Citation Nr: 1752213 Decision Date: 11/15/17 Archive Date: 11/22/17 DOCKET NO. 14-02 516 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include adjustment disorder with depressed mood, and post-traumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Oregon Department of Veterans' Affairs WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD K. Brandt, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1966 to May 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a Travel Board videoconference hearing before the undersigned Veteran's Law Judge in October 2016. A transcript of the hearing has been associated with the record. Evidence in the record suggests that the Veteran has been diagnosed with adjustment disorder with depressed mood. See August 2012 VA examination report. The United States Court of Appeals for Veterans Claims (Court) has held that the scope of a psychiatric disorder claim includes any psychiatric disorder that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and other information of the record, regardless of the diagnosis. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Therefore, in light of Clemons, the Board finds it appropriate to recharacterize the claim as entitlement to service connection for an acquired psychiatric disorder, to include adjustment disorder with depressed mood and PTSD. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran has claimed service connection for an acquired psychiatric disorder, to include adjustment disorder with depressed mood and PTSD. Although the Board regrets any additional delay in the Veteran's case, a remand is necessary prior to adjudicating the claim on appeal to ensure that there is a complete record upon which to afford the Veteran every possible consideration to his claim. See U.S.C. § 5103A (2014); 38 C.F.R. § 3.159 (2017). The Veteran contends that he suffers from an acquired psychiatric disorder as the result of his exposure to traumatic events during active service. Specifically, the Veteran testified that he had a confrontation with an armed Vietnamese boy and suffered verbal abuse and harassment while working on board a ship traveling to Vietnam. In a June 2012 VA treatment record, the Veteran was diagnosed with PTSD. The VA counselor noted the Veteran's stressors to include: harassment the Veteran endured while on the ship; a confrontation with an armed Vietnamese boy; and an encounter with an armed Vietnamese gang. The Veteran was then scheduled follow-up appointments in July 2012 for treatment of his chronic PTSD. The Veteran underwent a VA examination in August 2012. The examiner diagnosed the Veteran with adjustment disorder with depressed mood and noted that this condition is secondary to the Veteran's physical injuries that prevent him from enjoying daily activities. The examiner found that the Veteran's history and symptoms are not consistent with PTSD, and concluded that the Veteran did not meet criterion C of the DSM-IV for PTSD, given that he does not suffer from avoidance symptoms or a numbing of general responsiveness. Further, the August 2012 report contains some conflicting opinions regarding functional impairment of the Veteran's psychiatric disorder. In one section, the examiner stated that a mental condition was formally diagnosed, but symptoms were not severe enough to interfere with occupational and social functioning. However, later in the report the examiner stated that the PTSD symptoms cause clinically significant distress or impairment in social and occupational functioning. Then, in the opinion section, the examiner opined that the Veteran does not suffer significant social, emotional, or occupational impairment. The Boards finds the August 2012 examination inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The August 2012 examiner failed to address the June 2012 diagnosis of PTSD and the examination report also contains conflicting opinions regarding the clinical impairment of the Veteran's psychiatric condition. Further, the August 2012 examiner failed to address all of the Veteran's alleged stressors, specifically the harassment the Veteran suffered on board the ship. As there is evidence of a possible current acquired psychiatrist disability to include adjustment disorder with depressed mood and PTSD, and evidence of stressors adequate to support a diagnosis of PTSD, the Board finds that a new medical opinion by a psychologist or psychiatrist is required to determine whether the Veteran has an acquired psychiatric disorder to include adjustment disorder with depressed mood and PTSD that satisfies the required criteria under DSM-IV is needed. Accordingly, the case is REMANDED for the following action: 1. Send the Veteran a development letter for PTSD advising him of the need for credible supporting evidence for any claimed stressors that are not combat-related and notifying him that in-service personal assault may be corroborated by evidence from sources other than service records. Examples of such evidence, as listed in 38 C.F.R. § 3.304(f)(5), should be provided. If the Veteran provides information regarding stressors that are of sufficient detail, attempt to verify the claimed stressors with U.S. Army and JSRRC or any other agency deemed appropriate. Associate all search efforts and information obtained, including negative results, with the Veteran's claims file. 2. After the above development has been completed, schedule the Veteran for a VA examination with a psychiatrist or a psychologist to determine the nature and etiology of any acquired psychiatric disorder(s), including, but not limited to, adjustment disorder with depressed mood and PTSD. The claims folder, including a copy of this remand, should be made available to the examiner. After the record review and a thorough examination and interview of the Veteran, the VA examiner should offer his/her opinion with supporting rationale as to the following inquiries: (a) Identify whether the Veteran has a diagnosis of PTSD, which may have been present at any time during the pendency of this appeal, under the diagnostic criteria (DSM-IV), and if so, whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the disability is etiologically related to the Veteran's active military service, to include his service in Vietnam, being in fear of hostile military activity, and/or military personal assault. If specific stressors have been verified, the examiner should be advised of such stressors. The Board notes that "fear of hostile military or terrorist activity" means that the Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. (b) Identify whether the Veteran has any other acquired psychiatric disorder(s), under the diagnostic criteria, and if so, provide an opinion as to whether it is at least as likely as not that the disorder had its onset during, or is otherwise etiologically related to, the Veteran's active military service. If the examiner does not identify any other acquired psychiatric disorder, the examiner should, to the extent possible, reconcile his or her findings with any contrary medical evidence of record, including VA treatment records documenting a diagnosis of adjustment disorder with depressed mood. (c) A complete rationale for all opinions should be set forth. The examiner is advised that the Veteran is competent to report his symptoms and history. If the examiner rejects the Veteran's reports, the examiner must provide an explanation for such rejection. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 3. After completing the development requested above, re-adjudicate the Veteran's claims. If the benefit sought remains denied, provide the Veteran and his representative 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 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). _________________________________________________ MICHAEL LANE 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) (2017).