Citation Nr: 1336111 Decision Date: 11/06/13 Archive Date: 11/13/13 DOCKET NO. 13-00 055 A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUE Entitlement to service connection for an acquired psychiatric disorder to include posttraumatic stress disorder and major depression without psychotic features. REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD C. Ozger-Pascu, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1968 to January 1970, including service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2012 rating action issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah, which denied the Veteran's claim for service connection for an acquired psychiatric disorder to include posttraumatic stress disorder (PTSD) and major depression without psychotic features. The United States Court of Appeals for Veterans Claims (Court) has held that the scope of a mental health disability claim 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 (2009). Therefore, the Board has characterized the issue as shown on the first page of this decision. In October 2013, at a hearing held via video-conference before the undersigned Veterans Law Judge (VLJ). The Board also notes that in addition to the paper claims file there is a paperless, electronic claims file associated with the Veteran's claim. A review of the documents in such file reveals that they contain evidence relevant to the issue on appeal and any future consideration of this Veteran's case should take into consideration the existence of this electronic record. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). Expedited handling is requested. 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 asserts entitlement to service connection for psychiatric disability, to include PTSD, which he maintains is related to service. In support, he cites his in-service, Vietnam stressors and reports that he significantly increased his consumption of alcohol immediately following his return from Vietnam, which was a change from his pre-service behavior. He also reported having an aversion to firearms following his discharge from active duty. The Board notes that among the Veteran's relevant medical records are VA outpatient records and two VA psychiatric examinations. VA outpatient treatment records from July 2011 show that the Veteran was diagnosed as having an adjustment disorder and rule out PTSD. The following month, in an outpatient treatment record dated August 2011, the evaluator provided a diagnosis of "provisional" PTSD and major depressive disorder, recurrent, moderate. At his November 2011 VA psychiatric examination, the examiner concluded that the Veteran did not meet the DSM-IV diagnostic criteria for PTSD but that he did have a current diagnosis of major depression, recurrent, mild, without psychotic features. In October 2012, VA provided the Veteran with another VA psychiatric examination. At that time, the examiner provided a diagnosis of adjustment disorder with mixed subjective anxiety, depression and sleep disturbance but not PTSD, finding that the Veteran did not meet the DSM-IV criteria for PTSD. Based on the foregoing, the Board concludes that the medical evidence is inconsistent as to the Veteran's current psychiatric disorder. Diagnoses include "subclinical" PTSD, "provisional" PTSD, major depressive disorder and adjustment disorder with mixed subjective anxiety, depression and sleep disturbance, respectively. In light of Clemons v. Shinseki, 23 Vet. App. 1 (2009), although the Veteran is seeking service connection for PTSD, he is in fact seeking service connection for psychiatric symptoms regardless of how those symptoms are diagnosed. Therefore, a remand is required to reconcile his multiple diagnoses. Accordingly, the case is REMANDED for the following action: 1. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge and/or were contemporaneously informed of his psychiatric symptoms in and since service, to include any possible relationship to military service. He should be provided an appropriate amount of time to submit this lay evidence. 2. Obtain, either physically or electronically, outstanding VA treatment and/or hospitalization related to the Veteran's psychiatric condition since March 2013. All development efforts and any negative response(s) should be associated with the claims file, to include notation that no additional records are available on the Virtual VA. 3. Schedule the Veteran for a VA psychiatric examination to determine the nature, onset and etiology of any psychiatric disability found to be present. All psychiatric disability found to be present should be diagnosed and a diagnosis of PTSD must be ruled in or excluded. The claims folder should be made available to and reviewed by the examiner, who should record the full history of the disorder, including the Veteran's report of his symptoms. The examiner must opine as to whether it is at least as likely as not that the Veteran has a psychiatric disability that is related to or had its onset in service, to specifically include the Veteran's report of his in-service, Vietnam-related stressors. The examination report should reflect consideration and analysis of all evidence of record, medical and lay, including (A) the Veteran's competent account of his change in behavior, i.e., his increased consumption of alcohol following service and his aversion to firearms (B) the November 2011 and October 2012 VA examination reports; and (C) the July and August 2011 VA psychiatric assessments. All findings and conclusions, accompanied by a rationale and should be set forth in a legible report. 4. Then readjudicate the appeal. If the appeal is not granted in full, issue a Supplemental Statement of the Case (SSOC). An appropriate period of time should be allowed for response. Thereafter, the claim should be returned to this Board for further appellate 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. 2013). _________________________________________________ STEVEN D. REISS 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) (2013).