Citation Nr: 0531573 Decision Date: 11/21/05 Archive Date: 11/30/05 DOCKET NO. 02-00 893A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for a psychiatric disability, to include eating disorder, bipolar disorder, and post-traumatic stress disorder (PTSD). 2. Entitlement to an increased disability rating for residuals of a fracture of the right fifth metacarpal, currently noncompensably evaluated. 3. Entitlement to service connection for chloracne, to include as due to Agent Orange exposure. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD E. Ward, Associate Counsel INTRODUCTION The veteran had active duty from September 1967 to September 1971. This matter initially came before the Board of Veterans' Appeals (Board) on appeal of a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. The veteran testified at a May 2002 hearing before a hearing officer at the RO. A transcript of that hearing is of record. The case was remanded in December 2003 for further development. The issue of service connection for chloracne is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC). FINDINGS OF FACT 1. All pertinent notification and indicated evidentiary development have been accomplished as to the issues decided herein. 2. A chronic acquired psychiatric disorder, to include eating disorder, bipolar disorder, and post-traumatic stress disorder (PTSD), was not present in service; a psychosis was not manifested within one year of the veteran's discharge from service, and no currently present acquired psychiatric disorder is etiologically related to service. 3. The residuals of a fracture of the right fifth metacarpal are not manifested by limitation of motion or ankylosis of the right fifth finger; but loss of grip strength has been attributed to the fifth finger disability, and the evidence supporting impairment of the overall function of the hand is in equipoise. CONCLUSIONS OF LAW 1. A psychiatric disability, to include eating disorder, bipolar disorder, and PTSD, was not incurred in or aggravated by active service, and the incurrence or aggravation of a psychosis during such service may not be presumed. 38 U.S.C.A. §§ 1101, 1110, 1131 (West 2002); 38 C.F.R. §§ 3.303(c); 3.307, 3.309 (2005). 2. With resolution of reasonable doubt in the appellant's favor, the criteria for a 10 percent evaluation for the residuals of a fracture of the right fifth metacarpal are met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.20, 4.40, 4.45, 4.71a, Diagnostic Codes 5156, 5227, 5230 (2002, 2005). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 Initially, the Board notes that the Veterans Claims Assistance Act of 2000 (VCAA) [codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002)] and the regulations implementing it are applicable to the veteran's claims. The VCAA and implementing regulations provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. In addition, VA is required to notify the claimant that he should submit any pertinent evidence in his possession. The appellant filed his claims prior to the enactment of the VCAA. In the rating decisions, statements of the case, December 2003 Board remand, June 2005 supplemental statement of the case, as well as in various letters, e.g., VCAA letter dated July 2001 with attachments and PTSD questionnaire, notification letters dated in November 2001, January 2004, and September 2004, the RO notified the veteran of the evidence and information necessary to substantiate his claims, the specific information required from him to enable the RO to obtain evidence on his behalf, the assistance that VA would provide to obtain evidence on his behalf, and the evidence that he should submit if he did not desire VA to obtain the evidence on his behalf. Although VA has not specifically requested him to submit any pertinent evidence in his possession, it has informed him of the evidence that would be pertinent and requested him to submit such evidence or provide VA with the information and authorization necessary for the VA to obtain such evidence. The Board is satisfied that the veteran was on notice of the fact that he should submit any pertinent evidence in his possession. The Board also notes that in Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004) the United States Court of Appeals for Veterans Claims (Court) stated that the VCAA notice must be provided before an initial unfavorable determination. It also provided clarification essentially indicating that the failure to provide such notice in connection with adjudications prior to the enactment of the VCAA was not error and that in such cases, the claimant is entitled to "VCAA-content complying notice and proper subsequent VA process." Id. The record reflects that following compliance with the notice requirements of the VCAA and the implementing regulations, the RO readjudicated the veteran's claims and issued a supplemental statement of the case. There is no indication or reason to believe that the decision would have been different had the claim not been the subject of a prior adjudication. Therefore, in the Board's opinion, the veteran has been afforded proper VA process following provision of the required notice. The Board further notes that the service medical records and all available pertinent medical records have been obtained. The veteran has been afforded appropriate VA examinations. Neither the veteran nor his representative has identified any additional evidence or information which could be obtained to substantiate the claim. The Board is also unaware of any such outstanding evidence or information. Therefore, the Board is satisfied that the RO has complied with the duty to assist requirements of the VCAA and the implementing regulations. Accordingly, the Board will address the merits of the veteran's claim. II. Factual Background Service medical records reflect no psychiatric disability on enlistment examination. The veteran was seen in February 1971 for nerves, problems with his job, and personality conflict with his supervisor. He was sleeping poorly. He was advised to talk with his supervisor about the problem and to return if there was no improvement in the situation. There is no evidence that the veteran returned. A July 1971 separation examiner noted depression and worry, usually on weekends, and that the veteran drinks excessively every night, and has no problems when home. There was a fracture of right 5th metacarpal, no complications, and no sequelae. Post service records reflect a September 1973 x-ray of the right 5th metacarpal showing an old healed fracture. An October 1973 rating decision grated service connection for residuals of right 5th metacarpal, noncompensably evaluated effective from June, 26, 1973. Private and VA records of hospitalization and outpatient treatment from January 1985 to 1991 reflects a workers' compensation claim reporting an August 1984 diagnosis of acute lumbar strain. September 1989 workers compensation examination shows injury to the neck, back, and knee from a fall down an embankment in November 1988. Since 1991, the veteran has been followed for his psychiatric conditions by private providers and at VA, and voluminous records reflect private and VA hospitalization and treatment from 1991 through May 2005 showing various diagnoses through the years since 1991, such as dysthymia, bipolar disorder, major depression disorder. A March 1991 private treatment note reported continuous disability since 1991 due to back symptoms. April 1992 VA examination reported chronic low back pain. Diagnoses included marked depression. In a July 1992 VA examination, diagnosis was dysthymia, secondary type, late onset. An August 1992 private discharge summary reported severe back pain and depression since injury to the back and right knee in January 1991. The veteran was depressed because he could not work. An August 1992 mental health consultation report reflected injury at work in 1990 with depression since the end of 1991. The veteran reported active service in Thailand during the Vietnam War, but not in Vietnam. He had been followed for mental health problems since April 1992. Diagnoses included major depression and alcohol dependency in remission. The veteran filed a claim for an increased rating for residuals of fracture of right 5th metacarpal in November 1997. May 2000 VA examination reflected a history of fracture of the midshaft of the right 5th metacarpal in service. The examiner noted that the right first MP joint was enlarged and tender. The fifth metacarpal showed no tenderness. Grip was 4/5. The veteran could oppose the thumb to all of his fingers, and the fingertips brought in to the palmar crease. X-rays showed old healed fracture of the midshaft of the right 5th metacarpal. Diagnosis was arthritis of the right hand. In a February 2001 statement the veteran requested service connection for a nervous condition and eating disorder. He related having had nervous breakdown and increasing difficulty with his life, with anxiety, depression, restlessness and self-mutilation. He related being a B-52 aircraft mechanic crew chief, and having daily exposure to bombing in Okinawa and Thailand. He had been diagnosed as bipolar, and had had problems with suicidal thoughts and substance abuse. In a July 2001 notification letter, the RO sent the veteran a PTSD questionnaire, and requested that he provide medical evidence of a nervous condition, and information in support of his claim for service connection for post-traumatic stress disorder. He was advised to provide evidence of a diagnosis of PTSD as well as information in support of the exposure to detailed stressor experiences that contributed to his PTSD. In a July 2001 private physiatrist report the veteran complained of decreased grip on the right hand, with pain at the base of the hyperthenar eminence particularly with activity; difficulty gripping the wheel when driving; difficulty gripping with the right hand and writing or with activities of daily living, polishing shoes, holding a knife, or peeling potatoes. He drove a van but had difficulty on occasion. There was pain in the right hand which got numb and stiff, and reports of arthritis. He took Alperonol for gout in the lower extremities. The examiner noted that the thumb was crooked with pain and limited range. The veteran related that post service he worked in various jobs in general labor and construction, and last worked in 1991 when he became disabled with knee surgery. He reported problems with alcohol from 1967 to 1983, and constant depression. Examination of the right extremity showed motor strength intact. There was decreased touch and pain sensation throughout the right extremity, and decreased vibration sense, with proprioception intact. Deep tendon reflexes were 1+. Five position Jamar dynamometer testing revealed maximum grip of 34 Kgms for the left upper extremity and 30 Kgms for the right upper extremity. Pattern of grip indicated good cooperation. Upper extremity impairment evaluation showed 22 percent digit impairment for the right fifth finger. This was progressed to 7 percent whole person impairment. The examiner's indicated that there was no evidence of arthritis of the fifth digit, but there was arthritis of the thumb. This has resulted in limitation of range for the fifth finger as well as loss of grip strength. There was 7 percent whole person impairment for the right upper extremity. February 2002 VA outpatient treatment notes reflect complaints of inability to twist cap off small bottles, and loss of grip strength in the right hand. Assessment included arthritis of the metacarpal phalangeal joint of the right hand first digit - thumb; fracture of the fifth metacarpal. In a May 2002 hearing before a hearing officer at the RO, the veteran testified to the effect that he took medication for arthritis and pain of the right hand. He also testified to weakness, reduced grip strength, and pain with prolonged use of the right hand. VA outpatient mental health treatment notes from May 2001 to May 2002 reflect diagnosis of bipolar disorder, noncompliant. In May 2002 outpatient treatment note, the veteran asserted that his mental symptoms are related to his service, that on the flight line on his duty station in Thailand, he was exposed to incidents involving exposure to a B-52 aborting takeoff and bombs exploding all over the place, incursions by what he termed were the Viet Cong, and exposure to Agent Orange to which he attributed bumps on his feet and arms. August 2004 VA orthopedic examination by an orthopedic surgeon with review of the C file, discussed details of the veteran's service-connected injury in service from punching a wall, with fracture of the right 5th metacarpal and subsequent cast. Post-service, he reportedly did general laborer work, requiring gripping items with the hands. There was no paresthesias or numbness, and there was discomfort at the base of the right thumb. Examination revealed full extension and flexion of all fingers of the hand. The distal interphalangeal (DIP) joint of the right small finger has motion from 0 to 80 degrees; proximal interphalangeal (PIP) joint has motion from 0-90 degrees; the metacarpophalangeal (MCP) joint has motion from 0-90 degrees. Intrinsic muscle strength in both abduction and adduction is 4+/5 on the right compared with 5/5 on the left. Sensation is intact in all fingers. February 2002 X-rays showed evidence of prior midshaft small finger metacarpal fracture that had healed in a nearly anatomic alignment. All other fingers had full range of motion. Conclusions were of no limitation of motion that equates with amputation of the hand; no limitation of motion of the other fingers. The veteran has diminished grip strength associated with the hand fracture residuals. It was noted that this was previously measured by dynamometer in 2001, with the left hand (the nondominant hand) measuring 34 Kg of pressure versus the dominant right hand at 30 Kg pressure. This was approximately a 10 pound grip strength difference. The examiner opined that it is feasible that the reduction in grip strength is a residual of the fracture the veteran sustained to his right small finger or 5th metacarpal. On the question of limitation of motion including functional loss equated to amputation without metacarpal resection, the examiner noted there is no motion deficit objectively. The examiner noted that there is objective grip strength reduction and subjective discomfort which do interfere with the overall hand function. The examiner recommended redoing the dynamometer testing as the prior one was over three years old, and the examiner must ensure there was no malingering and that the test was valid. November 2004 VA psychiatric examination, with noted review of the C file, revealed no treatment for mental health problems while in service other than for a job problem and personality conflict with a superior in February 1971, prior to discharge. The examiner reported that from review of the veteran's C file, the veteran was hospitalized three times in 1992 and 1993 for major depression and bipolar disorder, which were the veteran's first reported treatment for mental illness. An August 1992 psychiatric evaluation by Dr. Humphreys detailed the veteran's symptoms as related to depression arising from chronic pain and his inability to provide for his family. Following a second hospitalization in September 1993, the veteran was diagnosed with bipolar disorder, mixed. The examiner noted that based on review of the record, this was the last hospitalization for mental illness the veteran had. In July 1993, he treated with lithium. Beginning in 1995, the veteran stopped using psychotropics for a period, ending in about March 2001, when he was treated for depression with Celexa, and refused other psychotropics until November 2001 when Dr. Ahmed of VA treated him with Depakote. The examiner noted that the record consistently showed treatment for bipolar disorder as early as 1991, and at the present, the veteran was being treated for bipolar disorder, manic. The examiner reported the veteran's military history, that he did not go to Vietnam, but was based in Thailand; was fearful of the bombs he worked around as an aircraft maintenance specialist; that planes he fixed would crash; that an aircraft at the base in Thailand blew up but he was in the barracks and did not witness the accident, but he saw the wreckage later; that 2 of his friends died in the service, none in his presence, and he felt guilty for encouraging them to join the service. On his separation physical, he reported anxiety and depression, daily excessive drinking, and one visit to the base facility for anxiety over conflict at work where he was encouraged to discuss the problem with the supervisor and return if unresolved. The examiner noted that the veteran has no direct, acute traumatic experiences reported either in his service or his personal life, and that in a peripheral sense, he felt anxiety and fear due to working around aircraft and ordinance, and all the dangers of a busy military airbase. On mental status examination the examiner opined that the reported stressors did not meet criteria for the major criteria (A) in DSM IV for a diagnosis of PTSD. It was noted that the veteran gave a history that is consistent with alcohol abuse developing into dependence, now in full remission, and had no treatment for mental health problems until early to mid 1990's, when he was hospitalized 3 times in a period of 1-2 years and was diagnosed with bipolar disorder, treated for bipolar disorder since that time, with the exception of a 6 year period from 1995 to 2001 when he refused treatment. The examiner concluded as follows: "[i]n my professional judgment, his mental illness did not originate in military service, nor did it manifest during military service, based on my review of the record and my interview with [the veteran]." Diagnoses included AXIS I bipolar disorder, Depressed. A June 2005 VA compensation and pension general medical examination reflects examination of the right 5th metacarpal. It was noted that the veteran had some minor weakness of the right fifth finger, and that arthritis of the thumb (non- service-connected) is part of the cause of the right hand weakness. He had arthritis in the right wrist and thumb. There was no gap between the finger and proximal transverse crease of the hand on maximal flexion of the finger. Range of motion of the right little finger at the metacarpal- phalangeal (MCP) joint, proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints were active against strong resistance with no additional limitation of motion on repetitive use. X-rays showed some deformity of the right fifth metacarpal probably associated with an old healed fracture. There was no acute fracture or dislocation, joint spaces were preserved, with no evidence of gout. It was noted that testing with dynamometer was unavailable, and gross testing was performed with the examiner's strength for comparison. Hand strength modalities were all normal except grasping which was noted as mild bilaterally, and mild right hand weakness was noted. Statements from the veteran are to the effect that his current psychiatric disability began in service, and that his right 5th metacarpal disability is more severely disabling than rated. III. Analysis A. Psychiatric disability. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Personality disorders are not diseases or injuries for VA compensation purposes. 38 C.F.R. § 3.303(c). Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests a psychosis to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without medical evidence of a current disability, medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) (table)]. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. In the present case, service medical records are absent treatment of psychiatric conditions. The veteran was seen on one occasion a few months prior to discharge in 1971, for reported personality conflict with a supervisor, with no further treatment. He reported anxiety and depression on his separation examination with excessive drinking usually on weekends, but no diagnosis of mental health disability. After his discharge in 1971, there was no further evidence of a psychiatric pathology until 1991-1992, which the psychiatrist attributed to injuries in 1991 which impaired his ability to work and to provide for his family In sum, voluminous post-service medical evidence from 1991 to the present confirms the presence of psychiatric disability beginning almost 20 years after discharge, variously diagnosed as dysthymia, depression, bipolar disorder. There is no indication in the post-service medical evidence that a chronic acquired psychiatric disorder was present within one year of discharge from service in 1971. There is also no evidence or opinion that any claimed psychiatric disability is etiologically related to service. Moreover, a VA medical opinion addressed the etiology of the veteran's current psychiatric disability and found no etiological relationship to his military service, and that a diagnosis of PTSD under DSM IV criteria was not warranted. This opinion was rendered following an examination of the veteran, review of the veteran's C file and detailed discussion of his entire medical history. The Board has considered the veteran's contentions. However, lay opinions concerning matters requiring medical expertise, no matter how sincere, are of no probative value. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). In light of these circumstances, the Board must conclude that the preponderance of the evidence is against the veteran's claim for service connection for a psychiatric disability. B. Increased Rating -Residuals of fracture of right 5th metacarpal During the pendency of the veteran's appeal, the schedular criteria by which ankylosis and limitation of motion of the fingers are rated changed. See 67 Fed. Reg. 48784-48787 (Jul. 26, 2002) (effective August 26, 2002). In Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003), the United States Court of Appeals for the Federal Circuit overruled Karnas v. Derwinski, 1 Vet. App. 308 (1991), to the extent it conflicts with the precedents of the Supreme Court and the Federal Circuit. See Karnas v. Derwinski, 1 Vet. App. 308, 312-313 (1991) (where the law or regulations change while a case is pending, the version most favorable to the claimant applies, absent Congressional intent to the contrary). In VAOPGCPREC 7-2003, the General Counsel held that Karnas is inconsistent with Supreme Court and Federal Circuit precedent insofar as Karnas provides that, when a statute or regulation changes while a claim is pending before the VA or a court, whichever version of the statute or regulation is most favorable to the claimant will govern unless the statute or regulation clearly specifies otherwise. The General Counsel held that the rule adopted in Karnas no longer applies in determining whether a new statute or regulation applies to a pending claim. The General Counsel indicated that pursuant to Supreme Court and Federal Circuit precedent, when a new statute is enacted or a new regulation is issued while a claim is pending before VA, VA must first determine whether the statute or regulation identifies the types of claims to which it applies. If the statute or regulation is silent, VA must determine whether applying the new provision to claims that were pending when it took effect would produce genuinely retroactive effects. If applying the new provision would produce such retroactive effects, VA ordinarily should not apply the new provision to the claim. If applying the new provision would not produce retroactive As to the criteria for rating residuals of an injury to the right 5th metacarpal of the right (dominant) hand, under the current or former criteria, limitation of motion, favorable ankylosis or unfavorable ankylosis of the fifth finger of the dominant or minor hand is considered noncompensably disabling. 38 C.F.R. § 4.71a, Diagnostic Codes 5227, 5230 (2002, 2005). Under the former criteria, extremely unfavorable ankylosis of the fifth finger was to be rated as an amputation under diagnostic code 5156. 38 C.F.R. § 4.71a, Diagnostic Code 5227 (2002). Amputation of the fifth finger of the dominant hand without metacarpal resection, at the proximal interphalangeal joint or proximal thereto warrants a 10 percent evaluation. With metacarpal resection (more than one-half of the bone lost), a 20 percent evaluation is authorized. 38 C.F.R. § 4.71a, Diagnostic Code 5156 (2002, 2005). A Note to revised Diagnostic Code 5227 provides that, in rating the disability, one should also consider whether it should be evaluated as amputation under Diagnostic Code 5156, whether an additional evaluation is warranted for limitation of motion of other digits, and whether an additional evaluation is warranted for interference with the overall function of the hand. The Board finds that this Note provides a possible basis for a compensable evaluation. Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2003). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Unfavorable ankylosis exists where it is not possible to bring the finger to within two inches (5.1 centimeters) of the median transverse fold of the palm or when the MCP and PIP joints are both ankylosed. Ankylosis of the MCP and PIP joints with either joint in extension or extreme flexion will be rated as amputation. 38 C.F.R. § 4.71a, Notes preceding DC 5216. Extremely unfavorable ankylosis of the fingers exists when all joints are in extension or in extreme flexion or with rotation and angulation of the bones, and this will be rated as an amputation. 38 C.F.R. § 4.71a, Notes following DC 5219. In the present case, the medical evidence shows that the veteran retains significant active motion of the joints of the right fifth finger, thus ankylosis is not present, and the functional impairment from the disability, even with consideration of all pertinent disability factors, is not in excess of extremely unfavorable ankylosis. The disability clearly is not comparable to amputation of the fifth finger with metacarpal resection and more than one-half of the bone lost. When most recently examined on October 10, 2004, the examiner opined that objective grip strength reduction and subjective discomfort interfere with overall function of the hand. However, a prior 2001 private physiatrist appeared to suggest that the grip reduction was the result of arthritis of the thumb rather than the residuals of right 5th metacarpal fracture. The physiatrist nevertheless concluded that there was at least a 22 percent digit impairment for the right 5th finger, converted to a 2 percent hand impairment, and a 7 percent whole person impairment. The Board concludes that the evidence of overall hand function favoring the claim is at least in equipoise with that against the claim. Accordingly, applying the new criteria under diagnostic code 5227, the Note, and resolving reasonable doubt in the veteran's favor, the Board finds that applying the revised regulations, at least a 10 percent rating is warranted for the service-connected disability for overall impairment in function of the hand due to weakness and grip reduction. A higher rating is unwarranted. The Board has considered all potentially applicable diagnostic codes. There is no basis for awarding a higher rating under the former or revised criteria. No limitation of motion or ankylosis is shown, and the veteran is consistently able to oppose his thumb to all fingers, and bring fingertips to the palmar crease. As the veteran has had full range of motion of the right hand and fingers throughout the period of the appeal, and continued functional use of his right 5th finger and right hand, it cannot, in the Board's judgment, be found that his disability is equivalent to amputation with metacarpal resection, which would be required for the next higher, 20 percent, rating under Diagnostic Code 5156. The Board recognizes that the veteran has other functional impairment of the hand in addition to the functional impairment of the fifth finger; however, at this time he is only service-connected for the residuals of a fracture of the fifth metacarpal and only those residuals are for consideration in evaluating the disability. If the veteran believes that service connection is warranted for additional disability of his right hand, he is free to file a claim for service connection for such disabilities. The Board has also considered whether the case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(b)(1). The record reflects that the veteran has not required frequent hospitalization for this disability and that the manifestations of the disability are consistent with the schedular criteria. There is no indication in the record that the average industrial impairment from the disability would be in excess of that contemplated by the assigned evaluation. Therefore, the Board has determined that referral of the case for extra-schedular consideration is not warranted. ORDER Service connection for a psychiatric disability, to include eating disorder, bipolar disorder, and post-traumatic stress disorder (PTSD), is denied. Entitlement to a 10 percent rating for residuals of fracture of the right fifth metacarpal, effective from October 18, 2004, is granted, subject to the rules and regulations governing the payment of VA monetary benefits. REMAND In May 2002, the veteran filed claims for service connection for diabetes and chloracne. The veteran filed a notice of disagreement to the January 2003 rating decision denying the claims, and also asserted service connection as due to Agent Orange exposure. In its prior December 2003 remand, the Board instructed that a statement of the case be issued. A June 2005 rating action granted service connection for diabetes mellitus on a direct basis. However, the veteran has not been provided a statement of the case in response to his notice of disagreement on the issue of service connection for chloracne. Consequently, remand is required for compliance with the Board's prior directives, and issuance of a statement of the case. See Manlicon v. West, 12 Vet. App. 238 (1999); Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, the case is REMANDED for the following action: 1. The veteran should be provided a statement of the case in response to his notice of disagreement with the January 2003 rating decision denying service connection for chloracne, to include as due to herbicide exposure. The veteran should also be informed of the requirements to perfect an appeal with respect to this issue. If a substantive appeal is not submitted, there is no jurisdiction of this issue to the Board. 2. If a substantive appeal is submitted, the case should be returned to the Board for further appellate action, if otherwise in order. No action is required of the appellant until he is otherwise notified but he has the right to submit additional evidence and argument on the matter the Board has remanded to the RO. See 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 The Veterans Benefits Act of 2003, Pub. L. No. 108-183, § 707(a), (b), 117 Stat. 2651 (2003) (to be codified at 38 U.S.C. §§ 5109B, 7112). ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs