Citation Nr: 1752791 Decision Date: 11/16/17 Archive Date: 11/22/17 DOCKET NO. 09-18 060 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD). REMAND The Veteran, who is the Appellant in this case, had active service from June 1971 to May 1974. This matter comes before the Board of Veterans' Appeals (BVA or Board) from an October 2008 rating decision by the above Department of Veterans Affairs (VA) Regional Office (RO). The Veteran provided testimony at a March 2015 Travel Board hearing before the undersigned Veterans Law Judge at the RO. A transcript of the hearing is associated with the claims folder. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. The Veteran contends that he has a psychiatric disability, to include PTSD, as a result of events that occurred during active service. However, he has not provided any information regarding the specific events that caused his claimed psychiatric disability. In a December 2002 statement, he stated that he believed his schizophrenia and claimed PTSD were related to the training and experiences incurred while he was in Vietnam. He also stated that he was stationed in Vietnam at an October 1998 VA psychological examination. However, his military personnel records show that he had no foreign service and did not receive any combat medals. A mostly illegible August 1978 VA treatment note indicates that the Veteran reported that he started becoming violent during his military service, and that his commander and other individuals harassed him. In a June 2015 decision, the Board denied service connection for a psychiatric disability to include PTSD, among other issues. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In March 2017, the Court issued a Memorandum Decision (Decision) that vacated and remanded only the portion of the Board's June 2015 decision which had denied service connection for a psychiatric disability. The Court, in its March 2017 Decision, cited multiple references in the medical evidence of record showing that the Veteran reported experiencing psychiatric symptoms both during active service and beginning three years after service separation, including the following: a January 1972 service treatment record noted that when the Veteran was seen in December 1971, he acted somewhat depressed; in January 1974, the Veteran reported general malaise and drowsiness; the Veteran's July 1977 report to medical provider that he ruminated on past military experiences, had problems with impulse control, and had thoughts of physically assaulting others; a July 1977 medical report that the Veteran had depression that was moderate in severity and that he was hostile and suspicious; his July 1978 report to medical provider that he was tortured in the military and that his reaction was to threaten violence if he perceived people were messing with him; an August 1978 private treatment note that indicated that the Veteran stated that he became violent with people and it began during his military service; a September 1983 record documenting that the Veteran was directed to "stay away from people"; a January 1982 record showing the Veteran continued to have problems with coworkers after his military service and wanted to transfer positions; a December 1994 VA psychiatrist notation that the Veteran was very suspicious and needed to take his medication; a December 1990 medical record documenting symptoms of nervousness, depression, and trouble sleeping; an August 1994 record documenting symptoms of paranoid ideation and delusional thought process. The Board concludes that in order to comply with Court's Memorandum Decision, a VA examination and opinion is necessary to determine whether any of the current psychiatric diagnoses are etiologically related to or were incurred during active service. Accordingly, the case is REMANDED for the following action: 1. Afford the Veteran an opportunity to attend a VA examination with a VA psychologist or psychiatrist addressing the nature and etiology of any and all current psychiatric diagnoses. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished, and a rationale for any opinion expressed should be provided. The claims file must be made available to the examiner for review of the history in conjunction with the examination, and the examination report should reflect that such review was accomplished. a. The examiner should first identify all current psychiatric diagnoses using the DSM-V criteria. b. Next, the examiner should offer the following opinion: Is it at least as likely as not (i.e., to at least a 50/50 degree of probability) that the Veteran's current psychiatric disability or disabilities were incurred during or caused by active service? The examiner should address the service treatment records documenting symptoms of depressed mood, malaise, and drowsiness, referenced above, in articulating his/her opinion. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 2. When the development requested has been completed, the issue of entitlement to service connection for a psychiatric disability to include PTSD should again be reviewed by the RO on the basis of the additional evidence. If any benefit sought is not granted, the Veteran and his agent should be furnished a Supplemental Statement of the Case and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. 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). The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of the claim. See 38 C.F.R. § 3.655. 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. §§ 5109B, 7112 (2012). _________________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), 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). ATTORNEY FOR THE BOARD T. Sherrard, Counsel Copy mailed to: Barbara R. Lincoln, Agent