Citation Nr: 1329403 Decision Date: 09/13/13 Archive Date: 09/20/13 DOCKET NO. 12-20 426 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for an acquired psychiatric disability. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD M. Yuan, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1969 to July 1971, including service in Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2010 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). A notice of disagreement was received in June 2010, a statement of the case was issued in June 2012, and a substantive appeal was received in July 2012. Although the Veteran has advanced his claim with reference to post-traumatic stress disorder (PTSD), preliminary review of the record reveals diagnoses of various psychiatric disorders at different times. The Board has therefore broadly described the issue in terms of an acquired psychiatric disability. Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009) (holding that VA should consider claims for specific mental disorders to include all mental disabilities reasonably indicated by the record). 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's VA treatment records reflect a long history of mental health treatment, along with multiple diagnoses of various psychiatric disorders. In 2009, the Veteran was diagnosed on multiple occasions with PTSD, depression and bipolar disorder during visits to the Gainesville, Florida VA Medical Center (VAMC) and the Marianna, Florida Community-based Outpatient Clinic (CBOC). He has also repeatedly screened positive for PTSD and depression. Moreover, a July 2009 treatment record indicates he was administered a care plan to treat anxiety. The Veteran has also been prescribed medications in the past to balance his mood. A January 2010 VA examination did not report a positive diagnosis according to the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV). The examiner at that time noted that the Veteran did not display objective indicators that conformed with the DSM-IV criteria, and that previous diagnoses were made in a clinical context, largely relying on subjective data alone. The examiner provides no further basis for his opinion, beyond noting the Veteran showed signs of mild rambling and considerable fatigue. The examiner also focused solely on the Veteran's PTSD and failed to address the issues of depression, anxiety, and bipolar disorder. Accordingly, the Board finds that remand is necessary to obtain an adequate VA examination and opinion before a determination on the merits may be made. It also appears that certain VA treatment records may remain outstanding. The Veteran submitted treatment records from the Marianna CBOC dated between August 2, 2012 and September 28, 2012, requested and printed in October 2012. These reference ongoing mental health treatment and group therapy. The most recent VA treatment records associated with the file that predate these were printed on October 29, 2010. In addition, the Veteran's most recent records from the Marianna CBOC indicate he was referred for outside treatment. Such outstanding records should be associated with the claims files upon remand. Accordingly, the case is REMANDED for the following action: 1. The RO should obtain copies of any (and all) pertinent outstanding VA treatment records of the Veteran related to a psychiatric disability from the Marianna CBOC and Gainesville VAMC dated since October 29, 2010. If such records cannot be obtained after reasonable efforts have been exhausted, the RO should issue a formal determination that they do not exist or that further efforts to obtain them would be futile and document that finding in the claims file. 2. After obtaining the necessary authorization, the RO should also obtain any additional pertinent outside treatment records, as referenced by his September 2012 Marianna CBOC records. Two attempts should be made to obtain these records, unless a formal finding can be made that a second request would be futile. See Pub. L. No. 112-154, § 505, 126 Stat. 1165, 1193 (2012). 3. If any records requested above are unavailable, clearly document and notify the Veteran of any inability to obtain these records pursuant to 38 C.F.R. § 3.159(e). He should also be notified to submit any pertinent VA or private records in his own possession. 4. After completion of the above to the extent possible, the Veteran should be scheduled for a VA examination by a psychiatrist to determine the nature, extent and etiology of any current psychiatric disabilities. The claims file should be made available to the examiner for review in connection with the examination. The examiner should respond to the following: a) Diagnose all current psychiatric disorders in accordance with the DSM-IV. Expressly indicate if the diagnostic criteria for PTSD, depression, bipolar disorder, or anxiety are not met and reconcile all such findings with the private or VA treatment records diagnosing these disorders. b) Is it is at least as likely as not (a 50% or greater probability) that any current psychiatric disability, to include PTSD, depression, bipolar disorder, or anxiety, was manifested during a period of the Veteran's service, within a year of service as to any psychosis, or is otherwise causally related to such service? The examiner should offer detailed reasons for all opinions. 5. In the event the Veteran fails to report for the examination, the RO should forward the claims file to a psychiatrist for review and response to the questions posed in the preceding paragraph number 4. 6. After completion of the above, the RO should then re-adjudicate the claim. If it remains denied, the RO should issue an appropriate supplemental statement of the case and afford the Veteran an opportunity to respond. The case should then be returned to the Board, if in order, for further review. 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). _________________________________________________ ALAN S. PEEVY 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).