.S.C.A. § 7107 (West 2002) and 38 C.F.R. § 20.900(c) (2012). This case was previously before the Board in September 2011 and January 2013, on which occasions it was remanded for additional development, to include a Travel Board hearing, which was ultimately conducted in May 2012. The case is now, once more, before the Board for appellate review. Finally, for reasons which will become apparent, this appeal is again being REMANDED to the RO via the Appeals Management Center (AMC) in Washington, D.C. VA will notify you if further action is required on your part. REMAND The Veteran in this case seeks entitlement to service connection for an acquired psychiatric disorder, specifically, posttraumatic stress disorder. In pertinent part, it is contended that the Veteran suffers from posttraumatic stress disorder which is the result of an inservice personal/sexual assault. In that regard, a review of the record discloses that available service treatment records are negative for evidence of a psychiatric disorder, including posttraumatic stress disorder. In fact, at the time of a service separation examination in October 1983, a psychiatric evaluation was within normal limits, and no pertinent diagnosis or findings were noted. Significantly, in a VA memorandum of September 2010, it was noted that no additional service treatment records, including of a reported period of inservice hospitalization in 1983, were available for review. The earliest clinical indication of the presence of an acquired psychiatric disorder is revealed by VA outpatient treatment records dated in December 2009, approximately 26 years following the Veteran's discharge from service, at which time he received a diagnosis of cannabis dependence and "posttraumatic stress disorder." Since the time of the Veteran's discharge from service, he has received additional psychiatric diagnoses of a depressive disorder, and posttraumatic stress disorder due to "military sexual trauma." The Board observes that, in a VA outpatient treatment record dated in December 2009, it was noted that the Veteran's father was an alcoholic, and "physically abusive." Further noted was that the Veteran was raised with six siblings, and that he was sexually abused from the ages of 4 to 6 by his stepbrothers. Significantly, while during the course of that outpatient treatment, the Veteran gave a history of inservice sexual trauma, available service personnel and treatment records are devoid of any evidence whatsoever of such trauma. Finally, the Board notes that, to date, the Veteran has yet to be afforded a VA psychiatric examination for the purpose of determining the exact origin of his current psychiatric disability. In light of the aforementioned, the Board is of the opinion that such an examination would be appropriate prior to a final adjudication of the Veteran's claim for service connection. Accordingly, the case is once again REMANDED to the RO/AMC for the following actions: 1. The Veteran should be afforded a VA psychiatric examination in order to more accurately determine the exact nature and etiology of his current psychiatric disability. The Veteran is hereby notified that it is his responsibility to report for the examination, and to cooperate in the development of his claim. The Veteran is further hereby advised that the consequences for failure to report for a VA examination without good cause may include denial of his claim. 38 C.F.R. §§ 3.158, 3.655 (2012). 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 Veteran's last known address. It should also be indicated whether any notice sent was returned as undeliverable. Following completion of the psychiatric examination, the examiner should specifically comment as to whether the Veteran currently suffers from a chronic, clinically-identifiable psychiatric disorder (including posttraumatic stress disorder), and, if so, whether such disorder at least as likely as not had its origin during, or is in some way the result of, an incident or incidents of the Veteran's period of active military service. A complete rationale must be provided for any opinion offered, and all information and opinions, once obtained, must be made a part of the Veteran's claims folder. The claims folder and a separate copy of this REMAND must be made available to and reviewed by the examiner prior to completion of the examination. In addition, the examiner must specify in the report that the claims file and Virtual VA records have been reviewed. 2. The RO/AMC should then review the examination report to ensure that it is in complete compliance with the directives of this REMAND, and that the examiner has documented his consideration of all records contained in Virtual VA. If the report is deficient in any manner, the RO/AMC must implement corrective procedures. 3. The RO/AMC should then readjudicate the Veteran's claim for service connection for an acquired psychiatric disorder, claimed as posttraumatic stress disorder. Should the benefit sought on appeal remain denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case (SSOC). The SSOC must contain notice of all relevant action taken on the claim for benefits since the issuance of the most recent SSOC in April 2013. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome in this case. The Veteran need take no action unless otherwise notified. 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). _________________________________________________ MICHAEL D. LYON 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).