Citation Nr: 1756856 Decision Date: 12/08/17 Archive Date: 12/15/17 DOCKET NO. 14-08 526 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Connolly, Counsel INTRODUCTION The Veteran served on active duty from August 1969 to March 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois, which denied service connection for PTSD. The January 2014 statement of the case listed the issue as service connection for an acquired psychiatric disorder, to include PTSD. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). The Veteran subsequently perfected this appeal. In March 2015, a Travel Board hearing was held before the undersigned Veterans Law Judge (VLJ). In September 2015, the Board remanded this case. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND The Veteran contends he has PTSD related to active service. Service records show he served in Vietnam from April 1970 to April 1971. He has asserted various stressors as follows. While the Veteran was in Vietnam, he was in the jungle assigned to fix a tank and he could hear friendly and enemy fire; he could hear enemy fire at other times and was scared; his truck was shot at by enemy fire; he saw a tank misfire causing possible injuries/deaths; he was also scared of local Vietnamese because of the Vietcong; his friend was injured when his hand blew up due to a fuel accident and he witnessed that incident which was traumatic; and he saw body bags, and soldiers in the hospital with amputations. As noted in the Board's remand, the Veteran underwent a VA initial PTSD examination in October 2011. The diagnosis was major depression, which the examiner believed was related to cervical spine surgery. The examiner stated that the Veteran's claimed stressor was not adequate to support a diagnosis of PTSD and further indicated that he did not meet the criteria for a PTSD diagnosis. However, the examiner did not cite to any claimed stressor as made by the Veteran. As such, this opinion was insufficient. Thereafter, the Veteran was diagnosed with PTSD in a private January 2015 report based on a report of inservice fear of death/witnessing death. The Board previously determined that another VA examination should be afforded to the Veteran since VA had recently adopted as final an interim rule adopting the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). In February 2016, the Veteran was afforded the requested VA examination. The examiner diagnosed PTSD. Only the tank misfiring incident was noted. There was no other mental disorder. The opinion indicated was the following: There is doubt that the history was as reported. On November 12, 2015 he reported no PTSD on his screen. On May 22, 2011 he was discharged from mental health because he had been "brief" with contact with them, he was "not motivated for treatment" and reported he was taking prescribed medication of 10 mg of his antidepressant" 2 to 3 times a week." He denied feeling distant or cut off." His stressor statements did not note fear or a stressor that had happened to someone else. This opinion is clearly incomplete as pointed out by the Veteran's representative and, as such, is insufficient. Accordingly, a medical addendum is needed. Accordingly, the case is REMANDED for the following action: 1. Obtain a VA psychiatric medical addendum. The record should be reviewed. The examiner is requested to state whether any reported stressors (that the Veteran could hear friendly and enemy fire; he could hear enemy fire at other times and was scared; his truck was shot at by enemy fire; he saw a tank misfire causing possible injuries/deaths; he was also scared of local Vietnamese because of the Vietcong; his friend was injured when his hand blew up due to a fuel accident and he witnessed that incident which was traumatic; and he saw body bags, and soldiers in the hospital with amputations) is adequate to support the diagnosis of PTSD. The examiner should, (a) clearly identify the stressor(s) underlying the diagnosis, and (b) fully explain how the diagnostic criteria are met, to include comment upon the link, if any, between the stressor and the Veteran's symptoms. The examiner should specifically consider whether the Veteran has a stressor related to fear of hostile military or terrorist activity. A complete rationale for any opinion expressed must be provided. 2. Review the medical opinion obtained above to ensure that the remand directives have been accomplished. If all questions posed are not answered or sufficiently answered, the case should be returned to the examiner for completion of the inquiry. 3. Readjudicate the claim on appeal in light of all of the evidence of record. If the issue remains denied, the Veteran should be provided with a supplemental statement of the case as to the issue on appeal, and afforded a reasonable period of time within which to respond thereto. 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). 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). S. L. Kennedy 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).