Citation Nr: 1320450 Decision Date: 06/25/13 Archive Date: 07/05/13 DOCKET NO. 08-20 871 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for an acquired psychiatric condition, to include posttraumatic stress disorder (PTSD) (but excluding a phobia disorder). 2. Entitlement to service connection for a phobia disorder. 3. Entitlement to service connection for hypertension. 4. Entitlement to service connection for cerebrovascular accident (CVA), to include as secondary to a service-connected disability. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD A. Spector, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1973 to June 1975 and from January 1991 to May 1991. This matter has come before the Board of Veterans' Appeals (Board) on appeal from a November 2004 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The Veteran submitted new evidence concerning her service connection claims in June 2005, to include a PTSD stressor questionnaire and medical records pertaining to hypertension and a CVA, within one year of the issuance of the November 2004 rating decision. 38 U.S.C.A. § 7105(b)(1), (c); 38 C.F.R. § 3.156(b); see also Buie v. Shinseki, 24 Vet. App. 242, 252 (2010) (a regional office decision becomes final "only after the period for appeal has run," and that "[a]ny interim submissions before finality must be considered by the VA as part of the original claim."). Thus, the November 2004 rating decision, which denied the claim of service connection for PTSD, hypertension, and CVA never became final. Subsequently, in an April 2006 rating decision, the RO again denied the Veteran's claims of service connection for PTSD, hypertension, and CVA. The Veteran filed a notice of disagreement (NOD) with this determination in April 2007, and timely perfected her appeal in June 2008. The Veteran testified at a Travel Board hearing before the undersigned Acting Veterans Law Judge in August 2011. A transcript of the hearing is associated with the claims file. In March 2012, the Board remanded the case on appeal for further examination. Evidence received since that examination reflects a diagnosis of simple phobia which, for procedural and factual purposes, will listed on the title page as a separate issue. The requested development has been completed and the claim of service connection for an acquired psychiatric disorder (other than a phobia disorder) is ready for review. Regrettably, as outlined below, further development is necessary before the Board can proceed on the issues of service connection for a phobia disorder, hypertension and a CVA. The Board notes that, in addition to the paper claims file, there is a Virtual VA paperless claims file associated with the above claims. A review of the documents in such file reveals that there are additional VA treatment records related to the Veteran's claims on appeal. These records have been reviewed and considered by the Board. The issues of service connection for a phobia disorder, hypertension and a CVA are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The evidence demonstrates it is not likely that the Veteran currently suffers from PTSD or any other acquired psychiatric disorder (other than a phobia disorder addressed in the remand), pursuant to the DSM-IV criteria. CONCLUSION OF LAW The criteria for a grant of service connection for an acquired psychiatric disorder, to include PTSD (but excluding a phobia disorder), have not been met. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist The 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 her representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 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 in accordance with 38 C.F.R. § 3.159(b)(1). 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). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 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. Here, the duty to notify was satisfied by way of letters sent to the Veteran in December 2003 and May 2004 that fully addressed all notice elements and was sent prior to the initial AOJ decision in this matter. The letters informed the Veteran of what evidence was required to substantiate the claims and of the Veteran's and VA's respective duties for obtaining evidence. In light of the denial of the Veteran's claim, no disability rating or effective date will be assigned, so there can be no possibility of any prejudice to the appellant under the holding in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Under the circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. VA must also make reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate the claim for the benefit sought unless no reasonable possibility exists that such assistance would aid in substantiating the claim. This duty includes assisting with the procurement of relevant records, including pertinent treatment records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board recognizes that, under VA's governing regulations, it is obligated to make reasonable efforts to assist an appellant in obtaining evidence necessary to substantiate her claim, including any "relevant records" in the custody of VA or another federal agency. 38 C.F.R. § 3.159(c)(2). However, with respect to the Veteran's claim of service connection for an acquired psychiatric disorder, the Board observes that the duty to assist is not boundless in scope, and VA is only required to make reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate her claim. VA is not required to assist her in obtaining identified records if no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(c)(1); Golz v. Shinseki, 590 F.3d 1317, 1321-22 (Fed. Cir. 2010). Additionally, the Board notes that although VA has a statutory duty to assist the Veteran in developing evidence pertinent to a claim, the Veteran also has a duty to assist and cooperate with VA in developing evidence; the duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). In this particular case, the Veteran reported that she received private treatment for her acquired psychiatric disorder. In July 2006, the Board remanded the claim of service connection for an acquired psychiatric disorder in order to obtain any outstanding private treatment records. The Appeals Management Center sent the Veteran March 2012 and June 2012 letters requesting any information pertaining to private treatment she received in relation to her claimed condition. While the Veteran reported in July and November 2012 statements that she was going to send additional evidence, she ultimately failed to submit any additional information. Additionally, the Board acknowledges that the RO is required to obtain Social Security Administration (SSA) records prior to adjudicating an appellant's claim in compliance with its duty to assist. See Murinscak v. Derwinski, 2 Vet. App. 363 (1992); 38 C.F.R. § 3.201(a) (2012). In this case, however, the Veteran's SSA records have been determined to be unavailable. Pursuant to the Board's prior remand, the Appeals Management Center (AMC) requested a complete copy of the Veteran's records from SSA. A May 2012 response from SSA determined that the Veteran's records from that agency had been destroyed. The AMC sent the Veteran a June 2012 letter informing her that they were unable to obtain her SSA records, and asking her to provide a copy of any SSA records in her possession; however, the Veteran failed to respond to this inquiry. In a July 2012 memorandum, the AMC made a formal finding of unavailability of SSA records, noting all efforts made to obtain these records. Accordingly, there was a reasonable effort made to assist the Veteran in obtaining any outstanding records. Thus, the Board finds that further efforts to obtain any records would be futile, and a remand for this purpose is not warranted. Sabonis v. Brown, 6 Vet. App. 426 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided); VAOPGCPREC 5-04 (2004), 69 Fed. Reg. 59,989 (2004). The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained the Veteran's service treatment records and VA treatment records, and afforded the Veteran a VA examination in June 2012. The VA examination report reflects a thorough review of the record, and provides adequate rationale for the conclusion reached on the issues other than a phobia disorder. The Board also finds that the RO has complied with the Board's remand directives by attempting to assist the Veteran in obtaining specified private records, attempting to obtain SSA records, obtaining a VA examination report, and readjudicating the claim. The record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Service Connection Service connection may be granted for a disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110. Service connection may also be granted for any disease diagnosed after discharge, 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). Establishing service connection generally requires competent evidence of (1) a current disability; (2) in-service occurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303(a). However, the absence of a documented disability while in service is not fatal to a claim for service connection. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). When a Veteran does not meet the regulatory requirements for a disability at separation, she can still establish service connection by submitting evidence that a current disability is causally related to service. Hensley v. Brown, 5 Vet. App. 155, 159-60 (1993). Service connection for PTSD requires medical evidence establishing a diagnosis of the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., the diagnosis must comply with the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders, 1994 (DSM-IV)); credible supporting evidence that the claimed in-service stressor occurred; and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. See 38 C.F.R. §§ 3.304(f), 4.125; see also Cohen v. Brown, 10 Vet. App. 128, 140 (1997). The evidence necessary to establish the occurrence of a stressor during service to support a diagnosis of PTSD will vary depending upon whether the Veteran engaged in "combat with the enemy" as established by official records. If VA determines that the Veteran engaged in combat with the enemy and an alleged stressor is combat-related, then the Veteran's lay testimony or statement is accepted as conclusive evidence of the stressor's occurrence and no further development or corroborative evidence is required providing that such testimony is found to be "satisfactory," i.e., credible, and "consistent with the circumstances, conditions, or hardships of service." See 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(f); Dizoglio v. Brown, 9 Vet. App. 163, 164 (1996); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). Moreover, the Board notes that, effective July 13, 2010, the regulations governing service connection for PTSD were amended to relax the adjudicative evidentiary requirements for determining what happened in service where the Veteran's claimed stressor is related to "a fear of hostile military or terrorist activity during service." Specifically, the new 38 C.F.R. § 3.304(f)(3) provides that, if a stressor claimed by a Veteran is "related to the Veteran's fear of hostile military or terrorist activity," and a VA psychiatrist or psychologist (or a psychiatrist or psychologist with whom VA has contracted), confirms that the claimed stressor is 1) adequate to support a diagnosis of PTSD, and 2) that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(3). Moreover, the amendment provides that, "fear of hostile military or terrorist activity" means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Id. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for the evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the Veteran. Acquired Psychiatric Disorder In this particular case, the Board does not reach the question of whether the Veteran sustained a verified in-service stressor, as the preponderance of the competent medical evidence does not indicate that she has a diagnosis of PTSD or any other acquired psychiatric disorder (other than a phobia disorder) for service connection purposes. As noted above, a threshold requirement for the granting of service connection is evidence of a current disability. In the absence of evidence of a current disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Veteran reported such fears during active duty as leaving her 12 year old child, water, claustrophobia, confrontations with another individual aboard the ship, being away from home, stressful environment of living aboard a ship, low self-esteem, and feelings of loneliness. She stated that her emotional and mental stability gradually deteriorated since her return from the Persian Gulf. She reported recurring episodes of panic attacks, anxiety, and depression. VA outpatient treatment records show multiple negative PTSD and depression screenings. A September 2001 VA treatment record noted a reported history of treatment for PTSD by a private physician. A psychiatric diagnosis was not given at the time. Additionally, the record contains a December 2011 VA Mental Health Consult report. The Veteran reported that, while on duty, it was difficult for her being away from her daughter. She also reported that she had claustrophobia and a fear of water while on the ship. She stated that when she came home from service, she had problems at work and at home and started drinking. Upon examination, the Veteran denied feeling depressed. She stated that she was a happy individual. She did not like to sleep, but reported that was her nature. She had enough energy, good appetite, and had interests. She reported low self esteem and had difficulty learning. She also denied manic symptoms including elevated mood, racing thoughts, decreased need for sleep, and increased energy. The Veteran reported no specific traumatic event reported. She stated that being away from her child bothered her. She also denied psychotic symptoms including hearing voices or seeing things. She underwent outpatient psychiatric treatment with Dr. Lynn Hungerford. She was treated for her Alcohol and her low self esteem and fear. She denied inpatient psychiatric treatment, past psychiatric medications, suicide attempts, and assaultive behavior. The Veteran reported a past drinking problem, but stopped in 2001 when she fell asleep and got in a car accident. The physician concluded that while her experiences during the Gulf War were unpleasant and she was harassed, she did not report any specific trauma, however she does report that fears she had in earlier life reappeared subsequent to her military service. The examiner stated that this was not PTSD. She admitted that she had chronic low self esteem which predated her service in the first Gulf War. The Veteran was diagnosed with Simple Phobia and a history of Alcohol Dependence, in remission. The Veteran submitted an April 2007 statement from her daughter, discussing how the Persian Gulf changed the Veteran's life. She reported how her mother was when she returned from service. She also overheard the Veteran speak of panic attacks. She had a fear of anything enclosing her face and constricting her body. In her lay statements, including her August 2011 hearing, the Veteran stated that she was first diagnosed with PTSD shortly after returning from her second period of service, when her employer sent her to counseling in response to problems related to alcohol. The Veteran stated that she believed these symptoms began in service as a result of a claustrophobia-induced panic attack she suffered during a drill while on active duty. The Veteran was afforded a VA examination in June 2012. The Veteran reported such military stressors as leaving her young daughter behind, claustrophobia while on the ship, and riding a tugboat that was anchored out to see during stormy weather. The examiner stated that the Veteran did not describe any stressor events during the military which would rise to a level of PTSD stressors. Review of her submitted stressor statements completed in her claims file also did not describe any events that would rise to the level of a PTSD stressor. The Veteran was not actively involved in combat. Upon examination, the Veteran described her mood as pretty happy. She did not report symptoms of feeling sad or down, a decline in interest and activities, appetite, difficulties with sleep, problems related to worthlessness or guilt, or problems related to concentration or memory. The examiner concluded that the Veteran had no psychiatric diagnosis. Adjustment prior to the military service appeared to have been satisfactory to the extent that there were no reported gross indicators of behavioral control problems with subjective unhappiness. The Veteran was not given a diagnosis on Axis I as she did not report any current functionally impairing symptoms related to anxiety, depression, or other psychiatric conditions. The Veteran had in the past discussed problems related to claustrophobia and fear of water. However, the Veteran did not discuss any functionally impairing symptoms with these problems at the present time. In addition, these symptoms were evident prior to her military service. The Veteran did not describe any events during the military that would rise to the level of a PTSD stressor. She did not describe any symptoms that would be suggestive of a diagnosis of PTSD. Indeed, the Veteran was functioning well. Based on the foregoing, the Board finds that the preponderance of the evidence weighs against the claim of service connection for an acquired psychiatric disorder, to include PTSD (excluding a phobia disorder). The Board notes that to be present as a current disability, the claimed condition must be present at the time of the claim for benefits, as opposed to sometime in the distant past. Gilpin v. West, 155 F. 3d 1353 (Fed. Cir. 1998). The Gilpin requirement that there be a current disability is satisfied when the disability is shown at the time of the claim or during the pendency of the claim, even though the disability subsequently resolves. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Board notes that while a September 2001 VA treatment record noted a reported history of treatment for PTSD by a private physician, a diagnosis of PTSD was not shown at the time of the claim or during the pendency of appeal. Additionally, December 2011 VA psychiatric consult later noted that the Veteran underwent outpatient psychiatric treatment with Dr. L.H., but was treated for problems with Alcohol, her low self esteem, and fear, not PTSD. Both VA treating providers and the June 2012 VA examiner reported that the Veteran did not have a diagnosis of PTSD or any other acquired psychiatric disability (other than a phobia disorder) throughout the pendency of the appeal. Under these circumstances, for the Board to conclude that the Veteran has PTSD related to her military service would be speculation, and the law provides that service connection may not be granted on a resort to speculation or remote possibility. 38 C.F.R. § 3.102; Obert v. Brown, 5 Vet. App. 30, 33 (1993). Simply put, in the absence of a present disability that is related to service, a grant of service connection is clearly not supportable. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Veteran was advised of the need to submit medical evidence demonstrating a current disorder and a nexus between a current disorder and service by way of the letter from the RO to her, but she has failed to do so. A claimant has a responsibility to present and support a claim for benefits under laws administered by the VA, 38 U.S.C.A. § 5107(a), and the Veteran was clearly advised in the letter of the need to submit medical evidence of a current disorder and a relationship between a current disorder and an injury, disease or event in service. The Board has carefully considered the Veteran's assertions that she has PTSD that is related to her active service. The Veteran has provided credible report about the symptoms that she has experienced. She has some corpsman training, but no specialized training in diagnosing psychiatric disorders. She is also competent to relay the diagnostic impressions of her private examiner, who she asserts diagnosed her with PTSD. Unfortunately, as the Veteran has not cooperated in her duty to assist in obtaining these records, the Board does not know how the examiner arrived at that conclusion and the rationale underlying the diagnosis. Thus, this information holds little probative value when compared to the extensive VA examination report. See generally Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that a medical opinion does not hold probative value when it fails to provide sufficient detail and rationale to allow the Board to make a fully informed evaluation of the disability). The Board also places greater probative value on the opinion of the VA examiner as opposed to the Veteran's self-diagnosis, as the VA examiner possesses greater training and expertise than the Veteran in diagnosing psychiatric disorders. There can be no doubt from review of the record that the Veteran rendered honorable and faithful service for which the Board is grateful, and the Veteran is sincere in her belief that she has PTSD that is related to her military service. While the Board has carefully reviewed the record in depth, it has been unable to identify a basis upon which service connection may be granted (other than potentially a phobia disorder which is addressed in the remand following this decision). The Board has also carefully considered the benefit of the doubt rule, but as the preponderance of the evidence is against the claim, the evidence is not in equipoise, and there is no basis to apply it. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for an acquired psychiatric condition, to include PTSD (but excluding a phobia disorder), is denied. REMAND A review of the record discloses further development is necessary prior to the adjudication of the Veteran's claims of service connection for a phobia disorder, hypertension and a CVA. The Veteran has provided credible testimony before the Board of a pre-service history of claustrophobia which initially interfered with her employability. She described experiencing fear and anxiety when having to wear firefighting equipment which she was able to mentally overcome and effectively perform her duties. The Veteran described a recurrence of these same symptoms during service when ordered to wear firefighting equipment. This time, however, the Veteran described an inability to overcome her fears and she never returned to firefighting duties. The Board notes that specific phobia, which includes claustrophobia, is listed among the anxiety disorders under DSM-IV. See DSM-IV, ICD-9 300.29. The December 2011 VA clinician diagnosed the Veteran with simple phobia. The June 2012 VA C&P examiner noted that the Veteran had a fear of water and claustrophobia, but found no current psychiatric diagnosis as she did not experience current functionally impairing symptoms. With the record currently before the Board, the Board must find that a current disability of simple phobia is shown although it may be asymptomatic. See McClain, 12 Vet. App. at 321. The Veteran's testimony and statements of record clearly and unmistakably demonstrate that her phobia disorder existed prior to active service from January 1991 to May 1991. As this disorder was not "noted" upon entrance into active duty in January 1991 and, therefore is presumed to be in sound condition for VA compensation purposes, service connection may be warranted unless there is undebatable evidence that her phobia disorder was not aggravated during service from January to March 1991. See 38 U.S.C.A. § 1111; Wagner v. Principi, 370 F. 3d 1089, 1096 (2004). See also Vanerson v. West, 12 Vet. App. 254, 258-59 (1999) (holding that the term "clear and unmistakable evidence," as used in 38 U.S.C.A. § 1111, has been defined as evidence that is "undebatable"). The Board finds that medical opinion is necessary to address this issue. 38 U.S.C.A. § 5103A(d). Additionally, the issues of service connection for hypertension are inextricably intertwined with the issue of service connection for a phobia disorder, so that an opinion causally linking the Veteran's phobia to her military service would trigger VA's duty to provide a medical examination for this disability. The Board has therefore concluded that it would be inappropriate at this juncture to enter a final determination on that issue. See Henderson v. West, 12 Vet. App. 11 (1998), for the proposition that where a decision on one issue would have a 'significant impact' upon another, and that impact in turn could render any review of the decision on the other claim meaningless and a waste of appellate resources, the claims are inextricably intertwined. Accordingly, the case is REMANDED for the following action: 1. Assist the Veteran in obtaining complete treatment records from Dr. Hungerford in approximately 1991, and Dr. Merritt in approximately 1999. 2. Associate with the claims folder the Veteran's clinical records of VA treatment since October 22, 2012. 3. Upon completion of the above, schedule the Veteran for a VA psychological examination with a psychologist or psychiatrist to determine the nature and etiology of her phobia disorder. The claims file should be made available to the examiner and reviewed in conjunction with this examination. Specifically, the VA examiner should address the following question: Whether there is undebatable evidence that the Veteran's phobia disorder which existed prior to service was not aggravated beyond the normal progress of the disorder during active service from January to March 1991? The examiner is specifically requested to address whether the Veteran's report of an inability to overcome her fear of wearing firefighting equipment in service, which she had been able to overcome prior to service, demonstrates a permanent aggravation of her phobia disorder beyond the normal progress of the disorder? The examiner should provide all examination findings, along with the complete rationale for each opinion expressed and conclusion reached. 4. If a positive medical nexus opinion is provided linking either a phobia disorder or hypertension to the Veteran's military service, schedule her for a VA examination with an examiner with the appropriate expertise to determine the nature and etiology of any disability associated with her cerebrovascular accident. The claims file should be made available to the examiner and reviewed in conjunction with this examination. Specifically, the VA examiner should address the following questions: a. Does the Veteran currently have a disability associated with her cerebrovascular accident? b. If so, is it at least as likely as not than any such current disability was caused and/or aggravated beyond the normal progress of the disorder by her military service and/or hypertension or phobia disorder (if linked to military service? The examiner should provide all examination findings, along with the complete rationale for each opinion expressed and conclusion reached. 5. Thereafter, the RO/AMC should readjudicate the claims in light of the additional evidence obtained. If the benefits sought on appeal remain denied, the Veteran and her representative should be provided a supplemental statement of the case. An appropriate period of time should then be allowed for a response. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ T. MAINELLI Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs