Citation Nr: 1330769 Decision Date: 09/25/13 Archive Date: 09/30/13 DOCKET NO. 10-43 723 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boise, Idaho THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depression, not otherwise specified (NOS). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. All, Associate Counsel REMAND The Veteran had active military service from November 1967 to June 1970. This case comes before the Board of Veterans' Appeals (Board) on appeal of an April 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Boise, Idaho. The Board observes that the Veteran initially submitted a claim for service connection solely for PTSD. The evidence of record indicates the Veteran has at one point been diagnosed with depression, NOS. The United States Court of Appeals for Veterans Claims (Court) has held that VA must consider alternate psychiatric disorders within the scope of a claim of service connection for a psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). In other words, the Court held that a claim of entitlement to service connection for a psychiatric disorder included any mental disability that may be reasonably encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. Id. As such, the Board has amended the issue on appeal as reflected above. The Veteran claims service connection for an acquired psychiatric disorder related to his active military service in Vietnam. He specifically asserts that he has PTSD. In October 2008, the Veteran received a mental health assessment at the VA PTSD clinic in Salt Lake City. The VA examiner concluded that the Veteran did not meet the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, (DSM-IV) criteria for a diagnosis of PTSD. Rather, the examiner diagnosed him with depression, NOS, and alcohol abuse, and assigned a Global Assessment of Functioning (GAF) score of 60. The report noted difficulties with social functioning and finances as Axis IV problems. In September 2010, the Veteran underwent a VA PTSD examination, at which time the VA examiner concluded that the Veteran did not meet the DSM-IV criteria for a PTSD diagnosis. The examiner gave a sole diagnosis of alcohol abuse and assigned a GAF score of 75. With regard to Axis IV problems, the report noted the Veteran was angry about the construction of a campground near his home. While the September 2010 VA examiner prepared a lengthy examination report, he made only passing reference to the Veteran's October 2008 diagnosis of depression in his report. The examiner failed to opine as to the etiology of the diagnosed depression or explain why the Veteran did not currently meet the diagnostic criteria for the same. As such, the September 2010 VA examination is inadequate for adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, a new examination and opinion is necessary prior to a Board decision with respect to these issues. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of any psychiatric disability found. The entire claims file, to include any pertinent medical records contained in Virtual VA, must be reviewed by the examiner in conjunction with the examination. (If the examiner does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not otherwise available must be printed and associated with the paper claims file for the examiner's review.) All appropriate tests and studies should be conducted, and any consultations deemed necessary should be accomplished. Psychological testing with a view toward determining whether the Veteran now meets the criteria for a diagnosis of PTSD should be accomplished. The examiner should specifically address the following: (a) The existence of any current acquired psychiatric disorders. (b) If the Veteran is not diagnosed with depression, NOS, explain why such diagnosis is not warranted, specifically commenting on the October 2008 VA treatment record that shows a diagnosis of depression, NOS. (c) For each diagnosed acquired psychiatric disorder, such as depression, NOS, PTSD, or any other psychiatric disability, state whether it is at least as likely as not (probability of at least 50 percent) that such disorder had its onset during service, or is otherwise attributable to military service. If PTSD is diagnosed, identify with specificity the stressor(s) that led to the development of the disability. An explanation for each opinion should be provided. The medical reasons for accepting or rejecting the Veteran's statements regarding symptoms, and especially any continuity of symptoms since military service, should be set forth in detail. 2. After the requested examination has been completed, the report should be reviewed to ensure that it complies with the directives of this remand. If the report is deficient in any manner, it should be returned to the examiner for corrective action. 3. After completing the above, and any other development deemed necessary, readjudicate the Veteran's claim based on the entirety of the evidence. If a benefit sought on appeal is not granted, he should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This case must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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. 2013). ________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board 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).