Citation Nr: 1333804 Decision Date: 10/25/13 Archive Date: 11/06/13 DOCKET NO. 13-00 261 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include schizoaffective disorder, bipolar type; schizophrenia; schizophreniform disorder; and bipolar II disorder (claimed as bipolar disorder). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD A. Dean, Associate Counsel INTRODUCTION The Veteran had active military service from September 1988 to June 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an April 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. Jurisdiction over the case was subsequently returned to the RO in Wichita, Kansas. The Veteran's claim for an acquired psychiatric disorder has been expanded to include all mental disorders, so not just bipolar disorder, but also schizoaffective disorder, etc. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). In Clemons, the Court has held that the scope of a mental health disability claim includes any mental disability that reasonably may be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. The Clemons Court found that, where a Veteran's claim identifies PTSD, without more, it cannot be a claim limited only to that diagnosis, but rather must be considered a claim for any mental disability that reasonably may be encompassed by the evidence of record. The Clemons Court indicated that, when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. Here, the Veteran has received several past diagnoses for his psychiatric disorder; therefore the Board is expanding the claim to encompass all of these diagnoses, as reflected on the first page of this decision. The Board notes that, in addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claim. A review of the documents in the electronic file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on 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 While the Board sincerely regrets the further delay that inevitably will result from this additional remand of this claim, it is necessary to ensure a complete and accurate record upon which to make an informed decision on this claim. The Veteran contends that he has an acquired psychiatric disability as a result of his military service. Specifically, in his Notice of Disagreement from May 2012, he states that he never had issues of hearing voices prior to his military service, and that he started hearing them while in active service. A review of the evidence of record reveals that his service treatment records (STRs) are entirely unremarkable for reference to problems with an acquired psychiatric disorder. Indeed, a March 1990 Report of Mental Status Evaluation completed as part of a physical examination for administrative discharge showed that the Veteran's behavior was normal, he was fully alert and fully oriented, his mood or affect was unremarkable, his thinking process clear, thought content normal, and memory was good. The examiner determined that the Veteran had no mental health problems that would require treatment or disposition through medical channels. However, the Board notes that the Veteran's service personnel records of record appear to be incomplete, as there is no paperwork relating to his administrative discharge. Where these records may prove vital in establishing the Veteran's claims, attempts to obtain these records must be made. See 38 C.F.R. § 3.159(c)(2) (2013). A review of the Veteran's post-service treatment records show his first symptoms and treatment for an acquired psychiatric disability were in 1995, when he was held pursuant to court order for 96 hours due to psychoses and homicidal intentions. Several days later, when the Veteran had been released to an outpatient program, the Veteran's mother stated he had not experienced psychiatric symptoms prior to February 1995. VA will provide a medical examination for an opinion when there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies; and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability; but (4) insufficient competent medical evidence on file for VA to make a decision on the claim. See 38 U.S.C.A. § 5103A(d)(2) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(c)(4)(i) (2013); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). A VA compensation examination has not yet been afforded the Veteran in connection with his service-connection claim. Although there is no official documentation in the service record of his claimed disability, the Veteran is competent to report factual matters of which he has firsthand knowledge, such as hearing voices. See Washington v. Nicholson, 19 Vet. App. 362 (2005). Additionally, he is competent to attest to experiencing symptoms that are within the realm of his personal knowledge; such knowledge comes to a witness through use of his senses - that which is heard, felt, seen, smelled, or tasted. See Layno v. Brown, 6 Vet. App. 465 (1994). It is within the Veteran's realm of personal knowledge whether he heard voices while in service. Therefore, the Veteran must be afforded a VA psychiatric examination to determine the nature and etiology of any currently present psychiatric disorders. In addition, the Board notes that the Veteran's treatment records appear to be incomplete. Therefore, full treatment records, to include any relevant current treatment records, should be obtained before a decision is rendered with regard to this claim. Accordingly, the case is REMANDED for the following action: 1. Obtain a copy of the Veteran's complete service personnel records, including all paperwork related to his administrative discharge. If any additional service personnel records are not obtainable (or none exist), the Veteran and his representative should be notified and the record clearly documented. 2. Obtain and associate with the Veteran's claims file his VA treatment records maintained by the VA Heartland Network, to include the VA Medical Center (VAMC) in Kansas City, Missouri, dated from October 2011 to the present. 3. Make arrangements to obtain any outstanding private treatment records, especially any relevant records from April 2004 to December 2007 and since December 2011 (to include, but not limited to, treatment records from ReDiscover and from Dr. Brillantes). 4. Thereafter, the Veteran should be afforded a VA examination. All indicated tests and studies are to be performed. In conjunction with the examination, the claims folder must be made available to the examiner for review. A notation to the effect that this record review took place should be included in the report of the examiner. The examiner should identify all psychiatric disorders found to be present, to include schizoaffective disorder, bipolar type; schizophrenia; schizophreniform disorder; and bipolar II disorder. In regard to EACH diagnosed condition, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the current disorder had its clinical onset during active service or is related to any in-service disease, event, or injury. In providing this opinion, the examiner should acknowledge the Veteran's report that he first heard voices in service. All examination findings, along with the complete rationale for all opinions expressed, should be set forth in the examination report. 5. Next, review the claims file and ensure that 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, after completing the requested actions, and any additional notification and/or development deemed warranted, readjudicate the claims on appeal. If any benefit sought on appeal remains denied, furnish the Veteran and his representative with an SSOC and afford them the appropriate time period for a response before the claims file is returned to the Board for further appellate consideration. 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).