Citation Nr: 1549883 Decision Date: 11/25/15 Archive Date: 12/03/15 DOCKET NO. 12-21 616 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depressive disorder and alcohol abuse. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD D. Rogers, Counsel INTRODUCTION The Veteran served on active duty from December 1965 to December 1967. He was awarded a Combat Infantryman Badge and a Purple Heart for a shrapnel injury sustained during service in Vietnam. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a May 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa. The Veteran and his spouse testified at a personal hearing before a Decision Review Officer (DRO) at the RO in October 2010 and at a Videoconference hearing before the undersigned Veterans Law Judge in November 2013. Transcripts of these hearings are associated with the claims file. From the date of the November 2013 Videoconference hearing, the record was held open for 60 days to allow for the submission of additional evidence for consideration. In November 2014, the Board denied the Veteran's claims for service connection for hearing loss and tinnitus and remanded his claim for service connection for an acquired psychiatric disorder for additional development. The case has since been returned to the Board for further appellate consideration. Although the Veteran has phrased his claim for service connection for psychiatric disability as a claim for service connection for PTSD, a review of the record shows that he has been diagnosed with multiple psychiatric disorders, to include depressive disorder not otherwise specified (NOS), and alcohol abuse. To adequately reflect the claim, the issue has been rephrased as shown on the title page of this decision. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board has reviewed the Veteran's electronic records (Virtual VA and VBMS) prior to rendering a decision in this case. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Board finds that additional development is necessary prior to adjudication of the Veteran's claim of entitlement to service connection for an acquired psychiatric disability, to include PTSD, depressive disorder and alcohol abuse. Private mental health treatment records dated from June to October 2004 from Pine Rest Christian Mental Health Services show that the Veteran initiated mental health treatment with a Licensed Independent Social Worker (LISW) after being sent home from work and required to obtain mental health treatment after he was found to be intoxicated and discussing his Vietnam combat experiences at work early one morning. The focus of the Veteran's treatment during this time included his alcohol abuse and response to the demands of being a construction foreman. Treatment records also, however, contained mention of the Veteran's Vietnam combat history and some preoccupation with casualties amongst those with whom he served. "PTSD" was noted to be present under review of symptoms in the category of "other," and in ongoing progress notes, but specific PTSD symptoms were not specifically enumerated. During this episode of treatment, Axis I diagnoses were adjustment disorder with depressed mood secondary to work stressors and alcohol abuse. Axis IV psychosocial stressors included work stressors and "PTSD connected to Vietnam." During VA psychiatric examination with a psychologist in March 2010, the examiner noted that the Veteran had abstained from alcohol use since his 2004 with the exception of a single relapse a few months prior to the March 2010 VA examination. Following a review of the record and examination of the Veteran, the examiner acknowledged that the Veteran had some mild symptoms of PTSD, but stated that they did not meet the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for diagnosis of PTSD. The examiner diagnosed depressive disorder NOS in remission with current treatment, and alcohol abuse in remission. While the examiner opined that such diagnoses could not be related to the Veteran's military service, no reasoning or supporting rationale was provided. In addition, it is unclear how long the Veteran's noted relapse of alcohol abuse in the months prior to the examination lasted, and whether it occurred during the claim (i.e., since the claim for service connection was received on January 12, 2010). In April 2015, the Veteran was afforded an additional VA psychiatric examination to determine if he has a current acquired psychiatric disability related to his military service. The examination report shows that under "Diagnostic Summary," the examiner marked "yes" in response to whether the Veteran has a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation. To the contrary, however, under "Remarks," the examiner stated that the Veteran's psychiatric symptoms did not meet the DSM-5 diagnostic criteria for diagnosis of PTSD. He explained that although the Veteran had stressor events that meet Criteria A for PTSD, he did not endorse sufficient symptoms in other areas to support a diagnosis of PTSD. Although the Veteran reported experiencing intrusive thoughts and disturbing dreams about combat twice a year, some mild startle response to noises on construction sites and some mild hypervigilance, the examiner stated that no Criteria D symptoms were endorsed (i.e., negative alterations in cognitions and mood associated with the traumatic events, beginning or worsening after the traumatic events occurred). The April 2015 examiner diagnosed unspecified depressive disorder. Despite the examiner's documentation of the Veteran's reports during examination that his currently prescribed antidepressant medication was started about 14 years prior (i.e. 2001); his depression started sometime after September 11, 2001, and that he was upset with the reception of military members returning from Operation Iraqi Freedom/Operation Enduring Freedom compared to the reception of service members returning from Vietnam; that his last alcohol use was in about 2001 and that he had a history of heavy drinking for the first several years after Vietnam, as well as documented behavioral observation during examination of some tears when recounting Vietnam trauma events and that a manifestation of depressed mood included tearfulness when thinking about the reception that Vietnam veterans had when returning home as compared to OIF/OEF soldiers returning home today, the examiner opined that the Veteran's unspecified depressive disorder diagnosed in VA and private treatment records and during examination was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner's sole rationale for this opinion is that the Veteran's depressive symptoms are stable and generally well controlled by medication; initial mental health treatment began after 2001; and there have been no mental health appointments since March 26, 2010. On review, however, the April 2015 examiner did not explain and it therefore remains unclear how and why the stability and maintenance of the Veteran's depressive symptoms is relevant to the etiology of his currently diagnosed depressive disorder. The Board also noted that the fact that depressive symptoms did not begin during service or for many years thereafter does not foreclose the possibility that such symptoms may nevertheless be related to incidents that occurred during or are related to the Veteran's military service. Finally, it is significant to note that during the DRO and Videoconference hearings the Veteran and his spouse explained that the Veteran has not received ongoing VA or private psychiatric treatment for his claimed acquired psychiatric disorder due to his long work hours prior to retirement and he simply does not feel comfortable discussing traumatic events that occurred during service. In light of the foregoing, the Board finds that the March 2010 and April 2015 VA medical opinions are inadequate for the purpose of deciding the Veteran's claim for service connection for an acquired psychiatric disorder, to include alcohol abuse, major depression, and PTSD. As such, an additional medical opinion must be obtained to clarify whether the Veteran has a current acquired psychiatric disability related to any incident of his military service. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Furthermore, given that previous VA examinations alternatively considered the DSM-IV and DSM-V, the Board finds that the criteria for a diagnosis of PTSD under both the DSM-IV and DSM-V must be considered. In addition, ongoing VA medical and psychiatric treatment records dating since April 2015, if any, should be obtained and associated with the claims file for review. See Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). The Veteran should also be provided another opportunity to identify and submit, or request VA's assistance in obtaining, any relevant private treatment records pertaining to his claimed acquired psychiatric disorder, to include any records from Dr. Blom, his private primary care provider prior to 2010 as alluded to during the Board hearing. Accordingly, the case is REMANDED for the following action: 1. Request that the Veteran identify any additional relevant medical and psychiatric treatment records, VA and non-VA, which pertain to his claim for service connection for an acquired psychiatric disability, to include PTSD, depressive disorder and alcohol abuse that have not yet been associated with the claims file. Also request that he provide authorization necessary to enable VA to obtain any relevant private medical and psychiatric treatment records pertaining to his claimed psychiatric disability, to specifically include all treatment records from Dr. Blom whom initially placed the Veteran on antidepressant medication as alluded to during the November 2013 Board hearing. Regardless of the Veteran's response, obtain and associate with the claims file any VA clinical treatment records from the Central Iowa VAHCS dating since April 2015. Appropriate steps should be taken to obtain any identified records and all attempts to obtain treatment records should be documented in the claims file. If the AOJ cannot obtain records identified, a notation to that effect should be inserted in the file. The Veteran and his representative are to be notified of unsuccessful efforts in this regard, in order to allow them the opportunity to obtain and submit those records for VA review. 2. Then, refer the Veteran's claims file to a psychologist or psychiatrist to determine the nature of his claimed acquired psychiatric disorder, to specifically include PTSD, depressive disorder and alcohol abuse. The Veteran's electronic claims file and a copy of this REMAND must be made available to and reviewed by the examiner in connection with providing the requested opinions. The examiner's report should note that the claims file and a copy of this REMAND has been reviewed. If the examiner determines that a new examination is necessary, it should be conducted. Following a review of the claims file, the examiner should document a complete, pertinent history of the Veteran's claimed acquired psychiatric disability, to include PTSD, depressive disorder, and alcohol abuse. The examiner should give particular attention to the Veteran's and his spouse's lay assertions and testimony during the October 2010 and November 2013 hearings and the pertinent medical evidence. A complete rationale for all opinions requested below must be provided. If the examiner cannot provide any of the requested opinions without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. Following a review of the complete history of the Veteran's claimed acquired psychiatric disorder, the examiner is requested to identify all currently diagnosed psychiatric disabilities, to include PTSD, depressive disorder, and alcohol abuse (under the DSM-IV and/or under the DSM-V). If PTSD is diagnosed, opine whether it is "at least as likely as not" (a 50 percent or greater probability) that there is a link between the current symptomatology and one or more of the Veteran's established in-service stressors sufficient to produce PTSD. As to each psychiatric diagnoses other than PTSD (e.g., depression, alcohol abuse, etc.) diagnosed in treatment records dating since January 2010 and during the March 2010 and April 2015 VA examinations, opine whether it is "at least as likely as not" (a 50 percent or greater probability) that any currently demonstrated psychiatric disorder other than PTSD had onset during active service or is related to any incident of the Veteran's military service. In doing so, the examiner is requested to address and consider the Veteran's contentions during VA examination in April 2015 to the effect that his depression had onset following the September 11, 2001 terrorist attacks and the Veteran's and his spouse's contentions during the October 2010 and November 2013 hearings to the effect that the Veteran drank alcohol to self-medicate his thoughts and feelings related to traumas that he experienced during combat service in Vietnam, and that his relapse in drinking alcohol was triggered by seeing the reaction of current troops coming home from war verses the reaction that he and other Vietnam veterans experienced upon returning from Vietnam. 3. Review the opinion to ensure that it is in complete compliance with the directives of this REMAND. If the report is deficient in any manner, corrective procedures must be implemented at once. 4. Then, readjudicate the issue on appeal. If the benefit sought on appeal is not granted, issue a supplemental statement of the case and afford the Veteran and his representative an opportunity to respond. Thereafter, the case should be returned to the Board, if in order. 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 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 2014). _________________________________________________ MICHAEL LANE 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).