Citation Nr: 1325865 Decision Date: 08/15/13 Archive Date: 08/26/13 DOCKET NO. 12-15 554 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUE Entitlement to an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), anxiety, dysthmic disorder, attention deficit disorder, and depression. REPRESENTATION Appellant represented by: Todd S. Hammond, Attorney WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Kristi L. Gunn, Counsel INTRODUCTION The Veteran served on active duty from April 1981 to July 1981. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon, which denied service connection for PTSD. With respect to the Veteran's claim for PTSD, the Board notes that recent case law emphasizes that a claim for a mental health disability 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. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). Given the holding in Clemons, the Board has recharacterized the issue to the broader issue of entitlement of service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), anxiety, dysthmic disorder, attention deficit disorder, and depression, as is reflected on the cover page. The Board has reviewed the contents of the Veteran's Virtual VA file and found that it contains additional medical evidence that has been considered by the RO in the most recent statement of the case (SOC). In June 2013, the Veteran testified at a personal hearing before the undersigned Veterans Law Judge. A copy of the transcript is of record. At the hearing, the Veteran waived initial RO consideration of the new evidence submitted in conjunction with the hearing. 38 C.F.R. § 20.1304 (c). Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). 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 After the June 2013 travel board hearing, the Veteran's attorney submitted several VA Forms 21-4142, Authorization and Consent to Release Information to VA. According to the VA Forms, 21-4142, the Veteran indicated that she has received treatment for her acquired psychiatric disorder from the Luckiamute Clinic in Falls City, Oregon; the Salem Clinic in Salem, Oregon; the Salem Vet Center in Salem, Oregon; Salem Hospital in Salem, Oregon; Polk County Mental Health and Addiction Services in Dallas, Oregon; Dr. Jack R. Doney, M.D. in Miami, Oklahoma; Lincoln County Jail in Newport, Oregon; Marion County Jail in Salem, Oregon; Columbia River Correctional Institution in Portland, Oregon; and Yamhill County Jail in McMinnville, Oregon. The Veteran also submitted a VA Form 21-4142 to obtain records recording her Social Security disability claim from McGinty and Belcher, Attorneys, P.C., in Salem, Oregon. The Board finds that an attempt should be made to obtain those records, if available, as they are relevant to the issues on appeal. Any recent VA treatment records should also be obtained, as well as the Veteran's complete records from the Social Security Administration (SSA). Furthermore, given the amount of potential medical evidence reflecting treatment for an acquired psychiatric disorder as well as personal statements submitted by the Veteran's cousin and mother dated June 2013, the Board finds that an additional VA examination is warranted to determine the etiology of the Veteran's acquired psychiatric disorder. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Make arrangements to obtain the Veteran's medical records from the Luckiamute Clinic in Falls City, Oregon; Salem Clinic in Salem, Oregon; Salem Vet Center in Salem, Oregon; Salem Hospital in Salem, Oregon; Polk County Mental Health and Addiction Services in Dallas, Oregon; Dr. Jack R. Doney, M.D. in Miami, Oklahoma; Lincoln County Jail in Newport, Oregon; Marion County Jail in Salem, Oregon; Columbia River Correctional Institution in Portland, Oregon; Yamhill County Jail in McMinnville, Oregon; and McGinty and Belcher, Attorneys, P.C., in Salem, Oregon. In requesting these records, the RO should follow the current procedures of 38 C.F.R. § 3.159(c) with respect to requesting records from private facilities. All records/responses received should be associated with the claims file. 2. Make arrangements to obtain the Veteran's complete VA treatment records, dated since May 2008. 3. Contact the SSA and request copies of all records pertaining to the Veteran, including any decisions and any medical evidence relied upon in making those decisions. If provided by disc, then print out the records and associate the copies with the claims file. 4. After receipt of all additional records, schedule the Veteran for a VA examination by a psychiatrist or psychologist. The claims folder should be made available to and reviewed by the examiner. All necessary studies and tests should be conducted. The examiner should identify all current psychiatric disorders found to be present, i.e., PTSD, depression, etc. (a) If PTSD is diagnosed (under DSM-IV criteria), the examiner should identify the specific stressor(s) upon which the diagnosis is based. The Veteran has stated that she was sexual assaulted by a superior officer during her active military service. (b) If the examination results in a psychiatric diagnosis(es) other than PTSD, the examiner should offer an opinion as to whether it is at least as likely as not (50% or greater probability) that any currently demonstrated psychiatric disorder (other than PTSD) had its clinical onset during active service or is related to any in-service disease, event, or injury. The examiner should set forth the complete rationale for all opinions expressed and conclusions reached. 5. Next, review the claims file and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action must be implemented. If the examination report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. 6. Finally, the issue on appeal should be readjudicated. If the benefit sought on appeal is not granted, the Veteran and her attorney should be provided with a supplemental statement of the case (SSOC) and afforded the appropriate time period within which 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). _________________________________________________ P.M. DILORENZO 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).