Citation Nr: 1808365 Decision Date: 02/09/18 Archive Date: 02/20/18 DOCKET NO. 13-36 813A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUE Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: John Berry, Attorney WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD R. Dodd, Counsel INTRODUCTION The Veteran served on active duty from February 2004 to November 2006. This case comes to the Board of Veterans' Appeals (Board) on appeal from a February 2010 decision by the Department of Veterans Affairs (VA) Regional Office in Hartford, Connecticut (RO). The Veteran was provided with hearing before the undersigned in March 2015. A copy of the transcript has been associated with the claims file and reviewed accordingly. The evidence shows that the Veteran has been diagnosed with multiple psychiatric disorders, including PTSD, major depressive disorder, attention deficit hyperactive disorder (ADHD), substance abuse, and a personality disorder among others. His claim therefore encompasses all of these diagnoses. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that the scope of a mental health disability claim includes any mental disability that reasonably may be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). As such, the caption on the title page has been amended to reflect this fact. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran has claimed that he currently suffers from PTSD as a result of combat experiences while serving in Iraq. In particular, the Veteran has attributed this condition to an incident with an improvised explosive device (IED), in which he also sustained a service-connected traumatic brain injury. This event occurred in September 2005 and, thus, this stressor event is conceded. It is also observed the Veteran earned the Combat Action Badge, consistent with his military occupational specialty; Armor Crewman. As such the issue turns upon a showing of a diagnosis of PTSD and a nexus for that diagnosis to this stressor. In this regard, the evidence shows records reflecting a diagnosis of PTSD since late 2007, with a VA examination conducted in February 2010 VA likewise reflecting that diagnosis related to the IED episode, (along with Major Depressive Disorder). Apparently unaware of the February 2010 examination, the RO denied service connection for PTSD in a February 2010 rating action, citing to the Veteran's failure to report for a previously scheduled examination in 2009. The Veteran appealed the February 2010 decision, which apparently prompted another examination for VA purposes in February 2013. At this time, the Veteran was not diagnosed to have PTSD or Major Depressive Disorder, but a personality disorder with prominent histrionic and antisocial features; as well as amphetamine induced mood disorder and amphetamine induced sleep disorder. The VA examiner determined these diagnoses based upon the Veteran displaying what he determined was a history of cluster B traits of lying and deception as well as substance abuse. However, it does not appear that the VA examiner actually considered the Veteran's conceded military stressor event when considering the diagnosis of PTSD, but rather found that the Veteran was an unreliable historian with regard to his stressors. The Board thus finds that the Veteran's updated treatment records and a new VA examination are necessary to adjudicate his claim. As such, the Veteran's claims file should be returned to the RO so that the Veteran's current VA Medical Center treatment records since 2011 may be obtained and associated with the claims file. Thereafter, the Veteran should be afforded a new VA examination to ascertain his diagnosis and etiology for his claimed acquired psychiatric disability. In this regard, the examiner should seek to reconcile the findings of the February 2010 VA examination and the February 2013 VA examination, as well as the Veteran's previous treatment for PTSD and other psychiatric disorders from 2007 to 2011. A complete rationale for any opinions must be provided. Additionally, as this case must be remanded for the foregoing reasons, any other recent relevant treatment records, including VA records, should also be obtained. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (c) (2017); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). Accordingly, the case is REMANDED for the following action: 1. The records of any VA mental health treatment of the Veteran dated after 2011 should be associated with the claims file. 2. The Veteran should be requested to provide the names, addresses and approximate dates of treatment of all non-VA medical care providers who have treated him for the disabilities on appeal. After the Veteran has signed the appropriate releases, those records should be obtained and associated with the claims folder. 3. Thereafter, the RO should schedule the Veteran for an appropriate examination to determine the diagnosis and etiology of his acquired psychiatric disorder. The electronic claims file should be provided to the examiner in connection with the examination. All necessary testing should be performed. After a review of the record on appeal and an examination of the claimant, the examiner should provide answers to whether it at least as likely as not (50 percent probability or more) that any diagnosis of PTSD is due to an in-service stressor, and whether any diagnosis other than PTSD, is a result of an in-service disease or injury. In providing answers to the above questions, the examiner should take note of the fact the Veteran has two prior VA examinations of record (February 2010 and February 2013) which have reached differing conclusions on the psychiatric disorders with which the Veteran is diagnosed and whether such disorders are attributable to military service. Additionally, the examiner should note that the Veteran has been previously diagnosed with multiple psychiatric disabilities since leaving military service, to include including PTSD, major depressive disorder, ADHD, substance abuse, and a personality disorder. To the extent possible, the examiner should seek to reconcile these findings in providing the ultimate opinion. A complete rationale for all opinions must be provided. 4. After completion of the above, the RO should review the expanded record and determine if the appeal can be granted. If the claims remain denied, the Veteran and his representative should be furnished an appropriate supplemental statement of the case. After an opportunity to respond, the case should be returned to the Board for appellate review. The appellant 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. §§ 5109B, 7112 (2012). _________________________________________________ MICHAEL E. KILCOYNE 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).