Citation Nr: 1301299 Decision Date: 01/14/13 Archive Date: 01/23/13 DOCKET NO. 06-12 828 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for depressive disorder, not otherwise specified (NOS). 2. Entitlement to service connection for an acquired psychiatric disability other than depressive disorder, including, but not limited to posttraumatic stress disorder (PTSD), generalized anxiety disorder, and major depressive disorder. 3. Entitlement to service connection for a chronic headaches disability. 4. Entitlement to a higher initial disability rating for the service-connected lumbar paravertebral myositis and muscle spasm with early degenerative changes from L3 to S1 (lumbar spine disability) rated as 30 percent disabling from December 21, 2003 and rated as 40 percent disabling from April 4, 2005. 5. Entitlement to an effective date prior to March 18, 2004 for the grant of service connection for hypertension. 6. Entitlement to an initial compensable disability rating for the service-connected right knee patellar tendonitis, status post anterior cruciate ligament (ACL) repair. 7. Entitlement to service connection for an ear disorder, other than tinnitus. 8. Entitlement to service connection for a disability of the cervical spine. 9. Entitlement to service connection for joint pain, muscular pain, loss of memory, dizziness, rash, fatigue and shortness of breath, to include as part of an undiagnosed illness pursuant to 38 C.F.R. § 3.317. 10. Entitlement to a total disability rating for compensation purposes based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Keith Snyder, Attorney ATTORNEY FOR THE BOARD L.B. Cryan, Counsel INTRODUCTION The Veteran served on active duty from September 1999 to December 2003. This case is before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in, May 2004, February 2005 and August 2005 by the San Juan, Puerto Rico Regional Office (RO) of the Department of Veterans Affairs (VA) . The case has a complicated procedural history. The Veteran filed his initial claim of service connection in January 2004, just one month after his discharge from active duty. In a May 2004 rating decision, the RO granted service connection for lumbar paravertebral myositis and muscle spasm with early degenerative changes from L3 to S1 (low back disability) and assigned an initial 30 percent rating, effective from December 21, 2003, the day following the Veteran's last day of active service. The RO also granted service connection for hypertension and assigned an initial disability rating of 10 percent, effective from March 18, 2004. In addition, the RO granted service connection for right knee patellar tendonitis (right knee disability) and assigned a noncompensable rating, effective from December 21, 2003. Finally, the RO denied claims of service connection for an ear condition, headaches of the migraine type and an acquired psychiatric disorder variously diagnosed. Notice of the May 2004 rating decision was sent to the Veteran in May 2004. In a June 2004 notice of disagreement (NOD), the Veteran specifically indicated disagreement with the following: 1. Ear Condition (Tinnitus) 2. Migraine Headaches 3. Depressive Disorder, Anxiety, Stress, Nightmares 4. Lower Back Condition 5. Hypertension - Effective Date Should Be the Date of My Claim Notably, this was the first time that the Veteran had specifically mentioned tinnitus, and the RO therefore treated that as a new claim of service connection for tinnitus, separate and apart from the issue of service connection for an ear condition. In a separate statement, also received in June 2004, the Veteran filed the following new claims of service connection: (1) neuropathy on both arms; (2) skin condition; (3) stomach condition. Possible irritated bowel condition; (4) chronic joint pain (all); and (5) upper cervical condition. In a December 2004 rating decision, the RO granted service connection for carpal tunnel syndrome (CTS) of the right and left hands and assigned separate 10 percent disability ratings for each hand, effective from December 21, 2003. Additionally, the RO granted service connection for duodenal ulcer and assigned an initial 10 percent disability rating effective from December 21, 2003. Decisions on entitlement to service connection for a cervical condition and a left knee condition were deferred. Finally, claims of service connection for headaches (as a result of exposure to ionizing radiation), folliculitis, and, right and left elbow olecranon bursitis were denied. The Veteran did not submit a timely NOD with respect to any issue decided in the December 2004 rating decision. Then, on January 12, 2005, the RO issued a statement of the case (SOC) addressing the 5 issues appealed in the Veteran's June 2004 NOD, as noted above. The following week, the RO received correspondence from the Veteran indicating a request to reopen the, "case of my right knee condition that was awarded a 0% service connected." The Veteran noted that there was new evidence, specifically an MRI report of the right knee which he requested to have reviewed in conjunction with a claim for increase. The Veteran specifically indicated in this correspondence that he disagreed with the decision made on the case of his right knee condition. This correspondence was received at the RO on January 19, 2005, within one year of the date on which the May 2004 notice of the May 2004 rating decision was issued. Because the Veteran specifically (and timely) disagreed with the initial noncompensable disability rating assigned for the service-connected right knee disability, and submitted new evidence to support his claim, the RO should have construed the January 2005 correspondence as a timely NOD to the May 2004 rating decision with respect to the initial noncompensable rating assigned for the right knee disability. 38 C.F.R. § 3.156(b). On January 21, 2005, the RO received correspondence from the Veteran in response to the January 2005 SOC. In this correspondence, the Veteran specifically indicated that he was replying to "your letter dated 1-12-05" (the SOC) and that he wanted his statement to be considered as a NOD. Because the Veteran was disagreeing with the SOC, and this disagreement was timely, it can only be construed as a substantive appeal to the Board. Although the Veteran did not submit his substantive appeal on a VA Form 9, he made clear in his statement dated January 18, 2005 and received at the RO on January 21, 2005, that he disagreed with the SOC of January 12, 2005. In his statement, he noted that he had been seeking treatment for all of his diagnosed and claimed conditions since discharge from service, which he pointed out was within the first post-service year. Because the Veteran clearly intended to appeal these issues, the RO accepted the correspondence in lieu of a VA Form 9. In Percy v. Shinseki, 23 Vet. App. 37 (2009, the United States Court of Appeals for Veterans Claims (Court) distinguished the issues of a timely notice of disagreement (NOD) versus a timely Substantive Appeal and held that a timely Substantive Appeal was not a jurisdictional requirement for the Board's consideration of a veteran's claim. In Percy, the Court specifically found that, because the RO had never addressed the issue of timeliness in the SOC, and because the veteran was not informed that there was a timeliness issue until his claim was before the Board, that the RO had essentially waived any objections it might have offered to the timeliness, and had implicitly accepted his appeal. Here, the RO never notified the Veteran that he did not timely appeal the issues addressed in the January 2005 SOC. Instead, the RO merely considered the Veteran's statements as claims for reconsideration. The RO later issued an SSOC in April 2008 informing the Veteran that those issues were on appeal. With respect to the lumbar spine disability, it is considered on appeal from the May 2004 rating decision, because a higher initial rating of 40 percent was assigned within one year, thus demonstrating that new and material evidence was received within one year of the May 2004 rating decision. See 38 C.F.R. § 3.156(b) (2012). Meanwhile, the January 2005 statement also raised new claims of service connection for PTSD and a claim of service connection for an undiagnosed illness manifested by symptoms of fatigue, muscle pain, shortness of breath, joint pain, rash, dizziness, memory loss and headaches. In addition, the Veteran indicated an inability to work as a result of his service-connected disabilities. Thus, a claim for a TDIU was raised. In a February 2005 rating decision, the RO granted service connection for tinnitus and assigned a maximum allowed 10 percent rating, effective from December 21, 2003, the first day following discharge from service. The RO also denied claims of service connection for a left knee disability (even though the Veteran never claimed service connection for a left knee disability) and a cervical condition. Notice of that determination was sent to the Veteran on February 24, 2005. In April 2005 correspondence, the Veteran once again referred to the claims for an increased rating for the service-connected back condition; PTSD and major depression; headaches, cervical condition, an earlier effective date for hypertension, and entitlement to a TDIU. This is also within one year of the May 2004 rating decision and also constitutes a substantive appeal. In an August 2005 rating decision, the RO increased the 30 percent disability rating to 40 percent for the low back disability, effective from April 4, 2005. Although the Veteran has always maintained that the effective date for the grant of service connection for hypertension should be earlier than March 18, 2004, the RO did not address this claim; instead, the RO confirmed and continued the initial 10 percent rating assigned for the service connected hypertension, an issue which has never been claimed by the Veteran. The RO also confirmed and continued a noncompensable rating for the service connected right knee disability, and confirmed and continued a 10 percent rating for the service-connected duodenal ulcer. In addition, the RO denied claims of service connection for PTSD and ear condition, as well as joint pain, loss of memory, dizziness, rash, fatigue, shortness of breath and entitlement to a TDIU. Finally, the RO confirmed and continued the prior denials of service connection for depressive disorder with anxiety features, headaches of the migraine type and a cervical condition, although the RO does not specifically indicate that these claims were previously denied claims. With regard to the claim of service connection for a cervical condition, the RO noted in the February 2005 rating decision that the STRs were negative for findings or a diagnosis of a cervical condition; however, on reconsideration in August 2005, the RO indicated that the STRs revealed one instance of a complaint of cervical pain, although no diagnosis was provided at that time. The RO nonetheless denied the claim in the August 2005 rating decision because no diagnosis of a cervical condition was provided in VA spine examinations of April 2004 or July 2005. In August 2005 correspondence, the Veteran disagreed with all of the denied issues in the August 2005 rating decision. In March 2006, the RO issued an SOC addressing all issues listed on the Cover Page of this decision, except the issue of entitlement to an initial compensable disability rating for the service-connected right knee patellar tendonitis, status post anterior cruciate ligament (ACL) repair. The Veteran's VA Form 9, substantive appeal to the Board, as to the issues addressed in the March 2006 SOC, was received at the RO in April 2006. Supplemental Statements of the Case were issued to the Veteran in April 2008 and January 2009. The Veteran's claim of service connection for a cervical condition was reconsidered in August 2005, following the receipt of an April 2005 notice of disagreement, and that denial was perfected on appeal. As such, the issue is one of service connection and not whether new and material evidence has been received to reopen a finally disallowed claim. With regard to the claim(s) of service connection for depressive disorder, not otherwise specified, and an acquired psychiatric disorder other than depressive disorder, not otherwise specified, to include PTSD, generalized anxiety disorder, and major depressive disorder, the United States Court of Appeals for Veterans Claims (Court) has held that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Therefore, the issue was recharacterized as shown on the first page of this decision. The issues on appeal have been recharacterized and/or reorganized as reflected on the cover page of this document for purposes of clarity and to provide better organization in an attempt to more specifically reflect the Veteran's intentions. The issues of entitlement to a higher initial disability rating for the service-connected lumbar paravertebral myositis and muscle spasm with early degenerative changes from L3 to S1 (lumbar spine disability) rated as 30 percent disabling from December 21, 2003 and rated as 40 percent disabling from April 5, 2005; entitlement to an effective date prior to March 18, 2004 for the grant of service connection for hypertension; entitlement to service connection for an acquired psychiatric disability other than depressive disorder, including, but not limited to PTSD, generalized anxiety disorder, and major depressive disorder; entitlement to an initial compensable disability rating for the service-connected right knee patellar tendonitis, status post anterior cruciate ligament (ACL) repair; entitlement to service connection for an ear disorder, other than tinnitus; entitlement to service connection for a disability of the cervical spine; entitlement to service connection for joint pain, muscular pain, loss of memory, dizziness, rash, fatigue and shortness of breath, to include as part of an undiagnosed multi-symptom illness pursuant to 38 C.F.R. § 3.317; and entitlement to a total disability rating for compensation purposes based on individual unemployability due to service-connected disabilities (TDIU) are addressed in the REMAND portion of the decision below and are REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. The medical and lay evidence of record is credible, and it establishes that the Veteran, as likely as not, developed depressive disorder, NOS, during service. 2. The medical and lay evidence of record is credible, and it establishes that chronic recurring headaches of the migraine type were first shown during service and have continued since that time. CONCLUSIONS OF LAW 1. Resolving all doubt in the Veteran's favor, depressive disorder, NOS, was incurred in service. 38 U.S.C.A. §§ 1101, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). Resolving all doubt in the Veteran's favor, a headache disability was incurred in service. 38 U.S.C.A. §§ 1110, 7104 (West 2002); 38 C.F.R. §§ 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The grant of service connection for a disability manifested by headaches of the migraine type, and depressive disorder, NOS, constitutes a complete grant of the benefits sought on appeal with respect to those issue. As such, any defect with regard to VA's duty to notify and assist the Veteran with the development of his claim with respect to these grants of service connection is harmless error, and no further discussion of VA's duty to notify and assist is necessary. The Veteran seeks service connection for an acquired psychiatric disorder and chronic headaches. Historically, the Veteran served on active duty from September 1999 to December 2003. He asserts that he developed a psychiatric disorder and chronic headaches during service and has experienced symptoms ever since. The Veteran has sought service connection for an acquired psychiatric disorder and a headache disorder since his separation from service in December 2003. His initial claim of service connection for a psychiatric disorder in January 2004 was denied because the RO indicated that the Veteran's service treatment records (STRs) failed to show a diagnosis or treatment for any acquired psychiatric disorder. The claim of service connection for headaches was initially denied because the RO determined that the Veteran did not have an in-service diagnosis of migraine, and therefore service connection on a direct basis was not warranted. Furthermore, the RO found that service connection on a presumptive basis was not warranted because although the diagnosis of migraine-type headaches was made within the first post-service year, the severity of the disability was not shown to be at least 10 percent disabling. Thus, service connection was not warranted pursuant to 38 C.F.R. § § 3.307, 3.309. In general, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also 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). Where there is a chronic disease shown as such in service or within the presumptive period under § 3.307 so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however, remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). This rule does not mean that any manifestations in service will permit service connection. To show chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time as distinguished from merely isolated findings or a diagnosis including the word "chronic". When the disease entity is established, there is no requirement of evidentiary showing of continuity. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Continuous service for 90 days or more during a period of war, or peace time service after December 31, 1946, and post-service development of a presumptive disease such as migraine headaches to a degree of 10 percent within one year from the date of termination of such service, establishes a rebuttable presumption that the disease was incurred in service. 38 U.S.C.A. §§ 1101, 1112, 1113; 1137; 38 C.F.R. §§ 3.307, 3.309. The credibility and weight of all the evidence, including the medical evidence, should be assessed to determine its probative value, and the evidence found to be persuasive or unpersuasive should be accounted for, and reasons should be provided for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a) (West 2002); 38 C.F.R. § 3.303(a) (2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Psychiatric disorder The STRs show that the Veteran reported psychiatric symptoms on his post-deployment health assessment forms in July 2003 after his return from Iraq. He specifically indicated that, although he was not directly involved in combat, he reported, by checking a box corresponding to "a lot" that he felt little interest or pleasure in doing things and felt down, depressed, or hopeless. The Veteran also reported that over the previous month, he had feelings of being on guard, watchful or being easily startled by an event. He also indicated that recent experiences made him feel numb or detached from others, activities and surroundings. The Veteran also indicated that he had thoughts or concerns that he may have serious conflicts with his spouse, family members or friends and/or that he might verbally lose control with someone. Shortly after discharge from service, a VA outpatient psychiatric treatment record from January 2004 reveals that the Veteran presented with a persistent depressed mood, irritability, insomnia, nightmares with war content, anxiety, death wishes and alcohol abuse for the prior month. The Veteran reported to the examiner that he had never before abused alcohol but he had been unable to control his intake over the previous month even though he knew it was hurtful to himself and his family. On examination, the Veteran's mood was depressed. The diagnostic impression was depression, not otherwise specified (NOS). The Veteran was prescribed medication for depression and anxiety. At a follow-up appointment one month later, the Veteran reported some improvement in his mood, although it was inconsistent. The Veteran stopped taking seroquel due to sedation. The diagnostic impression remained depressive disorder, NOS, and PTSD was to be ruled out. On what appears to be a Gulf War registry examination dated in March 2004, the Veteran reported depression, strange dreams and other psychiatric symptomatology. The examiner noted a diagnosis of PTSD (2003). At a VA psychiatric examination in April 2004, the Veteran reported nightmares of situations where he finds himself in the same place in the desert, dressed in uniform. Although the Veteran did not serve in direct combat, he reportedly witnessed casualties and was reportedly heavily impacted by the living conditions of the people in Afghanistan. The Veteran reported anxiety and insomnia, irritability and a lack of desire to socialize. The Veteran also reports that he becomes verbally aggressive with his wife. On examination, the Veteran's mood was anxious, depressed, and somewhat tense. Affect was constricted. Attention, concentration and memory were only fair. The diagnosis was depressive disorder, NOS, with anxiety features. A March 2005 private medical report from Dr. J.L.M., MD, indicates that the Veteran has a diagnosis of major depressive disorder, recurrent severe with psychotic features due to severe general medical conditions; and, a diagnosis of PTSD. The examiner also indicated that bipolar mixed type needed to be ruled out. In complete contrast to the VA medical records, the private report indicates that the Veteran's prognosis is "very poor poor" and that the Veteran is not able to handle his funds. A July 2005 VA "Gulf War Guidelines" examination also notes diagnoses of PTSD and anxiety disorder. A July 2005 VA psychiatric examination notes a review of the claims file, and in particular, the private treatment record of March 2005 noted above. The VA examiner specifically noted that the diagnosis of PTSD was not based on any identified stressors. Based on a mental status examination of the Veteran, the examiner concluded that the Veteran did not meet the DSM-IV criteria for a diagnosis of PTSD; however, he did diagnose depressive disorder, NOS. VA in-patient treatment records show that the Veteran was admitted as an in-patient to a VA facility due to mental health instability. A March 2006 discharge summary notes that the Veteran was admitted for approximately two weeks with an admission diagnosis of major depressive disorder recurrent with psychotic features; PTSD in acute exacerbation. In sum, the evidence of record reveals a clear and unquestionable diagnosis of depressive disorder, NOS, immediately after service separation and thereafter. In a VA medical record of February 2004 the Veteran's report of frequent nightmares and intrusive thoughts since returning from deployment was noted. He also had a sad mood, poor sleep, short temper, and often irritable. The clinician diagnosed depressive disorder, NOS. Although other psychiatric diagnoses have been suggested or diagnosed by one or more examiners, a depressive disorder has been consistently diagnosed by medical professionals since discharge from service. The Veteran reported symptoms of an acquired psychiatric disorder during service, and this is documented in the STRS. The evidence further reflects continuity of symptoms since discharge from service, beginning in January 2004, the month following discharge from service. In sum, the Veteran has a diagnosis of depressive disorder, NOS, which was diagnosed shortly after discharge from service. Given the Veteran's credible statements regarding the onset of his psychiatric symptoms in service, as well as the STR evidence showing reports of post-deployment symptomatology in service, and the continuity of the post-service medical evidence of record, beginning in January 2004, almost immediately following his December 2003 service separation, continuity of depressive disorder, NOS, symptoms since service is shown in this case. The Veteran is competent to report what happened to him, and in particular, when he began to have depressive symptoms, and there is no reason to doubt the Veteran's credibility in this regard. Moreover, continuity of symptoms is shown by the objective evidence of record in this case. The Veteran reported that he had depression and nervousness when he was discharged from service, and has attempted to establish service connection for the disability ever since. Based on the foregoing, it is at least as likely as not that the Veteran's depressive disorder, NOS, had its onset during service. In sum, the Veteran has medical evidence of a depressive disorder, NOS; he has provided competent and credible statements regarding in-service onset of symptoms and various VA examiner have noted the Veteran's in-service onset of symptoms and continuity ever since service. Furthermore, the claims file shows continuity of symptoms of major depressive disorder since discharge from service. Thus, the criteria for entitlement to service connection for major depressive disorder are met in this case. The Veteran is therefore entitled to the benefit of the doubt. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Accordingly service connection for depressive disorder, NOS, is warranted. Headaches With regard to the claim of service connection for headaches, the STRs also show, on the same 2003 post-deployment form, that the Veteran reported that he experienced headaches while deployed in the Middle East. A VA examination in April 2004 noted the Veteran's reports of the onset of headaches while in Afghanistan. He reportedly never went to sick call for the headaches. He took Panadol or Motrin with benefit within one hour. The Veteran described the headaches as right-sided, with a pressure combined with a pulsatile throbbing sensation with the pain rated a 7 out of 10 on the pain intensity scale. The headaches are accompanied by photo and sonophobia. The headaches were more frequent while on active duty, but he still reported about two per week currently. The examiner noted that the Veteran's medical chart revealed that the Veteran's current treatment involved multiple medications prescribed by his primary care physician. The diagnosis was chronic recurring headaches of the migraine-type, non prostrating, as described. After reviewing the evidence, the criteria for a headache disability are also met. The Veteran reported headaches on his post-deployment health assessment and a VA examiner in April 2004, only 4 months after discharge from service provided a diagnosis of migraine-type headaches. Although the severity of the headaches may not have risen to a compensable degree at that time, which would have warranted service connection on a presumptive basis, the evidence nonetheless establishes continuity of symptoms since service. As such, service connection on a direct basis is warranted. The Veteran is competent to report a symptom such as headache pain, and there is no reason to doubt his credibility in that regard. He reports that the headaches began in Afghanistan and continued thereafter and a medical professional has provided a diagnosis of chronic recurring headaches of the migraine-type. Evidence of headaches is shown on the STRs, and a chronic headache disability is diagnosed only 4 months post service. These findings, along with the Veteran's credible statements regarding his symptoms during service, and thereafter, during the VA examination of April 2004 provides the requisite evidence to grant this claim. Given the evidence of in-service onset of headaches, and, continuity of symptoms since service, all doubt is resolved in favor of the Veteran and the criteria are met for establishing service connection for headaches. The Veteran is therefore entitled to the benefit of the doubt. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Accordingly service connection for headaches is warranted. (CONTINUED ON NEXT PAGE) ORDER Service connection for depressive disorder, NOS, is granted. Service connection for migraine-type headaches is granted. REMAND In addition to having a diagnosis of depressive disorder, NOS, the Veteran's psychiatric disorder has been variously diagnosed as PTSD, a generalized anxiety disorder, adjustment disorder and major depressive disorder. As noted in the Introduction, the Court held that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Therefore, the Board must consider whether during the pendency of his claim, the Veteran suffers from psychiatric disabilities other than the service-connected depressive disorder, NOS, that are related to active service and determine whether any other service-connected disabilities may have different symptoms from those attributed to the service-connected major depressive disorder. Although VA's anti-pyramiding regulation precludes the evaluation of the same disability under various diagnoses, the Board must still determine whether the Veteran in fact has separately diagnosed disabilities. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (2009) (stating that the veteran's "bipolar affective disorder and PTSD could have different symptoms and it could therefore be improper in some circumstances for the VA to treat these separately diagnosed conditions as producing only the same disability"). It was noted that for rating purposes, the question is whether the defined diagnoses have overlapping symptomatology. Id. This is both factual and medical determination that may change over time. See Amberman. (noting the Board's acknowledgment that the veteran's bipolar affective disorder and PTSD may be assigned separate ratings "if the record ever subsequently contains competent evidence which distinguishes manifestations" of one disorder from the other). In light of the foregoing, the RO must determine whether the Veteran has PTSD, generalized anxiety disorder, major depressive disorder, adjustment disorder, and/or any other acquired psychiatric disorder. In this regard, the RO must schedule the Veteran for a VA examination to determine from what, if any, psychiatric disabilities the Veteran suffers, other than the consistently diagnosed depressive disorder, NOS, for which the Veteran has established service-connection. With regard to the Veteran's claim of service connection for PTSD, service connection for PTSD, as opposed to other acquired psychiatric disorders, requires that three elements must be present according to VA regulations: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) a link, established by medical evidence, between the current symptoms and the claimed in-service stressor. 38 C.F.R. § 3.304(f) (2011). See Cohen v. Brown, 10 Vet. App. 128, 138 (1997). The diagnosis of a mental disorder must conform to the Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV), and be supported by the findings of a medical examiner. See 38 C.F.R. § 4.125 (a) (2011). In adjudicating a claim for service connection for PTSD, VA is required to evaluate the supporting evidence in light of the places, types, and circumstances of service, as evidenced by service records, the official history of each organization in which the veteran served, the veteran's military records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a) (West 2002); 38 C.F.R. §§ 3.303(a), 3.304 (2011). The evidence necessary to establish the occurrence of a recognizable stressor during service to support a diagnosis of PTSD will vary depending upon whether the veteran engaged in "combat with the enemy." 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 appellant's service), the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. See 38 C.F.R. § 3.304(d) (2011); see also 38 U.S.C.A. § 1154(b) (West 2002); VAOPGCPREC 12-99. VA General Counsel has held that "[t]he ordinary meaning of the phrase 'engaged in combat with the enemy,' as used in 38 U.S.C.A. § 1154(b), requires that a veteran have participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality." The determination whether evidence establishes that a veteran engaged in combat with the enemy is resolved on a case-by-case basis with evaluation of all pertinent evidence and assessment of the credibility, probative value, and relative weight of the evidence. VAOGCPREC 12-99; 65 Fed. Reg. 6,256-58 (Feb. 8, 2000). Effective July 13, 2010, VA amended 38 C.F.R. § 3.304(f). The amended version of 38 C.F.R. § 3.304(f)(3) eliminated the need for stressor corroboration in circumstances in which the veteran's claimed in-service stressor is related to "fear of hostile military or terrorist activity." Specifically, the amended version of 38 C.F.R. § 3.304(f)(3) states: If a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. See 75 Fed. Reg. 39,843-39,852 (July 13, 2010), codified at 38 C.F.R. § 3.304(f)(3) (2011). It appears from the record that the Veteran's claimed stressors have not been corroborated, and that there may not be enough evidence to corroborated them. However, given the recent regulation change, and the fact that the Veteran's service included service in the war zone in Iraq and Afghanistan, the VA psychiatric examiner should obtain a history of the Veteran's deployment, and determine or opine as to whether the Veteran's stressor(s) are related to his fear of hostile military or terrorist activity; and, if so, whether the Veteran's symptoms meet the criteria for a DSM IV diagnosis of PTSD based on the Veteran's service. In addition, the Board notes that the Veteran's private physician, Dr. Lopez, diagnosed major depressive disorder due to severe general medical conditions including disorders that are not currently service-connected. As a result the issue of secondary service connection is raised and VA should notify the Veteran how he can substantiate his claim on that basis. The issues of entitlement to a higher initial disability rating for the service-connected lumbar paravertebral myositis and muscle spasm with early degenerative changes from L3 to S1 (lumbar spine disability) rated as 30 percent disabling from December 21, 2003 and rated as 40 percent disabling from April 5, 2005 must be remanded to afford the Veteran adequate due process of law. The RO increased the disability rating for the low back disability from 30 percent to 40 percent, effective from April 5, 2005, the date on which the RO perceived the Veteran to have filed a claim for an increased rating. However, as noted in the Introduction section above, the Board construes the April 2005 document as a substantive appeal with regard to the issue of entitlement to a higher initial rating for the service-connected lumbar spine disability. In light of this finding, the RO must readjudicate the claim for increase based on a finding that the Veteran's appeal is timely as to the issue of entitlement to an initial disability rating in excess of 30 percent for the service-connected lumbar spine disability. In other words, the RO must consider whether a disability rating in excess of 30 percent is warranted during the entire time period since the grant of service connection (and whether a rating in excess of 40 percent is warranted since April 5, 2005). Moreover, since the last VA examination of record was conducted in 2005, nearly 7 years ago, a contemporaneous VA examination of the spine is necessary to assess the current nature, extent and severity of the service-connected low back disability. With regard to the issue of entitlement to an effective date prior to March 18, 2004 for the grant of service connection for hypertension, the RO did not include this issue in any supplemental statements of the case (SSOC's) because it considered the issue unappealed. More specifically, as noted in the Introduction section above, the RO addressed the issue in a January 2005 SOC, but the RO never addressed the issue again because, as with the other issues listed on that SOC, the RO did not consider the Veteran to have timely appealed those issues. However, the Board has determined that the Veteran clearly intended to appeal the issues on the January 2005 and the RO should have considered the Veteran's numerous statements received within the appeal period as timely substantive appeals in lieu of a VA Form 9. As such, the issue of entitlement to an effective date prior to March 18, 2004 for the grant of service connection for hypertension is on appeal and the RO must now notify the Veteran of this fact and allow the Veteran an appropriate amount of time to submit evidence in support of his claim. With regard to the claim of entitlement to service connection for an ear disorder, other than tinnitus, there is some question as to what exactly the Veteran is claiming at this point. In his June 2004 NOD, the Veteran specifically indicated that the "ear condition" that he was claiming was tinnitus. The RO treated this as a new claim of service connection for tinnitus and subsequently granted service connection for tinnitus. The Veteran did not subsequently disagree with the initial 10 percent disability rating assigned for the service-connected tinnitus, and the Veteran has not subsequently expressed any desire or submitted any correspondence or evidence clarifying what, if any, "ear condition" other than tinnitus, he is intended to service connect. Thus, although the Veteran has perfected a claim of service connection for "an ear condition" it is unclear as to what disability, if any, the Veteran is claiming at this point as service connection for tinnitus has been granted. On remand, the Veteran should be asked to clarify what ear condition, if any, to include hearing loss and/or some specific ear disease, (other than tinnitus) for which he is claiming service connection. Then, if warranted, the Veteran should be afforded an appropriate examination to determine whether such ear condition exists and to obtain a nexus opinion. With regard to the claim of service connection for a cervical spine disorder, the claim was last denied because the evidence of record at that time did not show a current diagnosis of a neck disability. The RO found that the spine examinations of April 2004 and July 2005 specifically did not show complaints of a cervical condition. However, it is critical to note that these examinations were specifically limited to the lumbar spine; therefore, it is not surprising that the Veteran's neck complaints were not mentioned on those reports. Moreover, the more recent VA outpatient treatment records dated in January 2008 show a diagnosis of cervicalgia. Although the Veteran's one-time in-service notation of neck pain was associated with a viral gastroenteritis, the Veteran is nonetheless competent to state that he suffers from neck pain that began during service. In light of the foregoing, he should be afforded a VA examination to determine what current neck disability exists, and whether any current neck disability had its onset during service or is otherwise related thereto. With regard to the claims of service connection for joint pain, muscular pain, loss of memory, dizziness, rash, fatigue and shortness of breath, the Veteran asserts that he has joint pain, muscular pain, loss of memory, dizziness, rash, fatigue and shortness of breath, to include as part of an undiagnosed multi-symptom illness pursuant to 38 C.F.R. § 3.317. He asserts that service connection is warranted pursuant to 38 C.F.R. § 3.317 based on service in the Southwest Asia Theater of Operations during the Persian Gulf War. Because the Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War, service connection may also be established under 38 C.F.R. § 3.317. Under that section, service connection may be warranted for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than not later than December 31, 2016. 38 C.F.R. § 3.317(a)(1). (Effective December 29, 2011, VA revised § 3.317(a)(1)(i) to extend the period during which disabilities associated with undiagnosed illnesses and medically unexplained chronic multisymptom illnesses must become manifest in order for a veteran to be eligible for compensation. The period was extended from December 31, 2011 to December 31, 2016. See 76 Fed. Reg. 81,834 (Dec. 29, 2011) (interim final rule extending statutory period). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. 1117(d) warrants a presumption of service-connection. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117 ; 38 C.F.R. § 3.117 , unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. A medically unexplained chronic multi symptom illnesses is one defined by a cluster of signs or symptoms, and specifically includes chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome, as well as any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multi symptom illness. A "medically unexplained chronic multi symptom illness" means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multi symptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). For purposes of section 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). According to the Veteran's DD Form 214, he did serve in Southwest Asia, in both Afghanistan and Iraq. His STRs show that on an April 2003 post-deployment health assessment, the Veteran reported symptoms of fatigue, weakness, malaise, and headaches, generalized body aches, joint pain, skin rash, difficulty remembering, difficulty breathing and dizziness during his deployment. The Veteran also noted that he was not seen in sick call at all during that deployment, despite his complaints. At a July 2005 VA Gulf War Guidelines examination, the Veteran was diagnosed with various objectively identifiable disabilities including hypertension; a right ACL tear, post operative repair; degenerative disc disease of the lumbar spine; other unspecified degenerative joint disease (arthritis); muscular spasm due to low back pain; and gastroesophageal reflux disease. However, the examiner also noted "generalized arthralgias and myalgias" but provided no opinion as to etiology. In addition, the examiner did not address the Veteran's reports of fatigue, dizziness, shortness of breath, skin rash or claimed memory impairment, particularly in the context of whether the Veteran might have an undiagnosed illness manifested by a cluster of symptoms such as the ones he reports. In light of the Veteran's complaints in the STRs, as well as the reports of symptoms since service, as well as his reports of neck pain, he should be afforded a VA examination to determine whether he suffers from an undiagnosed illness manifested by the reported symptoms. If no undiagnosed illness is found, then the examiner should opine as to whether the Veteran has objective findings of the claimed symptoms and if so, whether there is any relationship between a current disability and service. With regard to the claim of entitlement to an initial compensable disability rating for the service-connected right knee patellar tendonitis, status post anterior cruciate ligament (ACL) repair, the RO issued a rating decision granting service connection for this disability in May 2004. In January 2005, the Veteran submitted a notice of disagreement (NOD) with respect to the initial noncompensable disability rating assigned following the grant of service connection for the right knee disability. The RO has not yet issued a Statement of the Case as to the issue of entitlement to an initial compensable rating for the service-connected right knee patellar tendonitis status post ACL repair. As such, the RO is now required to send the Veteran a statement of the case as to this issues in accordance with 38 U.S.C.A. § 7105 (West 2002) and 38 C.F.R. §§ 19.29, 19.30 (2012). In this regard, the United States Court of Appeals for Veterans Claims (Court) has held that where a Notice of Disagreement has been submitted, the veteran is entitled to a Statement of the Case. The failure to issue a Statement of the Case is a procedural defect requiring a remand. Manlincon v. West 12 Vet. App. 238 (1999); Godfrey v. Brown, 7 Vet. App. 398 (1995). In addition, VA treatment records dated from January 2008 should be obtained. See Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA has constructive notice of VA generated documents that could reasonably be expected to be part of the record). In addition, it appears that records dating from December 2004 to April 2006 may not all have been obtained. The Board notes that the Veteran is in receipt of Social Security Administration (SSA) disability benefits. It does not appear, however, that the RO attempted to obtain the records upon which SSA relied in reaching its decision. The Court of Appeals for Veterans Claims has held that VA's duty to assist encompasses obtaining medical records that supported an SSA award of disability benefits as they may contain information relevant to VA claims. Murincsak v. Derwinski, 2 Vet. App. 363, 369-70 (1992); see also 38 U.S.C.A. § 5103A(c)(3) (West 2002); 38 C.F.R. § 3.159(c)(2) (2011); Diorio v. Nicholson, 20 Vet. App. 193, 199-200 (2006); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Those records should be requested, and associated with the Veteran's claims file. Finally, the Veteran maintains that he is unable to work due to his service-connected disabilities. The law provides that TDIU may be granted upon a showing that the Veteran is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his or her service-connected disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. Consideration may be given to a Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his or her age or the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. In this regard, TDIU may be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). If there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. Id. If, however, a Veteran fails to meet the applicable percentage standards enunciated in 38 C.F.R. § 4.16(a), rating boards should refer to the Director, Compensation and Pension Service for extra-schedular consideration all cases where the Veteran is unable to secure or follow a substantially gainful occupation by reason of service- connected disability. 38 C.F.R. § 4.16(b). See also Fanning v. Brown, 4 Vet. App. 225 (1993). The Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16(b). With regard to the claim for a TDIU, this issue is inextricably intertwined with the above described increased rating and service connection issues. Thus, the Veteran's TDIU claim must be deferred pending the outcome of his other claim(s). See Holland v. Brown, 6 Vet. App. 443 (1994). Accordingly, the case is REMANDED for the following action: 1. Given the complicated procedural history in this case, send the Veteran an updated Duty-to-Assist letter to the Veteran addressing all of the Veteran's claims on appeal as indicated by this Decision/Remand. Ensure that the letter complies with 38 C.F.R. § 3.159 and that the Veteran is informed as to how he can substantiate his claim for service connection for a psychiatric disorder as secondary to service-connected disabilities. In the letter, inform the Veteran that his claim for an effective date prior to March 18, 2004 for the grant of service connection for hypertension is on appeal, and provide him with adequate notice of what is necessary to substantiate this claim. Clarify whether the Veteran's grant of service connection for tinnitus satisfies his claim of service connection for an ear condition, and if not, request that he provide a specific ear disability or symptoms of an ear disability for which he is claiming service connection, including, but not limited to, hearing loss. If the Veteran identifies a specific ear disability, or symptoms of an ear disability, then conduct any development deemed appropriate, including, but not limited to a VA examination. 2. Obtain and associate with the claims file the following VA medical records pertaining to the Veteran: a. VA medical records dating from December 2004 to April 2006; and b. VA medical records dating from January 2008. 3. Request, directly from the SSA, complete copies of any determination on a claim for disability benefits from that agency as well as the records, including medical records, considered in adjudicating the claim. All attempts to fulfill this development should be documented in the claims file. All attempts to fulfill this development should be documented in the claims file. If after continued efforts to obtain the records it is concluded that it is reasonably certain they do not exist or further efforts to obtain them would be futile, the RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the RO with respect to the claim; and (d) inform the Veteran that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. 4. Request that the Veteran identify any non-VA records relevant to his claims. With appropriate authorization from the Veteran, obtain and associate with the claims file all pertinent private treatment records identified by the Veteran that have not already been obtained. If, after making reasonable efforts to obtain named records the RO is unable to secure same, the RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the RO with respect to the claim; and (d) inform the Veteran that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. 5. Schedule the Veteran for a VA examination by an appropriate physician to examine the Veteran's cervical spine and lumbar spine. The claims file must be made available to, and reviewed by, the examiner, and the examination report must reflect that the claims file was reviewed. a. The examiner is specifically requested to identify any current disabilities of the cervical spine. Then, the examiner is requested to opine as to whether any such disability, at least as likely as not (50 percent probability or greater), had its onset during service or within the first post-service year; and/or whether any such disability is at least as likely as not related to any disease or injury in service. Importantly, the examiner's opinion should consider the Veteran's STRs which show complaints of joint pain. Additionally, the examiner should consider the Veteran's statements as to his injuries sustained during service and his description of symptoms during service and thereafter. b. With regard to the service-connected lumbar spine disability, the examiner should determine the nature, extent, and severity of the service-connected lumbar spine disability since his service separation. All indicated tests, including X-ray, magnetic resonance imaging (MRI) if indicated, and range of motion studies, must be conducted. The claims file must be made available to and reviewed by the examiner in conjunction with the examination. The examiner should indicate if the Veteran's low back disability is productive of incapacitating episodes as described in the rating schedule, and if so, determine the frequency of any incapacitating episodes in terms of the rating schedule. The examiner should provide an opinion as to the extent that pain limits the functional ability of the back in terms of additional functional limitation due to pain. The examiner should describe the extent the lumbar spine disability exhibits weakened movement, excess fatigability, incoordination, and/or ankylosis. These determinations should be expressed in terms of the degree of additional range of motion loss. The examiner should also portray the degree of additional range of motion loss due to pain on use or during flare-ups. The examiner should also determine whether the Veteran's service-connected low back disability is productive of any associated neurologic abnormalities, including in the lower extremities and bowel or bladder impairment and, if so, the level of severity. 6. Schedule the Veteran for the appropriate VA examination(s) to determine if the Veteran has an undiagnosed illness manifested by his reported symptoms of joint pain, muscular pain, loss of memory, dizziness, rash, fatigue and shortness of breath. In so doing, the examiner must first address each of the Veteran's reported symptoms and determine whether there are any objective signs and/or symptoms of the existence of such reported symptoms; and, if so, then opine as to whether any such symptoms can be attributed to a known clinical diagnosis. After addressing each symptom separately, the examiner should opine as to whether any diagnosed disability, at least as likely as not (a 50 percent or greater likelihood) had its onset during service, or is otherwise related to any disease or injury in service. For symptoms without a known diagnosis, the examiner should address whether the Veteran's reported undiagnosed symptoms represent an undiagnosed illness or a medically unexplained chronic multisymptom illness, such as chronic fatigue syndrome and/or fibromyalgia, for example. The claims file must be made available to, and reviewed by, the examiner, and the examination report must reflect that the claims file was reviewed. Importantly, the examiner's opinion should consider the Veteran's STRs which show post-deployment complaints of the above noted symptoms. Additionally, the examiner should consider the Veteran's credible and competent statements as to his symptoms during service and his description of symptoms and any treatment by healthcare providers thereafter. 7. Schedule the Veteran for a VA psychiatric examination to determine the current nature and likely etiology of any acquired psychiatric disorder, other than depressive disorder, NOS, to include, but not limited to PTSD, generalized anxiety disorder, major depressive disorder and adjustment disorder. The claims folder must be made available to and reviewed by the examiner in conjunction with the requested study. The examiner in this regard should elicit from the Veteran and record a full clinical history referable to acquired psychiatric disorders, including the PTSD. The examiner must thoroughly review the Veteran's claims file, to include a copy of this remand, and any additional pertinent evidence added to the record. The examiner should first identify what current psychiatric disorder(s) exist and reconcile the disorder(s) found with the psychiatric diagnoses of record. If the symptoms of one psychiatric disorder are overlapping with any other psychiatric disorder, the examiner should so state, in as much detail as possible. The examiner should opine as to whether the Veteran's acquired psychiatric disorder(s), diagnosed as adjustment disorder, major depressive disorder, and generalized anxiety disorder began in or are related to active service. See VA treatment records dated in April 2004 and August 2007 as well as the March 2005 report of Dr. Lopez. Please provide a complete explanation for the opinion. The examiner should also address whether it is at least as likely as not (a probability of 50 percent or greater) that adjustment disorder, major depressive disorder, and generalized anxiety disorder, are due to service-connected disabilities. See the March 2005 report of Dr. Lopez. Please provide a complete explanation for the opinion. If not, are adjustment disorder, major depressive disorder, and generalized anxiety disorder at least as likely as not aggravated (i.e., worsened in severity) beyond the natural progress by service-connected disabilities. Please provide a complete explanation for the opinion. Psychological testing deemed warranted should be conducted with a view toward determining whether the Veteran in fact meets the criteria for a diagnosis of PTSD. The VA or VA-contracted psychiatrist or psychologist must identify the specific stressor(s)underlying any PTSD diagnosis and comment upon the link between the current symptomatology and the Veteran's stressor(s). In the report, the examiner must address whether it is at least as likely as not (a probability of 50 percent or greater) that any diagnosed PTSD is related to his fear of hostile military or terrorist activity. If not, is it at least as likely as not (a probability of 50 percent or greater) that any diagnosed PTSD is related to a specific stressor identified by the Veteran. Please provide a complete explanation for the opinion. 8. Provide the Veteran with a Statement of the Case as to the issues of entitlement to an initial compensable disability rating for the service-connected right knee patellar tendonitis, status post anterior cruciate ligament (ACL) tear, in accordance with 38 U.S.C.A. § 7105 (West 2002) and 38 C.F.R. §§ 19.29, 19.30 (2012). If the Veteran perfects his appeal by submitting a timely and adequate substantive appeal, then the RO should return the claim to the Board for the purpose of appellate disposition. 9. After conducting any further development deemed necessary and ensuring that all examinations are complete, readjudicate the issues on appeal. If any benefit sought remains denied, the Veteran and his representative should be furnished a supplemental statement of the case in accordance with 38 C.F.R. § 19.31(b)(1), to include the issue of entitlement to an effective date prior to March 18, 2004, for the grant of service connection for hypertension, and be given an opportunity to respond. The case should then be returned to the Board for appellate review, if indicated. The appellant has the right to submit additional evidence and argument on the matter or matters 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 Supp. 2012). ______________________________________________ S. S. TOTH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs