Citation Nr: 1803874 Decision Date: 01/23/18 Archive Date: 01/31/18 DOCKET NO. 14-23 583 ) 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 posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Oregon Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Michael Duffy, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1987 through August 1995. This appeal comes to the Board of Veterans' Appeals (Board) from a July 2011 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) in February 2017. A transcript of the hearing is associated with the evidence of record. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND The Veteran was afforded a VA examination of his mental health in May 2014, and the VA examiner indicated that the Veteran did not have a current mental disability related to his military service. The examiner found the Veteran had an unspecified anxiety disorder, but the Veteran's symptoms did not meet the diagnostic criteria for PTSD under the DSM-V at the time of the examination. However, while the examiner addressed PTSD under the DSM-V, the examiner did not clearly opine whether the Veteran's symptoms met the criteria for PTSD under the DSM-IV during the period at issue. See, e.g., May 2010 Psychiatry Outpatient Notes from Metro East Community Based Outpatient Clinic (indicating that the Veteran seemed to have military-related PTSD under the DSM-IV at the time). The AOJ should obtain an addendum opinion from an appropriate examiner addressing whether the Veteran's symptoms met the criteria for PTSD under the DSM-IV during the period at issue. Additionally, the May 2014 VA examiner opined that the Veteran's psychiatric disability manifested in part as a chronic sleep impairment. A review of the record indicates that the Veteran's chronic sleep impairment is caused in part by pain from his service-connected disabilities including a spine disability. See, e.g., April 2008 statement from the Veteran's wife; April 2008 VA spine examination. The Veteran also indicated at the hearing that there was a correlation between an increase in his physical symptoms and psychiatric complaints including sleep impairment. As there is overlapping symptomatology between a current mental disability and a service-connected disability, the AOJ should obtain an opinion from a VA examiner addressing whether the Veteran's mental disabilities were caused or aggravated by a service-connected disability. Accordingly, the case is REMANDED for the following action: 1. The AOJ should contact the Veteran and his representative and request their assistance in identifying any relevant, outstanding VA and private treatment records. The AOJ should make reasonable attempts to obtain such records and associate them with the Veteran's claims file. 2. After associating any relevant outstanding records with the Veteran's claims file, the AOJ should afford the Veteran a new VA examination of his mental health with an appropriate examiner. The AOJ should provide the VA examiner with a complete copy of the Veteran's claims file to include this remand order. The VA examiner should follow these directives: (a) Please review the Veteran's claims file in its entirety including all mental health treatment records. Note any diagnoses of mental disorders such as an anxiety disorder to include a diagnosis of PTSD under the DSM-IV. See, e.g., May 2010 Psychiatry Outpatient Notes from Metro East Community Based Outpatient Clinic (indicating that the Veteran seemed to have military-related PTSD under the DSM-IV at the time). (b) Examine the Veteran and identify all current psychiatric disorders based on a review of the record, the Veteran's subjective complaints, and pertinent examination findings. Please opine whether the Veteran's symptoms have met the criteria for PTSD under the DSM-IV or DSM-V at any time during his treatment history through the date of the examination. (c) Please opine whether it is at least as likely as not (a 50 percent or greater probability) that any of the Veteran's current mental disabilities are related to his service to include any near drownings, personal assaults, or other stressful circumstances. The examiner should consider the statements of record from the Veteran and his wife regarding the onset and continuity of relevant symptoms. (d) Please opine whether it is at least as likely as not that any of the Veteran's current mental disorders are caused or permanently worsened beyond normal progression (aggravated) by the Veteran's service-connected spine disability, residuals of an ankle sprain, residuals of a kidney stone, scarring, or migraine headaches. Please explain why or why not. The examiner should consider statements from the Veteran's wife and medical examiners of record, which indicate that the Veteran's spine disability interferes with his sleep. If the examiner finds that a current mental disability was aggravated by a service-connected disability, the examiner must identify the baseline level of the disability that existed before aggravation by the service-connected disability occurred. 3. After completing the above actions and any other necessary development, the claim must be readjudicated. If the claim remains denied, a Supplemental Statement of the Case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, 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 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. HENEKS 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).