Citation Nr: 1316124 Decision Date: 05/16/13 Archive Date: 05/29/13 DOCKET NO. 12-14 339A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and psychosis not otherwise specified. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Devon Rembert-Carroll, Associate Counsel INTRODUCTION The Veteran had active service in the Army from April 1968 to March 1970. The matter is before the Board of Veterans' Appeals (Board) on appeal from a June 2011 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO) in Albuquerque, New Mexico. In Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a claim is not limited to the diagnosis identified by the Veteran. In this case, the Veteran has filed a claim for PTSD but the record shows other psychiatric diagnoses. As a result, the issue on appeal has been re-characterized on the title page. 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 contends that he has an acquired psychiatric disorder, to include an organic mood disorder, PTSD (combat-related), psychosis, NOS; and alcohol dependence, due to his traumatic experiences in service. Further development of the evidence is necessary prior to an adjudication of the claim. The Veteran was afforded a VA examination in April 2011. The VA examiner diagnosed the Veteran with cannabis dependence and alcohol dependence. The examiner stated that it did not appear that the Veteran's exposure met the full DSM-IV criteria for PTSD. However, the Veteran admitted to drinking before the examination and reported that he used marijuana on a daily basis and consumed one pint of Vodka a day. The examiner stated that in order to examine the Veteran more fully the Veteran would need to be substance free for a period of time. The Board notes that at the time of the VA examination the Veteran had not yet completely identified his stressors. However, in a November 2010 statement, he had reported dodging mines, mortars, and sniper rounds while stationed in Vietnam. This stressor was not developed by the RO at the time of the April 2011 VA examination. The Board also observes that following the VA examination, a letter was received from a private physician at the New Mexico Behavioral Institute. The letter, dated in October 2011, indicated that the Veteran had been treated for PTSD and substance dependence, and also included a description of his reported service stressors. Specifically, the Veteran reported that while stationed in Vietnam he saw a Vietnamese soldier who had a rod forced through his skull and was hung in the branches of a tree. The Veteran reported that he saw this man daily for several weeks until the soldier's neck deteriorated to the point that his body fell to the ground. The Veteran also reported that he witnessed an American soldier attempt to kill an American officer with a hand grenade, and then later saw the officer come and threaten to kill the soldier with a rifle. According to the Veteran, the officer shot several rounds in the direction of his own troops before he was restrained and subdued. The private physician also noted that the Veteran needed treatment for alcohol dependence, cannabis dependence, and PTSD. The record does not contain a completed stressor statement and the Veteran did not provide any approximate dates for the altercation between his fellow service men or the stressor involving the mines, and incoming mortar and sniper fire. Therefore, on remand, the RO must request that the Veteran provide more specific details about his claimed stressors in order for Joint Service Research Records Center (JSRRC) to attempt verification of his stressors. Additionally, a December 2009 letter from a social worker at the Las Cruces Vet Center indicates that the Veteran had been engaged in psychotherapy at the Vet Center since June 2009. The October 2011 letter from the New Mexico Behavioral Health Institute indicates the Veteran was treated for at least two months. Treatment records from these two facilities have not been associated with the claims file and must be obtained on remand. Finally, in a June 2012 statement the Veteran reported that he had been sober for the previous 10 months and requested a new VA examination. In light of the Veteran's reported sobriety, his newly identified service stressors, and the outstanding private medical records, an addendum to the April 2011 VA examination report must be obtained. See, Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007) (an adequate VA medical examination must consider the Veteran's pertinent medical history). Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran to obtain further details of his alleged stressors in service, including, but not limited to, the approximate date (within a two month range) and place of each stressor(s); the names, ranks, and units of persons involved; and the circumstances of the stressor(s). Particularly the Veteran should provide information on (1) dodging land mines, mortars, and snipers and (2) the altercation between the soldier and the officer. The RO must inform the Veteran that he must be as specific as possible, and also identify potential sources of evidence to corroborate his stressors, such as copies of letters written during service and statements from individuals familiar with his claimed stressors, e.g. former fellow service members, including peers, subordinates, or superiors. The RO must notify the Veteran that failure to provide such information may result in the denial of his claim. 2. With any additional information provided by the Veteran, and with the evidence already of record, the RO must prepare a summary of the Veteran's reported service stressors. This summary must be prepared regardless of whether the Veteran provides an additional statement, as requested above. This summary and a copy of the Veteran's DD 214 and other service personnel records should be sent to the U. S. Army and Joint Services Records Research Center (JSRRC) for verification of the claimed stressors. 3. Take appropriate steps to obtain and associate with the claims file, medical records from the Las Cruces Veteran Center in Las Cruces, New Mexico, dated June 2009 to present; and from the New Mexico Behavioral Health Institute. If any such records are unavailable, make a formal finding as to their unavailability and inform the Veteran and afford him an opportunity to submit any copies in his possession. 4. After associating any outstanding evidence with the claims folder, send it to the VA examiner who prepared the April 2011 examination report (or if the examiner is no longer available, a suitable replacement) and request that the examiner prepare an addendum to the April 2011 VA examination report. The examiner should offer an opinion as to whether the Veteran meets the criteria for a diagnosis of PTSD, and if so, what stressor(s) supports the diagnosis. If the psychiatrist or psychologist finds that the Veteran meets the criteria for a diagnosis of PTSD, then he or she should state whether it is at least as likely as not (a 50 percent or better probability) that the Veteran's current symptoms are related to the claimed stressor(s). The Veteran has reported stressors involving fear of hostile military or terrorist activity, therefore, the examiner should opine as to whether such reported stressors are adequate to support a diagnosis of PTSD. With respect to the other diagnoses that have been provided during the appeal, the examiner should opine as to whether or not these diagnosed conditions began in, or are at least as likely as not (a probability of 50 percent or greater) related to service. If the examiner does not find some of the conditions that have previously been diagnosed, the examiner should reconcile the conditions found with the other diagnoses of record. In rendering an opinion, the VA examiner must consider the Veteran's statements and the lay statements submitted by friends and family that address the Veteran's reported psychiatric symptoms. A fully articulated medical rationale for all opinions expressed should be set forth in the examination report. An examiner's report that he or she cannot provide an opinion without resort to speculation is inadequate unless the examiner provides a rationale for that statement. As such, if the examiner is unable to offer an opinion, it is essential that the examiner provide a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide the opinion is based on the limits of medical knowledge. 5. After the development requested above has been completed to the extent possible, the RO should again review the record. If any benefit sought on appeal, for which a notice of disagreement has been filed, remains denied, the Veteran and his representative, should be furnished a supplemental statement of the case and given the opportunity to respond thereto. 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). _________________________________________________ WAYNE M. BRAEUER 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).