Citation Nr: 1804037 Decision Date: 01/23/18 Archive Date: 01/31/18 DOCKET NO. 14-20 798 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. M. Stedman, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1969 to January 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. Concerning the Veteran's claim for service connection for PTSD, the Board notes that the record reflects various diagnostic impressions, including PTSD, a mood disorder not otherwise specified (NOS), a depressive disorder NOS, and an adjustment disorder with depressed mood. Because 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 and reported syndromes and all other information of record, the Board finds that it is more appropriate to characterize his mental health claims broadly, as a single claim of entitlement to service connection for an acquired psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). In March 2017, the Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing has been associated with the claims file. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND Unfortunately, the Veteran's claim must be remanded for further development. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide his claim so he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c), (d) (2017). At the outset, it appears that the Veteran's VA treatment records are incomplete. The April 2014 Statement of the Case references VA treatment records dated from April 2006 to February 2014. However, only records dated from June 2010 to April 2013, and one record dated in February 2014, are located in VBMS. On remand, his complete records must be obtained. Further, the Veteran has described four stressors: 1) when his plane landed at Cam Ranh Bay, the base started to receive 122 rocket fire; 2) in April 1970, when a soldier "lost it" and fired at his unit killing and wounding other soldiers; 3) having to retrieve a vehicle in the middle of the night with no infantry support; 4) in December 1970, while sitting in perimeter formation in the jungle, his unit was attacked by the VC and he witnessed three guys in the track next to him get hit with mortars, with one (his Commanding Officer) suffering fatal wounds and the other two needing a medivac. The RO attempted to verify the Veteran's stressors. With respect to the first stressor, the Operational Report Lessons Learned (OR LL) revealed that Cam Ranh Bay received a rocket and mortar attack on April 1, 1970 and April 8, 1970 and the Daily Staff Journals (DJs) submitted by the 18th Military Police Brigade documented that Cam Ranh Bay received a rocket attack on April 2, 1970. With respect to the second stressor, the OR LL and DJs did not document any such incident. However, it was noted that a Morning Report (MR), DA Form 1, may also be requested from the National Personnel Records Center (NPRC) in an attempt to document this incident. This should be accomplished on remand. The Veteran was afforded VA examinations in June 2013 and January 2014 to address the nature and etiology of his claimed acquired psychiatric disorder. Following in-person examinations, neither VA examiner found sufficient evidence to support diagnosing the Veteran with PTSD. See June 2013 VA Examination Report; January 2014 VA Examination Report. Rather, the January 2014 examiner diagnosed an adjustment disorder with depressed mood. VA treatment records, however, reflect that the Veteran has been diagnosed with, and treated for PTSD, as well as a depressive disorder NOS and a mood disorder NOS. See August 2012 Mental Health Consult (reflecting Axis I diagnoses of PTSD and mood disorder NOS); February 5, 2014 Mental Health Outpatient Note; and July 9, 2012 Psychology Consult. On remand, the Veteran should be afforded an additional VA examination that addresses all of the diagnosed psychiatric disorders. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran with the opportunity to complete and submit another VA Form 21-0781, Statement in Support of Claim for Service Connection for PTSD. He should be asked to submit a specific and detailed statement describing his alleged stressors. He should be informed that specific dates, locations, circumstances, and names of those involved in the reported incidents would prove helpful in attempting to verify his stressors. 2. Undertake any necessary stressor verification development, to include, but not limited to, requesting a Morning Report (MR), DA Form 1, from the National Personnel Records Center in an attempt to document the reported incident in April 1970 when a soldier in the Veteran's unit "lost it" and fired at his unit killing and wounding other soldiers. 3. Make arrangements to obtain the Veteran's VA treatment records, dated from April 2006 to June 2010 and from April 2013, forward. 4. Thereafter, schedule the Veteran for a VA examination with a psychiatrist or psychologist to determine the nature and etiology of any currently diagnosed psychiatric disorders. The Veteran's claims file must be reviewed by the examiner in conjunction with the examination. The examiner must address the following: a) Offer an opinion on whether the Veteran meets the DSM-IV or DSM-V criteria for a diagnosis of PTSD. The examiner is instructed to consider the Veteran's assertion that he was subject to incoming rocket and mortar attacks. b) If the Veteran meets DSM-IV or DSM-V criteria for a diagnosis of PTSD, offer an opinion whether it is at least as likely as not (probability approximately 50 percent), that PTSD is related to the above stressor and/or any other in-service stressor. c) If the Veteran meets the DSM-IV or DSM-V criteria for any psychiatric diagnoses other than PTSD, offer an opinion as to whether it is at least as likely as not (i.e., there is a 50 percent or greater probability) that the psychiatric disorder had its clinical onset during active service or is related to any incident of service, to include the above stressor and/or any other in-service stressor. With respect to c), an opinion should be rendered for each psychiatric condition with which the Veteran is currently diagnosed, as well as for the previous diagnoses of a depressive disorder NOS, a mood disorder NOS, and an adjustment disorder with depressed mood. See July 9, 2012 Psychology Consult; August 2012 Mental Health Consult; February 5, 2014 Mental Health Outpatient Note; and VA examination report dated in January 2014. The examiner is asked to provide a rationale for the opinions rendered. If the examiner concludes that an opinion cannot be provided without resort to mere speculation, this must be supported by a specific explanation that discusses this evidence, and discusses what data or information is missing that would be necessary to render the opinion. 5. Finally, after completing any other development that may be indicated, readjudicate the claims on appeal. If the benefits sought are not granted, the Veteran and his representative must be furnished a supplemental statement of the case (SSOC) 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). 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). _________________________________________________ P. M. DILORENZO 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).