Citation Nr: 1625292 Decision Date: 06/23/16 Archive Date: 07/11/16 DOCKET NO. 13-16 078 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia and posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant, spouse, and sister ATTORNEY FOR THE BOARD Matthew Miller, Associate Counsel INTRODUCTION The Veteran had active duty service from July 1969 to July 1973. This matter comes before the Board of Veterans' Appeals (Board) from April 2012 and December 2015 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. In April 2016, the Veteran appeared at a hearing held at the RO before the undersigned (i.e., Travel Board hearing). A transcript of that hearing is of record. This appeal was processed using the Virtual VA and Veterans Benefits Management System (VBMS) paperless claims processing systems. Any future consideration of this Veteran's case should take into account the existence of these records. The service connection claim for an acquired psychiatric disorder (claimed as schizophrenia) has been re-characterized as an acquired psychiatric disorder, to include schizophrenia and PTSD. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND Review of the record reveals that a remand is necessary to ensure that there is a complete record upon which to decide the Veteran's claim. Remand is also required to obtain an additional VA examination. The Veteran contends that he has an acquired psychiatric disorder, to include schizophrenia and PTSD, that is related to service. Review of the record shows that the Veteran first received psychological treatment in September 1979. The Veteran was diagnosed with paranoid schizophrenia and prescribed medication. Additional private treatment records reveal that he was seen periodically for follow-up treatment for this condition. The Veteran has received VA treatment for this condition as well. In addition to the Veteran's medical records detailing his treatment, there are a number of lay statements from the Veteran's family that describe his behavior upon his return from Vietnam, including instances of paranoia and aggression. The statements indicate that the Veteran's behavior has been erratic and that his medication is helpful in treating these episodes. The Veteran was afforded a VA examination for PTSD in October 2015. After reviewing the Veteran's virtual file, the examiner determined that the Veteran suffered from occupational and social impairment with reduced reliability and productivity, as well as anxiety, suspiciousness, sleep impairment, mild memory loss, and impaired judgment. The examiner described the Veteran's history, including his family background, his service in Vietnam, and post-service employment. The examiner noted that the Veteran received psychiatric outpatient treatment from the Region One Medical Center for many years. She also noted that the Veteran was psychiatrically hospitalized in 1980, 1988, and most recently in June 2014 after many years of stability on psychotropic medication. The Veteran described that while in service, he was subjected to racially motivated threats of assault and he returned from Vietnam in a mentally unstable state. Ultimately, the examiner determined that the Veteran did not meet the diagnostic criteria for PTSD under the DSM-V. Instead, the examiner diagnosed the Veteran with schizophrenia, and noted that an opinion on the relationship of this disorder to his military service could be added in an addendum report. In April 2016, the Veteran testified at his hearing that he reported instances of racism while in service and felt that this caused him retribution from his supervisors. He expressed fear that he would be killed or left behind in Vietnam, and upon his return, his life changed. The Veteran's family members also described occasions where the Veteran experienced psychological outbursts, which required hospitalization and medication. In light of the above, it appears that the Veteran was diagnosed with schizophrenia around 1979, and the October 2015 examiner indicated that an addendum opinion for this disorder could be provided. Therefore, an addendum opinion should be obtained to address whether any acquired psychiatric disorder, to include schizophrenia and posttraumatic stress disorder, is related to the Veteran's military service. During the hearing, the issue of secondary service connection was raised which should also be addressed on remand. Accordingly, the case is REMANDED for the following action: 1. Request authorization to obtain any additional private treatment records that may support the Veteran's claim. 2. Obtain all outstanding, pertinent VA medical records and associate them with the claims file. If any requested outstanding records cannot be obtained, the Veteran should be notified. 3. Provide notice to the Veteran concerning how to substantiate his claim as secondary to service-connected disability. Also inform the Veteran that, in connection with his claim for PTSD based on personal assault, he can provide evidence from sources other than his service records or evidence of behavior changes which may constitute credible supporting evidence of the stressor and allow him the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. 4. Return the claims folder and a copy of this remand to the VA examiner who conducted the October 2015 VA psychological examination for a clarifying medical opinion as to the etiology of any of the Veteran's acquired psychiatric disorders (or to a suitable substitute examiner, if the VA examiner who conducted the October 2015 examination is not available). The examiner must review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records and lay statements, and document that such a review took place in the examination report. The examiner should express an opinion as to the following: (a) For each diagnosed psychiatric disorder, please provide an opinion as to whether it is at least as likely as not (i.e. a 50% chance or greater) that the disorder is related to the Veteran's military service. Regarding the claim for PTSD based on personal assault, the examiner is asked to provide an opinion as to whether the evidence indicates that a personal assault occurred. See Board hearing transcript, pp. 24-25. (b) Please provide an opinion as to whether it is at least as likely as not that a diagnosed psychiatric disorder is due to or caused by the service-connected coronary artery diease or diabetes mellitus. (c) Please provide an opinion as to whether it is at least as likely as not that a diagnosed psychiatric disorder is aggravated (i.e., worsened) beyond the natural progress by the service-connected coronary artery diease or diabetes mellitus. A complete rationale for all opinions expressed should be provided. However, if the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion cannot be provided without resort to speculation. A report should be prepared and associated with the Veteran's VA claims folder. 4. Ensure that any opinion obtained is adequate and satisfies the terms of this remand. 5. Then, readjudicate the issue of entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia and PTSD. If any benefit sought on appeal is not granted to the Veteran's satisfaction, the Veteran and his representative should be furnished a supplemental statement of the case and provided an appropriate opportunity to respond before the case is returned to the Board for further appellate action. The appellant has the right to submit additional evidence and argument on the matter or 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 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). _________________________________________________ S.S. TOTH 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) (2015).