Citation Nr: 1415998 Decision Date: 04/10/14 Archive Date: 04/24/14 DOCKET NO. 12-16 489 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia THE ISSUE Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L. Zobrist, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty from January 1968 to April 1971. This matter is before the Board of Veterans' Appeals (Board) arising from a July 2011 rating decision of the Roanoke, Virginia, VARO. In August 2012, a Travel Board hearing was held before the undersigned. A transcript of the hearing is associated with the Veteran's claims file. As will be discussed below, the Veteran's claim was originally developed and adjudicated strictly as a claim of service connection for the psychiatric diagnosis of PTSD. Because the record suggests there may be additional psychiatric diagnoses, and in light of the United States Court of Appeals for Veterans Claims (Court) decision in Clemons v. Shinseki, 23 Vet. App. 1 (2009), it has been recharacterized as stated on the preceding page. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action on her part is required. REMAND The Veteran filed a claim seeking service connection for PTSD, and this matter has been thus developed/adjudicated by the RO, i.e., limited to such diagnosis. In Clemons, the Court held, in essence, that (with certain exceptions, none here applicable) the scope of a claim of service connection for a psychiatric disability encompasses all psychiatric diagnoses shown by the record, and is not limited by the characterization of the disability in the Veteran's claim. The record reflects diagnoses of psychiatric disabilities other than PTSD (e.g., depression and panic disorder), which the Veteran alleges are associated with her active service. Hence, this matter must be remanded for RO initial consideration of the expanded issue of service connection for a psychiatric disability, however diagnosed. Additionally, the January 2011 VA examiner concluded that the Veteran's confirmed stressor met the DSM-IV criteria for PTSD, but that she did not meet the symptom criteria. While the VA examiner explained which PTSD symptoms were shown and which were not, he did not explain which symptoms not shown were critical to a diagnosis of PTSD. Therefore, the examination was inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 311-312 (2007) (when VA undertakes to provide a VA examination, it must ensure that the examination is adequate). Accordingly, the case is REMANDED for the following: 1. The RO should ask the Veteran to identify the provider(s) of any (and all) treatment or evaluation she has received for any psychiatric disability. She should also be asked to provide all releases necessary for VA to secure all private records of such treatment and evaluation from sources identified by the Veteran. The RO should secure for the record copies of the complete clinical records of all evaluations and treatment from the sources identified. If any records sought are unavailable, the reason for their unavailability must be noted in the record. If a private provider does not respond to the RO's request for identified records sought, the Veteran must be so notified, and reminded that ultimately it is her responsibility to ensure that private treatment records are received. The RO should also obtain any/all additional records of VA psychiatric evaluations/treatment (records of which are not already in the record). 2. Thereafter, the RO should arrange for the Veteran to be examined by an appropriate psychiatrist or psychologist to ascertain the nature and likely etiology of her psychiatric disability(ies). The Veteran's claims file, to include this remand, must be reviewed by the examiner in conjunction with the examination. The examination and report thereof must be in accordance with the DSM-IV. Based on review of the record, in-person examination, and interview of the Veteran, the examiner should provide an opinion that responds to the following: (a) Please identify (by medical diagnosis) each acquired psychiatric disability found. (b) Does the Veteran have a diagnosis of PTSD based on a on a fear of terrorist or hostile activity in service? Please discuss the stressor and symptoms that support any diagnosis of PTSD. If PTSD is not diagnosed, indicate clearly what symptom(s) needed for such diagnosis is/are lacking. (c) As to each psychiatric diagnosis other than PTSD, please indicate whether such entity is at least as likely as not (a 50 % or better probability) related to the Veteran's military service/events or manifestations noted therein. The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. 3. The RO should then review the record and readjudicate the claim, to encompass all psychiatric diagnoses (in accordance with Clemons). If it remains denied, the RO should issue an appropriate supplemental statement of the case, and afford the Veteran and her representative the 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 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 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). _________________________________________________ George R. Senyk 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).