Citation Nr: 18160436
Decision Date: 12/26/18	Archive Date: 12/26/18

DOCKET NO. 14-02 838
DATE:	December 26, 2018
Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. 
Entitlement to a total rating based on individual unemployability (TDIU) is remanded.
The Veteran served on active duty from August 1958 to August 1962.
The Board has remanded the above issues for further development on two occasions, July 2014 and October 2017, respectively. 
Unfortunately, there is not been substantial compliance with the Board’s prior remand directives. A Board remand confers upon the Veteran, as a matter of law, the right to compliance with the remand order. Stegall v. West, 11 Vet. App. 268 (1998). Thus, in accordance with Stegall, a remand for full compliance with the Board’s prior directives is warranted.
1. Acquired psychiatric disorder, to include PTSD 
In November 2014, the AOJ only administered the Initial-PTSD DBQ, and not the Mental Disorders (other than PTSD) DBQ. Critical to this appeal, the July 2014 remand reopened the claim for service connection for an acquired psychiatric disorder, to include PTSD. While not explicitly stated in the July 2014 remand, its recharacterization of the Veteran’s claim as an acquired psychiatric disorder reflects VA policy that the AOJ must consider alternate psychiatric disorders within the scope of an initial claim for service connection for a specific psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). In other words, a claim of entitlement to service connection for a specific psychiatric disorder includes any mental disability that may be reasonably encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record. Id. Hence, while the Veteran filed an informal claim for “nervous disorder (PTSD)” in September 2012, his characterization of his psychiatric disorder as PTSD does not limit VA’s inquiry. In a September 2012 letter, the Veteran’s private physician wrote that he presents with restlessness, easy fatigue, muscle tension, irritability and episodes of nervousness, to include issues with driving. As indicated under Clemons, other psychiatric diagnoses should be considered as part of the underlying claim. As a result, the July 2014 remand had instructed the AOJ to afford the Veteran an examination to determine whether there exist “any current psychiatric disability” related to service. To date, however, the AOJ has not adjudicated the Veteran’s claim so broadly as to incorporate psychiatric diagnoses other than PTSD. Accordingly, on remand a VA examination for acquired psychiatric disorders other than PTSD is needed. 
Additionally, in reviewing the October 2018 VA medical addendum opinion, the Board notices that the examiner has referenced records that the Board cannot locate in the claims file. In particular, the examiner stated that from 2015 to 2016 the Veteran was seen by VA psychological services as part of “Health and Behavior Group Intervention” with a provisional, working diagnosis of “Other or Unspecified Factors affecting Medical Condition Cardio-Vascular.” The Board is required to conduct a de novo review of the Veteran’s claim, which entails reviewing the same evidence considered by the AOJ. As the basis of the AOJ’s continued denial of this claim, in part, was based on the VA examination report, these missing VA treatment records are important to the Board’s determination. On remand, the RO should ensure that VA treatment records reviewed by the AOJ in deciding the Veteran’s claim are associated with the claims file for the Board’s review.
Since the outcome of the Veteran’s claim for service connection for an acquired psychiatric disorder may impact his claim of entitlement to TDIU, the latter claim is inextricably intertwined with the former claim. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are “inextricably intertwined” when a decision on one issue would have a “significant impact” on a Veteran’s claim for the second issue). Therefore, adjudication of the TDIU claim must be deferred until the AOJ has adjudicated the Veteran’s remanded service connection claim.
The matters are REMANDED for the following action:
1. Obtain a complete copy of the Veteran’s VA psychological treatment records from September 2012 to present.
2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any acquire psychiatric disorder, other than PTSD. The examiner should specifically offer responses to the following: 
(a.) Identify all of the Veteran’s acquired psychiatric disorders that meet the DSM-IV or DSM-5 criteria, or that otherwise meet the criteria for a valid diagnosis for the purposes of VA benefits.
(b.) For each currently diagnosed acquired psychiatric disorder, other than PTSD, the examiner should offer an opinion as to whether it is at least as likely as not (probability of 50 percent or greater) that any such disorder is related to the Veteran’s military service, including addressing the Veteran’s lay contentions regarding the motor vehicle accident in service.
The examiner should also address the symptoms identified in the September 2012 letter from the Veteran’s private physician.
3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran’s claim for an acquired psychiatric disorder and TDIU should be readjudicated based on the entirety of the evidence. If either of the claims remains denied, the Veteran should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response.
Nathaniel J. Doan
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	A. Dellarco, Associate Counsel  

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