Citation Nr: 1510667 Decision Date: 03/13/15 Archive Date: 03/24/15 DOCKET NO. 13-03 496 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in White River Junction, Vermont THE ISSUE Entitlement to an initial evaluation in excess of 30 percent for a psychiatric disability. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD A. Odya-Weis, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1963 to September 1967, with confirmed service in the Republic of Vietnam. This case is before the Board of Veterans' Appeals (Board) on appeal from a February 2011 rating decision of the White River Junction, Vermont, Regional Office (RO) of the Department of Veterans Affairs (VA) that granted service connection and a noncompensable evaluation for bereavement, effective February 4, 2010. In a December 2012 Decision Review Officer decision, the psychiatric disorder was recharacterized as an anxiety disorder not otherwise specified, and the rating was increased to 30 percent, effective February 4, 2010. The record before the Board consists of the Veteran's paper claims file and an electronic records within Virtual VA and the Veterans Benefits Management System. REMAND Although the Board sincerely regrets the additional delay, a remand is required to comply with VA's duty to assist the Veteran in the development of the facts pertinent to this claim. See 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159(c) (2014). In January 2010, the Veteran filed a claim for entitlement to service connection for posttraumatic stress disorder (PTSD). In a September 2010 VA examination, the Veteran reported that he had good relationships with his wife and daughter, a number of friends that he saw once per week, and that he attended antique truck shows, collected toy trucks, had three prior violent incidents with his wife in the distant past, and was currently employed as a truck driver. He was noted to be clean, casually dressed, fully oriented, and cooperative, with anxious affect, mildly anxious mood, appropriate behavior, intact memory, and no obsessive behavior, panic attacks, or suicidal or homicidal ideation. He reported PTSD stressors of a loss of a friend and combat exposure in Vietnam but the examiner opined that the Veteran did not meet the full DSM-IV criteria for PTSD and diagnosed bereavement. A June 2010 VA treatment note reflects that the Veteran reported difficulty with his marriage, the death of a son in 1978, financial difficulties, a history of violence against his wife in 1986, and that he wanted to retire. The examiner found the Veteran to be well-groomed, calm, and fully oriented, with normal speech, anxious mood, appropriate affect, intact thought process, memory, and judgment, and no hallucinations or delusions. The examiner opined that the Veteran did not meet the full criteria for PTSD, but had obvious symptoms of depression, a few symptoms of PTSD, bereavement of the death of his son, and marital issues. In connection with September 2010 VA treatment, the Veteran indicated he was pessimistic and suspicious of government, very sad about his son's death, and wanted to retire from truck driving. He was found to have good hygiene, appropriate behavior, full affect, good insight, and clear, goal-directed thought processes. In May 2012, J.G., a mental health clinician, reported that the Veteran had diagnoses of PTSD and bereavement, more likely than not related to service in the brown waters of Vietnam, that were manifested by symptoms of isolation, inability to find pleasure in daily activities, insomnia, feelings of worthlessness, helplessness, irritability, angry outbursts, diminished concentration, intrusive thoughts, hypervigilance, hyperarousal, and sleep impairment that began in active service and were intermittently moderate to severe. On a November 2012 VA mental disorders examination, the Veteran was diagnosed with anxiety disorder not otherwise specified due to trauma exposure in Vietnam. The Veteran reported difficulty with his marital relationship, which he described as "cool," strained relationships with his two children, and a good group of friends. He stated that he enjoyed attending antique truck shows and participating in an antique truck historical society and a local veteran's organization. The Veteran reported receiving mental health treatment at the Bennington CBOC in 2010 and at the Keene Vietnam Veterans Outreach Center with J.G. in 2012. The examiner opined that symptoms of anxiety and disturbances of motivation and mood caused occupational and social impairment due to mild or transient symptoms. The Veteran also endorsed symptoms of feelings of detachment or estrangement from others, sleep impairment, and irritability. In a December 2014 informal hearing presentation, the Veteran's representative contended the claim should be remanded to obtain relevant treatment records referenced in the Veteran's November 2012 VA examination report. Review of the paper and electronic records indicates that private treatment records related to mental health treatment at the Keene Vietnam Veterans Outreach Center in 2012 are not currently included in the evidence of record. Therefore, further development to obtain any outstanding records from the Keene Vietnam Veterans Outreach Center is in order. As the case must be remanded, the originating agency should also obtain and associate with the record all outstanding, pertinent VA records from January 2015 to the present. Accordingly, this case is REMANDED to the RO or the Appeals Management Center (AMC), in Washington, D.C., for the following actions: 1. The RO or the AMC should undertake appropriate development to obtain any outstanding, pertinent medical records, to include VA treatment records for the time period from January 2015 to the present and private treatment records from the Keene Vietnam Veterans Outreach Center. 2. The RO or the AMC should also undertake any other development it determines to be warranted, to include affording the Veteran another VA examination if the Veteran asserts or the evidence otherwise suggests that the disability has increased in severity since the last VA examination in November 2012. 3. Then, the RO or the AMC should readjudicate the issue on appeal. If the benefit sought on appeal is not granted to the Veteran's satisfaction, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded the requisite opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. By this remand, the Board intimates no opinion as to any final outcome warranted. The Veteran need take no action until he is otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This REMAND must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), 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) (2014).