Citation Nr: 1308922 Decision Date: 03/15/13 Archive Date: 03/25/13 DOCKET NO. 05-40 645 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for osteoarthritis of the hips, shoulders, and knees. 2. Entitlement to service connection for a gastrointestinal disability, however diagnosed (to include a stomach disorder and/or gastroesophageal reflux disorder), to include as due to an undiagnosed illness. 3. Entitlement to service connection for a sinus disability, however diagnosed (to include chronic recurrent sinusitis), to include as due to an undiagnosed illness. 4. Entitlement to service connection for a bilateral ear infection disability, however diagnosed (to include chronic recurrent otitis), to include as due to an undiagnosed illness. 5. Entitlement to service connection for a skin disability, however diagnosed (to include eczema of bilateral axillary area), to include as due to an undiagnosed illness. 6. Entitlement to service connection for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), major depressive disorder, anxiety disorder, and panic disorder with agoraphobia. 7. Entitlement to service connection for a sleep disorder, to include as due to an undiagnosed illness, and to include as secondary to an acquired psychiatric disability. 8. Entitlement to service connection for a disability manifested by chronic fatigue, to include as due to an undiagnosed illness, and to include as secondary to an acquired psychiatric disability. 9. Entitlement to service connection for a liver disability, to include as due to an undiagnosed illness. REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran, his wife, and his sister ATTORNEY FOR THE BOARD M. M. Celli, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1984 to June 1987 and from November 1989 to March 1992, which included service in the Southwest Asia Theater of operations during the Gulf War. These matters are before the Board of Veterans' Appeals (Board) on appeal from a January 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. A July 2007 Board decision denied all of the claims on appeal except for service connection for hepatitis C, claimed as liver damage, including as due to an undiagnosed illness, which was remanded for evidentiary development. The Veteran appealed the July 2007 Board decision to the United States Court of Appeals for Veterans Claims (Court). In an August 2008 Order, the Court vacated the Board decision and remanded the case to the Board for compliance with an August 2008 Joint Motion for Remand (Joint Motion). Accordingly, in November 2009 the Board remanded all the issues on appeal. In December 2006, the Veteran testified before an undersigned Veterans Law Judge at a Travel Board hearing at the RO. In light of the poor quality of the recording, and pursuant to the Joint Motion, the Veteran testified before a second undersigned Veterans Law Judge during a November 2011 Travel Board hearing at the RO. At that time, the Veteran waived the right to testify before a third Veterans Law Judge who would be part of the panel that decides the current appeal. Transcript (T.) at p. 7. See Arneson v. Shinseki, 24 Vet. App. 379 (2011). Generally, the scope of a mental health disability claim includes any psychiatric disorder that may reasonably be encompassed by a veteran's description of the claim, reported symptoms, and the other information of record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). In June 2004, the Veteran submitted a claim of entitlement to service connection for depression. VA treatment records reflect multiple diagnoses, including PTSD, major depressive disorder, anxiety disorder, and panic disorder with agoraphobia. Accordingly, the Board has re-captioned the Veteran's claim as seen on the title page. Id. Additionally, on VA examination in August 2011, the Veteran related his current chronic fatigue and sleep disorder to his depression and nightmares. In a January 2013 written brief, the Veteran's representative highlighted the evidence of record that indicated a possible connection between the Veteran's acquired psychiatric disorder and a sleep disorder. Although there may be multiple theories or means of establishing entitlement to a benefit for a disability, if the theories all pertain to the same benefit for the same disability, they constitute the same claim. Robinson v. Mansfield, 21 Vet. App. 545 (2008). As a result, the Board has re-characterized the issues regarding chronic fatigue and a sleep disorder as shown above. Additional evidence was received by the Board in January 2013 and February 2013, without waiver of RO consideration. However, the Veteran is not prejudiced by the Board's adjudication of the issue of service connection for a psychiatric disability at this time as the benefit sought is granted herein. As noted in the November 2011 Board remand, testimony provided at the September 2011 Board hearing raised the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disability. As the record does not demonstrate that the the Agency of Original Jurisdiction (AOJ) has adjudicated the issue, the Board does not have jurisdiction over it, and it is again referred to the AOJ for appropriate action. The issues of entitlement to service connection for osteoarthritis of the hips, shoulders, and knees, for a gastrointestinal disability, for a sinus disability, for a bilateral ear infection disability, for a skin disability, and for a liver disability, to include as due to an undiagnosed illness; and entitlement to service connection for a disability manifested by chronic fatigue, and for a sleep disorder, to include as due to an undiagnosed illness, and to include as secondary to an acquired psychiatric disorder, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center in Washington, DC. FINDING OF FACT The evidence of record is in equipoise as to whether clinically diagnosed PTSD, major depressive disorder, anxiety disorder, and panic disorder with agoraphobia, are related to active service. CONCLUSION OF LAW Resolving all doubt in favor of the Veteran, PTSD, major depressive disorder, anxiety disorder, and panic disorder with agoraphobia, were incurred in active service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION As a preliminary matter, the Board finds that VA has substantially satisfied the duties to notify and assist, as required by the Veterans Claims Assistance Act of 2000. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). To the extent that there may be any deficiency of notice or assistance, there is no prejudice to the Veteran in proceeding with this appeal given the favorable nature of the Board's decision to grant the claim. Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In particular, service connection for PTSD requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) credible supporting evidence that the claimed in-service stressor(s) occurred; and (3) medical evidence establishing a link between the current diagnosis and the stressor(s) in service. 38 C.F.R. § 3.304(f). VA recently amended 38 C.F.R. § 3.304(f) to liberalize the evidentiary standard for establishing a required in-service stressor where a claimed stressor is related to fear of hostile military or terrorist activity. 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; or incoming artillery, rocket, or mortar fire, grenade, small arms 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. In each case where a veteran is seeking service connection for any disability, due consideration shall be given to the places, types, and circumstances of such veteran's service as shown by such veteran's service record, the official history of each organization in which such veteran served, such veteran's treatment records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, 492 F.3d at 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit, citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir.1996). The Veteran asserts that he has current acquired psychiatric disability that is related to his active service with the 218th Military Police Company, 4th Platoon during the Persian Gulf War. The Veteran contends that he feared for his life when his unit was receiving incoming fire and they were unable to return fire. He also states his unit came across burned and buried bodies. He reports that his depression began during service when he returned from Iraq and began to gain weight and experience symptoms of fatigue. The Veteran's DD-214's demonstrate that his military occupation specialty was military police during both periods of service. Service personnel records confirm that the Veteran served in the Southwest Asia Theater from December 3, 1990 to May 16, 1991, and that he served with the 218th Military Police Company. The Veteran's service treatment records do not reveal any complaints of, treatment for, or diagnoses of any acquired psychiatric disorder. A February 1992 report of medical history demonstrates the Veteran reported a history of frequent trouble sleeping and noted that he could not fall asleep at times. He denied having depression, excessive worry, or nervous trouble of any sort. Clinical examination at that time noted he was normal on psychiatric evaluation. A September 2004 VA treatment record indicates the Veteran reported feeling depressed since service in the Gulf War from 1990 to 1991, and a December 2004 VA treatment record reflects the Veteran's reports that he had a 10-year history of feeling depressed. An April 2006 VA treatment record demonstrates an impression of anxiety disorder - PTSD, prolonged, chronic; and major depressive disorder. In August 2011, the Veteran underwent VA psychological examination in conjunction with his claim. The VA examiner reviewed the Veteran's claims file. The Veteran reported having in-service combat experience while picking up enemy prisoners for the 1st Armored Division. The VA examiner noted the Veteran was currently receiving anti-anxiety treatment and treatment for other mental disorders. The Veteran reported feeling sad with occasional crying spells and feeling stressed out with respect to working a high pressure, physically demanding job. He also stated his service in the Persian Gulf War was stressful as he had a three-month year old son at home and had only been married for 16 months. The Veteran reported that his in-service duties involved operating a mobile camp and picking up prisoners of war. He asserted that they were fired upon at night, which was stressful as they had no idea of their whereabouts. He also reported coming across buried bodies during his deployment. He reported sleep impairment and panic attacks. The VA examiner diagnosed depressive disorder, not otherwise specified, and reported that symptoms of a panic disorder without agoraphobia were related to this diagnosis. The VA examiner opined that based on a review of the claims file, medical records, and the history provided by the Veteran, the Veteran's depression was less likely as not (less than 50/50 probability) caused by service-related events or experiences. No basis or rationale for the opinion was provided. In September 2011, the Veteran submitted written statements from his wife and his father in support of his claim. The Veteran's wife stated that his service in the Persian Gulf War had changed the Veteran significantly and that he had many health and mental health problems, including depression, anxiety, and memory problems, which began within the first two years after his return from service. She recalled that she first noticed certain symptoms in the middle of 1992 and reported that the Veteran had gotten progressively worse since that time. She reported that the Veteran was out of work due to his health problems. The Veteran's father stated the Veteran was often depressed and believed the Veteran was very close to a complete nervous breakdown. He stated that on one vacation trip, he observed the Veteran have to leave a noisy bus due to nervousness. The Veteran submitted a December 2011 private treatment record in support of his claim. The private physician recorded the Veteran's service as military police in the Gulf War and noted that he was currently being treated for PTSD. The private physician found the following symptoms caused social, personal, and occupational impairment: difficulty concentrating; generalized anxiety with panic attacks despite medication; bouts of short- and long-term memory loss; flashbacks/intrusive thoughts; insomnia and other sleep disturbance; overwhelming feelings of sorrow; acting withdrawn; and bouts of moderately severe to severe depression. The Veteran stated that prior to receiving treatment, he had been experiencing panic attacks almost daily since 2006. The private physician diagnosed "PTSD, chronic, delayed, severe" and opined that the Veteran presented with "classic symptomatology related to service[-]connected posttraumatic stress disorder." The private physician found the Veteran had outlined several in-service stressors and opined that the Veteran's stressors were the nexus between his current symptoms and his military service. Based on the clinical interview, observations, and review of the assessment measures and records, the private physician opined that the Veteran met all the criteria concerning a diagnosis of PTSD under the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV). No specifics were provided as to the reported military stressors relied upon in rendering the diagnosis. A February 2012 VA treatment record indicates a PTSD evaluation was positive, and an October 2012 VA treatment record shows the Veteran underwent psychotherapy for PTSD and depression. The assessment was major depressive disorder, recurrent, mild; dysthymia; panic disorder with agoraphobia; and "PTSD, chronic (Persian Gulf War)." In November 2012, the VA examiner who performed the August 2011 VA examination provided an addendum opinion. After reviewing the Veteran's claims file, treatment records, and the history provided by the Veteran, the VA examiner stated the Veteran's depression was less likely as not caused by service-related events or experiences in the Persian Gulf War. The VA examiner noted that the Veteran reported feeling depressed for the past year and cited difficult relationships with his wife and job-related problems. The VA examiner opined that the Veteran's stress related to his relationship with his wife and his problems at work had at least as likely as not contributed to his depressive disorder. Based upon a review of the evidence, the Board finds that entitlement to service connection for PTSD, major depressive disorder, anxiety disorder, and panic disorder with agoraphobia, is warranted. First, the medical evidence of record reveals diagnoses of PTSD, major depressive disorder, anxiety disorder, and panic disorder with agoraphobia during the pendency of the appeal. Next, the Board finds the Veteran has presented competent and credible testimony regarding in-service stressors. Here, service personnel records reflect that the Veteran's military occupation specialty was military police. As such, the Board finds that the Veteran's assertion concerning his duties finding, transporting and detaining prisoners of war, including under enemy fire, are credible and notes that nothing in the record contradicts the Veteran's statements. Additionally, the Board finds that the stressor of coming under enemy fire reported by the Veteran is consistent with the provisions of 38 C.F.R. § 3.304(f)(3). The stressor involved actual or threatened death or serious injury, and the Veteran's response involved a psychological state of fear. Because the reported stressor is credible and consistent with the circumstances of his service, the Board finds that the Veteran's lay testimony is sufficient to establish the occurrence of the reported in-service stressor. Furthermore, the December 2011 private physician diagnosed the Veteran with PTSD per the DSM-IV criteria and associated the Veteran's psychiatric disabilities with his active service. Although the specifics of the reported military stressors relied upon in rendering the diagnosis were not identified by the examiner, the Board notes that the circumstances of the Veteran's military service is consistent with his reported military stressors, and his reported stressors have remained consistent in content. The private physician found the Veteran presented with classic symptomatology related to service-connected PTSD and had outlined several in-service stressors that were related to his current symptoms. The Board notes that the evidence does not show that the private physician reviewed the Veteran's claim file. The Court has held that a failure to review the claims file renders a VA examination inadequate for rating purposes. See, e.g., Proscelle v. Derwinski, 2 Vet. App. 629, 932 (1992) ("The [VA] examiner should have the Veteran's full claims file available for review."), but see Snuffer v. Gober, 10 Vet. App. 400, 403-04 (1997) (review of claims file not required where it would not change the objective and dispositive findings made during a medical examination). See also 38 C.F.R. §§ 4.1 , 4.2 (2012). However, when contemplating a medical opinion, the relevant inquiry is whether "the examiner providing the report or opinion is fully cognizant of the claimant's past medical history." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Despite the absence of the claims file, the December 2011 letter reflects that the private physician was apprised of the Veteran's medical history of symptoms, and the Veteran's history of symptoms conveyed by the private physician is congruent with the evidence of record. In addition, VA treatment records support a diagnosis of PTSD and indicate that the Veteran's current PTSD symptoms are related to his service in the Persian Gulf War. Moreover, the Board may not disregard a favorable medical opinion solely because it was based on a history given by the Veteran. See Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005). Rather, reliance on a Veteran's statements renders a medical report not credible only if the Board rejects the statements of the veteran as lacking credibility. Coburn v. Nicholson, 19 Vet. App. 427 (2006). In this case, the Board finds no reason to doubt the Veteran's credibility with respect to his service and symptoms. The Veteran's statements throughout this appeal as well as in the medical records are consistent. As such, the December 2011 private opinion is adequate despite the fact that the private physician may not have reviewed the Veteran's VA claims file. Although the VA examiner in August 2011 and November 2012 reviewed the Veteran's claims file and rendered the opinion that the Veteran's depressive disorder was unrelated to his active service, the Board finds this opinion to be of little probative value. First, the VA examiner appears to focus solely on the Veteran's reported stressors regarding his marital and work-related problems. In fact, when providing rationale for the opinion, the VA examiner does not address the Veteran's active service in any manner, to include his reported in-service stressors. Further, the Board finds it significant that the VA examiner does not appear to have considered the diagnoses of PTSD as demonstrated in the evidence of record, to include documentation in VA treatment records dated prior to the November 2012 addendum opinion. Furthermore, throughout the pendency of the appeal, the Veteran has consistently asserted that he experienced depressive symptoms during and since his return from active duty. In addition, the Veteran's wife and father have asserted that the Veteran displayed symptoms of depression upon returning from active service. While lay persons are generally not competent to offer evidence which requires medical knowledge, such as opinions regarding medical causation or a diagnosis, they may provide competent testimony as to visible symptoms and manifestations of a disorder. Jones v. Brown, 7 Vet. App. 134, 137 (1994). The Board notes that the Veteran is competent to give evidence about what he experienced; i.e., that he has had symptoms of depression during and since his separation from service. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional); Charles v. Principi, 16 Vet. App. 370, 274 (2002) (finding Veteran competent to testify to symptomatology capable of lay observation); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting competent lay evidence requires facts perceived through the use of the five senses). Here, the Board finds nothing in the record that would refute the competency and credibility of the Veteran with respect to his symptoms since separation from active duty. Thus, the Board finds that the evidence is at least in equipoise regarding whether PTSD, major depressive disorder, anxiety disorder, and panic disorder with agoraphobia, are related to active service during the Persian Gulf War. Resolving the benefit of the doubt in favor of the Veteran, the Board finds service connection for these psychiatric disabilities is warranted. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for PTSD, major depressive disorder, anxiety disorder, and panic disorder with agoraphobia, is granted. REMAND In August 2011, the Veteran was afforded VA medical examinations in conjunction with his claims of entitlement to service connection for osteoarthritis of the hips, shoulders, and knees; a gastrointestinal disability, a sinus disability, a bilateral ear infection disability; a skin disability; a sleep disorder; fatigue; and a liver disability. Regarding the issues of service connection for a sleep disorder and fatigue, to include as due to an undiagnosed illness, the VA examiner stated there was no documented evidence of such a chronic condition during service. However, the evidence of record includes a February 1992 report of medical history that demonstrates the Veteran reported a history of frequent trouble sleeping and noted that he could not fall asleep at times. Because the VA examiner did not address this notation when rendering the opinion, the Board finds that addendum opinions are necessary for the purpose of adjudicating these issues of service connection. With respect to the issues of service connection for osteoarthritis of the hips, shoulders, and knees; a gastrointestinal disability; a sinus disability; a bilateral ear infection disability; a skin disability; and fatigue, the VA examiner opined that these conditions were less likely due to exposure to low levels of a "chemical warfare" agent. The VA examiner noted that there was no documented evidence of any chronic condition during service or immediately upon separation from service. The VA examiner also observed that in each case, the first documented evidence of the Veteran's condition was many years following service. As a result, the VA examiner found the Veteran's current conditions were less than likely due to service and were less than likely aggravated by service. Here, the VA examiner's opinions are inadequate because they did not address the Veteran's lay statements regarding his symptoms following service. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (holding that a veteran's statement is competent evidence as to events that are capable of lay observation); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (holding that a veteran's statements are competent evidence of what comes to him/her through his/her senses). Rather, the VA examiner focused on the lack of documentation concerning treatment for these conditions. Generally, "symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage v. Gober, 10 Vet. App. 488, 496 (1997), citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991); see also 38 C.F.R. § 3.303. Thus, the Board finds the August 2011 VA examinations and opinions are inadequate for purposes of determining service connection for these conditions. In order to satisfy VA's duty to assist, the Board finds that a remand is warranted to obtain an addendum opinion addressing the Veteran's lay testimony with respect to his symptoms. 38 U.S.C.A. §§ 5107(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012). With respect to the issue of service connection for a liver disability, the VA examiner stated that there was no evidence of hepatitis C or abnormal liver function as per the examination, and as a result, the VA examiner did not provide an etiological opinion. However, as noted in the November 2009 Board decision, the evidence of record includes persistent abnormal liver function tests dating back to the early 1990s. As the VA examiner did not address these tests or the Veteran's lay assertions regarding his symptoms, the Board finds a remand is warranted to obtain an addendum opinion. In addition, the VA examiner should provide an opinion as to whether the signs or the symptoms claimed are attributable to an undiagnosed illness associated with service in the Persian Gulf War. Finally, on VA examination in August 2011, the Veteran related his current sleep disorder to his depression and nightmares, and in January 2013, the Veteran's representative highlighted the evidence of record that indicated a possible connection between his acquired psychiatric disorder and a sleep disorder. As the Veteran is now service-connected for an acquired psychiatric disorder, a remand is necessary for proper notice concerning the way to substantiate his claim for a sleep disorder on a secondary basis. Further, a VA examination is necessary to address the claim as secondary to the Veteran's now service-connected acquired psychiatric disorder. RO adjudication must be made with consideration of all additional evidence received of record (including in January and February 2013) not previously considered. Accordingly, the case is REMANDED for the following actions: 1. Provide the Veteran with a VCAA notice letter that explains how to substantiate his claims for service connection for a disability manifested by chronic fatigue, and for a sleep disorder, as secondary to service-connected psychiatric disabilities and provide the Veteran and his representative with the appropriate amount of time to reply. 2. Then, schedule the Veteran for an examination for the purpose of determining the nature and etiology of any sleep disorder, and/or disability manifested by chronic fatigue, to include as due to an undiagnosed illness, and to include as secondary to service-connected psychiatric disability. The claims file must be provided to the examiner for review in connection with the examination. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. After examining the Veteran and reviewing the claims file, the examiner should provide opinions as to: * Whether it is at least as likely as not (50 percent likelihood or higher) that any current sleep disorder, and/or disability manifested by chronic fatigue, was incurred in or due to the Veteran's active service? * Whether it is at least as likely as not that any sleep disorder, and/or disability manifested by chronic fatigue, was caused or aggravated by the Veteran's service-connected psychiatric disabilities. * When providing any opinion, the examiner(s) should address the Veteran's February 1992 report of medical history of frequent trouble sleeping, and lay testimony with respect to the onset, continuity, and nature of his symptoms. * For any of the above signs and symptoms, which are not attributable to a known diagnosis, the findings should reflect all objective indications of chronic disability to include either objective medical evidence perceptible to a physician or other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(2). In other words, if not attributable to a known clinical diagnosis, the examiner is asked to express an opinion as to whether the signs or symptoms claimed are attributable to an undiagnosed illness associated with service in the Persian Gulf War. The examiner(s) should clearly outline the rationale for any opinion expressed. If any requested medical opinion cannot be given, the examiner(s) should state the reason why this is so. By aggravation the Board means a permanent increase in the severity of the underlying disability beyond its natural progression. The examiner is advised that the term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it. 3. The Veteran must be afforded VA addendum opinions as to the etiology of his osteoarthritis of the hips, shoulders, and knees; gastrointestinal disability; sinus disability; bilateral ear infection disability; skin disorder; and liver disability, to include as due to an undiagnosed illness. The entire claims file, to include a complete copy of the remand must be made available to the examiner who provided the August 2011 VA clinical opinions, or appropriate alternate clinician if the August 2011 VA examiner is not available. After reviewing the claims file, and examining the Veteran if deemed warranted by the clinician, the VA clinician(s) should expressly state opinions as to: * Whether it is at least as likely as not that the diagnosed osteoarthritis of the hips, shoulders, and knees; gastrointestinal disability; sinus disability; bilateral ear infection disability; skin disorder; and liver disability are due to service? The VA examiner should specifically include consideration of the evidence of record of persistent abnormal liver function tests dating back to the early 1990's, and the Veteran's reported continuity of symptoms of the disabilities at issue since service in rendering the opinions. The clinician(s) should clearly outline the rationale for all opinions expressed. If any requested medical opinion cannot be given, the clinician(s) should state the reason why this is so. 4. After conducting any additional development deemed necessary, the RO should readjudicate the claims of entitlement to service connection for osteoarthritis of the hips, shoulders, and knees, for a gastrointestinal disability, for a sinus disability, for a bilateral ear infection disability, for a skin disability, and for a liver disability, to include as due to an undiagnosed illness; and entitlement to service connection for a sleep disorder, and for a disability manifested by chronic fatigue, to include as due to an undiagnosed illness, and to include as secondary to an acquired psychiatric disorder considering all the evidence of record. If any benefit sought on appeal is not granted to the Veteran's satisfaction, the Veteran and his representative should be furnished a Supplemental Statement of the Case and be provided an opportunity to respond. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _____________________________ _____________________________ DENNIS F. CHIAPPETTA DEBORAH W. SINGLETON Veterans Law Judge Veterans Law Judge Board of Veterans' Appeals Board of Veterans' Appeals ______________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs