Citation Nr: 1337063 Decision Date: 11/14/13 Archive Date: 11/26/13 DOCKET NO. 13-14 828 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and adjustment disorder with depressed mood. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD M. Espinoza, Associate Counsel INTRODUCTION The Veteran had active military service from February 1964 to April 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. The Board recognizes that while the Veteran filed a claim for entitlement to service connection for PTSD, there is another psychiatric diagnosis of record. Specifically, the September 2011 VA examiner diagnosed the Veteran with adjustment disorder with depressed mood. Pursuant to the holding in Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), although a claim identifies PTSD without more, it must be considered a claim for any mental disability that may reasonably be encompassed by several factors including: the claimant's description of the claim, the symptoms the claimant describes, and the information the claimant submits or VA obtains in support of the claim. The Board therefore finds that the Veteran's claim is not limited solely to PTSD. Instead, the claim is properly characterized broadly as a claim of service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and adjustment disorder with depressed mood, as listed on the title page. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required. REMAND While further delay is regrettable, the Board finds that further development is required prior to adjudicating the Veteran's claim. See 38 C.F.R. § 19.9 (2012). In September 2011, the Veteran underwent VA examination in connection with his claim for entitlement to service connection for PTSD. The September 2011 VA examiner reviewed the Veteran's claims file and performed a psychological evaluation of the Veteran. The September 2011 VA examiner diagnosed the Veteran with adjustment disorder with depressed mood. However, the September 2011 VA examiner found the Veteran did not meet the full criteria for a current diagnosis of PTSD. The September 2011 VA examiner opined that the Veteran's adjustment disorder with depressed mood was related to his retirement and the fact that the Veteran's daughter and grandchildren were now living with him. The VA examiner opined that the Veteran's adjustment disorder with depressed mood was not related to his military experience. The Veteran is competent to report his psychiatric symptoms and he has consistently stated that his psychiatric symptoms have existed for years. See Layno v. Brown, 6 Vet. App. 465 (1994). The September 2011 examiner's opinion does not account for the fact that the Veteran reported his symptoms have existed for years. Thus, the medical opinion is of little evidentiary value because the probative value of a medical opinion comes from the factually accurate, fully articulated, and sound reasoning for the conclusion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Therefore, the Board finds that a remand is warranted for an additional examination regarding the etiology of any acquired psychiatric disorder diagnosed during the pendency of the appeal. 38 U.S.C.A. § 5103A(d)(2) (West 2002); 38 C.F.R. § 3.159(c)(4) (2013); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). Finally, it appears that the Veteran receives regular treatment from the Southeast Louisiana Veterans Health Care System. Updated VA treatment records, from the Southeast Louisiana Veterans Health Care System, since September 2011, should be obtained in light of the remand. See 38 U.S.C.A. § 5103A(c); 38 C.F.R. § 3.159(c)(2). See also Bell v. Derwinski, 2 Vet. App. 611, 613 (1992) (holding that documents which are generated by VA agents or employees are in constructive possession of VA, and as such, should be obtained and included in the record). Accordingly, the case is REMANDED for the following actions: 1. Obtain the Veteran's recent VA treatment records, since September 2011, from the Southeast Louisiana Veterans Health Care System and any associated outpatient clinics, and associate these records with the claims folder. All attempts to obtain these records must be documented in the claims file. The Veteran and his representative must be notified of any inability to obtain the requested documents. 2. Thereafter, schedule the Veteran for a VA psychiatric examination for the purpose of ascertaining the nature and etiology of any acquired psychiatric disorder diagnosed during the pendency of the appeal. The complete record, to include a copy of this Remand, the claims folder and Virtual VA records, must be made available to and reviewed by the examiner in conjunction with the examination. Any medically indicated tests should be accomplished, and all pertinent symptomatology and findings must be reported in detail. With respect to any acquired psychiatric disorder present during the period of this claim, (including adjustment disorder with depressed mood), the examiner is requested to offer an opinion as to whether it is at least as likely as not (50 percent probability or more) that any such diagnosed acquired psychiatric disorder, was incurred in or was caused by the Veteran's active service. In rendering the requested opinion, the examiner should specifically consider the Veteran's lay statements, to include that his symptoms have existed for years and since service (prior to retirement in 2006 and grandchildren living with him) regarding the onset of his symptoms. The term "at least as likely as not" does not mean within the realm of possibility, but rather that the evidence both for and against a conclusion is so evenly divided that it is as sound to find in favor of a certain conclusion as it is to find against it. A complete rationale for all opinions expressed must be provided. 3. The Veteran must be notified that it is his responsibility to report for the examination and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2013). 4. Finally, after undertaking any other development deemed appropriate, readjudicate the issue on appeal. If the benefit sought is not granted, furnish the Veteran and his representative with a supplemental statement of the case and afford them an opportunity to respond before the record is returned to the Board for further review. The Veteran 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 claim 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). _________________________________________________ U. R. POWELL 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).