Citation Nr: 1753464 Decision Date: 11/21/17 Archive Date: 12/01/17 DOCKET NO. 09-31 398 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depressive disorder not otherwise specified (NOS) with possible psychiatric features, and substance use disorder. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J.L. Reid, Associate Counsel INTRODUCTION The Veteran had active service in the United States Army from October 1973 to October 1974. This matter is before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. Jurisdiction has since been transferred to the Winston-Salem, North Carolina RO (hereinafter, Agency of Original Jurisdiction (AOJ)). The Veteran presented testimony before the undersigned Veterans Law Judge (VLJ) at a June 2012 hearing. A transcript of that hearing is of record. The case was previously before the Board most recently in December 2016 when it was remanded for additional development. The case now returns to the Board for further adjudication. The Board notes that the Veteran originally filed a claim for service connection for PTSD. In Clemons v. Shinseki, 23 Vet. App. 1 (2009), the United States Court of Appeals for Veterans Claims (CAVC) held that, in determining the scope of a claim, the Board must consider the claimant's description of the claim; symptoms described; and the information submitted or developed in support of the claim. Accordingly, given that the record reflects possible psychiatric diagnoses other than PTSD, the Board has amended the issue on appeal as entitlement to service connection for an acquired psychiatric disorder, to include PTSD, depressive disorder NOS, with possible psychotic features, and substance use disorder. The appeal is REMANDED to the AOJ. VA will notify the Veteran if further action is required. REMAND Although the Board regrets the additional delay, remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2017). The Veteran contends that his psychiatric condition is the result of an in-service incident where he was assigned to clean up the remnants of a fellow soldier's suicide by gunshot. This was followed by another suicide in the Veteran's unit. In-service, the Veteran reported self-medicating through alcohol and drug use to cope with the trauma he experienced, and reported continued self-medication and nightmares post-service. In connection with the claim, the Board sought to verify the Veteran's stressor, but remained unsuccessful. Pertinently, the joint service records research center (JSRRC) librarian was unable to confirm or deny the incident described by the Veteran, but suggested seeking criminal investigation records. In the December 2016 letter, the Army Crime Records Center was unable to verify the Veteran's stressor as the forty-year records retention period had lapsed. Consequently, the medical evidence of record fails to address the etiology of any claimed psychiatric disability other than PTSD. As the aforementioned stressor is unable to be corroborated as required for a formal PTSD diagnosis for VA purposes, but the Veteran holds additional psychiatric diagnoses (major depressive disorder, recurrent with psychotic features and substance use disorder), another medical opinion is necessary to determine if those conditions are related to service. Therefore, the Veteran should be afforded a VA examination in connection with the claim. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 U.S.C. § 5103A (d)(1); 38 C.F.R. § 3.159(c)(4) (holding, in relevant part, that in order to trigger VA's duty to provide an examination or obtain an opinion, there must be insufficient evidence to decide the case); see also 38 C.F.R. § 3.159(c)(4). Accordingly, the case is REMANDED for the following action: 1. Associate with the claims file any outstanding VA and private treatment records since the issuance of the July 2017 supplemental statement of the case. 2. Afford the Veteran an appropriate VA examination to determine the nature and etiology of his claimed psychiatric diagnoses. The examiner is asked to determine whether it is at least as likely as not (50 percent or greater probability) that any psychiatric disability (other than PTSD) had an onset in service or within the presumptive period, or is etiologically related to the Veteran's period of active service, to include his claimed allegation of cleaning up after a soldier's suicide, which the examiner is asked to accept as true. The examiner is requested to explain whether there is any medical reason to accept or reject the Veteran's contentions that his in-service self-medication of drug and alcohol use, and later experienced chronic nightmares and paranoia since separation represented the early onset of a chronic psychiatric disability. In addressing the aforementioned questions, the examiner should make note of the Veteran's enlistment and discharge examinations, where he was deemed psychologically normal for each milestone. Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the 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(s). 3. Upon completion of the above, and any additional development deemed appropriate, the AOJ should readjudicate the remanded issue. If any benefit sought on appeal remains denied, the Veteran and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response, the appeal must be returned to the Board for appellate review. 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). _________________________________________________ ROBERT C. SCHARNBERGER 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).