Citation Nr: 20007928 Decision Date: 01/30/20 Archive Date: 01/30/20 DOCKET NO. 16-43 605 DATE: January 30, 2020 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include depression, is remanded. Entitlement to service connection for erectile dysfunction as secondary to service connection for acquired psychiatric disorder is remanded. Entitlement to service connection for pes planus is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1973 to June 1976. This matter comes before the Board of Veteran’s Appeals (Board) on appeal from a rating decision issued in December 2014 by a Department of Veterans Affairs (VA) Regional Office (RO). In May 2019, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the record. At such time, the undersigned held the record open for 30 days for the submission of additional evidence, which was received later that month. 38 U.S.C. § 7105(e)(1). The Board observes that the Veteran has also perfected an appeal as to the issue of entitlement to service connection for sleep apnea, which was certified to the Board in September 2019; however, as he has requested a Board hearing before a Veterans Law Judge in connection with such appeal, the matter will be the subject of a separate Board decision issued at a later date. As relevant to all issues, the Board finds that a remand is necessary in order to obtain outstanding treatment records. In this regard, the record reflects that the Agency of Original Jurisdiction (AOJ) reported a review of VA treatment records from the Oklahoma City VA Medical Center (VAMC) dated from October 2001 to August 2016 and the Little Rock VAMC from November 2007 to October 2013 in the December 2014 rating decision and August 2016 statement of the case; however, VA treatment records dated only from October 2017 to November 2018 are on file. Furthermore, in his March 2014 application, the Veteran reported receiving treatment from MCRH and, at his May 2019 Board hearing, he indicated that he had received psychiatric treatment from Dr. Rouse in the past year. While he indicated that he did not want the processing of his claim to be delayed by obtaining records from MCRH in a December 2014 telephone call, such records may nevertheless be relevant to the claims on appeal. Consequently, on remand, the AOJ should obtain all outstanding VA and private treatment records. 1. Entitlement to service connection for an acquired psychiatric disorder, to include depression. The Veteran contends that he has an acquired psychiatric disorder, to include depression, as a result of his military service. In this regard, he claims that, while he was deployed to Korea, he became depressed as he missed his family and, as such, fabricated orders to Washington, D.C., where he flew to speak with his Congresswoman to see about being discharged, and was disciplined upon his return to Korea. The Veteran further reports that he experienced psychiatric symptoms since such time and, thus, service connection for an acquired psychiatric disorder is warranted. In this regard, in June 2018, Dr. Ellis, who is not a psychologist or psychiatrist, noted that the Veteran reported that he was homesick and depressed in service and, following his discharge, he experienced ongoing psychiatric symptomatology and was hospitalized twice in the psychiatric unit at the VA hospital. He then opined that it was more likely than not that the Veteran’s depression and anxiety are service-connected because of the occurrence of symptoms during service. Additionally, in May 2019, Dr. Rouse, the aforementioned psychologist, reported that, prior to his deployment to Korea, the Veteran began a relationship with a woman and they had a child together. In this regard, the Veteran indicated that the inability to make contact with his family and see his child resulted in panic, distress, anxiety, and depression and, thus, he fabricated orders to fly to Washington, D.C., to see his Congresswoman and, once there, was ordered back to Korea, where he was confined for 30 days. Dr. Rouse indicated that, based upon his multiple examinations of the Veteran, a review of the record, his education, training, and experience as it relates to veterans, and reasonable probability and certainty that the Veteran suffered a psychotic episode while serving in Korea due to the inability to see or communicate with his family. Specifically, the related distress and anguish triggered a manic phase that led him to altering records, going absent without leave (AWOL), and traveling to Washington, D.C. to see his representative. Dr. Rouse indicated that such behavior is conductive to a diagnosis of bipolar I. Further, he noted that the Veteran had otherwise served three years without any disciplinary issues or concerns and was honorably discharged. Thus, Dr. Rouse found that it was more likely than not that the Veteran’s psychiatric disorders, diagnosed as major depressive disorder, bipolar I, and general anxiety disorder, are a result and consequent of his military service. However, the Board finds that, as both Drs. Ellis’s and Rouse’s opinions are based on an inaccurate factual premise, they are inadequate to establish service connection. Specifically, the Veteran’s service treatment records are entirely negative for any complaints, treatment, or diagnosis of an acquired psychiatric disorder. Additionally, at the time of his separation examination in May 1976, he denied previously or currently experiencing frequent trouble sleeping, depression or excessive worry, loss of memory or amnesia, and nervous trouble of any sort and his psychiatric evaluation was normal. Furthermore, the Veteran received a Special Court Martial in May 1976 for using abusive language in February 1976, dereliction of duty in February 1976, disobedience of a lawful command in February 1976, and being AWOL from March 21 to 23, 1976. In this regard, while the record reflects that he has 13 days time lost, he was confined from April 24 to May 1, 1976, and was AWOL for two three-day time periods, from March 21 to 23, 1976, and April 21 to 23, 1976. Moreover, there is no report that he fabricated orders or flew to Washington, D.C. Also, in his September 1976 request to upgrade his reenlistment code, the Veteran reported no mitigating factors for the offenses underlying his Special Court Martial, to include his alleged distress over his separation from his family. Finally, the available VA treatment records reflect that the Veteran’s major depressive disorder had its onset in 2005. Nonetheless, the fact remains that there are missing treatment records, to include those cited and relied upon by Drs. Ellis and Rouse, and, as such may be potentially relevant to the instant matter, they must be obtained prior to the adjudication of the Veteran’s claim for service connection for an acquired psychiatric disorder. 2. Entitlement to service connection for erectile dysfunction as secondary to acquired psychiatric disorder. The Veteran contends that his erectile dysfunction is secondary to his acquired psychiatric disorder. Consequently, such matter is inextricably intertwined with the remanded claim for service connection for acquired psychiatric disorder. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, adjudication of such claim must be deferred pending the outcome of the Veteran’s claim for service connection for an acquired psychiatric disorder. 3. Entitlement to service connection for pes planus. The Veteran contends that his pre-existing pes planus was aggravated during his military service. In this regard, his March 1973 entrance examination revealed pes planus without symptoms on clinical evaluation. During the May 2019 Board hearing, the Veteran testified that he was aware that he had flat feet before entering service, but did not have any pain or limitations prior to service. He further indicated that he only started to experience symptoms when he began physical training in service, which have continued to the present time. However, while his May 1976 separation examination reflects the Veteran’s report of foot trouble, his service treatment records are otherwise negative for any complaint or treatment for pes planus and his feet were normal upon clinical evaluation at separation. Nonetheless, in June 2018, Dr. Ellis opined that the Veteran’s worsening of pes planus is service-connected because of the occurrence of symptoms while on active duty. In this regard, he noted that, having hereditary flat feet and overuse during physical training made him a risk for development of worsening of pes planus. However, outside of such report, the current record is entirely negative for any post-service complaints, treatment, or diagnosis of pes planus. Thus, as the aforementioned outstanding treatment records may be potentially relevant to the instant matter, they must be obtained prior to the adjudication of the Veteran’s claim for service connection for pes planus. The matters are REMANDED for the following action: 1. Obtain VA treatment records from the Oklahoma City VAMC from October 2001 to August 2016 and the Little Rock VAMC from November 2007 to October 2013. 2. After securing any necessary authorization from the Veteran, obtain all outstanding private treatment records from MCRH and Dr. Rouse. Make at least two (2) attempts to obtain such records. If any records are unavailable, inform the Veteran and afford him an opportunity to submit any copies in his possession. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Waite The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.