Citation Nr: 1221080 Decision Date: 06/15/12 Archive Date: 06/22/12 DOCKET NO. 06-03 853A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a right knee disability. 3. Entitlement to service connection for an acquired psychiatric disability other than PTSD, to include anxiety and depression. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The Veteran had active service from November 1990 to July 1991, including in the Persian Gulf War, and additional unverified Army National Guard (ANG) service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2005 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. Although the Veteran requested a Travel Board hearing when she perfected a timely appeal in February 2006, she failed to report for this hearing when it was scheduled in May 2009. See 38 C.F.R. § 20.704 (2011). The Board notes that, in Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Court held that claims for service connection for PTSD also encompass claims for service connection for all psychiatric disabilities afflicting a Veteran based on a review of the medical evidence. The medical evidence indicates that the Veteran has been diagnosed as having depression and anxiety. Thus, the claims of service connection for PTSD and for an acquired psychiatric disability other than PTSD, to include depression and anxiety, are as stated on the title page of this decision. In February 2010, the Board remanded this matter to the RO via the Appeals Management Center (AMC) in Washington, DC, for additional development. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). 38 U.S.C.A. § 7107(a)(2) (West 2002). Unfortunately, as is explained below in greater detail, the issue of entitlement to service connection for an acquired psychiatric disability other than PTSD, to include depression and anxiety, is addressed in the REMAND portion of the decision below and is REMANDED again to the RO/AMC. VA will notify the Veteran if further action is required on her part. FINDINGS OF FACT 1. The Veteran's service personnel records show that she served in the southwest Asia theater of operations during the Persian Gulf War. 2. The competent evidence suggests that the Veteran's current PTSD is related to active service. 3. In statements on a VA Form 21-4138 dated on October 11, 2010, and date-stamped as received by the RO on November 8, 2010, prior to the promulgation of a decision in this appeal, the Veteran requested a withdrawal of her appeal with respect to the denial of her claim of service connection for a right knee disability. CONCLUSIONS OF LAW 1. PTSD was incurred in active service. 38 U.S.C.A. §§ 1110, 1154, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.303, 3.304 (2011). 2. The criteria for withdrawal of an appeal by the appellant have been met on the issue of entitlement to service connection for a right knee disability. 38 U.S.C.A. §§ 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify the appellant of information and evidence necessary to substantiate the claim and redefined its duty to assist him in obtaining such evidence. 38 U.S.C.A. §§ 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156, 3.159, 3.326 (2011). With respect to the Veteran's service connection claim for PTSD, given the favorable disposition of the action here, which is not prejudicial to her, the Board need not assess VA's compliance with the VCAA. See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92, 57 Fed. Reg. 49,747 (1992). The Veteran contends that she incurred PTSD during active service. She specifically contends that her active duty unit came under enemy fire when they arrived in the southwest Asia theater of operations during Operation Desert Storm. She alternatively contends that she incurred PTSD as a result of in-service personal trauma. She also alternatively contends that her PTSD clearly and unmistakably existed prior to service and was aggravated beyond its natural progression by service. She finally contends that her current PTSD is related to active service. Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In the case of any Veteran who has engaged in combat with the enemy in active service during a period of war, satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, condition or hardships of such service, even though there is no official record of such incurrence or aggravation. Every reasonable doubt shall be resolved in favor of the Veteran. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with VA regulations; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f). See 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304(d) (pertaining to combat Veterans). If, however, 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. Examples of such evidence include, but are not limited to, statements from family members, and evidence of behavior changes following the claimed assault. 38 C.F.R. § 3.304(f)(3). In Patton v. West, 12 Vet. App. 272 (1999), the Court held that special consideration must be given to personal assault PTSD claims. In particular, the Court held in Patton that the provisions in M21-1, Part III, 5.14(c), which address PTSD claims based on personal assault, are substantive rules which are the equivalent of VA regulations and must be considered. See also YR v. West, 11 Vet. App. 393, 398-99 (1998). The Board notes that M21-1, Part III, Chapter 5, has been rescinded and replaced, in relevant part, by M21-1MR, Part III, Subpart iv, Chapter 4, Section H30. See generally M21-1MR, Part III, Subpart iv, Chapter 4, Section H30. These M21-1MR provisions on personal assault PTSD claims require that, in cases where available records do not provide objective or supportive evidence of the alleged in-service stressor, it is necessary to develop for this evidence. As to personal assault PTSD claims, more particular requirements are established regarding the development of "alternative sources" of information as service records may be devoid of evidence because many victims of personal assault, especially sexual assault and domestic violence, do not file official reports either with military or civilian authorities. See M21-1MR, Part III, Subpart iv, Chapter 4, Section H30b. Further, the relevant provisions of M21-1MR indicate that behavior changes that occurred around the time of the incident may indicate the occurrence of an in-service stressor and that "[s]econdary evidence may need interpretation by a clinician, especially if the claim involves behavior changes" and "[e]vidence that documents behavior changes may require interpretation in relation to the medical diagnosis by a neuropsychiatric physician". See M21-1MR, Part III, Subpart iv, Chapter 4, Section H30c. On July 13, 2010, VA published a final rule that amended its adjudication regulations governing service connection for PTSD by relaxing, in certain circumstances, the evidentiary standard for establishing the required in-service stressor. 75 Fed. Reg. 39843 (July 13, 2010) as amended by 75 Fed. Reg. 41092 (July 15, 2010) (providing the correct effective date of July 13, 2010 for the revised 38 C.F.R. § 3.304(f)). Specifically, the final rule amends 38 C.F.R. § 3.304(f) by redesignating current paragraphs (f)(3) and (f)(4) as paragraphs (f)(4) and (f)(5), respectively, and by adding a new paragraph (f)(3) that reads as follows: (f)(3) If a stressor claimed by a Veteran is related to the Veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. See 75 Fed. Reg. 39843 (July 13, 2010) as amended by 75 Fed. Reg. 41092 (July 15, 2010) (providing the correct effective date of July 13, 2010 for the revised 38 C.F.R. § 3.304(f)). The revised § 3.304(f) applies to claims of service connection for PTSD that were appealed to the Board before July 13, 2010, but have not been decided by the Board as of July 13, 2010. Because the Veteran's appeal for service connection for PTSD was pending at the Board before July 13, 2010, the Board finds that the revised 38 C.F.R. § 3.304(f) is applicable to the Veteran's claim. See 38 C.F.R. § 3.304(f) (effective July 13, 2010). Service connection may be established for a Persian Gulf Veteran who exhibits objective indications of chronic disability which cannot be attributed to any known clinical diagnosis, but which instead results from an undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2016. 38 C.F.R. § 3.317(a)(1)(i) (2011). See also 76 Fed. Reg. 81834 (Dec. 29, 2011). A "Persian Gulf Veteran" is one who served in the Southwest Asia theater of operations during the Persian Gulf War. Id. Objective indications of a chronic disability include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. The 6-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. A disability referred to in this section shall be considered service-connected for the purposes of all laws in the United States. 38 C.F.R. § 3.317(a)(2)-(5). Effective March 1, 2002, the law affecting compensation for disabilities occurring in Persian Gulf War Veterans was amended. 38 U.S.C.A. §§ 1117, 1118. Essentially, these changes revised the term "chronic disability" to "qualifying chronic disability," and involved an expanded definition of "qualifying chronic disability" to include: (a) an undiagnosed illness, (b) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. 38 U.S.C.A. § 1117(a)(2)(B); 38 C.F.R. § 3.317. The term "medically unexplained chronic multisymptom illness" means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). With claims based on undiagnosed illness, the Veteran is not required to provide competent evidence linking a current disability to an event during service. Gutierrez v. Principi, 19 Vet. App. 1 (2004). Signs or symptoms that may be a manifestation of an undiagnosed illness or a chronic multi-symptom illness include: fatigue, unexplained rashes or other dermatological signs or symptoms, headache, muscle pain, joint pain, neurological signs and symptoms, neuropsychological signs or symptoms, signs or symptoms involving the upper or lower respiratory system, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 U.S.C.A. § 1117(g); 38 C.F.R. § 3.317(b). Section 1117(a) of Title 38 of the United States Code authorizes service connection on a presumptive basis only for disability arising in Persian Gulf Veterans due to "undiagnosed illness" and may not be construed to authorize presumptive service connection for any diagnosed illness, regardless of whether the diagnosis may be characterized as poorly defined. VAOPGCPREC 8-98 (Aug. 3, 1998). Compensation may be paid under 38 C.F.R. § 3.317 for disability which cannot, based on the facts of the particular Veteran's case, be attributed to any known clinical diagnosis. The fact that the signs or symptoms exhibited by the Veteran could conceivably be attributed to a known clinical diagnosis under other circumstances not presented in the particular Veteran's case does not preclude compensation under § 3.317. Id. If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing the second and/or third element of a service connection claim. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. See Savage, 10 Vet. App. at 495-498. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. Reasonable doubt is one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. § 3.102. The Board finds that the evidence supports granting the Veteran's service connection claim for PTSD. The Veteran contends that she incurred PTSD during active service in the southwest Asia theater of operations during Operation Desert Storm. She also contends that her in-service stressors are related to her Persian Gulf War service. The Board notes initially that, although it is required to consider all possible theories of entitlement for service connection claims, and although the Veteran has raised multiple theories of entitlement to service connection for PTSD in her appeal, the competent evidence supports granting service connection for PTSD on a direct service connection basis, especially in light of the relaxed evidentiary standards found in the revised § 3.304(f). See Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004); see also 38 C.F.R. § 3.304(f) (effective July 13, 2010). Given the favorable disposition of this claim on a direct service connection basis, the Board will not consider the Veteran's alternative theories of entitlement. The Board also notes initially that, based on a review of the Veteran's service personnel records which confirm that she served in the southwest Asia theater of operations during Operation Desert Storm, she is considered a Persian Gulf Veteran for VA disability compensation purposes. 38 C.F.R. § 3.317(a)(1)(i) (2011). See also 76 Fed. Reg. 81834 (Dec. 29, 2011). A review of the Veteran's service treatment records shows no complaints of or treatment for PTSD at any time during active service, including while she was in the Persian Gulf in support of Operation Desert Storm. These records show that the Veteran was diagnosed as having anxiety in December 1990. In May 1991, although the Veteran reported an in-service medical history of depression or excessive worry and nervous trouble, the in-service examiner stated that there had been no change in the Veteran's condition. The competent post-service evidence supports granting the Veteran's service connection claim for PTSD on a direct basis. See 38 C.F.R. §§ 3.303, 3.304. This evidence shows that the Veteran has been diagnosed as having PTSD based on a credible in-service stressor. For example, in a lay statement submitted in support of the Veteran's claim and received at the RO in February 2005, L.M., a soldier who served with the Veteran during the Persian Gulf War, stated that the Veteran had been separated from her unit immediately after it had landed in Saudi Arabia. L.M. also stated that the Veteran had been separated from her unit for 3 days until she had been reunited with it. In a March 2005 statement, the Veteran identified her in-service stressor as being forced to run off a plane with her unit as the plane landed in Saudi Arabia during the Persian Gulf War. She stated that "live rounds [were] being fired near the airport" when the plane carrying her unit landed in Saudi Arabia. The Veteran also stated that she passed out and woke up in a field hospital. She stated further that she had been separated from her unit for 3 days. She identified another in-service stressor as watching a missile hit near the compound where her unit was located during the Persian Gulf War. On VA outpatient treatment later in March 2005, the Veteran's complaints included sleep difficulties, nervousness, and poor family relationships "for a long time." She reported having anxiety attacks at the time that her National Guard unit was activated and sent overseas during the Persian Gulf War. She also reported that she "hyperventilated and blacked out the first time I went in country; when I came to, I was in a field hospital." She reported further that she had been separated from her unit for 3 days and "was scared." Her in-service stressors also included hearing missile strikes and gunfire at night. Mental status examination of the Veteran showed she was alert, articulate, good eye contact, initially quiet, increased startle response, no suicidal or homicidal ideation, and full orientation. The assessment included questionable PTSD. An April 2005 VA social worker note indicated that the Veteran reported experiencing in-service trauma during the Persian Gulf War. On private outpatient psychological evaluation in July 2005, the Veteran complained of "depressive issues secondary to service while on active duty with the Alabama National Guard during Operation Desert Storm." She stated that, while on active service, she experienced a panic attack when her unit landed in Saudi Arabia. "She passed out, was unconscious, and was transported to the hospital. After being released from the hospital, she was unable to locate her primary unit. This left her considerably distraught and panicky." Mental status evaluation of the Veteran showed that she was well dressed and well groomed with "no specific tics or mannerisms," speech within normal limits, a sense of hopelessness and helplessness, feeling "considerably embarrassed about passing out as she was landing in Saudi Arabia," irritability and restlessness, "a hard time functioning on a daily basis," no delusions or hallucinations, full orientation, and a fair memory. The private psychologist concluded that the Veteran met all of the diagnostic criteria for chronic PTSD with "significant impairment in daily functioning." It was noted that the Veteran "relates her difficulties to a panic attack she had while landing in the combat zone during Desert Storm." The diagnoses included PTSD. In a July 2005 statement, the Veteran reported that her in-service stressors included being separated from her unit "upon arrival in Saudi Arabia," Scud missile attacks "surrounding our living area," and having a Patriot anti-missile battery "directly behind areas we were working in" while deployed overseas in the Persian Gulf War. On VA psychosocial assessment in July 2005, the Veteran reported that her active service in the Persian Gulf War had been "a very traumatic time for her." She also reported that she had been separated from her unit and was told that she would be taken to the front line "if her unit was not located." The diagnoses included PTSD. On VA outpatient treatment in February 2006, the Veteran complained that she was unable to work due to constant stress. Mental status examination of the Veteran showed full orientation, casual dress, no good eye contact, spontaneous and logical speech, no delusions, nightmares, flashbacks, depression, an inability to sleep, no auditory or visual hallucinations, slow but intact memory and concentration, and fair insight and judgment. The diagnoses included PTSD due to Gulf War service. In a March 2006 statement, the Veteran identified her in-service stressors as including becoming separated from her unit for 3 days immediately after arriving in Saudi Arabia during the Persian Gulf War. On VA outpatient treatment in May 2006, the Veteran reported that she was sleeping well "about 5 hours." She had found a full-time job. Her daughter was living with her. She was not dating anyone. She reported her energy level was good and her concentration was fair. She denied any suicidal or homicidal ideation or current nightmares. Mental status examination of the Veteran showed she was not agitated with good eye contact, linear and goal-directed thoughts, no suicidal ideation or plan, and good judgment and insight. The assessment included PTSD. In May 2009, the Veteran complained of anxiety and depression. She was living with her mother and got along well with her. She also reported that, when she experienced anxiety, she was restless and her mind was racing. She was working part-time. She also felt isolated and denied any suicidal or homicidal ideation or plan. Mental status examination of the Veteran showed normal speech, linear and goal-directed thought process, no active delusions or hallucinations, avoidance and hypervigilance, no suicidal or homicidal ideation, full orientation, grossly intact cognition, and good insight and judgment. The assessment included PTSD. In an April 2010 statement, the Veteran reported that, as her unit landed in Saudi Arabia during Operation Desert Storm, her commanding officer ordered her unit to "get off the plane and run due to the airport coming under fire." The Veteran stated that she became separated from her unit almost immediately after this incident and was not reunited with them for approximately 3 days. On VA outpatient treatment in May 2010, the Veteran complained of "just the same old depression." She reported being diagnosed as having depression in 2004 "but it probably started in Desert Storm." She also reported being missing in action for 3 days after her plane landed "in the midst of fire" and being told to "get off the plane and run." Her depression was almost daily. She also had "some periods of 1-2 days when she has increased goal-directed behavior and feels very good." She rated her depression as 7/10 on a pain scale (with 10/10 being the worst imaginable pain). She also reported "that she 'hardly ever' sleeps, usually averaging 4 hours a night," poor appetite, low self-esteem, suicidal thoughts "but has never made an attempt," no homicidal thoughts, reported auditory hallucinations, paranoia, and anxiety attacks. Her in-service stressors included being told to get off the plane and run when her unit arrived in Saudi Arabia during Operation Desert Storm. She experienced intrusive memories 2-3 times a week, nightmares, night sweats, avoidance, and irritability. Mental status examination of the Veteran in May 2010 showed she was alert, clean, well-groomed, and wore fitted jeans, boots, and a tightly fitting sweater. She also wore a shoulder-length wig "and tends to pull the hair forward to cover her face at times." She played with her hair constantly. No movement abnormalities were note "apart from mild psychomotor retardation." Her speech was soft and slightly slurred. Thoughts were linear "but vague." No active suicidal or homicidal ideation was noted. The Veteran reported possible auditory hallucinations. No delusions were noted. Her insight and judgment were "fairly good." The assessment included rule-out PTSD with a note that the Veteran's "in-service stressors are less clear but she has apparently carried this diagnosis in the past." In a December 2010 statement, L.M. reiterated that the Veteran had been separated from their unit immediately after it had arrived in Saudi Arabia during the Persian Gulf War. L.M. also stated that the Veteran had passed out as the plane carrying their unit had landed. The Veteran was taken off of the plane and separated from her unit for 3 days. On VA examination in May 2011, the Veteran complained of ongoing psychiatric symptoms including sleep difficulty, irritability, easy distractibility, and little concentration. The VA examiner reviewed the Veteran's claims file, including her service treatment records and post-service VA treatment records. The Veteran reported being on an anti-depressant which was "fair in controlling symptoms." The Veteran also reported serving in combat in Kuwait during Operation Desert Storm. She had no friends and preferred to be alone. She also was verbally aggressive towards others and had fought with an ex-husband during their marriage. She had been dating another man for 10 years although their relationship was "sometimes rocky." Mental status examination of the Veteran in May 2011 showed that she was neatly groomed with hand wringing, repetitive acts, restlessness, an agitated mood, easy distractibility, a short attention span, not oriented to time although oriented to person and place, unremarkable thought process and thought content, persistent persecutory and paranoid delusions, obsessive/ritualistic behavior, inappropriate behavior, panic attacks occurring 2-3 times a week lasting between 1-2 hours or all day (if severe), current homicidal ideation, past suicidal ideation, poor impulse control with episodes of violence, an inability to maintain minimum personal hygiene on a daily basis, problems with activities of daily living, mildly impaired remote and immediate memory, normal recent memory, and partial insight. The Veteran reported experiencing tactile hallucinations which were not persistent. She also reported getting in to arguments and physical fights with strangers and her boyfriend. She reported further that "some days she is unable to get out of the bed and does not address personal hygiene." The VA examiner noted that the Veteran "had difficulty making eye contact. She was extremely agitated." The Veteran identified her in-service stressors as including active service in a combat zone in Kuwait during the Persian Gulf War. She reported feeling helpless, horrified, "scared all the time," and anxious during this combat service. She also reported experiencing "a blackout when her unit landed at the airport and they were being fired upon." The VA examiner concluded that the Veteran met the diagnostic criteria for PTSD. This examiner also stated that the Veteran's PTSD "is most likely the result of" her combat experiences and a reported in-service attempted sexual assault. The diagnoses included PTSD. In a January 2012 addendum to the May 2011 VA examination report, the May 2011 VA examiner stated that he had reviewed the Veteran's claims file again. This examiner opined that it was at least as likely as not that the Veteran's PTSD was incurred in or caused by service. The examiner's rationale was that the Veteran's PTSD symptoms "occurred following her deployment to Kuwait. One of the officers in her unit verified that [the Veteran] lost consciousness upon arriving in country. According to the Veteran, they were under fire." This examiner's rationale also was based on a review of the statements from L.M. (discussed above) regarding how the Veteran became separated from her unit immediately upon arriving in Saudi Arabia and the Veteran "feared for her life during that time." The evidence persuasively suggests that the Veteran was in combat during the Persian Gulf War. She has reported that her in-service stressors were related to her active combat service in the Persian Gulf War. The competent evidence also shows that the Veteran has been diagnosed as having PTSD and she reported her in-service stressors, to include her active combat service in the Persian Gulf War, to the VA examiners who rendered this diagnosis. In summary, after resolving all reasonable doubt in the Veteran's favor, and especially in light of the relaxed evidentiary standards for PTSD claims found in the revised 38 C.F.R. § 3.304(f), the Board finds that the evidence supports granting service connection for PTSD. Withdrawal of Service Connection Claim for a Right Knee Disability In the currently appealed rating decision issued in May 2005, the RO denied the Veteran's claim of service connection for a right knee disability (which was characterized as joints pains (knees, elbows, and ankles)). The Veteran has perfected a timely appeal with respect to this claim. In statements on a VA Form 21-4138 dated on October 11, 2010, and date-stamped as received by the RO on November 8, 2010, prior to the promulgation of a decision in this appeal, the Veteran requested a withdrawal of her appeal with respect to the denial of her service connection claim for a right knee disability. The Board observes that it may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2002). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2010). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. Given the Veteran's October 2010 VA Form 21-4138 requesting withdrawal of her appeal for service connection for a right knee disability, there remain no allegations of errors of fact or law for appellate consideration with respect to this claim. Accordingly, the Board does not have jurisdiction to review this claim and it is dismissed. ORDER Entitlement to service connection for PTSD is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to service connection for a right knee disability is dismissed. REMAND Inasmuch as the Board sincerely regrets the additional delay of the adjudication of this matter, a remand is necessary before the Veteran's claim of service connection for an acquired psychiatric disability other than PTSD, to include depression and anxiety, can be adjudicated. The Veteran essentially contends that her current acquired psychiatric disability other than PTSD, to include depression and anxiety, is related to active service. She also contends that this disability existed prior to service and was aggravated by service. As noted above, the Veteran's service treatment records show treatment for anxiety contemporaneous to her active combat service in the southwest Asia theater of operations during the Persian Gulf War. It appears that the Veteran's in-service anxiety was attributed to claustrophobia from wearing her gas mask. The competent post-service evidence (in this case, the Veteran's VA and private outpatient treatment records) shows that she has been diagnosed as having depression and anxiety since her service separation. It is not clear from a review of these records whether the Veteran's current acquired psychiatric disability other than PTSD, to include depression and anxiety, is related to active service. The Board notes in this regard that, although the May 2011 VA examiner was asked to provide a nexus opinion concerning the Veteran's acquired psychiatric disability other than PTSD, to include anxiety and depression, this examiner limited his May 2011 opinion and January 2012 addendum to the Veteran's currently diagnosed PTSD. And the Board already has granted service connection for PTSD in this decision. The Board observes in this regard that the January 2012 VA examination report addendum was provided in a Disability Benefits Questionnaire (DBQ). Although the Board recognizes that DBQ's are a work in progress for VHA, the January 2012 DBQ in this case is extremely difficult to read or interpret for purposes of VA disability compensation. For example, it appears that the VA examiner did not answer the questions asked of him regarding the nature and etiology of the Veteran's acquired psychiatric disability other than PTSD, to include depression and anxiety, in the DBQ. This examiner stated in the DBQ that the Veteran's "disability" clearly and unmistakably existed prior to service and was aggravated beyond its natural progression by service. This examiner did not identify what disability existed prior to service and was aggravated by the Veteran's service, however. This examiner also provided a rationale for this opinion in which he discussed the Veteran's alleged in-service personal assault and post-service use of alcohol and marijuana as "ways of self-medicating in order to cope with the emotional pain inherent in her disorders." He did not identify the disorders he was referring to when he provided this rationale. The Board also observes that VA's duty to assist includes providing Veterans with examinations where necessary. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159. The Court has held that, when VA undertakes to provide a Veteran with an examination, that examination must be adequate for VA purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Having reviewed the May 2011 VA examination and January 2012 DBQ, the Board finds that this evidence is inadequate for purposes of adjudicating the Veteran's service connection claim for an acquired psychiatric disability other than PTSD, to include depression and anxiety. See 38 C.F.R. § 4.2 (2011). Given the foregoing, the Board finds that, on remand, the Veteran should be scheduled for appropriate VA examination to determine the nature and etiology of her acquired psychiatric disability other than PTSD, to include depression and anxiety. In order to avoid another remand on this claim, the Board requests that the DBQ format not be used at this examination. The RO/AMC also should attempt to obtain the Veteran's up-to-date VA and private treatment records. The Board notes in this regard that the Veteran has moved frequently during the pendency of this appeal. A review of the claims file also suggests that the Veteran currently may be homeless. Thus, any attempt by the RO/AMC to contact the Veteran either for purposes of obtaining her up-to-date VA and private treatment records and/or for purposes of scheduling her for another VA examination should include a determination of her current mailing address of record. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). Expedited handling is requested.) 1. After confirming the Veteran's current mailing address of record, contact the Veteran and/or her service representative and ask her to identify all VA and non-VA clinicians who have treated her for an acquired psychiatric disability other than PTSD, to include depression and anxiety, since her separation from active service. Obtain all VA treatment records which have not been obtained already. Once signed releases are received from the Veteran, obtain all private treatment records which have not been obtained already. A copy of any records obtained, to include a negative reply, should be included in the claims file. 2. Schedule the Veteran for appropriate examination to determine the nature and etiology of her acquired psychiatric disability other than PTSD, to include depression and anxiety. A Disability Benefits Questionnaire (DBQ) should not be used for this examination report. The claims file and a copy of this remand must be provided to the examiner for review. All appropriate testing should be conducted. The Veteran should be asked to provide a complete medical history, if possible. Based on a review of the claims file and the results of the Veteran's physical examination, and the Veteran's statements regarding the development and treatment of her claimed disorder, the examiner is asked to opine whether it is at least as likely as not (i.e., a 50 percent or greater probability) that an acquired psychiatric disability other than PTSD, to include depression and anxiety, if diagnosed, is related to active service or any incident of service. The examiner also is asked to opine whether it is at least as likely as not (i.e., a 50 percent or greater probability) that an acquired psychiatric disability other than PTSD, to include depression and anxiety, if diagnosed, clearly and unmistakably existed prior to active service and was aggravated beyond its natural progression by service. The examiner finally is asked to opine whether it is at least as likely as not (i.e., a 50 percent or greater probability) that an acquired psychiatric disability other than PTSD, to include depression and anxiety, if diagnosed, was caused or aggravated (permanently worsened) by the Veteran's service-connected PTSD. A complete rationale must be provided for any opinions expressed. If possible, the examiner is asked to distinguish between any symptomatology attributable to the Veteran's service-connected PTSD and to an acquired psychiatric disability other than PTSD, to include depression and anxiety, if diagnosed. The examiner is advised that the Veteran has contended that her acquired psychiatric disability clearly and unmistakably existed prior to service and was aggravated beyond its natural progression by service. The examiner also is advised that the Veteran has reported a history of childhood sexual abuse and domestic violence. 3. The Veteran should be given adequate notice of the requested examination, which includes advising her of the consequences of her failure to report to the examination. If she fails to report to the examination, then this fact should be noted in the claims file and a copy of the scheduling of examination notification or refusal to report notice, whichever is applicable, should be obtained by the RO and associated with the claims file. 4. Review all evidence received since the last prior adjudication and readjudicate the Veteran's claim. If the determination remains unfavorable to the Veteran, then the RO should issue a supplemental statement of the case that contains notice of all relevant actions taken, including a summary of the evidence and applicable law and regulations considered pertinent to the issue. An appropriate period of time should be allowed for response by the Veteran and her service representative. Thereafter, the case should be returned to the Board for further appellate consideration, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). ______________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs