Citation Nr: 1627052 Decision Date: 07/07/16 Archive Date: 07/14/16 DOCKET NO. 14-25 210A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUE Entitlement to service connection for acquired psychiatric disorder, to include depression, anxiety, and panic disorder. REPRESENTATION Appellant represented by: James G. Fausone, Attorney ATTORNEY FOR THE BOARD W. Ripplinger, Associate Counsel INTRODUCTION The Veteran served on active duty in the Navy from February 1977 to November 1982. This case comes before the Board of Veterans' Appeals (Board) on appeal from an April 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND Remand is necessary in this case to attempt to obtain private, VA, and Social Security Administration records referenced in the claims file as well as to schedule a VA medical examination. At the May 2014 VA medical examination, the Veteran reported receiving private psychiatric care for anxiety and self-esteem problems when he was first discharged from the military. He also mentioned mental health documentation that had been associated with his child custody dispute. The claims file currently contains medical records beginning in 2000; thus, VA must attempt to obtain these earlier records. In addition, remand is necessary to procure federal records not currently in the claims file. The November 1982 separation examination lists September 1979 and October 1981 medical examinations - diagnosing Dependent and Passive Aggressive Personality Disorders - which are not associated with the file. Although the RO made some attempts to locate these records, there is no formal finding of unavailability or explanation of the efforts attempted. In addition, the May 2014 VA medical examiner cited a lack of documentation verifying the Veteran's reported in-service stressors, but deck logs from the ship on which the Veteran served - the USS Ranger - have not been associated with the file. These records should be associated with the claims file on remand. Furthermore, the Veteran indicated in his October 2011 notice of disagreement that he has received Social Security disability benefits for depression and chronic back condition since 2000. These records must also be associated with the claims file. Finally, a new VA medical examination is necessary to consider the additional evidence obtained on remand as well as to address insufficiencies in the May 2014 VA medical examination. The examiner stated that there was no documentation of anxiety and depression in service or documentation of his reported in-service stressors. In addition, the examiner noted that there were no records of medical treatment until 2000 but did not address the Veteran's report of symptoms and treatment immediately following service. Therefore, VA must provide an additional VA examination on remand. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran with medical release forms and request that he execute them authorizing VA to obtain medical treatment records from private physicians who have provided mental health treatment, to include the community-based psychiatrist he reported seeing for anxiety and self-esteem problems when he was first discharged from the military. 2. Ask the Veteran to provide any other documents in his possession that relate to his mental health, to include documents from his child custody dispute. 3. Ask the Veteran to identify VA treatment he has received. Obtain all VA treatment records, to include complete records from the Loma Linda VAMC from 2000 to the present. Copies of the records must be associated with the virtual claims file. All efforts to obtain the records must be documented in the claims file. 4. Make an additional attempt to locate the missing September 1979 and October 1981 examinations referenced in the separation examination by contacting the appropriate facilities. Contact the Veteran to determine if he has any additional information about these examinations, to include the facilities in which they were given. All efforts to obtain the reported records must be documented in the claims file and any records received pursuant to this request must be associated with the claims file. If after following the appropriate protocol and contacting the Veteran the records remain unavailable, the AOJ must draft an appropriate memorandum of unavailability and notify the Veteran. 5. Contact the appropriate facility to request complete deck logs for the USS Ranger during the Veteran's period of service. All requests and responses received should be associated with the claims file. If the complete deck logs are unavailable, a formal finding of unavailability should be prepared and associated with the claims file. 6. Contact the Social Security Administration and obtain copies of all disability determinations, including the underlying medical records upon which the determinations were made. Copies of all records received must be associated with the Veteran's claims file. All efforts to procure these records must be documented in the claims file. 7. After completing the above, schedule a VA psychiatric examination. Following an examination of the Veteran and review of the claims file, the examiner should: a) Confirm the existence of any acquired psychiatric disorders, to include depression, anxiety, and panic disorder and determine whether it is at least as likely as not that any current or previously diagnosed psychiatric condition is etiologically related to any incident of the Veteran's active service. b) Discuss whether any current diagnoses are a continuation of the conditions diagnosed in service. This analysis should include a discussion of the Veteran's report of symptoms and treatment following service. The examiner must provide a full rationale (i.e. basis) for any expressed medical opinions. 8. Readjudicate the claim on appeal. If the benefit sought on appeal is not fully granted, issue a supplemental statement of the case before returning the case to the Board, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2015).