Citation Nr: 1322204 Decision Date: 07/11/13 Archive Date: 07/18/13 DOCKET NO. 12-26 034 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder, dysthymic disorder, recurrent major depressive disorder, and anxiety disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran, Veteran's son ATTORNEY FOR THE BOARD W. Yates, Counsel INTRODUCTION The Veteran served on active duty from February 1954 to January 1956. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The issue on appeal has been recharacterized to properly reflect the Veteran's variously-diagnosed psychiatric disorders. Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled); McClain v. Nicholson, 21 Vet. App. 319 (2007). The Board is taking this action to expand the scope of the Veteran's claim so that it recognizes any current psychiatric disorder found, regardless of how it may be diagnosed by individual physicians. This appeal has been advanced on the Board's docket. 38 U.S.C.A. § 7107(a)(2) (West 2002); 38 C.F.R. § 20.900(c) (2012). The appeal is remanded to the RO via the Appeals Management Center in Washington, DC. REMAND The Veteran is seeking entitlement to service connection for posttraumatic stress disorder (PTSD). He attributes this condition to family hardship, racial discrimination, and harassment while in the military. He further claims that he developed an acquired psychiatric disorder, secondary to the inservice death under mysterious circumstances of a friend. At his May 2013 hearing before the Board, the Veteran provided new information concerning his alleged inservice stressor. Specifically, he testified that his friend, named Ledbetter, died under mysterious circumstances while he was stationed at Camp Hanford in Washington state. He further testified that it was the fear associated with having lost his friend under mysterious circumstances which caused his current psychiatric disorder. Under these circumstances, the RO should attempt to obtain the Veteran's updated treatment records. Thereafter, the RO must schedule the Veteran for the appropriate examination to identify any current psychiatric disorders found, and provide an opinion as to whether any disorder identified was caused or aggravated by his military service. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Jandreau v. Nicholson, 492 F.3d. 1372, 1377 n.4 (Fed. Cir. 2007) (holding that a layperson is competent to identify observable symptoms). Accordingly, the case is remanded for the following action: 1. The RO must contact the Veteran and afford him the opportunity to identify or submit any additional evidence, to include VA and non-VA medical providers who have treated him for a psychiatric disorder, including PTSD, dysthymic disorder, recurrent major depressive disorder, and anxiety disorder since service. Regardless of his response, the RO must obtain updated treatment records relating to the Veteran, since August 2012, from the South Texas VA Health Care System. All attempts to secure this evidence must be documented in the claims file by the RO. If, after making reasonable efforts to obtain the identified records, the RO is unable to secure same, the RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the RO with respect to the claim; and (d) notify the Veteran that that he is ultimately responsible for providing the evidence. The Veteran and his representative must then be given an opportunity to respond. 2. The Veteran must be afforded the appropriate VA examinations to determine whether any psychiatric found is related to his military service. All pertinent symptomatology and findings must be reported in detail. Any indicated diagnostic tests and studies must be accomplished. The claims file and all records on Virtual VA must be made available to the examiner, and the examiner must specify in the examination report that the claims file and Virtual VA records have been reviewed. The examiner must specify the dates encompassed by the Virtual VA records that were reviewed. Based on the clinical examination, a review of the evidence of record, and with consideration of the Veteran's statements, the examiner must state whether any psychiatric disorder found, or previously diagnosed, to include PTSD, dysthymic disorder, recurrent major depressive disorder, and anxiety, is related to the Veteran's active duty service. If the Veteran meets the criteria for a diagnosis of PTSD, the examiner must specify the stressor or stressors that serve as the underlying basis for this diagnosis, and also provide as much detail as possible concerning each alleged stressor relied on in rendering the diagnosis. The examiner must also specify whether each stressor established by the record was sufficient to produce PTSD; and whether there is a link between the current symptomatology and one or more of the inservice stressors found to be established by the record and found sufficient to produce PTSD by the examiner. The examiner must also provide an opinion as to whether any of the Veteran's other psychiatric disorders, including PTSD, dysthymic disorder, recurrent major depressive disorder, and anxiety disorder found or previously diagnosed, began in service or otherwise is related to his military service; or whether they are related to post service injuries. A complete rationale for all opinions must be provided. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. The report prepared must be typed. 3. The RO must notify the Veteran that it is his responsibility to report for any examination scheduled, and to cooperate in the development of the claims. The consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained and associated with the Veteran's claims file that shows that notice scheduling the examination was sent to his last known address. Documentation must be also be obtained and associated with the Veteran's claims file demonstrating any notice that was sent was returned as undeliverable. 4. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claim remaining on appeal must be readjudicated. If the claim remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). _________________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals