Citation Nr: 0810904 Decision Date: 04/02/08 Archive Date: 04/14/08 DOCKET NO. 03-09 642 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to service- connected hepatitis C. 2. Entitlement to service connection for status post cholecystectomy, to include as secondary to service-connected hepatitis C. 3. Entitlement to service connection for status post appendectomy, to include as secondary to service-connected hepatitis C. 4. Entitlement to service connection for migraine headaches, to include as secondary to service-connected hepatitis C. 5. Entitlement to service connection for hypertension, to include as secondary to service-connected hepatitis C. 6. Entitlement to service connection for status post hysterectomy with a history of fibroid tumors, to include as secondary to service-connected hepatitis C. 7. Entitlement to service connection for a psychiatric disorder, to include major depression, an anxiety disorder with features of post-traumatic stress disorder (PTSD), and a psychotic disorder, to include as secondary to service- connected hepatitis C. 8. Entitlement to service connection for a chronic disability manifested by chest pain, to include as secondary to service-connected hepatitis C. 9. Entitlement to service connection for a chronic disability manifested by dizziness, to include as secondary to service-connected hepatitis C. 10. Entitlement to an initial compensable rating for service-connected recurrent urinary tract infections (UTIs). 11. Entitlement to a total disability rating based upon individual unemployability (TDIU) due to service-connected disabilities. ATTORNEY FOR THE BOARD E. Pomeranz, Counsel INTRODUCTION The veteran had active military service from March 1976 to March 1980. This matter comes before the Board of Veterans' Appeals (Board) on appeal of April 2004 and November 2004 rating actions by the Department of Veterans Affairs (VA) Regional Office (RO) located in Denver, Colorado. The Board notes that the issues of entitlement to service connection for the residuals of pre-eclampsia, hepatitis C, chronic fatigue syndrome, a chronic disability manifested by back and joint pains and post-operative residuals of a cesarean section necessitated by severe pre-eclampsia, to include a surgical scar, were all originally developed for appellate review. However, service connection for hepatitis C with chronic fatigue and back and joint pains as a result of pre-eclampsia, and service connection for status post cesarean scar, were ultimately granted by the RO in a July 2007 rating action. As the veteran has not appealed the ratings or effective dates assigned for these disabilities, there is no issue relating to hepatitis C with chronic fatigue and back and joint pains or status post cesarean scar that remains in appellate status. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). By a November 2005 action, the Board remanded this case for additional development. For the reasons addressed in the REMAND portion of the decision below, it is again necessary to return the issues of entitlement to service connection for a psychiatric disorder, to include major depression, an anxiety disorder with or without features of PTSD, to include as secondary to service-connected hepatitis C, and entitlement to a TDIU to the RO for further development. These issues are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. GERD was not shown during service or for many years thereafter; the preponderance of the evidence is against a nexus between a current diagnosis of GERD and service; the preponderance of the evidence is against a finding that the veteran's service-connected hepatitis C caused or aggravated her GERD. 2. The veteran underwent a cholecystectomy many years after her discharge from the military; the preponderance of the competent evidence is against a causal link between the veteran's gall bladder disease or cholecystectomy and active service; the preponderance of the competent evidence is against a finding that the veteran's service-connected hepatitis C caused or aggravated her gall bladder disease, cholecystectomy or residuals of a cholecystectomy. 3. The veteran underwent an appendectomy many years after her discharge from the military; the preponderance of the competent evidence is against a causal link between the veteran's appendectomy and active service; the preponderance of the competent evidence is against a finding that the veteran's service-connected hepatitis C caused or aggravated her appendicitis, appendectomy or residuals of an appendectomy. 4. The medical evidence shows that the veteran's migraine headaches were first diagnosed many years after her discharge from the military; the preponderance of the competent evidence is against a causal link between her migraine headaches and active service; the preponderance of the competent evidence is against a finding that the veteran's service-connected hepatitis C caused or aggravated her migraine headaches. 5. Hypertension was not shown during service or for many years thereafter; the preponderance of the evidence is against a nexus between a current diagnosis of hypertension and service; the preponderance of the evidence is against a finding that the veteran's service-connected hepatitis C caused or aggravated her hypertension. 6. The veteran underwent a hysterectomy due to fibroid tumors many years after her discharge from the military; the preponderance of the competent evidence is against a causal link between the veteran's fibroid tumors or resultant hysterectomy and active service; the preponderance of the competent evidence is against a finding that the veteran's service-connected hepatitis C caused or aggravated her fibroid tumors, hysterectomy or residuals of a hysterectomy. 7. There is no competent medical evidence of record showing a current diagnosis of a chronic disability manifested by chest pain. 8. There is no competent medical evidence of record showing a current diagnosis of a chronic disability manifested by dizziness. 9. The veteran has a history of intermittent UTIs that have not required long-term drug therapy, one to two hospitalizations per year or intermittent intensive management. CONCLUSIONS OF LAW 1. GERD was not incurred in or aggravated by active military service; nor is it proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1131, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.310 (2007). 2. The veteran's cholecystectomy and any residuals thereof were not incurred in or aggravated by active military service, nor are they proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1131, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.310 (2007). 3. The veteran's appendectomy and any residuals thereof were not incurred in or aggravated by active military service, nor are they proximately due to or the result of a service- connected disability. 38 U.S.C.A. §§ 1131, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.310 (2007). 4. A disability manifested by migraine headaches was not incurred in or aggravated by active military service, nor may an organic disability of the nervous system manifested by headaches be presumed to have been incurred therein; migraine syndrome is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1112, 1113, 1131, 1137, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2007). 5. Hypertension was not incurred in or aggravated by active military service, nor may hypertension be presumed to have been incurred therein; hypertension is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1112, 1113, 1131, 1137, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2007). 6. Fibroid tumors with a hysterectomy and residuals of a hysterectomy were not incurred in or aggravated by active military service, nor are they proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1131, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.310 (2007). 7. A claimed chronic disability manifested by chest pain was not incurred in or aggravated by active military service, nor is it proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1131, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.310 (2007). 8. A claimed chronic disability manifested by dizziness was not incurred in or aggravated by active military service, nor is it proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1131, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.310 (2007). 9. The criteria for an initial compensable disability rating for recurrent UTIs have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.115, 4.115b, Diagnostic Code 7512 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) The enactment of the VCAA, codified at 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002), significantly changed the law prior to the pendency of these claims. VA has issued final regulations to implement these statutory changes. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2007). The VCAA provisions include an enhanced duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits, and they redefine the obligations of VA with respect to the duty to assist the veteran with the claim. In the instant case, the Board finds that VA fulfilled its duties to the veteran under the VCAA. Duty to Notify VA has a duty to notify the veteran of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103. The Board concludes that the March 2003, July 2004, and January 2006 letters sent to the veteran by the RO adequately apprised her of the information and evidence needed to substantiate the claims. The RO thus complied with VCAA's notification requirements. In order to meet the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b), VCAA notice must: (1) inform the claimant about the information and evidence necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; (3) inform the claimant about the information and evidence the claimant is expected to provide; and (4) request that the claimant provide any evidence in his possession that pertains to the claim. Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). Additionally, during the pendency of this appeal, on March 3, 2006, the Court of Appeals for Veterans' Claims (Court) issued a decision in Dingess v. Nicholson, 19 Vet. App. 473, 484, 486 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id., at 486. This notice must also inform the veteran that a disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id. The Board finds that VA has met these duties with regard to the claims adjudicated on the merits in this decision. There is no issue as to providing an appropriate application form or completeness of the application. Written notice provide in March 2003, July 2004, and January 2006 fulfills the provisions of 38 U.S.C.A. § 5103(a). That is, the veteran was effectively informed to submit all relevant evidence in her possession and received notice of the evidence needed to substantiate her claims, the avenues by which she might obtain such evidence, and the allocation of responsibilities between herself and VA in obtaining such evidence. See Beverly, 19 Vet. App. at 394, 403; see also Mayfield v. Nicholson, 19 Vet. App. 103, 109-12 (2005) (Mayfield I) rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The Board also recognizes that, according to Pelegrini II, proper VCAA notice must "precede an initial unfavorable [agency of original jurisdiction (AOJ)] decision on a service-connection claim." With respect to the veteran's claims for service connection for GERD, status post cholecystectomy, status post appendectomy, migraine headaches, hypertension, and status post hysterectomy with fibroid tumors, written notice was provided in March 2003, prior to the appealed from rating decision, along with the subsequent notice provided in January 2006, after the decision that is the subject of this appeal. With respect to the veteran's claims for service connection for disabilities manifested by chest pain and dizziness, written notice was provided in July 2004, prior to the appealed from rating decision, along with the subsequent notice provided in January 2006, after the decision that is the subject of this appeal. With respect to the veteran's claim for a higher rating for her service-connected recurrent UTIs, written notice was provided in January 2006, after the RO's April 2004 grant of service connection and assignment of the initial noncompensable rating. As to any timing deficiency with respect to these notices, the veteran's claims were readjudicated in a July 2007 supplemental statement of the case. The United States Court of Appeals for the Federal Circuit has held that timing-of- notice errors can be "cured" by notification followed by readjudication. Mayfield v. Nicholson, 444 F.3d 1328, 133-34 (Fed. Cir. 2006) (Mayfield II); see Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) ("The Federal Circuit specifically mentioned two remedial measures: (1) The issuance of a fully compliant [section 5103(a)] notification, followed by (2) readjudication of the claim."); Pelegrini v. Principi, 18 Vet. App. 112, 122-24 (2004) ("proper subsequent VA process" can cure error in timing of notice). The Court has held that a supplemental statement of the case that complies with applicable due process and notification requirements constitutes a readjudication decision. Mayfield v. Nicholson, 20 Vet. App. 537, 541-42 (2006) (Mayfield III); see also Prickett, supra (holding that a statement of the case that complies with all applicable due process and notification requirements constitutes a readjudication decision). As the supplemental statement of the case complied with the applicable due process and notification requirements for a decision, it constitutes a readjudication decision. Accordingly, the provision of adequate notice followed by a readjudication "cures" any timing problem associated with inadequate notice or the lack of notice prior to an initial adjudication. Mayfield III, 20 Vet. App. at 541-42, citing Mayfield II, 444 F.3d at 1333-34.b With respect to notice of the two Dingess elements relating to effective dates and disability ratings, the Board notes that the veteran received this information in a July 2007 letter but such notice was post-decisional. See Pelegrini II, supra. As to this timing deficiency, the Board is cognizant of recent Federal Circuit decisions pertaining to prejudicial error. Specifically, in Sanders v. Nicholson, 487 F.3d 881 (2007), the Federal Circuit held that any error by VA in providing the notice required by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)(1) is presumed prejudicial and that once an error is identified by the Veterans Court, the burden shifts to VA to demonstrate that the error was not prejudicial. The Federal Circuit reversed the earlier holding of the Veterans Court in Sanders that an appellant before the Veterans Court has the initial burden of demonstrating prejudice due to VA error involving: (1) providing notice of the parties' respective obligations to obtain the information and evidence necessary to substantiate the claim: (2) requesting that the claimant provide ant pertinent evidence in the claimant's possession; and (3) failing to provide notice before a decision on the claim by the agency of original jurisdiction. See also Simmons v. Nicholson, 487 F. 3d 892 (Fed. Cir. 2007). The Court has held that an error "whether procedural or substantive, is prejudicial when [it] affects a substantial right so as to injure an interest that the statutory or regulatory provision involved was designed to protect such that the error affects 'the essential fairness of the [adjudication].'" Mayfield v. Nicholson, 19 Vet. App. 103, 109-12 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). That is, "the key to determining whether an error is prejudicial is the effect of the error on the essential fairness of the adjudication." Id. " [A]n error is not prejudicial when [it] did not affect 'the essential fairness of the [adjudication],'" and non-prejudicial error may be proven by demonstrating "that any defect in notice was cured by actual knowledge on the part of the [veteran] that certain evidence (i.e., the . . . evidence needed to substantiate the claim) was required and that [he] should have provided it." Id., at 121; accord Dalton v. Nicholson, 21 Vet. App. 23, 30 (2007) (determining that no prejudicial error to veteran resulted in defective VCAA notice when the veteran, through his counsel, displayed actual knowledge of the information and evidence necessary to substantiate his claim). Moreover, the Court has observed that "there could be no prejudice if the purpose behind the notice has been satisfied . . . that is, affording a claimant a meaningful opportunity to participate effectively in the processing of [the] claim. . . ." Mayfield, supra, at 128. The Board finds that the presumption of prejudice raised by the failure to provide timely notice of the Dingess requirements is rebutted because, as will be explained below in greater detail, the preponderance of the evidence is against the veteran's claims. Thus, any questions as to the appropriate disability ratings or effective dates to be assigned are moot. See Dingess, supra. Such a lack of timely notice did not affect or alter the essential fairness of the RO's decision. While the veteran does not have the burden of demonstrating prejudice, it is pertinent to note that the evidence does not show, nor does the veteran contend, that any notification deficiencies, either with respect to timing or content, have resulted in prejudice. Also, with respect to the claim for a compensable rating for recurrent UTIs, the Board notes that in the recent Court of Appeals for Veterans Claims case of Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), the Court found that, at a minimum, adequate VCAA notice requires that VA notify the claimant that, to substantiate such a claim: (1) the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life; (2) if the diagnostic code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect of that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement to the claimant; (3) the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes; and (4) the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation. In this case, the Board is aware that the VCAA letters of record do not contain the level of specificity set forth in Vazquez-Flores. However, the presumed error raised by such defect is rebutted because documentation in the claims file shows that the nature of the argument presented on behalf of the veteran displays actual knowledge of what is required to substantiate a claim for a compensable rating for recurrent UTIs. The Board also notes that the statement of the case issued to the veteran and his representative includes the criteria for a compensable rating for recurrent UTIs. Duty to Assist VA also has a duty to assist the veteran in obtaining evidence necessary to substantiate the claim. 38 U.S.C.A. § 5103A(a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the veteran in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth Secretary's various duties to claimant). VA informed the veteran of its duty to assist in obtaining records and supportive evidence. With respect to the veteran's claims for service connection for GERD, status post cholecystectomy, status post appendectomy, migraine headaches, and hypertension, and the veteran's claim for an initial compensable rating for service-connected recurrent UTIs, the veteran in fact did receive VA examinations in May 2007, which were thorough in nature and provided findings that are adequate for the purposes of deciding the aforementioned claims. These evaluations included nexus opinions, to include addressing the question of whether any of these disabilities are related to the veteran's hepatitis C. However, with respect to the veteran's claims for service connection for status post hysterectomy with a history of fibroid tumors, a chronic disability manifested by chest pain, and a chronic disability manifested by dizziness, the veteran did not receive a VA examination for the purposes of deciding these claims, apparently because the RO did not deem such an opinion or examination to be "necessary" to render its decision on the claims. See 38 U.S.C.A. § 5103A(d)(1); accord 38 C.F.R. § 3.159(c)(4). 38 U.S.C.A. § 5103A(d)(2) and 38 C.F.R. § (c )(4) require the Secretary to treat an examination or opinion as being necessary to make a decision on a claim if, taking into consideration all information and law or medical evidence (including statements of the veteran), there is "(1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim." McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); 38 U.S.C.A. § 5103A (d)(2); 38 C.F.R. §. 3.159(c)(4); see Disabled Am. Veterans v. Sec'y of Veterans Affairs, 419 F.3d 1317, 1318 (Fed. Cir. 2005) (discussing provisions of 38 U.S.C.A. § 5103A(d)); Paralyzed Veterans of Am. v. Sec'y of Veterans Affairs, 345 F.3d 1334, 1354-56 (2003) (discussing provisions of 38 C.F.R. § 3.159(c)(4) and upholding this section of the regulation as consistent with 38 U.S.C.A. § 5103A(d)). An affirmative answer to these elements results in a necessary medical examination or opinion; a negative response to any one element means that the Secretary need not provide such an examination or solicit such an opinion. See McLendon, supra, 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). Although the evidence of record shows that the veteran underwent a hysterectomy due to fibroid tumors, the record contains no competent medical opinion linking her fibroid tumors and hysterectomy to her active service or to her service-connected hepatitis C. Given the absence of a competent opinion supporting the contended causal relationship and the number of years that have elapsed since service, the Board finds that VA has no duty to provide an examination or medical opinion with respect to the claim for direct service connection. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon, supra; Wells v. Principi, 326 F.3d 1381, 1384 (Fed. Cir. 2003). As to the secondary service connection aspect of the claim, there is no competent evidence that suggests the veteran's fibroid tumors and hysterectomy for same was caused or aggravated by her hepatitis C, nor has any plausible theory of such a relationship been advanced. Thus, there is no duty to provide a medical opinion addressing this latter matter. With respect to the veteran's claims for service connection for chronic disabilities manifested by chest pain and dizziness, as explained below, the evidence of record does not reveal that the veteran currently has a chronic disability manifested by chest pain or a chronic disability manifested by dizziness. Under these circumstances, there is no duty to provide an examination or medical opinion. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon, supra. In view of the foregoing, the Board finds that the VA fulfilled its VCAA duties to notify and to assist the veteran, and thus, no additional assistance or notification was required. The veteran has suffered no prejudice that would warrant a remand, and her procedural rights have not been abridged. See Bernard v. Brown, 4 Vet. App. 384. II. Service Connection Claims A. Pertinent Law and Regulations Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in line of duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. "In line of duty" means any injury incurred or aggravated during a period of active military service, unless such injury was the result of the veteran's own willful misconduct or, for claims filed after October 31, 1990, was the result of the veteran's abuse of alcohol or drugs. 38 U.S.C.A. § 105(a); 38 C.F.R. §§ 3.1(m), 3.301. For certain chronic disorders, including organic diseases of the nervous system and cardiovascular- renal disease, to include hypertension, service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). Where the determinative issue involves medical causation or a medical diagnosis, there must be competent medical evidence to the effect that the claim is plausible; lay assertions of medical status do not constitute competent medical evidence. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). Alternatively, the nexus between service and the current disability can be satisfied by medical or lay evidence of continuity of symptomatology and medical evidence of a nexus between the present disability and the symptomatology. 38 C.F.R. § 3.303; see also, e.g., Voerth v. West, 13 Vet. App. 117 (1999); Savage v. Gober, 10 Vet. App. 488, 495 (1997). Service connection may also be established on a secondary basis for a disability which is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by a service-connected disability or (b) aggravated by a service- connected disability. Id.; Allen v. Brown, 7 Vet. App. 439, 488 (1995) (en banc). The Court has held that, when aggravation of a veteran's non-service-connected disability is proximately due to or the result of a service-connected disease or injury, it too shall be service connected, at least to the extent of the aggravation. Allen, 7 Vet. App. at 439. Effective October 10, 2006, 38 C.F.R. § 3.310 was amended to implement the holding in Allen v. Brown, 7 Vet. App. 439 (1995) for secondary service connection on the basis of the aggravation of a nonservice-connected disorder by service- connected disability. See 71 Fed. Reg. 52744 (2006). The amendment essentially codifies Allen with language that requires that a baseline level of severity of the nonservice- connected disease or injury must be established by medical evidence created before the onset of aggravation. B. GERD, Status Post Cholecystectomy, Status Post Appendectomy, Migraine Headaches, Hypertension and Status Post Hysterectomy With a History of Fibroid Tumors, all to Include as Secondary to Service-Connected Hepatitis C Factual Background The veteran's service medical records are negative for any complaints or findings of GERD, migraine headaches, hypertension, and/or fibroid tumors. The records are also negative for any evidence showing that the veteran underwent a cholecystectomy, an appendectomy, or a hysterectomy. The records show that in January 1980, the veteran underwent a Chapter 8 (hardship due to pregnancy) separation examination. At that time, in response to the question as to whether the veteran had ever had or if she currently had frequent indigestion, stomach, liver, or intestinal trouble, gall bladder trouble or gallstones, frequent or severe headaches, high or low blood pressure, and/or been treated for a female disorder, the veteran responded "no." The veteran's lungs and chest, heart, and abdomen and viscera were all clinically evaluated as "normal." The veteran was also clinically evaluated as "normal" for neurologic purposes. In a private medical statement from S.J., M.D., dated in November 2000, Dr. J. stated that the veteran suffered from numerous problems including recurrent migraine headaches and reflux disease which was well controlled with her present therapy. In August 2001, the RO received records from the Social Security Administration (SSA), which included a Disability Determination and Transmittal Report, dated in October 2000. The SSA Disability Determination and Transmittal Report shows that the veteran was awarded Social Security disability benefits for hepatitis C (primary diagnosis) and migraine headaches (secondary diagnosis). The SSA records also included private medical records, dated from February 1995 to June 2000. The records show that in February 1995, the veteran was diagnosed with migraine headaches and was prescribed medication. In August 1996, the veteran was treated in the Emergency Room for complaints of abdominal pain over the past week. She had an ultrasound taken of her gallbladder which showed that she had gallstones. The veteran subsequently underwent a laparoscopic cholecystectomy with operative cholangiograms, and a laparoscopic appendectomy. The post-operative diagnosis was cholelithiasis with biliary colic. In March 1999, the veteran was treated for complaints of abdominal pain. At that time, she stated that she had had the pain for the past few years. She subsequently underwent a pelvic ultrasound which showed that she had fibroids. In April 1999, the veteran underwent a transabdominal hysterectomy, a bilateral salpingo-oophorectomy, and adhesiolysis. The final diagnoses were uterine fibroids and endometriosis. In February 2004, the RO received VA Medical Center (VAMC) outpatient treatment records, dated from April 2003 to February 2004. The records show that in April 2003, the veteran was examined for unrelated disorders and the examiner noted that the veteran's hypertension was controlled with medication. According to the records, in August 2003, the veteran was treated for numerous complaints, including migraine headaches. At that time, she stated that the onset of the migraine headaches was approximately 10 to 15 years ago. She indicated that she had the headaches three to four times a week. She also noted that she had GERD. The diagnoses included migraine headaches and GERD Also in February 2004, the veteran underwent a VA examination. At that time, she stated that she had a history of GERD. The examiner noted that in 1996, the veteran underwent a cholecystectomy and an appendectomy. According to the examiner, the veteran had been going to the hospital for abdominal pain and no etiology could be found. The veteran underwent the aforementioned surgeries because the physicians thought that either one of those organs could be causing the problem. However, the veteran's abdominal pain did not resolve following the surgeries. In regard to the veteran's migraine headaches, she reported that her headaches started 15 years ago or approximately 1989. (The veteran was on active duty from March 1976 to March 1980.) According to the veteran, she had migraine headaches two to three times a week. With respect to her hypertension, the veteran noted that her hypertension was diagnosed two years ago and that she was started on medication. The veteran indicated that in 1998, she was treated for abdominal pain and was diagnosed with fibroid tumors. She subsequently underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Following the physical examination, the veteran was diagnosed with the following: (1) GERD, (2) status post appendectomy, (3) status post cholecystectomy, (4) migraine headaches, (5) hypertension, controlled, and (6) fibroids, status post hysterectomy. In September 2006, the RO received private medical records, dated from March 2002 to September 2004. The records show that in September 2004, the veteran was hospitalized for two days with an episode of severe left-sided headache, associated with aphasia. Upon admission, it was reported that she had a history of chronic headaches and hypertension. Her discharge diagnoses included episode of aphasia with severe headache, possibly complicated migraine, and hypertension. Pursuant to the Board's November 2005 remand decision, in May 2007, the veteran underwent a VA examination. At that time, the examiner noted that the veteran's medical history included GERD, status post cholecystectomy in 1996 for cholelithiasis with biliary colic, status post appendectomy, laparoscopic, in 1996, hypertension (the veteran had not been on any medications since March 2007 due to improvement in her blood pressure), chronic hepatitis C, transfusion induced, diagnosed in the 1980's, dizziness, and episode of aphasia, with severe headache, questionable complicated migraine in September 2004, with a normal MRI (magnetic resonance imaging) of the brain in September 2004. The examiner stated that the veteran underwent a hysterectomy in 1999 and was found to have fibroids. In regard to migraine headaches, the veteran reported that she developed intense migraines in the ninth month of her pregnancy. According to the veteran, after her delivery, she was migraine free for approximately one and a half years, at which time they restarted. She indicated that she currently had migraine symptoms three times per month, but that they were much less severe than what she had experienced during pregnancy. In regard to GERD, the veteran stated that her reflux symptoms started after she ended her military service. At present, she used medication to control her GERD. Following the physical examination, the pertinent diagnoses were hepatitis C, migraine headaches, and GERD, well controlled. The examiner stated that the veteran contracted hepatitis C during the birth of her son in March 1980 through blood transfusions secondary to medical complications of the pregnancy including pre-eclampsia. The examiner also noted that the veteran had undergone cholecystectomy and appendectomy for treatment of chronic abdominal pain, without significant improvement. The veteran was also found to have fibroids and underwent a subsequent hysterectomy. According to the examiner, it was not likely (less than 50 percent probability) that those symptoms and resultant procedures were related to the pre- eclampsia pregnancy or hepatitis C. The examiner reported that the same was true for GERD, migraine headaches, and hypertension. By a July 2007 rating action, the RO granted service connection for hepatitis C, with chronic fatigue, back and joint pains as a result of pre-eclampsia. Analysis In regard to the veteran's claims for service connection for GERD, status post cholecystectomy, status post appendectomy, migraine headaches, hypertension, and status post hysterectomy, with fibroid tumors, the Board finds that, based on a thorough review of the record, the preponderance of the evidence is against the aforementioned claims. In this regard, the veteran's service medical records, including the January 1980 separation examination, are negative for any complaints or findings of GERD, migraine headaches, hypertension, and/or fibroid tumors. The records are also negative for any evidence showing that the veteran underwent a cholecystectomy, an appendectomy, or a hysterectomy. Therefore, none of these disorders are shown during service. See 38 C.F.R. § 3.303. Furthermore, the first evidence of any of the claimed conditions is found, at the earliest, in private medical records which show that in February 1995, the veteran was diagnosed with migraine headaches. Accordingly, the earliest medical evidence of any of the claimed conditions comes at least 15 years after separation from active duty service. This lengthy period without treatment is evidence that there has not been a continuity of symptomatology, and it weighs against the claims. See Maxson v. West, 12 Vet. App. 453, 459 (1999), affirmed sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000), [it was proper to consider the veteran's entire medical history, including a lengthy period of absence of complaints]; see also Forshey v. Principi, 284 F.3d 1335 (Fed. Cir. 2002) ["negative evidence" could be considered in weighing the evidence]. With respect to the veteran's claims for service connection for hypertension and migraine headaches, the Board specifically notes that there is no medical evidence of hypertension or migraine headaches within one year subsequent to service discharge. See 38 C.F.R. §§ 3.307, 3.309. In the veteran's February 2004 VA examination, the veteran stated that he had been diagnosed with hypertension two years ago, which would have been approximately 22 years after the veteran's separation from the military. In addition, the Board also recognizes that at the time of the February 2004 VA examination, although the veteran reported that her headaches started 15 years ago, which would have been in approximately 1989 or about 9 years after service, she also indicated upon the May 2007 VA examination that she first developed migraine headaches in the ninth month of her pregnancy or within one year of service. However, while the veteran can attest to having a headache, as a layperson, she is not competent to diagnose migraine headaches or provide an opinion on the etiology of her headaches. See Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005); Espiritu v. Derwinski, 2 Vet. App. 482 (1992). And the first medical evidence of the veteran's migraine headaches in the claims file is in February 1995, approximately 15 years after the veteran's discharge from the military. With respect to negative evidence, the Court held that the fact that there was no record of any complaint, let alone treatment, involving the veteran's condition for many years could be decisive. See Maxson, supra. The same analysis applies to the issue of hypertension: the veteran is not competent to diagnose hypertension or provide an opinion on its etiology and the record is devoid of any findings attributable to hypertension until many years post-service. Thus, the preponderance of the evidence is against a finding that the veteran's migraine headaches or hypertension was present during or within one year of service and the weight of the evidence is against a finding of a causal link between either disability and service. In this case, there is no medical evidence or competent opinion of record which links the veteran's GERD, cholecystectomy, appendectomy, migraine headaches, hypertension, and/or hysterectomy with a history of fibroid tumors to her period of active military service. In addition, there is also no competent medical evidence or record which shows that the veteran's service-connected hepatitis C caused or aggravated her GERD, gall bladder disease with a cholecystectomy, appendectomy, migraine headaches, hypertension, and/or hysterectomy with a history of fibroid tumors. The only competent medical evidence addressing the pertinent secondary issues in this case is the opinion from the examiner from the veteran's May 2007 VA examination and that opinion weighs against the claims. In the May 2007 VA examination report, the examiner specifically concluded that it was not likely that the veteran's cholecystectomy and appendectomy were related to her service- connected pre-eclampsia pregnancy or hepatitis C. The examiner further opined that it was not likely that the veteran's GERD, migraine headaches or hypertension were related to her service-connected pre-eclampsia pregnancy or hepatitis C. The Board has considered the veteran's statements to the effect that her GERD, cholecystectomy, appendectomy, migraine headaches, hypertension, and/or hysterectomy with fibroid tumors are either linked to her period of active military service, or, in the alternative, that the aforementioned conditions were caused or aggravated by her service-connected hepatitis C. As noted above, lay statements are considered to be competent evidence when describing the features or symptoms of an injury or illness. Layno v. Brown, 6 Vet. App. 465 (1994); Washington, supra; see also Falzone v. Brown, 8 Vet. App. 398, 405 (1995). However, when the determinative issues involve a question of medical causation, only individuals possessing specialized training and knowledge are competent to render an opinion. Espiritu, supra. The evidence does not show that the veteran possesses medical expertise and it is not contended otherwise. Therefore, her opinions that these disabilities are either linked to her period of active military service, or, in the alternative, were caused or aggravated by her service- connected hepatitis C is not competent evidence. In view of the foregoing, the Board concludes that the preponderance of the evidence is against the veteran's claims for service connection for GERD, status post cholecystectomy, status post appendectomy, migraine headaches, hypertension, and status post hysterectomy with fibroid tumors, to include as secondary to her service-connected hepatitis C. As the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not for application and the claims must be denied. 38 U.S.C.A. § 5107(b); see also, generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). C. Chronic Disabilities Manifested by Chest Pain and Dizziness, To Include as Secondary to Service-Connected Hepatitis C The veteran contends that she currently has chronic disabilities manifested by chest pain and dizziness that are either related to her active military service or related to her service-connected hepatitis C. Service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. (Emphasis added.) See Watson v. Brown, 4 Vet. App. 309, 314 (1993); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Boyer, supra. In the instant case, there is no competent medical evidence showing a current diagnosis of a chronic disability manifested by chest pain or a chronic disability manifested by dizziness. The veteran's service medical records reflect that in October 1976, the veteran was treated for complaints of chest pain with a cough, which resulted in a diagnosis of an upper respiratory infection. However, according to the records, in January 1980, the veteran underwent a Chapter 8 (hardship due to pregnancy) separation examination and at that time, in response to the question as to whether she had ever had or if she currently had pain or pressure in chest, or dizziness or fainting spells, the veteran responded "no." The lung, chest and heart were clinically evaluated as "normal." The neurological examination was also normal. The separation examination was negative for a diagnosis of a disability manifested by chest pain or dizziness. In September 2006, the RO received private medical records, dated from March 2002 to September 2004. The records show that in April 2003, the veteran was treated for numerous problems, including chest pain. Upon physical examination, the veteran's heart had a regular rate and rhythm and there was no murmur. S1 and S2 were normal. The veteran's lungs were clear to auscultation and percussion. The diagnosis was chest pain. In May 2007, the veteran underwent a VA examination. At that time, she stated that in regard to her claimed chest pain, she had stabbing pains associated with palpitations one to two times per month. According to the veteran, she also had several episodes of "fainting spells," with her last episode in January 2007. She reported being on the toilet when she felt extremely dizzy and felt like "passing out." The physical examination showed that the veteran's lungs were clear to auscultation. The cardiac evaluation showed regular rhythm and rate. Upon neurological evaluation, the veteran had normal cerebellar function. In this case, the only evidence of record supporting the veteran's claim is her own lay opinion that she currently has chronic disabilities manifested by chest pain and dizziness which are related to his military service, or, in the alternative, related to her service-connected hepatitis C. While the veteran is competent to state that she experiences chest pain and dizziness, the record does not show, nor does the veteran contend, that she has specialized education, training, or experience that would qualify her to provide a medical diagnosis of an underlying disease productive of chest pain or dizziness, or to provide a medical nexus opinion. It is now well established that a lay person such as the veteran is not competent to opine on medical matters such as diagnoses or etiology of medical disorders, and her opinion that she currently has disabilities manifested by chest pain and dizziness is therefore entitled to no weight of probative value. See Cromley v. Brown, 7 Vet. App. 376, 379 (1995); Espiritu, 2 Vet. App. at 492, 494-95. In light of the above, the Board finds that there is no medical evidence of record showing a current medical diagnosis of a chronic disability manifested by chest pain. The Board recognizes that according to private medical records, in April 2003, the veteran was assessed with chest pain. However, a symptom, such as pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). Therefore, the Board finds that the preponderance of the evidence is against the veteran's claim for service connection for a chronic disability manifested by chest pain. It is also the Board's determination that there is no medical evidence of record showing a current medical diagnosis of a chronic disability manifested by dizziness. Thus, the Board finds that the preponderance of the evidence is against the veteran's claim for service connection for a chronic disability manifested by dizziness. Accordingly, service connection for these disabilities must be denied. In reaching this decision, the Board has considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the veteran's claims, the doctrine is not for application. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 49 (1990). III. Higher Rating Claim A. Factual Background The veteran's service medical records show that in October 1976, and again in January 1978, the veteran was diagnosed with a urinary tract infection (UTI). VA medical records reflect that in April 1980, the veteran was diagnosed with a UTI. Private medical records reflect that in February 1997, the veteran was treated for complaints of pain upon urination and abdominal pain. The veteran also noted that she urinated frequently. The diagnosis was UTI and she was prescribed medication. In a private medical statement from Dr. S.J., dated in November 2000, Dr. J. stated that she had been treating the veteran for numerous disorders, including interstitial cystitis. In February 2004, the veteran underwent a VA examination. At that time, she stated that she had a UTI one to two times a year and was usually treated with antibiotics. According to the veteran, she had not had a UTI in nine months. The symptoms included increased frequency of urination, as well as pain with urination. Following the physical examination, the diagnosis was recurrent UTIs. By an April 2004 rating action, the RO granted the veteran's claim of entitlement to service connection for recurrent UTIs. At that time, the RO assigned a noncompensable disability rating under Diagnostic Code 7512, effective from May 24, 2002, for the veteran's service-connected recurrent UTIs. Pursuant to the Board's November 2005 remand in May 2007, the veteran underwent a VA examination. At that time, the examiner noted that the veteran's medical history included recurrent UTIs. The examiner observed that the veteran had not had a UTI in 2007; it was noted her last UTI was in 2006, approximately nine months earlier. According to the veteran, she experienced one to two UTIs per year. Symptoms consisted of frequency, dysuria, and intermittent hematuria. The veteran did not often require antibiotics and her last course of antibiotics was in mid to late 2005. She had not been hospitalized for a UTI since leaving the military. The examiner indicated that the veteran had no known renal dysfunction. It was further noted that the veteran had no history of hospitalizations for UTIs; no UTI in the last 1 & 1/2 to 2 years; a normal creatinine; a negative urinalysis; and a history of at most 1 to 2 UTIs a year. It was also observed that the veteran indicated that her UTIs were less frequent and less severe in the last several years. The diagnosis was history of recurrent UTIs/cystitis, currently asymptomatic. B. Analysis Disability ratings are determined by the application of VA's SCHEDULE FOR RATING DISABILITIES (Rating Schedule) codified in 38 C.F.R. Part 4 (2007), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2007). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with the impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2007). Regulations require that where there is a question as to which of two evaluations is to 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. 38 C.F.R. § 4.7 (2007). As the veteran has taken issue with the initial rating assigned following the grant of service connection, separate ratings may be assigned for separate periods of time based on the facts found-a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). Thus, the Board must evaluate the relevant evidence since May 24, 2002. The veteran's service-connected recurrent UTIs are currently assigned a noncompensable evaluation under Diagnostic Code 7512. Diagnostic Code 7512 provides that chronic cystitis, including interstitial (cystitis) and (of) all etiologies, infections and "non-infections" are rated as a voiding dysfunction. 38 C.F.R. § 4.115b, Diagnostic Code 7512. Voiding dysfunction is rated for the particular condition as Urine Leakage, Frequency, or Obstructed Voiding. 38 C.F.R. § 4.115a. Continual Urine Leakage, Post Surgical Urinary Diversion, Urinary Incontinence, or Stress Incontinence requiring the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day is rated 60 percent. If it requires the wearing of absorbent materials which must be changed 2 to 4 times per day, it is rated 40 percent. Requiring the wearing of absorbent materials which must be changed less than 2 times per day, it is rated 20 percent. Id. Urinary Frequency, with daytime voiding interval less than one hour, or awakening to void five or more times per night, is rated 40 percent. Daytime voiding interval between one and two hours, or awakening to void three to four times per night is rated 20 percent. Daytime voiding interval between two and three hours, or awakening to void two times per night is rated 10 percent. Id. Obstructed voiding with urinary retention requiring intermittent or continuous catheterization is rated 30 percent. Marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following: (1) Post void residuals greater than 150 cc; (2) Uroflowmetry; markedly diminished peak flow rate (less than 10 cc/sec); (3) Recurrent urinary tract infections secondary to obstruction; and (4) Stricture disease requiring periodic dilatation every 2 to 3 months, is rated 10 percent. Obstructive symptomatology with or without stricture disease requiring dilatation 1 to 2 times per year, is rated noncompensable (0 percent). Id. The Board also notes that UTIs are specifically identified under 38 C.F.R. § 4.115, which includes specific criteria for rating infections. A UTI with poor renal function is rated as Renal Dysfunction. With recurrent symptomatic infection requiring drainage/frequent hospitalization (greater than two times/year), and/or requiring continuous intensive management, UTI is rated 30 percent. With long- term drug therapy, 1-2 hospitalizations per year and/or requiring intermittent intensive management, it is rated 10 percent. Id. The veteran maintains that her recurrent UTIs warrant a compensable rating. She maintains that the symptoms of her UTIs include frequency, dysuria, and intermittent hematuria. In this regard, lay statements are considered to be competent evidence when describing symptoms of a disease or disability or an event. However, symptoms must be viewed in conjunction with the objective medical evidence of record. Espiritu, 2 Vet. App. at 492. In order to warrant a compensable rating under the specific criteria for rating UTIs, there must be a showing of long- term drug therapy, one to two hospitalizations per year, and/or therapy requiring intermittent intensive management. See 38 C.F.R. § 4.115a. In this regard, as can be seen from the history of complaints and treatment for the veteran's UTIs, she has had only intermittent complaints and treatment, with only short-term drug therapy, and no therapy requiring intermittent intensive management. The Board also notes that with the exception of a hospitalization for a UTI shortly after the veteran's discharge in March 1980, the veteran has had no other hospitalizations for a UTI. In addition, there is no indication that UTIs have resulted in a voiding dysfunction, such as urine leakage, frequency, or obstructed voiding. Accordingly, the veteran's service-connected UTI disability picture does not warrant assignment of a compensable rating under the applicable rating criteria for UTI at any time during the period of time at issue. Finally, in reaching this decision, the Board considered the doctrine of reasonable doubt. However, since the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 49. ORDER Entitlement to service connection for GERD, to include as secondary to service-connected hepatitis C, is denied. Entitlement to service connection for status post cholecystectomy, to include as secondary to service-connected hepatitis C, is denied. Entitlement to service connection for status post appendectomy, to include as secondary to service-connected hepatitis C, is denied. Entitlement to service connection for migraine headaches, to include as secondary to service-connected hepatitis C, is denied. Entitlement to service connection for hypertension, to include as secondary to service-connected hepatitis C, is denied. Entitlement to service connection for status post hysterectomy with a history of fibroid tumors, to include as secondary to service-connected hepatitis C, is denied. Entitlement to service connection for a chronic disability manifested by chest pain, to include as secondary to service- connected hepatitis C, is denied. Entitlement to service connection for a chronic disability manifested by dizziness, to include as secondary to service- connected hepatitis C, is denied. Entitlement to an initial compensable rating for service- connected recurrent UTIs is denied. REMAND In the instant case, the veteran contends that she currently has a psychiatric disorder that is either related to her active military service, or, in the alternative, related to her service-connected hepatitis C. The veteran's service medical records are negative for any complaints or findings of a psychiatric disorder, to include major depression, an anxiety disorder, PTSD, and a psychotic disorder. In January 1980, the veteran underwent a Chapter 8 (hardship due to pregnancy) separation examination. At that time, in response to the question as to whether the veteran had ever had or if she currently had depression or excessive worry, or nervous trouble of any sort, she responded "no." The veteran was clinically evaluated as "normal" for psychiatric purposes. In February 2004, the veteran underwent a VA psychological evaluation. At that time, she stated that she was receiving treatment for depression. She gave a history of having some unusual perceptual experiences including what she called "an open vision" where she saw a "beast that had reptile skin and was in a dessert." According to the veteran, she was kidnapped by a cousin at age four, and physically abused between the ages of five to 12. She indicated that she was also sexually abused from the ages of eight to 12. At the age of 12, she was put in a boarding school and after her graduation from high school, she joined the military. Following her discharge, she gave birth to her son and was despondent after his birth. According to the veteran, she lacked finances and a place to live at that time. The veteran remembered those difficult experiences in her life with a great deal of sadness, frustration, and anger. The diagnosis was the following: (Axis 1) (1) major depression, chronic, moderate to severe; (2) anxiety disorder not otherwise specified with features of PTD related to childhood symptoms, panic attacks, generalized anxiety, and dissociative symptoms, and (3) psychotic disorder, not otherwise specified, (Axis II) personality disorder, (Axis IV) unemployment, limited social sphere, chronic physical problems, chronic mental health problems, early environmental deprivation, and (Axis V) Global Assessment of Functioning (GAF) score of 50. A VA examination was conducted in May 2007. Following the physical examination, the examiner stated that the veteran had residuals of the surgical treatment of the pre-eclampsia, which included emergency C-section and multiple blood transfusions. According to the examiner, the veteran contracted hepatitis C secondary to the blood transfusion. The examiner opined that the veteran's chronic fatigue, multiple arthralgias, insomnia, and non-specific neurological symptoms, as well as psychiatric symptoms, were likely secondary to the diagnosis of hepatitis C. (Service connection is currently in effect for hepatitis C with chronic fatigue, back pain and joint pain as secondary to preeclampsia. Emphasis added.) The Board recognizes that in the February 2004 VA examination report, the examiner diagnosed the veteran with major depression, an anxiety disorder with features of PTSD and a psychotic disorder. While this clinician linked the veteran's features of PTSD to childhood physical and sexual abuse, and not to her period of military service or her service-connected hepatitis C, in the May 2007 VA examination report, that examiner opined that the veteran had psychiatric symptoms which were secondary to her service-connected hepatitis C. The examiner, however, did not specify what psychiatric symptoms the veteran experienced and it is far from clear whether the veteran has a diagnosis of a psychiatric disorder that is linked to her hepatitis C. Accordingly, the Board finds that a VA examination, as specified in greater detail below, should be obtained in order to determine the nature and etiology of any psychiatric disorder that may be present, to include depression, an anxiety disorder, PTSD and a psychotic disorder. In the instant case, the veteran maintains that she is unable to work because of her service-connected disabilities. In this regard, the Board notes that the evidence of record is negative for a VA opinion as to how the veteran's service- connected disabilities affect her ability to work. Such an opinion is required before the Board can decide the TDIU issue. See Friscia v. Brown, 7 Vet. App. 294 (1995). Therefore, the veteran should be afforded a VA examination in order to address the issue of whether she is unemployable due to her service- connected disabilities. In view of the foregoing, the claims for service connection for a psychiatric disorder, to include as secondary to the veteran's service-connected PTSD, and entitlement to a TDIU are REMANDED to the AMC/RO for the following action: 1. The RO should arrange for an examination to determine the nature, extent, and etiology of any psychiatric disorder that may be present, to include major depression, an anxiety disorder, PTSD and/or a psychotic disorder. The claims file and a copy of this remand must be made available and reviewed by the examiner. The psychiatrist should consider any pertinent findings set forth in the veteran's claims folder (including the February 2004 and May 2007 VA examination reports). Following a review of the relevant medical evidence in the claims file, the medical history, the clinical evaluation, and any tests that are deemed necessary, the psychiatrist is asked to address the following questions: (a) Is it at least as likely as not (50 percent or more likelihood) that any psychiatric disability that may currently be present, to include major depression, an anxiety disorder, PTSD and/or a psychotic disorder, began during service or is causally linked to any incident of service? (b) Is it at least as likely as not (50 percent or more likelihood) that any psychiatric disability that may currently be present, to include major depression, an anxiety disorder, PTSD and/or a psychotic disorder, was caused or aggravated by the veteran's service- connected hepatitis C? The psychiatrist is advised that the term "as likely as not" does not mean within the realm of possibility. Rather, it means that the weight of the medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. More likely and as likely support the contended causal relationship or a finding of aggravation; less likely weighs against the claim. The psychiatrist is also advised that aggravation for legal purposes is defined as a worsening of the underlying disability beyond its natural progression versus a temporary flare-up of symptoms. The psychiatrist is requested to provide a rationale for any opinion expressed. If the examiner finds it impossible to provide any part of the requested opinion without resort to pure speculation, he or she should so indicate. 2. The veteran must be afforded a VA examination to determine to what extent her service-connected disabilities (to include any psychiatric disability if granted by the RO following the examination and opinion requested above) provide limitations on her ability to obtain employment. The claims folder must be made available to the examiner for review prior to each examination. The examiner must elicit from the veteran and record for clinical purposes a full work and educational history. Following a review of the relevant evidence in the claims file, the clinical examination, any additional (specialty) examinations that are warranted and any tests that are deemed necessary, the examiner must provide an opinion on the following: Is it at least as likely as not (50 percent or more likelihood) that the veteran's service-connected disabilities alone preclude her from securing and following substantially gainful employment consistent with her education and occupational experience. The clinician is advised that the term "as likely as not" does not mean within the realm of possibility. Rather, it means that the weight of the medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. More likely and as likely support the claim of unemployability; less likely weighs against the claim. 3. After completion of the above and any other development deemed necessary, the RO should review and re-adjudicate the issues on appeal. If any claim remains denied, the RO must provide the veteran and her representative a supplemental statement of the case and an appropriate period of time must be allowed for response. Thereafter, the case must be returned to this Board for appellate review. The veteran 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. 2007). ______________________________________________ R. F. WILLIAMS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs