Citation Nr: 1612465 Decision Date: 03/28/16 Archive Date: 04/07/16 DOCKET NO. 12-33 637A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Philadelphia, Pennsylvania THE ISSUE Entitlement to service connection for an acquired psychiatric disorder other than an obsessive-compulsive disorder (OCD) to include a panic disorder, a not otherwise specified depressive disorder, an anxiety disorder, and posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Pennsylvania Department of Military and Veterans Affairs ATTORNEY FOR THE BOARD J. T. Hutcheson, Counsel INTRODUCTION The Veteran is the appellant in the instant appeal. He had active service from August 1969 to August 1971 and additional duty with the Puerto Rico Army National Guard. The Veteran served in the Republic of Vietnam. This matter came before the Board of Veterans' Appeals (Board) on appeal from a March 2012 rating decision of the Philadelphia, Pennsylvania, Regional Office (RO) which, in pertinent part, determined that new and material evidence had not been received to reopen the Veteran's claim of entitlement to service connection for an anxiety neurosis. In March 2015, the Board, in pertinent part, determined that new and material evidence had been received to reopen the Veteran's claim for service connection and remanded the issue of service connection for an acquired psychiatric disorder to include a generalized anxiety disorder to the RO for additional action. In July 2015, the Appeals Management Center (AMC) granted service connection for OCD; assigned a 50 percent evaluation for that disability; and effectuated the award as of August 9, 2011. In September 2015, the Board remanded the issue of service connection for an acquired psychiatric disorder other than OCD to include anxiety, depression, and PTSD to the RO for additional action. The Board has reviewed both the Veterans Benefit Management System (VBMS) and the "Virtual VA" files. This appeal was processed using the VBMS paperless claims processing system. Accordingly, any future consideration of the Veteran's appeal should take into consideration the existence of this electronic record. The Board has reframed the issue on appeal in accordance with the United States Court of Appeals for Veterans Claims' (Court) decision in Clemons v. Shinseki, 23 Vet. App. 1 (2009) (finding that a claim for benefits for one psychiatric disability also encompassed benefits based on other psychiatric diagnoses and should be considered by the Board to be within the scope of the filed claim). The Veteran's appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND VA clinical documentation dated between June 2013 and August 2015 reflects that the Veteran was repeatedly diagnosed with and treated for OCD, a panic disorder without agoraphobia, and an unspecified depression disorder. The Board's September 2015 Remand instructions direct that the RO was to submit the Veteran's claims file to the examiner who conducted a July 2015 VA mental disorders examination and to request that "the examiner provide an opinion as to whether the Veteran has psychiatric diagnoses other than OCD to include anxiety, depression, and PTSD." If any such disorders were diagnosed, the examiner was to "provide an opinion as to whether it is at least as likely or not (a 50 percent or greater probability) that such psychiatric disorder or disorders, to include anxiety, depression, and/or PTSD, are of service onset, otherwise related to the Veteran's service, or are symptoms of or related to the Veteran's service-connected obsessive compulsive disorder." The Veteran's records were referred to the examiner who conducted the July 2015 VA psychological evaluation. An October 2015 addendum to the July 2015 VA examination report states that: "[t]he Veteran's does not meet criteria any other psychiatric disorder;" he "denied any history of psychotic symptoms, thus, he never met the criteria for a psychotic disorder and did not meet the criteria for a psychotic disorder at the time of this C&P;" and "he does not have, and did not report any other psychiatric symptoms, which are better explained by another psychiatric diagnosis, outside of or related to OCD." The VA psychologist failed to discuss or to otherwise note the VA clinical documentation dated between June 2013 and August 2015 and the multiple diagnoses of a panic disorder without agoraphobia and an unspecified depression disorder contained therein. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Given the failure of the October 2015 addendum to address the multiple VA diagnoses of both a panic disorder and a not otherwise specified depressive disorder, the Board finds that further VA psychiatric examination is required to adequately address the issues raised by the instant appeal. Clinical documentation dated after September 2015 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claim. See Murphy v. Derwinski, 1 Vet. App. 78, 81-82 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and request that he provide information as to all treatment of his acquired psychiatric disorders other than OCD after September 2015, including the names and addresses of all health care providers whose records have not already been provided to VA. Upon receipt of the requested information and the appropriate releases, the RO should contact all identified health care providers and request that they forward copies of all available clinical documentation pertaining to treatment of the Veteran, not already of record, for incorporation into the record. If identified records are not ultimately obtained, the Veteran should be notified pursuant to 38 C.F.R. § 3.159(e) (2015). 2. Associate with the record any VA clinical documentation not already of record pertaining to treatment of the Veteran, including that provided after September 2015. 3. Schedule the Veteran for a VA psychiatric examination in order to assist in determining the nature and etiology of the Veteran's claimed acquired psychiatric disorders other than OCD. The examiner should advance an opinion as to whether it is as likely as not (i.e., probability of 50 percent or more) that any identified acquired psychiatric disorder other than OCD had its onset during active service; is related to the Veteran's service in the Republic of Vietnam; or otherwise originated during active service. The examiner should specifically address the multiple VA diagnoses of both a panic disorder and a not otherwise specified depressive disorder. All relevant medical records must be made available to the examiner for review of pertinent documents therein. The examination report should specifically state that such a review was conducted. A rationale for all opinions should be provided. 4. Then readjudicate the issue on appeal. If any benefit sought on appeal remains denied, the Veteran should be provided a supplemental statement of the case (SSOC) which addresses all relevant actions taken on the Veteran's claim for benefits, to include a summary of the evidence considered, since the issuance of the last SSOC. An appropriate period of time should be allowed for response before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on the 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 or by 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). ______________________________________________ BRADLEY W. HENNINGS Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board is appealable to the Court. 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) (2015).