Citation Nr: 1313005 Decision Date: 04/18/13 Archive Date: 05/02/13 DOCKET NO. 09-23 358A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for Type II diabetes mellitus, claimed as due to Agent Orange exposure. 2. Entitlement to service connection for a chronic acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD). WITNESS AT HEARING ON APPEAL The Veteran and Mr. D.R. ATTORNEY FOR THE BOARD Bernard T. DoMinh, Counsel INTRODUCTION The Veteran served on active duty in the United States Navy from April 1972 to September 1974. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a February 2005 rating decision by the Columbia, South Carolina, Regional Office of the Department of Veterans Affairs (VA). The agency of original jurisdiction over the current appeal is the Montgomery, Alabama, VA Regional Office (RO). In March 2012, the Veteran, accompanied by his witness, Mr. D.R., appeared at the RO to present oral testimony in support of his appeal at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of this hearing has been obtained and associated with the Veteran's claims file for the Board's review and consideration. The Board subsequently issued a decision in June 2012 reopened the previously denied claims for Type II diabetes mellitus and a chronic acquired psychiatric disorder (to include PTSD) and then remanded these matters to the RO in June 2012 via the Appeals Management Center (AMC) in Washington, D.C., for additional evidentiary and procedural development. This included obtaining copies of the Veteran's medical records relating to a claim for Social Security Administration (SSA) benefits and scheduling him for a psychiatric examination for purposes of clarifying his psychiatric diagnoses and obtaining a nexus opinion. Following this development, the claims for VA compensation for diabetes and a chronic psychiatric disorder were denied in a December 2012 supplemental statement of the case. The case was then returned to the Board in February 2013 and the Veteran now continues his appeal. For the reasons that will be further discussed below in the REMAND portion of this decision, the issue of entitlement to service connection for a chronic acquired psychiatric disorder (to include PTSD) is REMANDED to the RO/AMC. The Veteran will be notified by VA if any further action is required on his part. FINDINGS OF FACT 1. The Veteran served aboard the naval vessel USS Flint (AE 32) during active duty. This vessel operated in the waters offshore from the Republic of Vietnam but did not anchor at port in, or otherwise traverse the interior waterways of the Republic of Vietnam while the Veteran served aboard her. 2. The Veteran does not have verified service or visitation within the territorial confines of the Republic of Vietnam during his period of Vietnam War Era active service. 3. The objective clinical evidence does not establish onset of Type II diabetes mellitus during the Veteran's period of active duty, a diagnosis of diabetes mellitus within one year of service discharge, or a link between the present diagnosis of Type II diabetes and his active service. CONCLUSION OF LAW Type II diabetes mellitus was not incurred, nor is it presumed to have been incurred in active service. 38 U.S.C.A. §§ 1110, 1116 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA's Duties to Notify and Assist The Board notes at the outset that, in accordance with the Veterans Claims Assistance Act of 2000 (VCAA), VA has an obligation to notify claimants what information or evidence is needed in order to substantiate a claim, as well as a duty to assist claimants by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). With respect to the service connection claim on appeal which will be decided herein, generally, the notice requirements of a service connection claim have five elements: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must also: (1) inform the claimant about the information and evidence necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; (3) inform the claimant about the information and evidence the claimant is expected to provide; and (4) request that the claimant provide any evidence in his possession that pertains to the claim. See 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b); Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). During the course of the claim, § 3.159(b) was revised and the requirement that VA request that the claimant provide any evidence in his possession that pertains to the claim was removed from the regulation. The diabetes claim on appeal stems from the Veteran's application for VA compensation, which was filed in June 2004. In response, VCAA notice letters addressing the applicability of the VCAA to the diabetes claim and of VA's obligations to the Veteran in developing this claim were dispatched to the Veteran in November 2005 and March 2006, which collectively addressed the matter and satisfied the above-described mandates, as well as the requirements that the Veteran be informed of how VA calculates degree of disability and assigns an effective date for the disability, as prescribed in Dingess v. Nicholson, 19 Vet. App. 473 (2006). To the extent that there was a timing of notice defect, as fully compliant notice did not precede the initial adjudication of the Veteran's VA diabetes claim in the February 2005 rating decision currently on appeal, as these later notices were followed by subsequent readjudications of the diabetes claim, most recently in a supplemental statement of the case issued in December 2012, the error in timing of notice is deemed to be cured. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). VA also has a duty to assist the Veteran in obtaining evidence necessary to substantiate the claim. 38 U.S.C.A. § 5103A(a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the Veteran in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth Secretary's various duties to claimant). VA informed the Veteran of its duty to assist in obtaining records and supportive evidence. The Board observes that the Veteran's service treatment records from his period of active duty and private, VA, and SSA records dated in 1993 and for the period from 2004 to 2013 have been obtained and associated with the claims file. The Veteran has been afforded ample opportunity to submit evidence in support of his diabetes claim or otherwise notify the Board of any additional relevant evidence that is not presently associated with his claims file. In this regard, the Veteran has claimed that the USS Flint, shown in his personnel records as the vessel on which he served during active duty, operated on the interior waterways within the Republic of Vietnam, which, he asserts, establishes his presence within the territorial confines of Vietnam for purposes of presumed exposure to Agent Orange. The claims file reflects that VA contacted the Joint Services Records Research Center (JSRRC) and, in August 2012, obtained a detailed report from the JSRRC showing where the USS Flint operated during the Veteran's time aboard this ship. In January 2011, the Veteran was also provided with a VA examination for diabetes mellitus, during which the examining VA clinician had opportunity to review the Veteran's pertinent medical history, perform an examination, consider the Veteran's lay history, and provide an opinion regarding time of onset of this disease. The Board finds this examination to be adequate for purposes of adjudicating the claim decided herein. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007; Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the Decision Review Officer or Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. See Bryant v. Shinseki, 23 Vet. App. 488 (2010). During the March 2012 Board hearing, the issues on appeal were both initially identified as new and material evidence claims for service connection for a psychiatric disorder and diabetes mellitus. However, the Board ultimately determined in a June 2012 appellate decision that new and material evidence had been submitted to reopen the psychiatric disability claim for a de novo review on the merits, and also that the diabetes mellitus claim is one for direct service connection and not a new and material evidence claim. Notwithstanding the initial characterization of the diabetes mellitus issue as a new and material evidence claim, the undersigned Veterans Law Judge and the Veteran's testimony during the Board hearing focused on the elements necessary to substantiate the Veteran's claim for direct service connection for diabetes. [See Transcript of March 27, 2012 Board hearing at p. 7-8.] Thus, the Veterans Law Judge presiding over the March 2012 hearing has substantially fulfilled his obligations as required under 38 C.F.R. § 3.103(c)(2). Bryant, supra. The Board is ultimately satisfied that the evidence is sufficiently developed for appellate adjudication and that no further development is necessary with respect to the diabetes claim. The Board notes that the Veteran is unrepresented in the current appeal, but he has received ample assistance from VA in the development of his diabetes claim and, as previously noted, has had opportunity to submit additional evidence in support of the claim up to the time when the case was received by the Board in February 2013. He has not indicated that there are any outstanding relevant medical or service records or other pertinent evidence that must be considered in this current appeal with respect to the issue decided herein. Furthermore, the Board has searched the Veteran's claim on the Virtual VA electronic database for any other additional medical records pertinent to his claim. Reference is made to a notation in the Veteran's Virtual VA file indicates that he has apparently waived first review by the agency of original jurisdiction of VA outpatient records viewable on Virtual VA. In any case, no prejudice would result from the Board's consideration of those records added to the database after the latest supplemental statement of the case dated December 2012, as those record pertaining to the diabetes claim only demonstrate that the Veteran has a current diagnosis of Type II diabetes mellitus. This is a medical fact that is not presently in contention, and the records in question do not otherwise contain any opinion addressing the relationship between this disease and the Veteran's service. Based on the foregoing, the Board finds that VA fulfilled its VCAA duties to notify and to assist the Veteran in the evidentiary development of his service connection claim decided herein, and thus no additional assistance or notification is required. The Veteran has suffered no prejudice that would warrant a remand, and his procedural rights have not been abridged. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board will therefore proceed with the adjudication of the diabetes claim on appeal. Analysis The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant). Service connection involves many factors, but basically means that the facts, shown by the evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if pre-existing such service, was aggravated therein. This may be accomplished by affirmatively showing inception or aggravation during service or through the application of statutory presumptions. 38 C.F.R. § 3.303(a). With chronic disability or disease shown as such in service (or within the presumptive period under 38 C.F.R. § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any positive tests for the presence of sugar in urine during service will permit service connection for Type II diabetes mellitus, first shown as a clear-cut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." When the disease identity is established, there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may be granted for any disease diagnosed after discharge from active duty when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 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. By reasonable doubt is meant 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 (2012). The Board first addresses the Veteran's factual assertion that he was exposed to chemical herbicides (Agent Orange) during his period of active duty in the Vietnam War Era. Although the Veteran has expressly stated in his written statements and oral testimony to VA and in his reported history to his treating physicians that he never actually set foot inside the Republic of Vietnam, he asserts that the naval vessel on which he served, the USS Flint, had entered the inland waterways of Vietnam while he was aboard and that he was thusly exposed to Agent Orange in this manner. Veterans are presumed to have been exposed to chemical herbicides if the facts establish that their service was within the territorial confines of the Republic of Vietnam during the Vietnam War Era, or otherwise involved duty or visitation in the Republic of Vietnam. Such service must be either "foot-on-ground" service or on the inland waterways in the interior of the Republic of Vietnam ("brown water service"). See 38 C.F.R. § 3.307(a)(6)(iii); Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008); 66 Fed. Reg. 23,166 (May 8, 2001); VAOPGCPREC 27-97. If such exposure to chemical herbicides is established, certain diseases, including Type II diabetes mellitus, are presumed to be due to chemical herbicide exposure. 38 C.F.R. § 3.309(e). The Veteran's service records for his period of active duty from April 1972 to September 1974 do not demonstrate that he had ever served or had visitation in the Republic of Vietnam, which is consistent with his oral testimony and written statements in this regard. He served in the United States Navy, but his sea service aboard ship was limited only to the USS Flint (US Navy hull number AE 32). The historical research of naval military records conducted by the JSRRC has definitively established that while the USS Flint operated in the ocean waters offshore from Vietnam, this vessel never actually docked at a Vietnamese port or entered the inland waterways of Vietnam at any time during the Veteran's service. Offshore "blue water" naval service off the coast of Vietnam does not confer any presumption of exposure to chemical herbicides for naval personnel serving aboard a "blue water" ship. See 38 C.F.R. § 3.307(a)(6)(iii); Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008); 66 Fed. Reg. 23,166 (May 8, 2001); VAOPGCPREC 27-97. As such, the Board finds that the Veteran's account of being aboard the USS Flint as it operated on the inland waterways of Vietnam is contradicted by the documented historical record and is thus non-credible for purposes of establishing this fact. The Board will therefore not concede that the Veteran was exposed to Agent Orange in service. Therefore, he is not entitled to any of the presumptions provided by 38 U.S.C.A. § 1116 and 38 C.F.R. §§ 3.307, 3.309. The Veteran's service treatment records relating to his period of active duty from April 1972 to September 1974 show that his endocrine system was clinically normal throughout his entire period of active duty. Urinalysis test results were within normal ranges and did not indicate the presence of sugar in his urine, and no diagnosis of diabetes mellitus was presented in these medical records. Post-service medical records do not indicate that Type II diabetes mellitus was clinically manifest to a compensable degree within one year following the Veteran's separation from active duty in September 1974, such that service connection could be awarded on a presumptive basis under 38 C.F.R. §§ 3.307, 3.309. Urinalysis was negative for sugar on tests conducted even as late as April 1993 and August 1993. The earliest clinical record showing a diagnosis of Type II diabetes mellitus is presented in a private medical report dated in September 2004, noting that the Veteran "was recently diagnosed as a diabetic." The diabetes diagnosis is amply reported in subsequent clinical records. However, these records are completely devoid of any objective clinical opinion that definitively associates the Type II diabetes mellitus diagnosis with the Veteran's period of active duty. In this regard, the January 2011 VA diabetes mellitus examination report shows that the examining clinician concluded that the year of onset of the Veteran's diabetes was in 2003, based on her review of the clinical record, which is almost three decades after the Veteran's discharge from active duty in September 1974. In view of the foregoing, the Board concludes that the weight of the evidence is against the Veteran's claim of entitlement to service connection for Type II diabetes mellitus on a direct or presumptive basis. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, diabetes mellitus falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Diabetes mellitus is not the type of condition/disease that is readily amenable to mere lay diagnosis or probative comment regarding its etiology, as the evidence shows that urine and/or blood testing and other specific findings are needed to properly assess and diagnose the disorder. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); and Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). That is, although the Board readily acknowledges that Veteran is competent to report symptoms of thirst, nausea, urinary frequency, and fatigue, there is no indication that the Veteran is competent to etiologically link any such symptoms that he may have had in service to his diabetes mellitus, diagnosed nearly 20 years after service discharge. The Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that the Veteran received any special training or acquired any medical expertise in evaluating endocrine disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed.Cir.2012). Accordingly, this lay evidence does not constitute competent medical evidence and lacks probative value. In view of the foregoing discussion, the Board must deny the Veteran's appeal for service connection for Type II diabetes mellitus as the preponderance of the evidence is against allowing his claim. Because the evidence in this case is not approximately balanced with respect to the merits of this claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for Type II diabetes mellitus is denied. REMAND A remand is warranted in this case because the agency of original jurisdiction failed to substantially comply with the instructions of the Board's prior remand of June 2012. The Court has held in the case of Stegall v. West, 11 Vet. App. 268 (1998), that a remand by the Board confers on a veteran or other claimant the right to VA compliance with the remand order and imposes on the Secretary of VA a concomitant duty to ensure compliance with the terms of such an order. The Court has also held in the case of Dyment v. West, 13 Vet. App. 141, 146-47 (1999), that exact compliance with the directives of a Board remand are not necessarily required if the purpose of the remand has been met, such that the RO's post-remand development is in substantial compliance with the Board's remand instructions. However, as will be discussed in detail below, the VA clinician tasked by the RO to provide a definitive psychiatric diagnosis of the Veteran failed to adhere to a critical instruction in the June 2012 remand, such that the Board cannot concede that there was substantial compliance with its order. The only appropriate remedy is to therefore remand the matter for such compliance. As relevant, the Veteran claims that he has PTSD as a result of in-service stressors that include being present in an active combat zone and of personally knowing several shipmates who attempted suicide by jumping off the ship or had overdosed on drugs. The VA psychiatric treatment records associated with the claims file primarily reflect Axis I diagnoses of depression and mood disorder and, on some occasions, note that the Veteran had reported the aforementioned stressors but did not meet the Axis I criteria for PTSD. However, diagnoses of PTSD have been presented in the clinical record, in April 2011 and, most significantly, in a November 2011 VA psychiatric treatment report, which shows a clear Axis I diagnosis of PTSD that has been expressly linked to general combat zone stressors. This diagnosis and nexus was presented by a VA psychiatric physician, albeit not accompanied by a discussion or a supportive rationale. The Board recognized the need to resolve these conflicting Axis I diagnoses regarding PTSD. Towards this end, the case was remanded in June 2012 for a psychiatric VAX to obtain a definitive psychiatric diagnosis and to determine whether or not the Veteran does, in fact, have a valid diagnosis of PTSD. The remand also requested that nexus opinions be provided addressing each Axis I diagnosis presented. The requested examination was provided in September 2012. Unfortunately, upon review of the examination report the Board finds that it is inadequate for adjudication purposes in its present state. Although the opining examiner stated that he had reviewed the Veteran's claims file and determined that the Veteran's Axis I diagnosis was depressive disorder NOS that was not due to service and that he did not meet the criteria for PTSD, the examiner's opinion expressly stated, ". . .[a] review of the veteran's VA treatment record reveals no diagnosis of PTSD and only variants of depression or Mood Disorder NOS. . ." Given the PTSD diagnosis presented in the VA treatment reports of April and November 2011, this statement is in clear contradiction to the clinical record and the VA examiner does not otherwise mention the April 2011 or November 2011 VA records in his discussion, much less state why he disagrees with the PTSD diagnosis presented. This deficit frustrates the purpose of the June 2012 BVA remand and is in noncompliance with the Board's remand directions. Indeed, records as recently as February 2013 suggest that the Veteran may meet the criteria for a PTSD diagnosis. The Court has held that when VA undertakes the effort to provide an examination for a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). An opinion is considered adequate when it is based on consideration of an appellant's prior medical history and examinations and describes the disability in sufficient detail so that the Board's evaluation of the claimed disability is a fully informed one. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Therefore, in view of the foregoing discussion, the case must be remanded once more to the RO/AMC so that an addendum opinion may be obtained that addresses the aforementioned deficit. This addendum should, to the extent that it is possible, be presented by the same clinician who conducted the September 2012 VA psychiatric examination. Accordingly, the case is REMANDED to the RO/AMC for the following action: 1. The RO should provide the Veteran with the opportunity to submit additional evidence in support of his claim, or otherwise identify relevant psychiatric treatment sources. After obtaining the appropriate waivers, the RO should attempt to obtain copies of any such records not already associated with the Veteran's claims file. If the RO cannot obtain records identified as relevant by the Veteran, a notation to that effect should be inserted in the file. The Veteran is to be notified of unsuccessful efforts in this regard. 2. To the extent possible, the Veteran's claims file should be provided to the VA clinician who conducted and drafted the report of the September 2012 VA psychiatric examination for his review. If this clinician is unavailable, the claims file should be reviewed by an appropriate specialist to determine the Veteran's present Axis I psychiatric diagnosis/diagnoses in the context of his relevant clinical history. The reviewing clinician must state in his/her report that the Veteran's claims file was reviewed. Thereafter, the reviewing clinician should provide addendum opinions, presented in the context of the medical record, with complete supportive rationales, addressing the following: (a) The clinician shall identify all current psychiatric diagnoses, to include PTSD. (b) The clinician shall specifically comment on whether the Veteran has a diagnosis of PTSD consistent with the criteria for a diagnosis under the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). The opining clinician should note the PTSD diagnosis presented in the medical record, to include (but not limited to) the April 2011, November 2011, and February 2013 VA treatment reports showing a PTSD diagnosis (or possible diagnosis), and express an opinion either concurring with the diagnosis or rejecting the diagnosis, discussing in detail why he/she has arrived at this conclusion. If the clinician concludes that the Veteran has a PTSD diagnosis, he/she should present an opinion as to whether it is at least as likely as not that the Veteran's PTSD is the result of any claimed in-service stressor event. In so doing, the clinician should determine whether the claimed stressor is related to the Veteran's fear of hostile military or terrorist activity. Thereafter, the clinician should confirm whether the claimed stressor(s) is/are adequate to support a diagnosis of PTSD and whether the Veteran's symptoms are related to the claimed stressor. If a diagnosis of PTSD is deemed appropriate, the clinician must identify the specific stressor(s) underlying the diagnosis, and should comment upon the link between the current symptomatology and the Veteran's claimed stressor(s). If a diagnosis of PTSD is not rendered, the clinician should reconcile his/her opinion and diagnostic conclusions with the findings of the April 2011, November 2011, and February 2013 psychiatric treatment reports and other treatment records that present a diagnosis of PTSD. (c) If the clinician determines that the Veteran has an Axis I psychiatric diagnosis other than PTSD, the clinician is requested to render an opinion as to whether it is at least as likely as not that any such diagnosed psychiatric disorder had its onset in service or is otherwise etiologically related to the Veteran's active service, including his in-service stressors. In doing so, the clinician must acknowledge any reports of a continuity of psychiatric symptoms since service. The clinician should also address whether the Veteran's presence aboard a ship where there were suicides, attempted suicides, or drug overdoses would result in any of the diagnosed psychiatric disabilities. In providing the requested addendum opinions, the clinician must consider and reconcile any additional opinions and diagnoses of record or any contradictory evidence regarding the above. A rationale for all requested opinions shall be provided. If the clinician cannot provide an opinion without resorting to mere speculation, he/she shall provide a complete explanation stating why this is so. In so doing, the clinician shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he /she has exhausted the limits of current medical knowledge in providing an answer to the particular question(s). 3. After the above addendum opinion(s) have been obtained, the RO shall readjudicate the claim of entitlement to service connection for an acquired chronic psychiatric disorder (to include PTSD) in consideration of the additional evidence obtained. If the claim is not granted to the Veteran's satisfaction, he should be provided with a supplemental statement of the case and provided with sufficient opportunity to submit additional evidence and/or argument in response before returning the file to the Board for further appellate consideration of the claim. The Board intimates no opinion as to the outcome in this case by the action taken herein. The appellant has the right to submit additional evidence and argument on the matter 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). ______________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs