Citation Nr: 1311318 Decision Date: 04/05/13 Archive Date: 04/19/13 DOCKET NO. 10-26 981 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for a left ankle disorder. 2. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), schizophrenia, anxiety disorder, and major depression. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Sarah Richmond, Counsel INTRODUCTION The Veteran had active military service from December 1961 to May 1962. This matter comes to the Board of Veterans' Appeals (Board) from an August 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Honolulu, Hawaii, which denied service connection for a left ankle disorder and PTSD. The claims file was subsequently transferred to the RO in Muskogee, Oklahoma after the Veteran relocated. Regarding the service connection claim for PTSD, although the Veteran only asserted entitlement to PTSD, review of the medical evidence of record shows the Veteran has other psychiatric diagnoses of record, including schizophrenia, anxiety disorder, and major depressive disorder, which can be reasonably encompassed by the Veteran's description of symptoms. For this reason, the claim has been modified as reflected on the first page of this decision to include all of the Veteran's psychiatric diagnoses. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that the scope of a service connection claim for a mental disability is not restricted to the specific diagnosis alleged by the claimant, but includes any mental disability which may reasonably be encompassed by the claimant's description of the claim, the reported symptoms, and other information of record). In August 2011, the Veteran testified before the undersigned Veterans Law Judge at a Board video conference hearing at the RO. The Board notes that the Veteran originally sought service connection for a right ankle disorder in May 1962, which was denied by the RO in August 1962. The service treatment records note an injury to the right ankle involving hospitalization and a cast, which is consistent with the Veteran's testimony regarding an ankle injury, except the Veteran is now claiming a left ankle disorder. The service treatment records are negative for any left ankle disorder, nor is there any post-service evidence of a left ankle disorder, which will be discussed in greater detail below. To the extent that the Veteran might have made an error and intended to submit a petition to reopen his service connection claim for a right ankle disorder, the Board does not have jurisdiction over any service connection claim for a right ankle disorder, as the Veteran has not submitted this claim. He also has made no arguments regarding his right ankle during the Board hearing or during the course of the appeal. Therefore, any service connection claim for a right ankle disorder is not before the Board. The issue of entitlement to service connection for an acquired psychiatric disorder is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The preponderance of the evidence of record shows that the Veteran does not have a left ankle disorder related to any event in military service. CONCLUSION OF LAW A left ankle disorder was not incurred in, or aggravated by, active military service. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his case, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Prinicipi, 353 F.3d 1369 (Fed. Cir., 2004). An RO letter dated in April 2009 informed the Veteran of all five elements required by 38 C.F.R. § 3.159(b), as stated above. Regarding the duty to assist, VA obtained the Veteran's service treatment records and copies of the Veteran's VA treatment records. The Veteran provided copies of private treatment records. VA treatment records note that the Veteran receives income from the Social Security Administration (SSA) and Supplemental Security Income (SSI). These records have not been obtained. In Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2009), however, the United States Court of Appeals for the Federal Circuit (Federal Circuit) acknowledged that VA's duty to assist was limited to obtaining relevant SSA records. The Federal Circuit rejected the appellant's argument in Golz that SSA records are always relevant and VA always is required to obtain them. The Federal Circuit then defined relevant records as "those records that relate to the injury for which the claimant is seeking benefits and have a reasonable possibility of helping to substantiate the Veteran's claim." Id. at 1321 (emphasis added). The Federal Circuit also stated, "Not all medical records for a Veteran will have a reasonable possibility of aiding in the substantiation of a VA disability claim." Id. The Federal Circuit concluded in Golz, "There must be specific reason to believe these records may give rise to pertinent information to conclude that they are relevant." Id. at 1323. In support of a 2002 nonservice-connected pension claim, the Veteran indicated that he was in receipt of SSI benefits, only, and stated that he could not work due to a combination of limitations from a mental disability, heart disability, and lung problems. The VA treatment records show medical problems include coronary artery disease, hypertension, hyperlipidemia, history of cellulitis, asthma, and back pain. However, there is no treatment for any left ankle disorder at any time in the record. Therefore, the Board determines that any SSA or SSI records would not be relevant to the Veteran's claimed disability and would thus have no reasonable possibility in aiding in the substantiation of the Veteran's service connection claim for a left ankle disorder. For this reason, VA has no duty to obtain SSA or SSI records regarding the left ankle claim. The RO did not afford the Veteran a VA examination for the claimed left ankle disorder. In McClendon v. Nicholson, 20 Vet. App. 79 (2006), the Court reviewed the criteria for determining when an examination is required by applicable regulation and how the Board applies 38 C.F.R. § 3.159(c). The three salient benchmarks are: competent evidence of a current disability or recurrent symptoms; establishment of an in-service event, injury, or disease; and indication that the current disability may be associated with an in-service event. The record does not show that the Veteran has any left ankle disorder related to military service. His statements concerning his left ankle injury are found not to be credible, as discussed below, and the service treatment records show no treatment for the left ankle, nor do post-service treatment records show any left ankle disorder. Therefore, the Board finds that the evidence of record does not trigger the necessity of an examination in order to decide the claim on the merits. See 38 C.F.R. § 3.159(c). The Veteran was afforded a hearing before a Veterans Law Judge in which he presented oral argument in support of his service connection claim for a left ankle disorder. The record does not show, and neither the Veteran nor his representative has identified any prejudice in the conduct of the Board hearing. See Bryant v. Shinseki, 23 Vet. App. 488 (2010). The duty to assist has therefore been satisfied and there is no reasonable possibility that any further assistance to the appellant by VA would be capable of substantiating his claim. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the appellant in adjudicating this appeal. II. Service connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Service connection can be demonstrated for a disease diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994) (holding that proof of direct service connection may entail proof that exposure during service caused the malady that appeared many years later); Cosman v. Principi, 3 Vet. App. 503, 505 (1992) (holding that service connection can still be established even when a Veteran did not have a particular condition diagnosed during service or for many years thereafter). In order to establish service connection, the evidence must generally 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); see generally 38 C.F.R. § 3.303. Alternatively, under 38 C.F.R. § 3.303(b), the second and third Shedden/Caluza elements can be established through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Barr, 21 Vet. App. at 307. The Federal Circuit has recently held that for purposes of 3.303(b), where the veteran asserts entitlement to a chronic condition but there is insufficient evidence of a diagnosis in service, the veteran can establish service connection by demonstrating a continuity of symptomatology since service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, --- F.3d ----, No. 2011-7184, 2013 WL 628429 *5 (Fed. Cir. February 21, 2013), affirming Walker v. Shinseki, No. 10-2634, 2011 WL 2020827 (Vet. App. May 25, 2011). [emphasis added]. For disabilities that are not listed as chronic under 38 C.F.R. § 3.303(b), the only avenue for service connection is by showing inservice incurrence or aggravation under 38 C.F.R. § 3.303(a), or by showing that a disease that was first diagnosed after service is related to service under 38 C.F.R. § 3.303(d). 38 U.S.C.A. § 1154(a) requires VA to give "due consideration" to "all pertinent medical and lay evidence" when evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Generally, the Board should determine whether the Veteran's particular disability is the type of disability for which lay evidence is competent, and, if so, weigh that evidence against the other evidence of record in making its determinations. Kahana v. Shinseki, 24 Vet. App. 428, 433 n.4 (2011). The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). "Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer." Jandreau, 492 F.3d at 1377, n4. A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Lastly, a layperson may also be competent to testify to the manifestations of a chronic condition during service or a presumptive period or to continuity of symptomatology. Hickson, 12 Vet. App. at 253. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the Federal Circuit, citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Veterans Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). The Veteran seeks service connection for a left ankle disorder. He testified at the Board hearing that he injured his left ankle during physical training in the Spring of 1961 and that his ankle was casted for three to four weeks. He indicated that he was diagnosed with bursitis and that he has continued to experience symptoms in his left ankle since service. The service treatment records are negative for any findings or complaints of injury to the left ankle. The treatment records note that the Veteran sprained his right foot in January 1962 and had subsequent treatment for injury to the right ankle and right heel in April 1962. The Veteran was diagnosed with acute right precalcaneal bursitis due to prolonged drilling. He was given a plaster cast for this injury. However, there is no evidence of any injury to the left ankle in service, or at any time after service. Based on the foregoing, the Board finds that the preponderance of the evidence shows that the Veteran's claimed left ankle disorder is not related to any event in service. In making this determination, the Board finds it significant that the only evidence of record indicating the presence and possible nexus between any current left ankle disorder and his military service are the Veteran's assertions. The Board acknowledges that the Veteran is competent to report that he has continued to experience symptoms in his left ankle since service. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007) (holding that lay testimony is competent to establish the presence of observable symptomatology); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). The Veteran is also competent to report that he injured his left ankle in service. See Washington v. Nicholson, 19 Vet. App. 362 (2005) (holding that a Veteran is competent to report what occurred during service because he is competent to testify as to factual matters of which he has first-hand knowledge). Competent testimony is limited to that which the witness has actually observed and is within the realm of his personal knowledge; such knowledge comes to a witness through use of his senses-that which is heard, felt, seen, smelled, or tasted. Layno v. Brown, 6 Vet. App. 465 (1994). It is within the Veteran's realm of personal knowledge whether he had a left ankle injury in service and continued to experience problems with his ankle since that time. However, the Board finds that the Veteran's statements are not credible with respect to the onset and continuity of his left ankle symptoms. Specifically the Veteran's recollection of events in service is not accurate. The Veteran indicated that he injured his left ankle in the spring of April 1961 and that his ankle was casted, but in fact, he was shown to have injured the right ankle in April 1962. Also, even though he has stated that he has experienced symptoms in his left ankle since service, none of the treatment records in the claims file show any treatment for any left ankle disorder. The Veteran was seen for multiple other complaints, and it would be reasonable to deduce that he would seek treatment for pain that he was having in his left ankle. This is not a situation involving the absence of medical records, but rather the presence of medical records showing the Veteran has sought treatment for a myriad of other disorders, but has never mentioned any problems with his left ankle. Therefore, with respect to the onset and continuity of experiencing left ankle symptoms, the probative value of the Veteran's lay assertions is significantly diminished and the Board cannot rely on his statements. The Veteran contends that he has a current left ankle disorder related to his military service; however, there is no competent medical evidence or opinion to corroborate these contentions. See 38 C.F.R. § 3.159(a)(1) (competent medical evidence means evidence provided by a person who is qualified through education, training or experience to offer medical diagnoses, statements, or opinions). The Veteran's opinions are insufficient to provide the requisite nexus between an in-service event or injury and any current disability because, as a lay person, he is not competent to establish a medical etiology merely by his own assertions; such matters require medical expertise. See 38 C.F.R. § 3.159(a)(1); Duenas v. Principi, 18 Vet. App. 512, 520 (2004); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997) (holding that a layperson is generally not capable of providing opinions on matters requiring medical knowledge, such as the condition causing or aggravating the symptoms); see also Bostain v. West, 11 Vet. App. 124, 127 (1998); Stadin v. Brown, 8 Vet. App. 280, 284 (1995); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). As such, his statements regarding the etiology of any present left ankle disorder are merely speculation as to a possible cause as he is not medically qualified to prove a matter requiring medical expertise, such as an opinion as to medical causation. As such, after weighing and balancing the evidence of record, the Board finds that the preponderance of the evidence of record is against a finding that the Veteran has any present left ankle disorder that had its onset during active service or is related to any in-service disease, event, or injury. See 38 U.S.C.A. § 1110. Accordingly, the Board finds that the criteria for service connection for a left ankle disorder are not met and the Veteran's claim must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. See 38 U.S.C.A. § 5107(b). However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). ORDER Entitlement to service connection for a left ankle disorder is denied. REMAND The Veteran seeks service connection for PTSD, secondary to a military sexual assault. As he also has diagnoses of schizophrenia, anxiety disorder, and major depressive disorder, the issue has been recharacterized as a claim for an acquired psychiatric disorder, to include PTSD, schizophrenia, anxiety disorder, and major depressive disorder. In statements and testimony, the Veteran has described two incidents in service in which he was sexually assaulted. The first involves his time with a recruiter who let him stay at his house with his wife and children and told him he would help him get into the Marines. The Veteran stated that he agreed because he wanted to get away from his step-father, but that the recruiter took advantage of him sexually by promising to help him get ahead in the military. No physical force or violence was used against him, as reported on Vet Center records in March 2010. The second incident involves when he was in the military and five Marines reportedly preyed on him and sexually assaulted him over the course of several weeks. He testified that he was too afraid to seek treatment after the assaults. The March 2010 Vet Center record notes that the Veteran reported that the assaults would take place in the shower and that he would be held down and assaulted by each Marine. They threatened to harm him if he told anyone about the assaults; one Marine held a bayonet to him and said he would kill him if he told anyone about the assaults. He feared for his life, felt suicidal, and reportedly kept a shell in his rifle for protection. He stated that he reported the assaults to his supervisor but the supervisor showed no interest in addressing it. He went AWOL twice to get away from the situation, spent 30 days in the brig, and was brought to Court Martial, but he did not disclose the assaults. The March 2010 Vet Center record also noted that the Veteran had been molested as a child by a relative and that his stepfather was abusive toward him and his mother. The events he felt had the worst impact on him were the violence he experienced as a child and the sexual assaults while in the Marines. The molestation as a child and by the recruiter was reportedly unpleasant but he did not experience fear related to these incidents. The family violence and sexual assaults in the Marines involved fear. The service treatment records show that the Veteran was given a psychiatric evaluation in May 1962 after several unauthorized absences. At the time of the evaluation he was confined to the Brig for 20 days for unauthorized absence. The entrance examination in December 1961 was negative for any psychiatric disorder; psychiatric clinical evaluation was normal. However, in a May 1962 Aptitude Board report, it was concluded that the Veteran's clinical picture was typical of a passive and dependent, ineffectual youth, and that the likelihood of any adequate adjustment to the stresses of military life was inconceivable. The examiner noted that clinically the Veteran was of dull mental abilities and he was found unsuitable for service in the Marine Corps. The Veteran's disciplinary problems in service do not, in and of themselves, necessarily show that the Veteran was sexually assaulted in service. However, poor performance in service is listed as one of the factors to be considered for claims based on sexual assault, as it might demonstrate a change in behavior. See 38 C.F.R. § 3.304(f)(3). These alternative types of evidence can be supportive of a claim based on military sexual assault, as these types of assault often would not be documented in the service treatment records due to the nature of these injuries. After service, the Veteran saw a VA social worker in December 1997 for housing assistance, but there is no record of any consistent psychiatric treatment until 2008. Over the course of treatment, the Veteran has received diagnoses of PTSD, schizophrenia, anxiety disorder, and major depressive disorder. The Veteran also has related his history of sexual assault in the military. The Veteran's sister submitted a statement in October 2012 that the Veteran's behavior changed significantly after entering the military. Prior to going into the service the Veteran always had a positive outlook and she found comfort in the Veteran's laughter and smile. After service, the Veteran's sister did not recall the Veteran ever smiling and she has watched the Veteran be depressed for years. The Veteran submitted a medical opinion dated in September 2011 from a private physician, Dr. Bumgardner. Dr. Bumgardner noted that the Veteran was receiving ongoing individual psychotherapy and that he met the criteria for PTSD and major depressive disorder. Dr. Bumgardner found that the Veteran met the clinical criteria based on current symptomatology and self-reported abuse stemming from multiple events of severe sexual abuse related trauma incurred during active service. While this opinion is favorable to the Veteran's claim, it does not have a high probative value, as Dr. Bumgardner did not provide a rationale for the opinion, or indicate that she had considered the Veteran's entire history, including his molestation as a child or physical abuse from his stepfather. Nonetheless, this opinion, the evidence of disciplinary problems in the service, the Veteran's lay statements regarding the in-service assaults, and his sister's statement regarding the Veteran's changed behavior after service, trigger VA's duty to get an examination and opinion in this matter. The applicable law requires VA to deem an examination necessary to adjudicate a claim for service connection when there is competent evidence that a claimant has a current disability, or persistent or recurrent symptoms of disability; the information or evidence indicates that the disability or symptoms may be associated with the claimant's active service; but, the file does not contain sufficient medical evidence for VA to make a decision. See 38 U.S.C.A. § 5103A(d)(2); McClendon v. Nicholson, 20 Vet. App. 79 (2006). The three salient benchmarks are: competent evidence of a current disability or recurrent symptoms; establishment of an in- service event, injury, or disease; and, indication that the current disability may be associated with service or with another service-connected disability. McClendon, 20 Vet. App. at 81. The Court cautioned in McClendon that an "absence of actual evidence is not substantive 'negative evidence.'" Id. at 85. It further noted that an indication that a current disability "may" be associated with service is a low threshold. Id. at 83. In light of the Veteran's continued complaints referable to his mental health, as well as the current findings, and some question as to whether the claimed disabilities are related to the Veteran's military service, a remand for VA examination is necessary. 38 U.S.C.A. § 5103A ; McClendon, supra. As the Veteran's assertions of PTSD are based on sexual assault suffered in service, the Veteran should be notified of the alternative sources of information that can be used to corroborate the event, pursuant to 38 C.F.R. § 3.304(f)(3). None of the VCAA letters in the claims file reflect that the Veteran was provided with such notice. Finally, the Veteran testified that a psychiatrist through Med Corps was going to visit him the next day as the start of ongoing treatment as part of his claim for SSI benefits. These records should be obtained. Also, any recent VA psychiatric treatment records should be obtained. In addition, the Veteran testified that he had sought counseling from a private doctor in New Mexico approximately 15 years ago at Cibola Counseling. The Veteran thought that the records might have been transferred to the RO in Honolulu. Efforts should be made to locate these records, as well. Accordingly, the case is REMANDED for the following action: 1. Make arrangements to obtain copies of the Veteran's Social Security Administration (SSA) records, pertaining to his receipt of any SSA disability benefits, and SSI benefits including ongoing treatment from a private psychiatrist through Med Corp. 2. Make arrangements to obtain any relevant VA treatment records from the VAMC in Honolulu since February 2009, and Vet Center treatment records since March 2010. 3. Ask the Veteran to identify all other VA and non-VA medical care providers that have treated him for any psychiatric problems since his military service, including from Cibola Counseling in New Mexico. Make arrangements to obtain all records that he adequately identifies. 4. Send the Veteran a notice letter addressing his service connection claim for an acquired psychiatric disorder to include PTSD, schizophrenia, anxiety disorder, and major depressive disorder that includes the criteria for substantiating a PTSD claim based on personal assault, specifically the alternative forms of evidence that can be used to substantiate the claim. 5. Thereafter, schedule the Veteran for a VA psychology examination with a psychologist or psychiatrist. The claims file must be made available to, and reviewed by, the examiner. All appropriate testing should be conducted. The examiner should state whether the Veteran has a present psychiatric disability, i.e., PTSD, schizophrenia, anxiety disorder, and/or major depressive disorder, etc. The examiner also should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any present psychiatric disorder had its clinical onset during active service or is related to any in-service disease, event, or injury. In providing this opinion, the examiner should acknowledge the Veteran's statements regarding his being sexually assaulted by five Marines in 1962 over the course of a few weeks; and his statements asserting symptoms in service and since his discharge from service. The examiner also should review the pertinent service treatment records, and post-service records of psychiatric treatment. The examiner should acknowledge the service treatment records showing that the Veteran went AWOL a number of times and received Court Martial proceedings; the 1962 inservice psychiatric examination; the medical opinion in September 2011 from Dr. Bumgardner attributing the Veteran's PTSD and major depressive disorder to military sexual trauma; and the lay evidence of record including that of the Veteran's sister. The examiner should provide a complete rationale for his/her opinion. 6. After the requested examination has been completed, the report should be reviewed to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, it should be returned to the examiner for corrective action. 7. Finally, readjudicate the claim on appeal. If the benefit sought remains denied, issue the Veteran and his representative a Supplemental Statement of the Case and allow for a reasonable period to respond. 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.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs