Citation Nr: 1753355 Decision Date: 11/21/17 Archive Date: 12/01/17 DOCKET NO. 14-09 055A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Honolulu, Hawaii THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Diane C. Harr, Attorney WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Tracie N. Wesner, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from April 1979 to February 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2012 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Honolulu, Hawaii. The Veteran presented sworn testimony at a hearing before the undersigned in September 2016. The Veteran's claim of service connection for depression and anxiety has been recharacterized to include all psychiatric disorders reasonably raised by the record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND The Veteran seeks service connection for an acquired psychiatric disorder, to include PTSD. His VA and private medical records show that he has been diagnosed with PTSD, Adjustment Disorder with mixed anxiety and depressed mood, Anxiety Disorder NOS, Dysthymia and Major Depressive Disorder during the appeal period. He reports that his psychiatric symptoms, including depression, began during service and have been recurrent since that time. See September 2016 Hr'g Tr. at 12; see also September 2010 VA Mental Health Initial Evaluation Note. He reported experiencing stressful events during service that caused or exacerbated his psychiatric symptoms, including a sexual assault and a motor vehicle accident. See February 2011 and April 2012 Written Statements. The Veteran further reported that he attempted suicide in service by drinking bleach, and that he was hospitalized as a result of this incident. See January 2009 Psychiatric Evaluation; September 2016 Hr'g Tr. at 7. The Board finds that remand is necessary for the purpose of making attempts to obtain the Veteran's Reserve records and in-patient hospitalization service treatment records, and to provide him with a VA examination. Reserve and In-Service Hospitalization Records The service treatment records that have been associated with the file include a January 1990 examination and medical history that appears to have been completed during the Veteran's period of Reserve service. It does not appear that attempts were made to obtain any other Army Reserve records. As those records may include information that is relevant to the Veteran's claim, they should be sought. The Veteran reported that he was hospitalized and/or received psychiatric treatment after a suicide attempt in service. He could not recall when the hospitalization or treatment took place, but recounted that it occurred between August 1977 and August 1978, while he was stationed in Panama. Although the Veteran has not provided a specific date or 60 day time frame during which his hospitalization or psychiatric treatment took place, the Board finds that there is sufficient information available for VA to request a record search be performed. See Gagne v. McDonald, 27 Vet. App. 397, 403-404 (2015) (holding that "the duty to assist required VA to submit multiple 60-day record searches"). Accordingly, multiple 60-day record searches should be performed in an attempt to obtain these records. VA Examination The Veteran's VA medical records show that during the appeal period he has been diagnosed with PTSD, Adjustment Disorder with mixed anxiety and depressed mood, Anxiety Disorder NOS, Dysthymia and Major Depressive Disorder. He reported that his depressive symptoms began in service and have been recurrent since that time. There is insufficient evidence in the record linking his current psychiatric disorder(s) to the symptoms he reported experiencing during service. Thus, the Veteran should be afforded a VA examination. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). As this matter is being remanded, all outstanding VA medical records should be obtained. Sullivan v. McDonald, 815 F.3d 786 (2016). Moreover, the Veteran should be given an opportunity to identify any private medical records he would like considered in connection with his appeal. 38 C.F.R. § 3.159(c). Accordingly, the case is REMANDED for the following action: 1. Obtain all outstanding VA medical records. The Board notes that the Veteran has been treated at the Leeward Oahu Community Based Outpatient Clinic. 2. Ask the Veteran to identify any private medical care providers who treated him for a psychiatric disability. After securing any necessary authorization, obtain records from any identified providers. 3. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of his in-service and post-service psychiatric symptomatology. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 4. Make attempts to obtain the Veteran's Army Reserve records. 5. Make attempts to obtain the Veteran's in-patient hospital records and/or psychiatric treatment records during the period between August 1977 and August 1978. Multiple requests should be made if necessary. 6. After obtaining the requested records (to the extent possible), schedule the Veteran for an appropriate VA examination to address the nature and etiology of his psychiatric disorder(s). The claims file should be made available to and reviewed by the examiner and all necessary tests should be performed. All findings should be reported in detail. After a review of the claims file, the examiner should address the following: (1) whether the Veteran's symptomatology and presentation at any point during the appeal period (October 2010 to the present) meets the diagnostic criteria for PTSD; and, if so, the underlying stressor supporting that diagnosis; (2) whether it is at least as likely as not that any of the Veteran's psychiatric disorders diagnosed at any point during the appeal period (October 2010 to the present), including PTSD, Adjustment Disorder with mixed anxiety and depressed mood, Anxiety Disorder NOS, Dysthymia and Major Depressive Disorder, had its onset in service or are otherwise related to an event, injury or disease incurred in service. In reaching his or her conclusions, the VA examiner should specifically review and consider the lay statements of the Veteran, as well as the VA medical records noting his psychiatric symptoms. If any opinion requested above cannot be rendered without resorting to speculation, the examiner should 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). 7. After completing the above development, including any additional development that may be warranted, readjudicate the appeal. 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. §§ 5109B, 7112 (2012). _________________________________________________ C. CRAWFORD 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).