Citation Nr: 1323076 Decision Date: 07/19/13 Archive Date: 07/24/13 DOCKET NO. 08-08 815 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depression. 2. Entitlement to a compensable evaluation for service-connected bilateral hearing loss. 3. Entitlement to a total disability evaluation based upon individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Katrina Eagle, Attorney ATTORNEY FOR THE BOARD D. Rogers, Associate Counsel INTRODUCTION The Veteran served on active duty January 1965 to January 1967, with prior and subsequent service in the U.S. Navy Reserves. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California. In a July 2007 decision, the RO denied the Veteran's claim for service connection for PTSD, granted service connection for a bilateral hearing loss disability evaluated as noncompensably disabling, effective September 8, 2006; and deferred a decision as to his claim for entitlement to a TDIU. The Veteran submitted a notice of disagreement solely pertaining to the denial of service connection for PTSD. In a subsequent April 2009 decision, the RO denied the Veteran's subsequent claim for a compensable evaluation for his service-connected bilateral hearing loss disability and entitlement to a TDIU. In March 2013, prior to certification and transfer of this appeal to the Board in May 2013, the Veteran withdrew his claims of entitlement to service connection for a respiratory condition, chloracne, type II diabetes mellitus, kidney failure, hypertension, and colon cancer. As such, these issues are not before the Board for appellate consideration. See 38 C.F.R. § 20.204(b)(3). In April 2013, the Veteran withdrew his request for a Travel Board hearing. See 38 C.F.R. § 20.704(e) (2012). In June 2013, the Veteran's attorney submitted additional evidence accompanied by a waiver of initial RO consideration. See 38 C.F.R. § 20.1304 (2012). The issues of entitlement to a compensable evaluation for service-connected bilateral hearing loss and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Department of Veterans Affairs Regional Office. This appeal has been advanced on the Board's docket. 38 U.S.C.A. § 7107(a)(2) (West 2002); 38 C.F.R. § 20.900(c) (2012). FINDING OF FACT Resolving doubt in the Veteran's favor, the evidence demonstrates that he has a currently diagnosed acquired psychiatric disability, to include PTSD and major depressive disorder, which have been related by a VA mental health professional to his in-service personal traumas, which are consistent with the circumstances of his service. CONCLUSION OF LAW The criteria for entitlement to service connection for an acquired psychiatric disorder, to include PTSD and major depressive disorder, have been met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.304(f) (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). As the Board is granting service connection for an acquired psychiatric disability, the issue decided herein is substantiated, and there are no further VCAA duties with regard to that issue. Wensch v. Principi, 15 Vet. App. 362, 367-68 (2001); see also 38 U.S.C.A. § 5103A(a)(2) (Secretary not required to provide assistance "if no reasonable possibility exists that such assistance would aid in substantiating the claim"); VAOPGCPREC 5-2004; 69 Fed. Reg. 59989 (2004) (the notice and duty to assist provisions of the VCAA do not apply to claims that could not be substantiated through such notice and assistance). Analysis Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2012). In general, service connection requires (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Establishment of service connection for PTSD requires: (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). See also Cohen v. Brown, 10 Vet. App. 128 (1997); 38 C.F.R. § 4.125(a). If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships 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)(1). See also 38 U.S.C.A. § 1154(b). That is not the case here, so this will be discussed no further. If there is no combat experience, or if there is a determination that the Veteran engaged in combat but the claimed stressor is not related to such combat, there must be independent evidence to corroborate the Veteran's statement as to the occurrence of the claimed stressor. Doran v. Brown, 9 Vet. App. 163, 166 (1996). Moreover, a medical opinion diagnosing PTSD does not suffice to verify the occurrence of the claimed in-service stressors. Cohen, 10 Vet. App. at 142, Moreau v. Brown, 9 Vet. App. 389, 395-96 (1996). The regulations pertaining to PTSD were (relatively) recently amended, and 38 C.F.R. §3.304(f)(3) no longer requires the verification of an in-service stressor if the Veteran's stressors involve "fear of hostile military or terrorist activity." Since that is not the case here, it is not necessary to discuss this any further. The Veteran contends that he is entitled to service connection for an acquired psychiatric disorder, to include PTSD. He has reported four specific stressors or in-service traumas to which his claimed psychiatric disability is related to. In order of severity, his reported stressors include: (1) getting locked in a hot engine storage room in an isolated are of the ship below the water line while stationed aboard the U.S.S. BON HOMME RICHARD (CVA-31) off of the coast of Vietnam where it became so hot that he "became unglued" and experienced intense fear for his life; (2) hearing a sailor fall overboard on a "pitch black" night and feeling profound helplessness having nothing to throw over for him; (3) the death of another sailor who was ordered to wash down the boiler room in extreme temperatures and humidity which caused him to feel horrified as it could happen to anyone on the ship, and; (4) a plane dropped 2 bombs on the flight deck when it hit some wires on the ship. He has also indicated that he was constantly harassed by his supervisors and forced to work in inhumane conditions in terms of high heat and humidity with little access to drinking water. Although the Veteran has not specifically claimed that he was physically assaulted during service, the Board notes that there are special development procedures pertaining to the processing of a claim, for service connection for PTSD based on physical or sexual assault. See Patton v. West, 12 Vet. App. 272 (1999) (citing VA Adjudication Procedural Manual M21-1, Part III, paragraph 5.14(c) (Aug. 1, 2006)). Because personal assault is an extremely personal and sensitive issue, many incidents are not officially reported, which creates a proof problem with respect to the occurrence of the claimed stressor. In these situations, it is not unusual for there to be an absence of service records documenting the events the veteran has alleged. The victims of this type of trauma may not necessarily report the full circumstances of it for many years after it occurred. Thus, when a PTSD claim is based on a personal assault in service, evidence from sources other than the Veteran's service records may corroborate the Veteran's account of the stressor incident. 38 C.F.R. § 3.304(f)(5). Examples of such evidence include, but are not limited to: records from law enforcement authorities; rape crisis centers; mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. 38 C.F.R. § 3.304(f)(5). Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. Id. Having considered all the evidence of record, the Board finds that the Veteran indeed suffers from PTSD and major depressive disorder as a result of his claimed stressors. As such, service connection is warranted. The Veteran's service treatment records do not reflect that he was treated for a psychiatric disability during active service, or that he complained of any injuries that may be attributable to a personal assault. However, his service personnel records show that he received decreasing marks on his individual performance record in nearly all areas from the time his active service began until it ended. In March 1966, an administrative remark stated that the Veteran was not qualified for engine room watch duty due to the fact that he could not stand to be confined to an engineering space. He required constant supervision and his military appearance was only passable. He only got along adequately with his shipmates. In September 1966, it was noted that he had difficulty following commands and regulations. Despite an overall trait average of 3.01 on his active duty performance record, the Veteran was eligible for reenlistment on separation and he was authorized to wear a Good Conduct Medal based on service dating since September 1966. The Board acknowledges that there is no documentation of record confirming that the Veteran was harassed, mistreated, or trapped in a engine storage room as alleged. Notwithstanding, however, the above documentation in his service personnel records is persuasive circumstantial evidence that is sufficient to enable to Board to concede that his claimed stressors of getting trapped in a hot engine room and being harassed by supervisors occurred during service as alleged. Post-service private treatment records indicate that following the Veteran's discharge from service, he was gainfully employed from 1969 to 1975 as a janitor and supervisor. From 1975 to 1991, he was employed as director of housekeeping and linens. From 1985 until 1991, he experienced difficulty coping with his supervisors and authority. This created significant stress and ultimately resulted in a "breakdown" that required a 3 month disability leave of absence from September to December 1989. Thereafter, he returned to work until 1991 when either his employment or position was terminated. Upon undergoing an emergency psychiatric evaluation in March 1991 due to severe depression, Dr. CWH, Ph.D., indicated that the Veteran exhibited all of the classic symptoms of a PTSD superimposed on a sever recurrent major depression directly related to his work situation. He was placed on 30 day disability. During subsequent psychiatric evaluation in May 1991, there were clear indications of affective depression and generalized anxiety. In March 1992, the Veteran was hospitalized due to severe depression. It appears that the Veteran received private psychiatric treatment at S. Hospital/CMC in 1992 and at VA in 1994. VA treatment records show ongoing psychiatric treatment with medication and counseling for multiple psychiatric disorders, to include PTSD. In August 1997, it was noted that he needed psychological follow-up as soon as possible due to complaints of depression and insomnia following diagnosis with colon cancer. During inpatient VA psychiatric treatment in September 2003, the Veteran related his PTSD and depression to termination of his employment at VCH in 1991. During a follow-up outpatient primary care appointment, the Veteran attributed social stressors to his loss of work. A follow-up psychiatry note in October 2003 shows that prior to inpatient treatment, the Veteran had a conflict with his business partner who did things his own way. In July 2005, more than 1 year prior to the date the claim for service connection for an acquired psychiatric disorder was received, the Veteran was more angry and irritable related to working on a statement about his "harassment" during service. He felt that a sailor died because he was ordered to work in the boiler room. He reported verbal abuse, degradation, and was reportedly ordered to stop urinating mid stream by an officer. He lost his liberty due to inconsistent room inspection evaluations and was trapped in a hot storage room. Five months later, in December 2005, the Veteran was still having difficulty working on his stressor statement. It was noted that his difficulties with superiors during service is likely related to his difficulty with authority since that time. Since the claim for service connection was received in September 2006, psychiatric diagnoses have included: PTSD, chronic major depression, dysthymic disorder, claustrophobia, anxiety disorder not otherwise specified (NOS) and personality disorder NOS. In November 2006 it was noted that the Veteran was doing much better since his paperwork had been submitted to VA as it was very difficult for him to relive his military traumas. In an April 2007 VA psychiatry note, Dr. AAH, the Veteran's VA treating psychiatrist since July 2000, stated that the Veteran's traumas during service are the direct cause of many of his psychiatric symptoms and the responses of his supervisors further traumatized him. He relived trauma with every encounter with authoritarian, hyper critical, arrogant persons. In a February 2009 statement, Dr. AAH, M.D., Ph.D., stated that he had provided the Veteran with psychiatric treatment for diagnoses of PTSD and chronic major depressive disorder since July 2000. He indicated that the Veteran reported symptoms consistent with all three core clusters of PTSD due to prior traumatic events that and symptoms linked to his active duty service. Dr. AAH opined that all evidence available to him strongly suggested that the Veteran's psychiatric condition is the result of traumatic experiences during service. In March 2011, the Veteran was afforded a VA psychiatric examination to determine the nature and etiology of his current acquired psychiatric disorder, to include PTSD. When discussing issues that developed over the last several years, the Veteran intervened with comments that were not on topic and seemed hyperfocused on injustices he feels that he has endured. The Veteran indicated that he was never a victim of physical or sexual assault but he felt mentally harassed. His mood was angry, especially when he learned that he needed to appear for a psychiatric examination. His thoughts were borderline obsessive and ruminated on injustices that he had been dealt both during his military service and his post-service civilian employment. Almost all responses somehow related to being unfairly treated, degraded, and misunderstood. He reportedly experienced panic attacks when thinking about his military service that were described as feeling like a rush inside as if he is on a freight train going full blast. Following a review of the claims file and examination of the Veteran, the examiner diagnosed major depressive disorder and personality disorder not otherwise specified (NOS). The examiner stated that it was difficult to provide a clear picture of the Veteran's condition since his claimed PTSD is not based on typical traumas (i.e., combat, sexual assault, POS, etc.). While VA treatment records note history of PTSD diagnosis, when PTSD was first diagnosed it was noted as a result of conflicts with his post-service civilian employer and subsequent job loss. The examiner stated that she could not provide a diagnosis of PTSD because the Veteran did not endorse symptoms indicative of persistently re-experiencing his military traumas (i.e., flashbacks, nightmares, distressing images, physiological distress, physiological arousal to triggers of his military trauma. Instead, the Veteran had physical and psychological reactions towards others who reminded him of domineering supervisors from his military service. He also did not experience persistent avoidance symptoms related to his military service. He would discuss his military travesties with anyone who would listen, which strained his relationships. His detachment was related to his intense anger toward the system and feeling like he is being denied his rights. His lack of interest in hobbies was the result of his inability to get along with others and his failing health. Finally, the Veteran did not endorse hypervigilance or an exaggerated startle response. His problems with concentration and anger could be accounted for by his characterological traits and depressive symptoms. The degree of the Veteran's reported symptoms seemed skewed to the level of trauma he actually experienced. He was not in the infantry, combat, or in a typical war zone where he had to kill anyone. Therefore, the examiner disagreed with prior clinical opinions indicating that that there are no Axis II characterological traits that have impacted the severity of the Veteran's condition. The examiner opined that the Veteran's personality structure is one in which the traumas he did endure seem to have a lasting impact on his ability to maintain healthy social situations and relationships. The March 2011 VA examiner also noted a history of major depressive disorder which she opined is at least as likely as not caused by or the result of the Veteran's military service. It appeared that his depression began shortly after having difficulties in the work place. He struggled with individuals who he felt disrespected him and it is likely that his inability to cope with change in his environment led his employer to let him go. In February 2013, a statement was received from a social worker from the Veteran's private dialysis provider, HL. Since January 2010, the Veteran had informed the staff at that office about his PTSD and he provided VA psychiatric treatment notes that confirmed and detailed the Veteran's military experiences with intrusive recollections of those experiences. HL stated that several times while receiving dialysis the Veteran's PTSD had been triggered while watching TV which resulted in emotional episodes so severe they required intervention and supportive counseling from their social services crisis intervention. In a January 2013 statement, the Veteran's treating psychiatrist, Dr. AAH, stated that the purpose of that statement was to supplement his February 2009 opinion and to provide a response to March 2011 VA psychiatric examination findings. He stated that he judged the Veteran to be a highly credible reporter as to his history and mental states. He reasoned that he had treated the Veteran for 12 years and during evaluation the Veteran provided nuanced and sometimes responses that would be unexpected from someone during an evaluation where so much is at stake. In any event, Dr. AAH outlined the Veteran's four in-service stressors as previously noted in order of severity. He documented the Veteran's associated mental and physiological responses to those stressors and how the Veteran felt at the time they occurred. He opined that the Veteran's psychiatric symptoms do meet the criteria for a current diagnosis of PTSD and he outlined the Veteran's symptoms as to each criteria required for diagnosis of PTSD. Examples of the Veteran's genuineness during examination included his admission that his single recurring and distressing dream of falling overboard in the dark had decreased in frequency in the last 2 years. The content of his dream did not appear to be embellished; rather, it had the ring of an authentic recurrent nightmare. With respect to the Veteran's veracity, it was significant to note that the Veteran denied ever having experienced flashbacks. Another mark as to the genuineness of symptoms was that when the Veteran was asked about physiological reactivity on exposure to internal and external triggers, he stated, "I feel a rushing inside" and he described his heart "going 100 miles per hour." As to avoidance symptoms, the Veteran explicitly and spontaneously stated that he tries to forget when asked about his military experiences. As to the Veteran's genuineness, he admittedly did not have to try to avoid triggers as much as he used to in the past when he would just work all the time. He structured his life to keep his mind full of thoughts other than his military traumas and so as not to come into contact with triggers. Predictably, several symptoms worsened when the Veteran was no longer able to work. He also avoided speaking with other veterans and veteran-related events because their voices are "quiet and tense." The Veteran began drinking alcohol during service and after to avoid thoughts and feelings about his traumatic military experiences. He further described symptoms of social isolation and emotional numbing. Another example of the Veteran's genuineness was that he admittedly had not had thoughts of a foreshortened future. He also experienced hyperarousal symptoms of chronic difficulty falling and staying asleep, anger and frustration in multiple contexts, difficulty concentrating, being "leery" of people, and sometimes having and exaggerated startle response. The psychiatrist stated that the Veteran's PTSD has been chronic since his military service until the present time and it had caused profound distress and interfered with his family and social functioning. It was noted that it is important to point out that the death of a sailor in the boiler room occurred prior to the Veteran being locked in a hot storage room where he feared for his life. As to the March 2011 VA examination report, Dr. AAH stated that in finding that the Veteran does not suffer from PTSD, the examiner erroneously stated that the Veteran does not persistently re-experience his prior traumas and that he does not experience persistent avoidance. Indeed, avoidance is one of the most prominent features of the Veteran's PTSD. The examiners statement that the Veteran does not experience an exaggerated startle response or hypervigilance was also false. The Veteran's hypervigilance and hyper startle response was not in response to a physical threat since his trauma was not related to a physical threat; rather, it was in response to authority figures who amplified his distress and to being in situations where he is prompted to talk about his traumatic experiences. Dr. AAH stated that the symptoms in the DSM diagnostic criteria for PTSD can certainly be shared with other disorders at the same time that they are met for PTSD. He stated that the Veteran is a difficult person to interview as he tends to go off on tangents and his avoidance is so significant that without probing for details it is easy for the interviewer to miss important historical details of his current symptoms (i.e., the Veteran tends to easily derail conversations onto his anger at the military for his situation which may have further distracted the March 2011 examiner. Dr. AAH stated that it is critically important for whoever interviews the Veteran to repeatedly direct him back to the topic at hand. Finally, he stated that the Veteran's comorbidities such as major depressive disorder can distract the interviewer from the underlying chronic PTSD. The Board notes that the sufficiency of a stressor is a medical determination, and adjudicators may not render a determination on this point without independent medical evidence. West v. Brown, 7 Vet. App. 70 (1994). VA treatment records from Dr. AAH and his most recent statement in support of the Veteran's claim explained that the Veteran was traumatized by being trapped in a storage engine room where he was hot and felt unable to breathe, especially when he was aware that someone had died in similar conditions on prior occasion. He further noted that the Veteran's superiors' response to his military traumas further traumatized him and likely resulted in his subsequent problem with authoritarian figures. In sum, the Board concedes the occurrence of the Veteran's military stressors of being trapped in a hot, humid engine storage room where he experienced difficulty breathing and feared that he would die, and further traumatization due to the response or behavior of his superiors during service are sufficient to support the Veteran's diagnosis of PTSD. Moreover, the Veteran has a current diagnosis of PTSD related to his military traumas. Therefore, the evidence is at least in equipoise for the claim, and entitlement to service connection for PTSD is warranted. Thus, the claim is granted. Moreover, the March 2011 VA examiner related the Veteran's currently diagnosed major depressive disorder to his military service, to include his struggles in dealing with people who he feels have disrespected him and his inability to cope with change in his environment. As to the Veteran's diagnosed dysthymic disorder, the Board notes that this diagnosis was sometimes listed as underlying the Veteran's diagnosed major depressive disorder. Similarly, his anxiety symptoms are related to his military stressors as described in Dr. AHH's January 2013 statement. Moreover, he stated that there can certainly be shared symptoms with other disorders at the same time that they meet the criteria for diagnosis of PTSD. As to the Veteran's diagnosed personality disorder, the Board notes that it is a developmental defect, which is not a diseases or injury within the meaning of applicable legislation. 38 C.F.R. § 3.303(c). Resolving all doubt in the Veteran's favor, the Board finds that the criteria for service connection for an acquired psychiatric disorder, to include PTSD and major depression, have been met. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and major depression, is granted. REMAND As to the Veteran's claim for increase for his service-connected bilateral hearing loss disability, the Board initially notes that it appears that it was most recently evaluated during a March 2009 VA audiological examination. Unfortunately, the March 2009 VA examination report currently associated with the claims file appears to be incomplete as there is only one page, which contains a "concluding statement." Numeric audiometric findings from the March 2009 examination are not of record. Thus, a complete copy of the March 2009 VA audiological examination, to include numeric audiometric findings on puretone examination must be obtained and associated with the claims file for review. The Board also observes that the portion of the examination report available for review notes that the Veteran did not indicate the effects/impact that his bilateral hearing loss has on his daily functioning and activities. In Martinak v. Nicholson, 21 Vet. App. 447, 453-4 (2007), the United States Court of Appeals for Veterans Claims held that a VA audiologist must fully describe the functional effects caused by a hearing disability in the final report of the examination. As the March 2009 VA audiological examination is inadequate due to lack of acknowledgement or discussion of any functional effects related to the Veteran's bilateral hearing loss disability, it is necessary to obtain a new VA audiological examination. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that it is adequate). Moreover, in correspondence dated in June 2013, the Veteran's attorney indicated that the fact that the Veteran had been issued hearing aids by VA is indicative that his hearing loss disability may have worsened since it was last evaluated in March 2009, more than four years ago. Accordingly, she requested that the claim be remanded to afford the Veteran with a contemporaneous VA audiological examination. Accordingly, the Board finds that a contemporaneous VA medical examination is warranted. See Littke v. Derwinski, 1 Vet. App. 90, 92 (1990) (noting that VA's duty to assist includes the conduct of a contemporaneous medical examination, in particular where it is contended that a service-connected disability has become worse); see also Snuffer v. Gober, 10 Vet. App. 400 (1997) (finding that a veteran is entitled to a new VA examination where there is evidence that the condition has worsened since the last examination). As to the Veteran's claim of entitlement to TDIU, he contends that his service-connected disabilities have rendered him unable to secure or follow a substantially gainful occupation. Given the Board's favorable decision to grant the full benefit sought on appeal with respect to the Veteran's claim for service connection for an acquired psychiatric disorder, the claim must now be returned to the RO so that an appropriate disability rating and effective date may be assigned. It is also unclear at this time whether the Veteran's service-connected bilateral hearing loss disability meets the criteria for the assignment of a compensable disability rating. Such determinations may have a substantial impact on the Veteran's claim for TDIU. In this regard, the Board notes that as of the date of this remand, the Veteran's combined disability rating is 10 percent and his service connected disabilities include tinnitus (10 percent), bilateral hearing loss (0 percent), and an acquired psychiatric disorder for which a disability rating has yet to be assigned. See 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). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Contact the Veteran and his attorney and afford them the opportunity to identify or submit any additional pertinent evidence in support of the claims remanded herein. Based on their response, if any, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. Regardless whether a response is received, relevant ongoing VA treatment records, if any, must be obtained from the San Francisco VA Medical Center dating since 2008 and from the Fresno VA Medical Center dating from 1990 to 2002 and since 2008. If the RO cannot locate such records, the RO must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The RO must then: (a) notify the Veteran and his attorney of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claim. The Veteran and his attorney must then be given an opportunity to respond. 2. Then, arrange for an audiological evaluation of the Veteran to evaluate the current severity of his bilateral hearing loss. The examiner is also requested to provide an opinion concerning the functional effects of bilateral hearing loss, including on the Veteran's ability to work at any occupation for which he may be otherwise qualified. The claims file, including a copy of this remand, must be made available to the examiner for review in connection with the examination. All indicated studies, including audiological testing, should be conducted, and the reports of any such studies should be incorporated into the examination report to be associated with the claims file. A complete rationale should be given for all opinions and conclusions expressed. 3. Thereafter, the Veteran should be accorded a VA psychiatric examination to assess the Veteran's ability/inability to work based on his service-connected disabilities. All necessary tests should be conducted and the examiner should review the results of any testing prior to completion of the report. The examiner is also requested to indicate the impact of the service-connected disabilities (acquired psychiatric disorder to include PTSD and major depression, bilateral hearing loss, and tinnitus) on the Veteran's ability to obtain and retain gainful employment, specifically whether they preclude him from securing and following a substantially gainful occupation. In that regard, although the Veteran has not worked since 1991 and he has been in receipt of Social Security disability benefits since age 50, the examiner should acknowledge and discuss the fact that the Veteran has work working for a live personal entertainment show or he has been self employed at least through 2008. The Veteran has indicated that he has some college education, he frequently works with computers, and he previously worked as laundry supervisor at a hotel. The examiner is informed that the Veteran's age and nonservice-connected disabilities may not be considered in connection herewith; only the service-connected disabilities and their impact on the Veteran's ability to obtain and retain substantially gainful employment are for consideration. The claims folder and a copy of this remand must be made available and reviewed by the examiner in conjunction with the examination. The examiner should provide a complete rationale for all conclusions reached. 4. Then, readjudicate the issues on appeal. If the benefits remain denied, the Veteran and his attorney should be provided a supplemental statement of the case and given an appropriate opportunity to respond. The case should then be returned to the Board for further consideration. The Veteran has the right to submit additional evidence and argument on this matter. Kutscherousky v. West, 12 Vet. App. 369 (1999). This appeal 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). ______________________________________________ A. C. MACKENZIE Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs