Citation Nr: 1237019 Decision Date: 10/25/12 Archive Date: 11/08/12 DOCKET NO. 10-29 131 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Fargo, North Dakota THE ISSUE Entitlement to service connection for a psychiatric disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Keyvan, Associate Counsel REMAND The Veteran had active service from September 1967 to July 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Fargo, North Dakota. In his April 2009 claim, the Veteran sought entitlement to service connection for a "mental condition" broadly defined, and in May 2009, the Veteran amended his claim to include the issue of entitlement to service connection for posttraumatic stress disorder (PTSD). In the October 2009 rating decision, the RO denied the Veteran's claim for service connection for major depressive disorder. Indeed, the medical evidence in this case shows diagnoses of not only PTSD and depressive disorder, but also provides diagnoses of anxiety disorder and mood disorder. Therefore, the Veteran's claim will not be limited to that which he has written on his applications. Although a claimant for disability compensation who has no special medical expertise may testify as to the symptoms he can observe, he is not generally competent to provide a diagnosis that requires the application of medical expertise to the facts presented. Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009); Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The agency of original jurisdiction (AOJ) should construe a claim based on the reasonable expectation of the non-expert claimant and the evidence developed in processing that claim. Clemons, 23 Vet. App. at 5. Accordingly, given the various psychiatric diagnoses shown by the evidence in this case, the Board has re-characterized the issue on appeal more broadly as one for service connection for any psychiatric disability. During the current appeal, and specifically in April 2011, the Veteran testified at a videoconference hearing conducted before the undersigned Veterans Law Judge (VLJ), who was designated by the Chairman to conduct the hearing pursuant to 38 U.S.C.A. § 7107 (c) (West 2002 & Supp. 2011). A transcript of the testimony has been associated with the Veteran's claims file. The law provides that the VA shall make reasonable efforts to notify a claimant of the evidence necessary to substantiate a claim and requires VA to assist a claimant in obtaining that evidence. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). Such assistance includes providing the claimant a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C.A. § 5103, 5103A (West 2002, Supp. 2012); 38 C.F.R. § 3.159. The Veteran contends that he suffers from psychiatric problems after encountering several traumatic experiences in service. In his stressor statement, date stamped as received in June 2009, the Veteran alleges that during his period of basic training, his drill sergeant singled him out, beating him and humiliating him a number of times in front of the other members of his unit. The Veteran also recalled an incident when his drill sergeant forcibly removed the Veteran's protective gas mask while he was working in a chlorine gas chamber. During his April 2011 hearing, the Veteran testified that he passed out and had to be carried out of the gas chamber after his mask was removed. According the Veteran, he began experiencing increasing paranoia and nightmares after these events, and to this day, he believes his drill sergeant was trying to hurt him. See April 2011 Hearing Transcript (T.), pp. 5-9. A review of the service treatment records reflects that a psychiatric disorder may have pre-existed the Veteran's entrance into service. Nevertheless, every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled in service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111. History provided by the Veteran of the pre-service existence of conditions recorded at the time of the entrance examination does not, in itself, constitute a notation of a preexisting condition. 38 C.F.R. §§ 3.304(b)(1); Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Crowe v. Brown, 7 Vet. App. 238, 246 (1995). To rebut the presumption of sound condition under section 1111 of the statute for disorders not noted on the entrance or enlistment examination, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. VAOPGCPREC 3-2003. A presumption is an assumption of fact resulting from a rule of law which requires such fact to be assumed from another fact or group of facts found or otherwise established in the action. Black's Law Dictionary 1067 (5th ed. 1979). Therefore, where the presumption of sound condition at entrance to service cannot be rebutted, the fact for which the presumption stands - that is, that the Veteran was in sound condition at entry to service as to the disability for which he seeks service connection - must be assumed as a matter of law. Accordingly, service connection may not be granted on the basis of aggravation of a preexisting disease or injury in such a case. Rather, where the government fails to rebut the presumption of soundness under section 1111, the Veteran's claim must be considered one for service incurrence or direct service connection. See Wagner v. Principi, 370 F.3d 1089, 1094, 1096 (Fed. Cir. 2004). At his August 1967 entry examination, the clinical evaluation of his psychiatric condition was shown to be normal, and the Veteran denied a history of depression, excessive worry, or nervous trouble of any kind in his reports of medical history. In addition, the Veteran had a physical profile of S1 at the time of this examination. See Odiorne v. Principi, 3 Vet. App. 456, 457 (1992) (observing that the 'PULHES' profile reflects the overall physical and psychiatric condition of the Veteran on a scale of '1' (high level of fitness) to 4 (a medical condition or physical defect which is below the level of medical fitness for retention in the military service)). Clinical records dated in October 1967 reflect that the Veteran was seen at a military clinic on a number of occasions with complaints of severe anxiety, and subsequent treatment records indicate that his anxiety was linked to his gastrointestinal issues. An October 1967 Gastrointestinal Consultation report reflects that the Veteran presented as an "immature, very passive dependent, inadequate young man" who has experienced "psychophysiologic symptoms since early childhood." During the interview, the Veteran reported that he had had a stomach ulcer since he was eight years old, and since that time, he regularly developed gastrointestinal difficulties whenever faced with a stressful situation. It was noted that the Veteran quit school after the eighth grade, and had been working in "simple, repetitive, menial type position" since this time. The treatment provider described basic training as "a very psychologically and physically stressful situation" and noted that since the Veteran had been in basic training, there had been an increase in the frequency and intensity of his [gastrointestinal] tract symptoms." According to the treatment provider, the Veteran had not been doing anything in his basic training unit because of his psychophysiologic difficulties, and there was no reason to believe that his symptoms, which were described as "long-standing" and "a characterological part of his personality structure" would decrease while he was in basic training. The treatment provider ultimately recommended that the Veteran be separated from service as quickly as possible. In April 1968, the Veteran presented at a Neurology Clinic and a brief historical overview reflects that he developed retrograde amnesia after being hit over the head, and was being evaluated for brain damage. In the consultation report, it was noted that the Veteran had been followed intermittently by a psychiatrist for "questionable depression and anxiety type reactions" prior to entering service, but had been doing well from the time of his entry in September 1967 until January 1968, when he was hit in the back of the head and rendered unconscious for an unknown period of time while standing on a street corner watching a fight among motorcycle gang members. After the Veteran was discovered and it was determined that he was with the U.S. Army, he was taken back to his duty station where he was hospitalized. Soon thereafter, the Veteran was transferred to the Fitzsimons General Hospital where he underwent a complete psychiatric evaluation and received treatment of his amnesia. According to the Veteran, from the period between late January 1968 to the last week of February, he had no memory of past events prior to his injury as well as the events that transpired during that month. However, the Veteran maintains that he was able to regain his memory during the last week of February, and could recall his past childhood events as well as the events leading up, prior to, and immediately following the January 1968 incident. Based on his evaluation of the Veteran, the treatment provider observed no evidence of any neurological deficit and described the Veteran's neurological condition as normal. In a June 1968 discharge report, the Veteran's medical history from the time he developed and recovered from amnesia was once again reviewed and discussed, and it was noted that the Veteran received psychiatric treatment for several years (1958 to 1966) prior to service. The Veteran was discharged with diagnoses of acute, severe dissociative reaction, and chronic, moderate emotional instability reaction and it was noted that the Veteran's dissociative reaction was secondary to head trauma incurred, and manifested by total amnesia, depersonalization, confusion and flat affect. It was further noted that the Veteran's emotional instability reaction was manifested by poor judgment under stress, fluctuating emotional attitudes in relation to the proper authority, and difficulty with the law prior to entering service. The Veteran's moderate chaotic family history was listed as a precipitating factor to this diagnosis, and it was also noted that the Veteran was predisposed to this diagnosis due to a "moderate, life history of evidence of above characterological defect." The discharge report further reads that any additional attempts at rehabilitation would be of no avail considering the Veteran's severe characterological defect. The military psychiatrist further recommended that the Veteran not be reassigned to another unit but rather considered for administrative separation from service due to his personality defect. A June 1968 Memorandum issued by the Department of the Army provided that while the Veteran was found physically qualified for duty, he was considered unsuitable for continuance in military service, and recommended that he be considered for administrative separation under the appropriate regulations due to a personality defect. The Veteran was separated from service soon thereafter, and in his June 1968 separation examination report, the clinical evaluation of his psychiatric system was shown to be abnormal due to his acute, severe dissociative reaction. Post-service treatment records dated from December 2008 to September 2010 reflect the Veteran's diagnoses of PTSD, depressive disorder, mood disorder and anxiety disorder. These treatment records also reflect a history of substance abuse, as well as a diagnosis of methamphetamine dependence. The Veteran was afforded a VA examination in September 2009, at which time he provided his medical history and described his psychiatric and psychological discomfort and substance abuse history as "very nearly continuous from the time that he got out of...military service." The examiner noted that the Veteran walked with a distinctively wider gait than normal, seemed tremulous, and was in a constant state of nervousness when he walked. The Veteran stated that he had been adopted and described his parents as "loving" individuals with whom he still had a warm relationship. He denied any problems with delinquent behavior or conduct disturbances prior to service, and reported only one legal infraction prior to service. During the interview, the Veteran provided his military history, and related how his drill sergeant beat him on several different occasions, called him names, and embarrassed him in front of all the troops in his unit on more than one occasion. He also described a second incident, wherein his unit was in a chlorine gas chamber and his drill sergeant approached him and removed the Veteran's protective mask. With regard to his military history, the Veteran could not recall whether he had any disciplinary infractions in service, and partially attributed his memory loss to his six-month period of amnesia. However, it was noted that his post-service military history involved a number of arrests and jail sentences. Upon evaluating the Veteran's mental status, the examiner noted that the Veteran communicated verbally in a very effective way, denied any hallucinations or delusions, and was well oriented to all domains. The examiner noted that the Veteran's primary PTSD symptoms were the beatings he suffered in service at the hands of his drill sergeant, as well as the removal of his respiration device during a training exercise in a chlorine gas chamber. However, the examiner determined that it was difficult to apply the PTSD criteria to the Veteran "since he did not get very far in his training nor did he spend a significant amount of time in the military." Based on his discussion with, and evaluation of the Veteran, the examiner diagnosed the Veteran with major depressive disorder, taking into account his vivid memories of being beaten and mistreated by his drill sergeant in service. According to the examiner, the Veteran had no history of any problems in his life prior to his entry into service, and the only real pre-military difficulty that may have been exaggerated as a direct result of his time in the military and the mistreatment he received by his drill sergeant, may have had to do with the Veteran's "sense of belongingness or acceptability as a person." The examiner went on to explain how with most people who have been adopted at an early age, "there is always the lingering question about what was wrong with them that their own biological parents could not or would not accept them and raise them as their own child." Based on the examiner's assessment, at some point during the beatings and other forms of mistreatment suffered at the hands of his drill sergeant, the question about his own acceptability in a 'family' type unit, which in this case was the military unit, was reignited. "This is not an uncommon history in veterans who are adopted and who are treated in this manner. Nor is it uncommon to see non-military citizens who are adopted as children but are mistreated or rejected by contemporary adults who routinely re-experience that fantasy about somehow not being good enough, which ultimately leads to significant psychiatric and psychosocial impairment from that point forward in the person's life. According to the examiner, "this is exactly what has happened to this veteran as a result of his difficulty in...service." The examiner further opined that the Veteran's substance abuse from the time he left service to approximately one year ago was "his own misguided effort to medicate himself and change his moods associated with the feeling of confirmation of his own unacceptability which was stimulated by the beatings. . . ." According to the examiner, it would take a more intensive examination to avoid the necessity for speculation at this point. In the October 2009 rating decision, the RO denied entitlement to service connection for an acquired psychiatric disorder on the basis that the evidence did not show that this disability was incurred in, caused by, or aggravated by his period of active service. In the June 2010 Statement of the Case (SOC), the Decision Review Officer (DRO) took note of a September 2009 letter issued by the Fargo VA RO Coordinator for Joint Services Records Research Center (JSRRC), which held that there was sufficient evidence of exposure to an in-service personal assault in the Veteran's service treatment records. However, the DRO noted that the Veteran described a completely different set of stressful events involving his drill sergeant during the September 2009 VA examination, and this type of stressful event was neither documented, nor corroborated in his service treatment records. In a letter dated in November 2010, the Veteran's psychiatrist , D.S., M.D. indicated that the Veteran had been under his care through the Black Hills VA Healthcare System and carried a dual diagnosis of PTSD and major depressive disorder. According to Dr. S., the Veteran was actively engaged in treatment and traces the development of his PTSD to the traumatic experiences he confronted during his period of basic training. Dr. S. further noted that the Veteran continues to experience significant symptoms of PTSD related to these traumatic experiences. The Board recognizes that the present case, which involves allegations of a personal assault (the alleged assault of the Veteran by his drill sergeant on multiple occasions during basic training), falls within the category of situations in which it is not unusual for there to be an absence of service records documenting the events about which the Veteran complains. See, e.g., Patton v. West, 12 Vet. App. 272, 281 (1999). As noted under Part IV, Subpart ii, Chapter 1, Section D, Paragraph 17 of the VA Adjudication Procedures Manual Rewrite (M21-1 MR), personal assault is an event of human design that threatens or inflicts harm. Examples of this are rape, physical assault, domestic battering, robbery, mugging, and stalking. Id. Service records may not contain evidence of personal assault, and alternative sources, including testimonial statements from confidants such as family members, roommates, fellow service members, or clergy, may provide credible evidence of an in-service stressor premised on personal assault. See YR v. West, 11 Vet. App. 393, 399 (1998). The Manual also notes that because personal assault can be an extremely personal and sensitive issue, many incidents of personal assault are not officially reported, making it difficult to obtain direct evidence and requiring that alternative evidence be sought. Likewise, under 38 C.F.R. § 3.304(f)(4), if a PTSD claim is based on in-service personal assault, evidence from sources other than the Veteran's service records may corroborate the Veteran's account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; or tests for sexually transmitted diseases, and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. The Board notes that § 3.304(f)(4) also stipulates that VA will not deny a PTSD claim that is based on in-service personal assault without first advising the claimant that evidence from sources other than the Veteran's service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. In this case, a review of the record reflects that the Veteran has not been apprised of 38 C.F.R. § 3.304(f)(4) or that evidence from other sources could help corroborate the claimed in-service personal assault stressor, nor has he been provided a list of those alternative sources from which he could submit evidence to help substantiate the stressor incident. As such, the AOJ must further develop the Veteran's claim in accordance with those special alternative evidentiary development procedures associated with personal assault claims as noted in 38 C.F.R. § 3.304(f)(4) and the M21-1 MR, Part IV, Subpart ii, Chapter 1, Section D, Paragraph 17. Thus, the Board finds action is required to satisfy the notification provisions of the Veterans Claims Assistance Act of 2000 (VCAA). See Disabled American Veterans v. Secretary of Veterans Affairs, 327 F. 3d 1339 (Fed. Cir. 2003); Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007) (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 appellant's service and the disability; (4) degree of disability; and (5) effective date of the award). After providing the required notice, the AOJ must again attempt to obtain any pertinent outstanding evidence for which the Veteran provides sufficient information and, if necessary, authorization. See 38 U.S.C.A. § 5103A(a), (g); 38 C.F.R. § 3.159. See also Charles v. Principi, 16 Vet. App. 370 (2002); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Regarding the Veteran's claimed in-service stressor, the Board notes that the Veteran has stated on a number of occasions that his current claimed psychiatric disorder is related to multiple incidents in service, in which he was assaulted and placed in life-threatening situations by his drill sergeant. The Veteran has provided the last name of the drill sergeant as well as the time period the assaults occurred. Credible supporting evidence that a claimed in-service stressor occurred is important in light of the specific elements necessary to substantiate a service connection claim for PTSD compared to other psychiatric disorders. See 38 C.F.R. § 3.304(f) (2012). Under the circumstances of this case, the Board believes that additional effort should be undertaken to allow the Veteran to submit any corroborating evidence, to include supportive statements from other individual(s) who may be able to provide corroborative evidence of the Veteran's claimed personal assault stressor. Therefore, on remand, the AOJ must search for other evidence corroborating the assault. Furthermore, as instructed in the remand, the Veteran must be notified if the search for corroborating information leads to negative results. The Board acknowledges that the Veteran was afforded a VA examination in September 2009. If VA undertakes the effort to provide a veteran with a medical examination, it must ensure that such examination is an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). It is well established that medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. See e.g. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) 20 Vet. App. 79, 83 (2006) (finding doctor's opinion that "it is possible" and "it is within the realm of medical possibility" too speculative to establish medical nexus); Goss v. Brown, 9 Vet. App. 109, 114 (1996) (using the word "could not rule out" was too speculative to establish medical nexus); Warren v. Brown, 6 Vet. App. 4, 6 (1993) (medical opinion expressed only in terms such as "could have been" is not sufficient to reopen a claim of service connection). Significantly, the Board finds the September 2009 VA medical opinion to be unclear and somewhat contradictory. First, the VA examiner indicated that the Veteran did not have a history suggestive of any pre-existing problems prior to his military service. Yet, in his explanation, the examiner appears to find that the Veteran's in-service experiences may have triggered a psychiatric condition that pre-existed his period of service. The examiner did not clearly state as such, nor did he discuss whether such disorder was aggravated as a result of his in-service experiences. Additionally, the examiner did not address the service treatment records indicating that the Veteran did in fact seek psychiatric treatment prior to his period of military service. Furthermore, the examiner did not provide a clear and definitive explanation as to why the Veteran did not meet the diagnostic criteria for PTSD. Thus, the Board finds that further clarification is required to determine the nature and etiology of the Veteran's psychiatric disorder(s). On remand, the Veteran must be afforded another VA psychiatric examination in order to obtain a current diagnosis based on both examination and a review of his claims file. Specifically, the Veteran must be afforded a psychiatric evaluation by a VA or VA-contracted psychiatrist or psychologist, to include particular attention to the diagnoses made as a result of VAMC treatment. In the report, the examiner must address the relationship between any diagnosed PTSD and the Veteran's claimed in-service stressor and must specifically discuss whether the identified stressor is adequate to support a diagnosis of PTSD, and whether his symptoms are related to the identified stressor. Further, under Clemons, supra, the designated examiner must provide a medical nexus opinion with respect to any other identified acquired psychiatric disorder. The opinion must address 1) whether the Veteran had a psychiatric disorder that existed prior to service, and, if so, 2) whether the pre-existing psychiatric disorder was aggravated by his service. If the examiner finds that the Veteran's psychiatric disorder did not pre-exist service, then he or she must determine whether the Veteran has any psychiatric disorder(s) that is/are related to service. Such an opinion is also important in view of the evidence contained in the Veteran's post-service treatment records that suggests that he also has diagnoses of depressive disorder, anxiety disorder and mood disorder. In addition, during his hearing, the Veteran testified that he spent some time at a state hospital in Pueblo, Colorado for alcohol abuse after his separation from service. See T., p. 4. However, the specified treatment records have not been associated with the claims file; nor has any attempt been made to obtain the specified treatment records. Under the VCAA, VA has an obligation to make a reasonable effort to obtain identified private treatment records. See 38 C.F.R. § 3.159(c)(1). As such, the claim must be remanded to attempt to obtain the specified treatment records. In addition, the Veteran asserts that he has received on-going psychiatric treatment with Dr. S. at the VAMC in Fort Mead, South Dakota. As this matter is being returned for additional development, ongoing medical records should also be obtained. 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (noting that VA medical records are in constructive possession of the agency and must be obtained if pertinent). Accordingly, the case is REMANDED for the following action: 1. The Veteran and his representative must be sent a letter requesting that the Veteran provide sufficient information, and if necessary authorization, to enable any additional pertinent evidence not currently of record to be obtained. The Veteran should also be invited to submit any pertinent evidence in his possession. The AOJ must explain the type of evidence that is the Veteran's ultimate responsibility to submit. In addition, the AOJ must send the Veteran a corrective VCAA notice letter that explains specifically what evidence and information is required to substantiate a claim of service connection for PTSD based on a claim of in-service personal assault. See 38 C.F.R. § 3.159 (2012). The Veteran must be specifically told of the information or evidence he should submit and of the information or evidence that VA will obtain with respect to his claim of service connection for PTSD. The Veteran must be specifically notified that an alleged personal assault in service may be corroborated by evidence from sources other than his service records, as defined in 38 C.F.R. § 3.304(f)(4). (All specific examples of alternative sources of evidence listed in this regulation must be included in the notification letter.) 2. The Veteran's claim for service connection for PTSD must be further developed in accordance with those special alternative evidentiary development procedures associated with personal assault claims as noted in 38 C.F.R. § 3.304(f)(4) and the VA Adjudication Procedures Manual Rewrite (M21-1 MR), Part IV, Subpart ii, Chapter 1, Section D, Paragraph 17. In this respect, a request must be made to the Veteran, with a copy to his representative, that he provide as much detail as possible regarding the alleged physical assaults by his drill sergeant, to include any other evidence corroborating the incident(s). The Veteran should be asked to specifically provide statements from any witnesses to these incidents, or from the authorities to whom he may have reported the incidents. A letter must be prepared asking the service department to provide any available information that might corroborate the Veteran's alleged in-service personal assault stressor. Specifically, any unit records showing that the Veteran reported the incident to a commander or other authority should be sought. All lay statements or investigative reports maintained by the service department relating to the Veteran should be sought. Any additional action necessary for independent verification of the alleged personal assault stressor must be accomplished. If the search for corroborating information leads to negative results, this must be documented in the claims file. Then, the Veteran must be notified of this fact, of the efforts taken to obtain the information, and of any further action taken. 3. The Veteran should be asked to provide the full address for the state hospital in Pueblo, Colorado where he reportedly received psychiatric treatment, as well as the specific dates during which he received treatment there. After acquiring this information, instruct the Veteran to complete a release form authorizing VA to request his private medical records from this treatment center. After securing the appropriate release from the Veteran, attempt to obtain any clinical or medical records regarding psychiatric treatment the Veteran received at this institution at any time since July 1968. If any records are not obtained, inform the Veteran and provide him an opportunity to submit the records. All such available documents should be associated with the Veteran's claims folder. 4. Request records of relevant psychiatric treatment that the Veteran may have received with Dr. S. or any other VA healthcare provider, since November 2010 at the VAMC in Fort Mead, South Dakota. Copies of such records should be associated with the claims folder. 5. After associating with the claims file all available records and/or responses received pursuant to the above-requested development, the Veteran must be scheduled for a VA psychiatric examination and notified that failure to report to any scheduled examination, without good cause, could result in a denial of his claim. See 38 C.F.R. § 3.655 (2012). The examiner(s) must thoroughly review the Veteran's claims file, to include a copy of this remand. Psychological testing must be conducted with a view toward determining whether the Veteran in fact meets the criteria for a diagnosis of PTSD. A VA or VA-contracted psychiatrist or psychologist must review the Veteran's claims file, service treatment records, and test results, examine the Veteran, and provide an opinion as to whether the Veteran has symptomatology that meets the diagnostic criteria for PTSD. The examiner must identify the specific stressor(s) underlying any PTSD diagnosis and comment upon the link between the current symptomatology and the Veteran's reported in-service stressor that he was physically assaulted by his drill sergeant. In the report, the examiner must address the relationship between any diagnosed PTSD and the Veteran's in-service stressors, and must specifically address whether an identified stressor is adequate to support a diagnosis of PTSD; and whether his symptoms are related to any identified stressor. A complete rationale must be provided for all opinions expressed. For each acquired psychiatric disorder other than PTSD, the examiner must answer the following questions: a. Did the Veteran have an acquired psychiatric disorder prior to his entry into military service in September 1967? If so, is the evidence clear and unmistakable (undebatable) that such a disorder existed prior to service? (Identify such clear and unmistakable evidence or medical principle that makes it so.) b. If there was a pre-existing disorder, the examiner should express an opinion as to the medical probabilities that the pre-existing psychiatric disorder underwent a permanent increase in severity during the Veteran's period of service, and if so, state whether permanent increase in severity during service was due to the natural progress of the condition. c. If a psychiatric disorder did not pre-exist his September 1967 entry, then the examiner should express an opinion as to whether it is at least as likely as not, i.e., a 50 percent probability or greater, that any such disability diagnosed on current examination had its onset in service or is otherwise causally or etiologically related to active service, including his claimed in-service stressors. In answering this question, the examiner should address the Veteran's competent assertions that he has experienced psychiatric problems since service. The medical reasons for accepting or rejecting the Veteran's statements of continuity should be set forth. If the examiner determines that he/she cannot provide an opinion without resorting to speculation, the examiner should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, he/she should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). (The agency of original jurisdiction should ensure that any additional evidentiary development suggested by the examiner be undertaken so that a definite opinion can be obtained.) 6. Thereafter, readjudicate the issue of entitlement to service connection for an acquired psychiatric disability, to include PTSD. If a benefit sought on appeal is not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for appellate review. No action is required of the Veteran until he is notified; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claim. 38 C.F.R. § 3.655 (2012). The Veteran has the right to submit additional evidence and argument on the matter that 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 or by the Court 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). _________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board is appealable to the Court. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).