93 Decision Citation: BVA 93-16340 Y93 BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 DOCKET NO. 91-16 875 ) DATE ) ) ) THE ISSUE Entitlement to service connection for an acquired psychiatric disorder. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Audrey Grosenick, Associate Counsel INTRODUCTION The appellant served on active duty from August 1975 to May 1983 and also had a subsequent period of service in the Reserves which has not been verified. A rating decision of October 1990 from the Wichita, Kansas, Regional Office (hereinafter RO) denied the Appellant's claim for entitlement to service connection for paranoid schizophrenia. A notice of disagreement was received in November 1990. A rating action of January 1991 confirmed the earlier decision. A statement of the case was issued in February 1991. A substantive appeal was received in February 1991. This case was received and docketed at the Board of Veterans' Appeals (hereinafter the Board) in April 1991. In a decision issued in August 1991, the Board denied the appellant's claim for entitlement to service connection for an acquired psychiatric disorder. The Board's decision was appealed to the United States Court of Veterans Appeals (hereinafter the Court). In January 1993, the Appellee, Secretary of Veterans Affairs, filed an Unopposed Motion For Remand (Motion). In January 1993 the Court granted the Motion, vacated the Board's decision and remanded the case to the Board for compliance with the instructions in the Motion. [citation redacted]. The appellant was represented before the Board by The American Legion and appeared pro se before the Court. REMAND While this case was before the Court, the Appellee requested a search for additional service medical records from the National Personnel Records Center (NPRC). Pursuant to this request, some service records of a hospitalization in June 1979 for treatment of an aspirin overdose were located and forwarded to the Appellee. Since these records were not considered by the Board in its decision of August 1991, the Appellee requested a remand of the case to the Board with instructions to remand the case to the RO for readjudication. 38 C.F.R. § 3.156(c). In addition, pursuant to the Appellee's motion, the Board has been instructed to obtain any additional service medical records including "...psychological records from 1986 and/or 1987..." (Motion at 2). Reportedly, while in the Reserves, the appellant received psychiatric treatment. According to a letter dated February 1993 from a physician with the Reserves, to the best of the physician's recollection, the appellant was counseled in June 1986 at the 410th Evacuation Hospital and referred for psychiatric evaluation. Reportedly, the appellant had threatened to kill his unit commander. The appellant contends that a psychiatric evaluation at Fort Riley, Kansas led to his discharge from the Army Reserves in September 1987. After discharge from active duty in 1983, the appellant reportedly served in the Reserves. Any periods of active duty, active duty for training or inactive duty for training have not been verified. The RO has made various requests for the complete service medical records, but in view of the fact that the appellant was in the Reserves, it is possible that the request for records may not have been submitted to the correct agency. According to M21-1, Part 3, Ch. 4.01c, outpatient records may be with the Reserve unit or at the Army Reserve Personnel Center (ARPERCEN). When the appellee requested a search at NPRC for records for treatment at Fort Riley during 1987, NPRC indicated that the records were not on file and gave the following address: HQ; Attn: In-patient records; USA MEDDAC; Fort Riley, KS. 66442. The RO should contact ARPERCEN, the Reserve unit and the above address (if different than the address for the Appellant's Reserve unit) for any additional outpatient records. The appellant has not alleged that there were any periods of hospitalization while in service or in the Reserves other than a hospitalization in July 1979. The RO should ask the appellant to confirm this. If there were any other periods of hospitalization, the RO should obtain the inpatient clinical records, which are retained by the treating facility and then sent to NPRC. These records must be requested by name of hospital and date of hospitalization. M21-1, Part 3, Ch. 4.02h. In addition, the appellant claims that in 1977, a voice told him to kill himself and he tried to overdose on aspirin. He also claims that in 1980 a voice told him to go to the NCO club and kill everyone but that when he arrived, he was disarmed. After the Board's decision, the appellant submitted a statement from the State of Alabama in reference to a criminal conviction in 1981. The RO should request service personnel records in an attempt to verify these incidents including but not limited to the following records: counseling; suicide attempts; assaults; an attempt to kill others at the NCO Club in 1980; violation of service regulations; disciplinary actions; and State criminal actions taken against the appellant while on active duty. According to a report from Osawatomie State Hospital (Osawatomie) 1989, the appellant was at Coffeyville Regional Medical Center (Coffeyville) for approximately two weeks and was then transferred to Osawatomie State Hospital. The RO requested records from Coffeyville for treatment on August 22, 1989; however, Coffeyville indicated that there was no treatment on the specified date. It appears from the record that the veteran was hospitalized at Coffeyville just before admission to Osawatomie in September 1989. The appellant was also hospitalized at a VA medical center for a prolonged period commencing in October 1989. The only record relating to this hospitalization is an interim summary dated in August 1990. The complete hospitalization records, including a discharge summary should be obtained. According the interim summary, the appellant had previously been treated for polysubstance abuse and dependence at a VA facility. These records should also be obtained by the RO. The VA has a duty to assist the claimant in the development of facts pertinent to his claim. 38 U.S.C.A. § 5107(a), (West 1991). The Court has held that the duty to assist the claimant in obtaining and developing available facts and evidence to support his claim includes obtaining private medical records to which the claimant has referred, Littke v. Derwinski, 1 Vet.App. 90, 92 (1990) and governmental records. Murphy v. Derwinski, 1 Vet.App. 78, 82, (1990). Accordingly, this case is REMANDED to the RO for the following: 1. The RO should verify all periods of active duty for training, inactive duty for training or any other type of service in the Reserves. The exact dates of such service are required. 2. The appellant should be contacted and requested to provide information with respect to where and from whom he received treatment for a psychiatric disorder or drug/alcohol abuse during and after service (to include any treatment during Reserve duty), and specify whether the treatment was inpatient or outpatient. For any hospitalizations during service, the appellant should indicate the name of the hospital and the date of treatment. 3. Upon receipt of this information, the RO should obtain any additional service medical records for all periods of service, to include any periods of Reserve duty. The RO should specifically request psychological records from 1986 and/or 1987, and a psychiatric evaluation at Fort Riley, Kansas prior to the appellant's discharge from the Army Reserves. For any additional outpatient records, the RO should contact ARPERCEN, the Reserve unit and the following address: HQ; Attn: In-patient records; USA MEDDAC; Fort Riley, KS. 66442, (if different than the address for the Appellant's Reserve unit). For any additional inpatient records, the RO should contact the hospital and NPRC, providing the name of hospital and date of hospitalization. M21-1, Part 3, Ch. 4. 4. In addition, the RO should request service personnel records in an attempt to verify any administrative action regarding an alleged suicide attempt while on active duty, an alleged attempt to kill everyone at the NCO club in 1980, a State criminal conviction in 1981 and a threat to kill his unit commander while in the Reserves. These records should include any records of counseling, suicide attempts, assaults, violation of service regulations, disciplinary actions, and State criminal actions taken against the appellant while on active duty. 5. Following this development, the RO should obtain complete clinical records from all sources indicated by the appellant, to include records from Coffeyville for a hospitalization in 1989, VA clinical records for a hospitalization in 1989 and 1990 and VA hospitalization records for treatment for polysubstance abuse and dependence. The RO should carefully review all additional service medical records, private medical and VA records received for reference to any other treatment for a psychiatric disorder, to include polysubstance abuse and dependence. If there is reference to any records not in the claims folder, the RO should obtain those additional records. 6. Thereafter, the appellant should be examined by a board-certified VA psychiatrist to determine the exact diagnosis, if any, of the appellant's psychiatric disorder. The examination report should include a detailed account of all pathology found to be present. If there are different psychiatric disorders, to include polysubstance abuse and dependence, the examiner should reconcile the diagnoses and should specify which symptoms are associated with each of the disorders. If certain symptomatology cannot be disassociated from one disorder or another, it should be specified. The examiner should also indicate the relationship between any polysubstance abuse and dependence and the other psychiatric disorders. The report of examination should include a complete rationale for all opinions expressed. All necessary special studies or tests should be conducted and the examiner should review the results of any testing prior to completion of the report. The claims folder and a copy of this REMAND must be made available to, and reviewed by the examiner prior to the examination. The examiner should provide complete rationale for all conclusions reached. 7. The RO should review the examination report and determine if it is adequate for rating purposes and in compliance with this REMAND. If not, the report should be returned for corrective action. Following completion of these actions, the RO should review the evidence and determine whether the Appellant's claim may now be granted. If not, the appellant and his representative should be provided with a supplemental statement of the case, which includes a discussion of the additional evidence submitted. They should also be given a reasonable period of time in which to respond. The case should then be returned to the Board for further appellate consideration. BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 RICHARD B. FRANK JAN DONSBACH JOAQUIN AGUAYO-PERELES Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. 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) (1992).