Citation Nr: 1327228 Decision Date: 08/26/13 Archive Date: 08/29/13 DOCKET NO. 12-13 147 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and depression. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. Bruce, Counsel INTRODUCTION The Veteran served on active duty from August 1986 to August 1992. This matter comes before the Board of Veterans' Appeals (Board) from a February 2010 rating decision of the Department of Veteran's Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The Veteran's appeal, which has previously been construed as consisting of a claim for service connection for PTSD has been recharacterized by the Board as indicated on the title page of this decision in light of the Court's holding in Clemons v. Shinseki, 23 Vet. App. 1 (2009) (claimant seeking service connection for psychiatric disability who has no special medical expertise is not competent to provide diagnosis requiring application of medical expertise to facts such as claimant's description of history and symptoms; VA should construe claim for service connection based on reasonable expectations of a non-expert claimant). A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. 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 record is not ready for appellate review of the issue on appeal. The following further development is required. In an August 2010 VA examination, the examiner found that the Veteran did not have PTSD under the DSM-IV criteria. However, while the examiner diagnosed a depressive disorder, the examiner did not state whether depression was linked to military service. Accordingly, the case is REMANDED for the following action: 1. Request any treatment records not already of record from the Fayetteville, North Carolina, VAMC. 38 C.F.R. § 3.159(c)(2). The Veteran also must be appropriately notified if unable to obtain these records. 38 C.F.R. § 3.159(e)(1). 2. Return the claims file and a copy of this remand to the examiner who conducted the August 2010 VA psychiatric examination. If that examiner is not available, schedule the Veteran for a VA psychiatric examination, to be conducted by a qualified examiner. Issue an opinion that specifically addresses the question below with a full explanation for any conclusions. The following considerations will govern the examination: a. The claims files MUST be made available to and thoroughly reviewed by the examiner in connection with the examination, and the examiner must acknowledge such receipt and review in any report generated as a result of the examination. b. The examiner must review the Veteran's statements, as well as service treatment records and personnel records in conjunction with the examination. Any special diagnostic studies deemed necessary must be performed. c. With respect to the review of the claims file, the Board calls the examiner's attention to the following: (i) The November 2008 mental health group counseling note that provided an Axis I diagnosis of PTSD and related the diagnosis to military experience on Axis IV. (ii) The April 2009 private psychological evaluation the provided an Axis I diagnosis of chronic PTSD, recurrent major depressive disorder, superimposed on mood disorder due to general medical condition and cocaine abuse by history. (iii) The Veteran's April 2009 statement addressing his claimed stressors. (iv) The March 2009 statement in support from a fellow soldier describing events the unit witnessed and participated in during Operation Desert Shield/Storm. (v) The October 2009 letter from the Joint Services Records Research Center verifying that the Veteran's unit conducted a fire support mission on enemy emplacements, killing and wounding many enemy soldiers in February 1991. (vi) The September 2008 VA examiner diagnosed the Veteran with depressive disorder and not PTSD. d. After reviewing the records, examining the Veteran, and identifying all appropriate symptoms and diagnoses, the examiner must provide medical findings or opinions responsive to the following question: Does the Veteran have any psychiatric disorder (TO INCLUDE A DEPRESSIVE DISORDER, ANXIETY, PTSD ON RE-REVIEW OR ANY OTHER MENTAL DISORDER) that was CAUSED BY OR AGGRAVATED BY MILITARY SERVICE? e. The examiner must provide a complete explanation for his or her opinion(s), based on his or her clinical experience, medical expertise, and established principles. f. If the examiner is unable to render the requested opinion(s) without resort to speculation, he or she must so state. However, a complete explanation for such a finding must be provided, such as whether there is inadequate factual information, whether the question falls within the limits of current medical knowledge or scientific development, whether the cause of the condition in question is truly unknowable, and/or whether the question is so outside the norm of practice that it is impossible for the examiner to use his or her medical expertise and training to render an opinion. 4. After the above has been completed, the RO must 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 any report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. 5. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the issue on appeal. If the benefit sought on appeal remains denied, in whole or in part, the Veteran and his representative should be provided with a Supplemental Statement of the Case and be afforded reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. 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). _________________________________________________ Vito A. Clementi 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).