Citation Nr: 1644353 Decision Date: 11/23/16 Archive Date: 12/02/16 DOCKET NO. 14-29 348 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to service connection for a variously diagnosed psychiatric disability, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Illinois Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Bayles, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty from January 1954 to April 1954. This matter is before the Board of Veterans' Appeals (Board) on appeal from an April 2013 rating decision by the St. Paul, Minnesota, Department of Veterans Affairs (VA) Regional Office (RO) that denied service connection for PTSD; the Veteran's file is now in the jurisdiction of the Chicago, Illinois, RO. In August 2016, a Travel Board hearing was held before the undersigned, and a transcript is associated with the record. As the record shows psychiatric diagnoses other than PTSD, in accordance with Clemons v. Shinseki, 23 Vet. App. 1 (2009), the issue is characterized to encompass any psychiatric disability shown, however diagnosed. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action on his part is required. REMAND A psychiatric disability was not noted on the Veteran's June 1953 entrance examination, and he is presumed sound for such disability on entrance in service. See 38 U.S.C.A. § 1111. His service treatment records (STRs) note his report during Medical Board proceedings that he received psychiatric treatment prior to service; however, his lay statements are not sufficient to rebut the presumption of soundness. A July 2014 VA medical opinion does not clearly indicate whether the Veteran's current psychiatric disability is related to his documented psychiatric symptoms in service or discuss the matter in light of the presumption of soundness. Therefore, it is inadequate for rating purposes. A September 2013 private medical opinion indicates that the Veteran has PTSD related to service; however, that opinion does not identify the constellation of symptoms and corroborated stressor that support the diagnosis. A VA examiner subsequently explained why the Veteran does not meet the DSM-IV or DSM-V diagnostic criteria for PTSD. Therefore, the private opinion is likewise inadequate for rating purposes. Consequently, a new examination to secure an adequate medical advisory opinion is necessary. Accordingly, the case is REMANDED for the following: (This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. The AOJ should arrange for the Veteran to be examined by an appropriate psychiatrist or psychologist to determine the nature and likely etiology of his psychiatric disability. The entire record must be reviewed by the examiner, and all pertinent findings should be described in detail. Based on examination of the Veteran and review of his record the examiner should provide opinions that respond to the following: (a) Please identify (by diagnosis) each psychiatric disability entity found. Specifically, does the Veteran have a diagnosis of PTSD related to his service. If not, please identify the requirement(s) for such diagnosis found lacking. (b) Regarding any (and each) psychiatric disability entity other than PTSD diagnosed, please identify the likely etiology of such disability. Opine whether the disability was first manifested prior to service, during service, or postservice (identifying the factual data that support the responds). (c) As to any diagnosed psychiatric disability entity that was manifested in service, but was not noted on induction, please indicate whether there is any evidence in the record that renders it undebatable from a medical standpoint that such disability pre-existed service. If so, please identify such evidence. (d) If a psychiatric disability manifested in service is shown by clear and unmistakable evidence to have pre-existed service (rebutting the presumption of soundness, please opine further whether there is any evidence in the record that renders it undebatable from a medical standpoint that such disability was not aggravated by service. If so, please identify such evidence. (e) Regarding any psychiatric disability entity that was initially manifested after service, please opine whether it is at least as likely as not (a 50% or better probability) that such disability is related to the Veteran's service/psychiatric complaints therein. The examiner must explain the rationale for all opinions, citing to supporting factual data, and medical literature, as deemed appropriate. The examiner should specifically consider and address the Veteran's lay accounts regarding continuity of psychiatric symptoms ever since his active service, and his wife's supporting accounts. 2. The AOJ should then review the record, ensure that all development sought is completed, and readjudicate the claim of service connection for a psychiatric disability. If it remains denied, the AOJ should issue an appropriate supplemental statement of the case, afford the Veteran and his representative opportunity to respond, and return the case to the Board. The Veteran 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 for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ GEORGE R. SENYK 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).