Citation Nr: 1630222 Decision Date: 07/28/16 Archive Date: 08/04/16 DOCKET NO. 10-24 554 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and mood disorder. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Dominic Jones, Associate Counsel INTRODUCTION The Veteran served on active duty from July 2005 to October 2008 in the United States Army. This matter is before the Board of Veterans' Appeals (Board) on appeal from a May 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. Relevant to the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder, such was originally adjudicated by the agency of original jurisdiction (AOJ) as entitlement to service connection for PTSD. In Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the United States Court of Appeals for Veterans Claims (Court) held that, in determining the scope of a claim, the Board must consider the claimant's description of the claim; symptoms described; and the information submitted or developed in support of the claim. The Veteran sought service connection for bipolar disorder in August 2009. The record reveals diagnoses of a range of psychiatric conditions. In light of the record and the Court's decision in Clemons, the Board has recharacterized the issue on appeal as entitlement to service connection for an acquired psychiatric disorder, to include PTSD and mood disorder as reflected on the title page. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND The Veteran received a VA examination in February 2014. The examiner indicated that the Veteran did not have a diagnosis of PTSD. Specifically, the examiner stated that "[b]ased on today's interview using the CAPS-DX, it is less likely than not that the veteran meets the full criteria for PTSD based on either DSM-IV or DSM-V." Furthermore, the examiner stated the Veteran "did not endorse full criteria for PTSD on interview. The examiner did nonetheless diagnose the Veteran as having "Mood disorder NOS, currently depressed." With regard to the mood disorder, the examiner opined that it was less likely than not it had its onset during the Veteran's period of active service. The examiner noted that the Veteran's service treatment records revealed that he was prescribed Citalopram and Zolpidem in August 2008 and that "Unspecified Mental Disorder (nonpsychotic), Insomnia related to Axis I/II Mental Disorder (nonorganic) and Adjustment Disorder" were on the Veteran's problem list. However, the examiner stated that there was no documentation of mental health treatment that would indicate what the medication was for and it would be purely speculative to opine this would relate to prodromal signs of the current diagnosis. The examiner further highlighted that it was just as likely that the medication the Veteran had been prescribed in service was due to problems the Veteran was experiencing due to situational stressor events having to do with the end of the Veteran's marriage. The examiner's opinion appears to be based on a misunderstanding of the criteria for establishing service connection. The examiner appears to concede that the Veteran had some sort of psychiatric disorder noted in service and was prescribed medication, but then indicates that because it was at least as likely that the medication prescribed and issues experienced by the Veteran in service were due to problems with his marriage, the claimed condition did not have its onset during military service. The Board notes in order to establish entitlement to service connection, it is sufficient that the claimed disorder had its onset in service, regardless of whether the psychiatric disorder that commenced in service was related to marital stressors or military experiences. Thus, this case must be remanded for a medical opinion on the question of whether the Veteran's current psychiatric disability commenced during his military service or is otherwise related to his military service. Accordingly, the case is REMANDED for the following action: 1. Return the claims folder to the February 2014 VA examiner for an addendum. If the examiner is no longer available, arrange for an opinion from another qualified medical examiner. Schedule the Veteran for an examination only if deemed necessary by the examiner in order to provide the opinion. The examiner must review the claims folder and note such review in the report. The examiner should then opine as to whether it is at least as likely as not (a degree of probability of 50 percent or higher) that any presently diagnosed psychiatric condition had its onset during service, OR is otherwise related to service. In responding to this request, the examiner is asked to explain the significance of the August 2008 service treatment records referenced by the February 2014 VA examiner. In particular, the examiner is asked whether it is at least as likely as not that the records showing the Veteran was prescribed Citalopram and Zolpidem and showing that "Unspecified Mental Disorder (nonpsychotic), Insomnia related to Axis I/II Mental Disorder (nonorganic) and Adjustment Disorder" were noted on his problem list indicate that any currently diagnosed psychiatric disorder had its onset during service. If PTSD is diagnosed, the examiner should identify the stressor or stressors upon which the diagnosis was made. A complete rationale should be given for any opinion provided. 2. Thereafter, readjudicate the appeal. If the benefit sought remains denied, issue a supplemental statement of the case and return the case to the Board. The Veteran 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). _________________________________________________ M. HYLAND 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).