Citation Nr: 1746929 Decision Date: 10/20/17 Archive Date: 10/31/17 DOCKET NO. 14-01 799 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and generalized anxiety disorder (GAD). REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD M. C. Wilson, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1969 to November 1970, including service in the Republic of Vietnam from September 1969 to November 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In light of Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Board has recharacterized the Veteran's August 2011 claim for service connection for PTSD as a claim for service connection for an acquired psychiatric disorder, to include PTSD and GAD. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran asserts that his current psychiatric disability developed secondary to in-service stressors, which have been identified as follows: (1) two members of his unit were killed by rocket and mortar attacks while on convoy in Vietnam in April 1970; and (2) the Veteran witnessed the death of a sergeant as a result of a motor vehicle rollover. See VA Form 21-0781 (Statement in Support of Claim for Service Connection for PTSD), dated in September 2011. In February 2012, VA issued a memorandum in which it verified the first stressor. The record indicates that the Veteran has had a diagnosed psychiatric disorder since at least October 2001, at which time private physician Dr. R. Gaddis documented an impression of chronic anxiety and self-medication with alcohol. During the period October 2002 to December 2003, impressions of chronic depression, chronic anxiety, and associated insomnia were also noted. In July 2005, February 2006, and March 2008, Dr. Gaddis documented chronic anxiety and depression. In September 2010, Vet Center counselor M. Moore reported that the Veteran endorsed symptoms consistent with the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) diagnosis for PTSD and subsequent Vet Center records that are dated during the period on appeal document a finding of subthreshold PTSD. Additionally, in October 2011, Dr. Gaddis reported that the Veteran was taking medication for anxiety, panic attacks, and depression, and a similar report was documented in August 2012. In December 2016, GAD, depression, major depressive affective disorder, anxiety, and PTSD were identified in a non-VA problem list. See December 2016 East Tennessee Medical Group record. In October 2011, VA provided an examination to identify and determine the likely etiology of the Veteran's current psychiatric disability. The examiner reported that the Veteran had an Axis I diagnosis of GAD that is less likely than not related to the Veteran's military service, as research suggests that GAD is not incurred by a specific stressor. Additionally, the examining clinician reported that the Veteran did not meet the criteria for PTSD under the DSM-IV at that time. The Board notes that the Veteran has had a positive PTSD screen since his October 2011 examination. See January 2012 VA treatment records. In light of the foregoing, the Board finds that the AOJ must consider whether either of the Veteran's reported stressors is adequate to support a diagnosis of PTSD under the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition). See 38 C.F.R. § 4.125(a) (2016). Additionally, the AOJ must obtain an opinion as to the likely etiology of any currently diagnosed psychiatric disorders, to include those conditions that were diagnosed during the appeal period (or since August 2011). See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); see also Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013). Thus, a new examination should be provided on remand. 38 U.S.C.A. § 5103A(d) (West 2014); 38 C.F.R. § 3.159(c)(4) (2016). In addition, the Board notes that the Veteran previously authorized VA to obtain records from Dr. W. Weatherhead for medical treatment provided from January 1995 to December 2000. See VA Form 21-4142 (Authorization and Consent to Release Information to the VA), dated in August 2012. The Board finds that reasonable efforts must be made to obtain these records on remand. 38 U.S.C.A. § 5103A(b); 38 C.F.R. § 3.159(c)(1); Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). While on remand, the AOJ should also attempt to verify the Veteran's second reported stressor-that he witnessed the death of a sergeant as a result of a motor vehicle rollover. Accordingly, the case is REMANDED for the following action: 1. Attempt to verify the Veteran's report that he witnessed the death of a sergeant as a result of a motor vehicle rollover. See VA Form 21-0781, dated in September 2011. All relevant findings should be memorialized in the claims file. 2. Ask the Veteran to provide or authorize VA to obtain records of his treatment by Dr. W. Weatherhead. In addition, recent VA treatment records and any other pertinent records identified by the Veteran during the course of the remand should be obtained and associated with the claims file. If any records requested by VA are not available, this should be indicated in the file. 3. After completing the development requested above, provide an examination and obtain a medical opinion from an appropriate clinician regarding the nature and etiology of the Veteran's psychiatric disability, to include PTSD, generalized anxiety disorder, and any other identified psychiatric disorder that has been identified since August 2011. A diagnosis of PTSD must be ruled in or excluded. The Veteran's claims file should be made available to and be reviewed by the examiner, and he or she must indicate whether such review was accomplished. (a) After reviewing the evidence of record, identify all psychiatric disorders diagnosed during the period on appeal (or since August 2011), and state specifically whether the Veteran has a diagnosis of PTSD under either DSM-IV or DSM-5 criteria. (b) For each disorder identified in (a), provide an opinion as to whether it is at least as likely as not that the disorder had its onset during his period of active service (May 1969 to November 1970). (c) For each disorder identified in (a), provide an opinion as to whether it is at least as likely as not that it had its onset within one year of the Veteran's November 1970 discharge from his period of active service. (d) For each disorder identified in (a), provide an opinion as to whether it is at least as likely as not that it was caused by his period of active service (May 1969 to November 1970). (e) Please opine as to whether it is at least as likely as not that the Veteran has a psychiatric disability that was caused or aggravated by his service-connected disability, to include the aggregate impact of the conditions. All findings, conclusions, and the rationale for all opinions expressed should be provided in a report, which must reflect the examiner's consideration and analysis of both the medical and lay evidence of record. Please note that an examiner's report that (s)he cannot provide an opinion without resort to speculation is inadequate unless the examiner provides a rationale for that statement. 4. Readjudicate the claim on appeal, after undertaking any additional development as may become necessary. If any of the benefits sought on appeal remain denied, issue the Veteran and his representative a Supplemental Statement of the Case, and allow for a reasonable period for response. 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 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). _________________________________________________ STEVEN D. REISS 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) (2016).