Citation Nr: 1805841 Decision Date: 01/30/18 Archive Date: 02/07/18 DOCKET NO. 14-11 757 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD P. M. Johnson, Counsel INTRODUCTION The Veteran served on active duty from February 1995 to March 2001. This matter comes before the Board of Veterans Appeals (Board) on appeal from a rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan in September 2012. The issue of entitlement to service connection for PTSD has been restyled to better reflect the evidence and the Veteran's stated interests. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran testified at a videoconference hearing in May 2017 before the undersigned. A copy of the transcript 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 Board finds that further development is necessary prior to adjudication of the Veteran's claim on appeal. In August 2012, the Veteran was provided a VA medical examination in relation to her claim for service connection for PTSD as due to military sexual trauma. The examiner, a male psychologist, stated after review of the Veteran's claim file and an interview of the Veteran that she did not have a current diagnosis of a psychiatric disability. The examiner stated that the Veteran did not report any current symptoms that met the diagnostic criteria for PTSD or any current symptoms that met criteria for any mental health diagnoses. Generally, to establish service connection a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Subsequent to the Veteran's examination, she has provided statements that she felt uncomfortable with the male examiner and that it is difficult for her to talk with men about her personal feelings. She has stated that her desire to end the examination as soon as possible may have affected the accuracy of the examination. In addition to the Veteran's complaints regarding her anxiety during the exam, the Board notes some inaccuracies in the 2012 examination. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (It is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes probative value to a medical opinion.) As noted above, the examiner stated in providing his conclusions that "the Veteran did not report any current symptoms that met the diagnostic criteria for PTSD or any current symptoms that met criteria for any mental health diagnoses. Nor was there any indication any current psychiatric diagnoses on her psychological testing results." However, the examination report states that the Veteran reported symptoms of anxiety, a Beck's Anxiety Inventory score of 9 indicating moderate to severe anxiety was provided, and a problem list from the Iron Mountain VAMC indicated a previous diagnosis of generalized anxiety disorder in August 2008. As the evidence indicates that the Veteran did have an indication of a current psychiatric diagnosis on the Beck's Anxiety Inventory and the examiner did not discuss the indication of a diagnosis of generalized anxiety disorder in the Veteran's medical records, a new medical examination should be obtained. Accordingly, the case is REMANDED for the following action: 1. First, undertake appropriate efforts to obtain any relevant treatment records from the Iron Mountain VAMC since September 2012 or any other relevant treatment records reported by the Veteran. 2. After the above development is accomplished, schedule the Veteran for appropriate VA examination by a female examiner, if possible. The entire claims file and all electronic records should be made available to the examiner. The examiner must report review of the claims file. Any indicated tests and studies must be accomplished and all clinical findings must be reported. The VA examiner should offer opinions with supporting rationale as to the following inquiries: a) At any time since January 28, 2011, has the Veteran had a current diagnosis of an acquired psychiatric disorder, to include PTSD or generalized anxiety disorder? If providing the opinion that the Veteran has not had a diagnosis of a psychiatric disorder during the appeal period, the examiner is asked to discuss the problem list from August 2012 indicating a diagnosis of generalized anxiety disorder in August 2008, the March 2014 statement of C.Z. regarding symptoms of anxiety on a daily basis during the appeal period, and the statements provided by the Veteran and her husband in May 2017. b) If the Veteran has a current diagnosis of an acquired psychiatric disorder, the examiner should opine whether any current acquired psychiatric disorder is related to any incident of the Veteran's active service, to include: experiences with her ex-husband or sexual harassment from military superiors. c) If a diagnosis of PTSD is warranted, the examiner is to note and address any credible behavioral markers in service. The examiner should consider and discuss the Veteran's lay statements as well as the pertinent medical evidence of record. The examiner must provide a rationale for any opinions expressed and reconcile any contradictory evidence of record. If the examiner is unable to render an opinion, she/he should so state with supporting rationale. 3. After completing the development indicated above and any other appropriate development, the AOJ should readjudicate the Veteran's claim in light of all of the evidence of record. If any benefit sought on appeal remains denied, the Veteran and her representative should be furnished a fully responsive supplemental statement of the case and afforded a reasonable opportunity for response. The appellant 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 (2014). _________________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2014), 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).