Citation Nr: 1317102 Decision Date: 05/24/13 Archive Date: 05/31/13 DOCKET NO. 12-27 944 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUE Entitlement to an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depression, and anxiety attacks. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD K. L. Wallin, Counsel INTRODUCTION The Veteran served on active duty from September 1995 to February 1996. The Veteran also had a period of Reserve service. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from an August 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts. The RO, in pertinent part, denied the claim for PTSD with depression and anxiety attacks. The Board is obligated to construe a claim for an acquired psychiatric disorder liberally and thus, the claim for PTSD has been recharacterized as it appears on the cover page of the instant decision. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). The Veteran presented testimony before the Board in March 2013. A transcript has been associated with Virtual VA (electronic database storage). The Veteran submitted additional evidence to the Board at her hearing; she waived initial RO review and as such, it was considered in preparation of this Remand. 38 C.F.R. § 20.1304(c). The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required. REMAND The Veteran claims entitlement to service connection for an acquired psychiatric disorder, to include PTSD, depression, and anxiety attacks. Specifically, she alleges that the claimed condition is the result of military sexual trauma (MST). A preliminary review of the record discloses the matter is not ready for appellate disposition. The record compiled for appellate review of this matter to this point appears incomplete. The Board notes that the RO attempted to obtain the Veteran's service personnel record and in January 2010, the Records Management Center indicated there were no records for the Veteran. The RO was directed to use DPRIS web to obtain the information from the Veteran's official military personnel folders in custody of the Department of Defense. The only records received from DPRIS were the Veteran's DD-214, Memorandum for Distribution of the Army Reserve Component Achievement Medal, and the Report of Separation and Record of Service from the Departments of the Army and the Air Force National Guard Bureau. The Veteran's complete service personnel record, to include enlisted performance reports and dates of active duty or inactive duty training, is not of record. Such attempts must be made to obtain any outstanding records. 38 C.F.R. § 3.159(c)(2). A March 2012 letter from the Veteran's counselor indicates the Veteran received mental health treatment related to MST at the VA Medical Center (VAMC) in Boston, Massachusetts. Notably, the provider indicated the Veteran began individual treatment with her in October 2010 and continued to attend regularly. The provider further noted the Veteran participated in Seeking Safety Groups, which targeted both PTSD and substance abuse issues, between January 2010 and August 2011. The last VA treatment records from the Boston VAMC associated with the claims folder are dated in December 2009. Any missing and/or ongoing VA medical treatment records pertinent to the issue must be obtained upon Remand. Id. Finally, the Veteran was not afforded a VA examination in connection with her claim. An examination and opinion are necessary to determine whether the Veteran has an acquired psychiatric disorder, to include PTSD, depression, and anxiety attacks, that is related to her active military service. See McClendon v. Nicholson, 20 Vet. App. 79 (2006); 38 C.F.R. § 3.159(c)(4). Accordingly, the case is REMANDED for the following action: 1. The RO should take all indicated action in order to obtain copies of any VA clinical records, to include from the Boston VAMC, not on file pertaining to treatment of the claimed disability from December 2009 to the present. All requests for records and their responses must be clearly delineated in the claims folder. 2. Contact the appropriate record depository, to include the Massachusetts Adjutant General, and obtain copies of the Veteran's complete service personnel record, to include enlisted performance reports and specific dates of inactive and active duty for training. All requests for records and their responses must be clearly delineated in the claims folder. 3. After completion of the foregoing, schedule the Veteran for the appropriate VA examination to determine the nature and etiology of the claimed acquired psychiatric disorder, to include PTSD, depression, and anxiety attacks. The Veteran's entire claims file (i.e. the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE) must be reviewed by the examiner before the examination. If the examiner does not have access to Virtual VA, any relevant treatment records in Virtual VA that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. All indicated tests or studies must be completed. The examiner should describe all findings in detail. The AMC/RO must first specify for the examiner the stressor or stressors which have been corroborated. The examiner should be notified that the Veteran reported a 29-year history of physical and sexual abuse by the father of her children to VA treatment providers in 2009. The examiner should clearly report diagnoses for all current acquired psychiatric disorders. The examiner should then respond to the following: (a) Is a diagnosis of PTSD warranted? If so, is it at least as likely as not (a 50% or higher degree of probability) causally related to any corroborated stressor during service, to include MST, or a history of physical and sexual abuse by the father of her children? b) Is it at least as likely as not (a 50% or higher degree of probability) that any other current acquired psychiatric disorder(s) is/are causally related to the Veteran's active duty service? A rationale should be furnished for all opinions. Note: if the examiner concludes that there is insufficient information to provide an etiology opinion without resorting to mere speculation, the examiner should state whether the inability to provide a definitive opinion was due to a need for further information (please identify) or because the limits of medical knowledge had been exhausted regarding the etiology of the claimed conditions. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 4. In the interest of avoiding further remand, the RO should ensure that the requested actions have been accomplished (to the extent possible) in compliance with this REMAND. 5. After completing the requested actions, and any additional notification and/or development deemed warranted, the RO should readjudicate the issue in light of all evidence of record, to include any pertinent evidence contained within Virtual VA. If any benefit sought on appeal remains denied, the RO must furnish to the Veteran and her representative with an appropriate supplemental statement of the case and afford a reasonable opportunity for response. The Veteran 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). _________________________________________________ ROBERT E. SULLIVAN 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).