Citation Nr: 1315809 Decision Date: 05/14/13 Archive Date: 05/15/13 DOCKET NO. 07-20 845 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a psychiatric disorder, other than PTSD. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Fagan, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1981 to July 1983 and with the National Guard from November 2004 to January 2006. This case comes before the Board of Veterans' Appeals (Board) on appeal from a November 2007 decision of a Department of Veterans Affairs (VA) Regional Office (RO). In January 2009, the Veteran testified during a videoconference Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the claims file. In April 2009 and February 2011, the Board remanded the current issue for further evidentiary development. The requested development was completed, and the case has now been returned to the Board for further appellate action. The Board notes that the Veteran originally filed a claim for service connection for PTSD. However, in light of the nature of the claim and the symptomatology described during the course of the claim, the Board amended the issues as a claim for service connection for PTSD and a claim for service connection for psychiatric disorders other than PTSD. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The issue of entitlement to service connection for a psychiatric disorder other than PTSD is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required on his part. FINDING OF FACT The most probative evidence indicates that the Veteran does not meet the diagnostic criteria for PTSD. CONCLUSION OF LAW The criteria for establishing service connection for PTSD have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). In this case, an October 2007 letter provided the Veteran with notice regarding what information and evidence is needed to substantiate his claim for service connection for PTSD, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The letter also advised the Veteran of how disability evaluations and effective dates are assigned, and the type of evidence which impacts those determinations. The claim was last readjudicated in May 2012. The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran including service treatment and personnel records, and private records from Dr. Stern. Electronic records in Virtual VA were reviewed. Additionally, the Veteran was afforded an adequate VA mental health examination in connection with his claim. Although verification of all of the Veteran's reported stressors was not accomplished, the RO issued a July 2009 formal finding of a lack of information required to corroborate stressors. Moreover, as a verified stressor is not determinative in this case, the Board finds that additional remand for further attempts at stressor verification is unnecessary and would only result in additional delay with no benefit to the Veteran. The Veteran was afforded a February 2008 RO hearing and a January 2009 videoconference Board hearing before the undersigned Veterans Law Judge. The United States Court of Appeals for Veterans Claims has held that, under 38 C.F.R. § 3.103(c)(2), a VA officer who chairs a hearing has the duty to fully explain the issues presented and to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). However, the Veteran has not contended, and the evidence does not otherwise show, that the RO hearing officer or the undersigned Veterans Law Judge committed prejudicial error, either by failing to adequately apprise the Veteran of the issues presented or by neglecting to suggest the submission of helpful evidence that may otherwise have been overlooked. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.103(c)(2); Bryant, 28 Vet. App. at 296. On the contrary, the hearing transcripts reflect that collectively, the RO hearing officer and the Veterans Law Judge identified the pertinent facts and laws underlying the appeal. Furthermore, they elicited testimony from the Veteran regarding the nature and course of his psychiatric symptoms, specific information regarding his reported stressors, sources of treatment, and his theories as to why service connection was warranted. The Veteran's testimony alerted the Board to the need for additional evidentiary development, which was thereafter accomplished to the extent possible pursuant to the April 2009 remand. Therefore, the above Veterans Law Judge not only succeeded in explaining the relevant issue "in terms of the scope of the claims for benefits," but also fully articulated "the outstanding issues material to substantiating the claims." See Bryant, 23 Vet. App. at 497. In any event, the Board observes that, throughout the pendency of his appeal, the Veteran has displayed actual knowledge of the bases for the prior denials of his service connection claim as well as the particular elements that have been found lacking in connection with those claims. See Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007) (explaining that actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what was necessary to substantiate his or her claim). Thus, no further action pursuant to Bryant or 38 C.F.R. § 3.103(c)(2) is necessary. As discussed above, the Veteran was notified and aware of the evidence needed to substantiate the claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between the Veteran and VA in obtaining such evidence. The Veteran was an active participant in the claims process by submitting evidence and argument. Thus, he was provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notices is not shown to have any effect on the case or to cause injury to the Veteran. Therefore, any such error is harmless and does not prohibit consideration of this matter on the merits. See Dingess, supra; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Analysis Establishing service connection generally requires medical or, in certain circumstances, lay evidence of: (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Establishing service connection for PTSD generally requires: (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f) (2012); see also Cohen v. Brown, 10 Vet. App. 128 (1997). If the Veteran did not serve in combat, or if the claimed stressor is not related to combat, there must be independent evidence to corroborate a veteran's statement as to the occurrence of the claimed stressor. See Doran v. Brown, 6 Vet. App. 283, 288-89 (1994). Generally, the Veteran's testimony alone cannot establish the occurrence of a non-combat stressor. See Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). Furthermore, an opinion by a medical health professional based on post-service examination of the Veteran cannot be used to establish the occurrence of a stressor. See Moreau v. Brown, 9 Vet. App. 389, 395-96 (1996). However, effective July 13, 2010, if a stressor claimed by a veteran is related to that 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 a 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 that veteran's service, a veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. "[F]ear 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. 39,843 (Jul. 13, 2010) (codified at 38 C.F.R. § 3.304(f)(3)). The Board has reviewed all of the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). In this case, the Veteran asserts that he has PTSD as a result of various service-related stressors that occurred during his service in Kuwait. He has reported proximity to blasts from improvised explosive devices (IED) and witnessing injured soldiers arrive at the base where he was stationed. He also contends that his PTSD is related to worrying about his family while he was deployed; an in-service car accident; alerts on base that sounded when terrorists were suspected to have crossed the Iraqi-Kuwait border; and, watching private videos of people being killed. The Veteran's service personnel records are negative for any combat medals. In October 2007, the Vermont Army National Guard responded to a request for stressor verification, noting that the Veteran was stationed in Kuwait where there was no combat, IED attacks/incidents, or special hostile situations. Furthermore, the October 2007 letter noted that while a number of military occupational specialties (MOS), such as truck driver or mechanic, convoyed into Iraq on a regular basis, the Veteran's MOS was administrative in nature. In July 2009, the RO made a formal finding that there was a lack of information required to verify the Veteran's stressors in connection to his claim. Service treatment records document that the Veteran was in a motor vehicle accident in service. Those records also show that the Veteran's mother died during his deployment. During a May 2005 dental questionnaire, the Veteran denied a history of nervousness. Additionally, though the Veteran's MOS was administrative in nature, a June 2005 service treatment record notes the Veteran to be a guardsman. On his November 2005 post-deployment health assessment, the Veteran reported that during his deployment, he saw wounded or dead coalition members, and that he felt he was in great danger of being killed. He further reported that he had concerns that he might have serious conflicts with a spouse, family members, or friends, and was interested in receiving help for stress, emotional, alcohol, or family problems. Significantly, however, on the Veteran's November 2005 post-deployment health assessment, depression and PTSD screenings were negative, and on a subsequent November 2005 report of medical assessment, the Veteran listed various areas of health concern, but did not include PTSD or psychiatric problems. Based on the foregoing, the Board concedes that the Veteran was in a motor vehicle accident, that his mother died, and that he likely saw injured or dead coalition members during his deployment. Nevertheless, the Board finds that the Veteran does not have PTSD. The first mention of posttraumatic stress disorder in the medical evidence of record is a June 2006 private psychological evaluation for a possible mood disorder. The Veteran expressed concerns about another deployment and the effects it would have on him and his family. He also discussed some marital tension, financial stress, and the death of his mother and brother. He discussed his deployment to Kuwait, reporting that there was an ongoing threat, but no active combat. He recollected some difficult situations, but denied intrusive reexperiencing. The examiner diagnosed an adjustment disorder with mixed emotional feelings, apparently associated with a variety of readjustment issues post return from deployment. The private psychologist noted that he was not impressed by specific posttraumatic stress symptomatology, and found that most of the acute current anxiety related to the potential for re-deployment. Significantly, prior to that initial June 2006 private treatment, a January 2006 VA PTSD screen was negative and the Veteran was noted to be adjusting well. In fact, during January 2006 VA treatment, the Veteran expressly denied trauma in service or a need for counseling. Similarly, during September 2006 VA treatment, the Veteran denied depressive symptoms. The Veteran was afforded a VA examination in October 2006 during which the examiner determined that, based on a review of the record and clinical evaluation, no psychiatric diagnosis was warranted. Significantly, that examination occurred prior to when the Veteran filed a claim for VA benefits for PTSD, and is therefore, accorded significant probative value, as the statements made during that examination were not made in connection with a claim for benefits. VA treatment notes thereafter show that, in February 2007, the Veteran reported depression "in context of 'PTSD'." The Veteran reported treatment for depression with a private psychologist, but "curiously ha[d] not spoken of PTSD with him - nor brought this up to him." Following clinical evaluation, the examiner noted that, though multiple stressors were reported, the overwhelming majority of them did not relate to actual military service, but rather, were sequelae from his time away from home. The Veteran did mention nightmares of being back on base on guard duty, but was nebulous in his reporting. However, he was consistent about financial and relationship stressors. The VA psychiatrist found the evidence to be more suggestive of a depressive episode than PTSD, but noted there could be co-morbid PTSD. Thereafter, in October 2007, the Veteran was noted to have "known mild/moderate PTSD" without any discussion of the origin of the diagnosis. During January 2008 VA mental health evaluation for polytrauma/traumatic brain injury (TBI), the Veteran reported some trauma associated with a motor vehicle accident in service, not being able to get home to his mother prior to her death, and he witnessed several bodies of colleagues being carried back to the base. The VA psychiatrist found that the Veteran's symptoms could likely be accounted for by a depressive disorder, such as major depressive disorder, and noted that there were also some trauma based symptoms. He opined that the Veteran would benefit from treatment for MDD and/or PTSD. Significantly, however, he did not diagnose PTSD. In March 2008, the Veteran was diagnosed with, among other conditions, rule out PTSD. However, another treatment note dated the same month found that his history was not consistent with PTSD. In this regard, the Veteran did not report any military-related trauma, and the VA physician noted that the onset and content of the Veteran's dreams suggested that the bad dreams were likely part of prolonged bereavement relating to his brother's death. In April 2008, the Veteran reported nightmares about bombs going off at his checkpoint in service. However, it was noted that a bomb exploding at his checkpoint did not actually occur, but that the Veteran had seen videos of what to do should that occur. A diagnosis was made of probable PTSD. In May 2008, the Veteran's treating psychologist provided a diagnosis of rule out PTSD. Significantly, during that treatment the Veteran did not identify specific service-related trauma and, while he reported nightmares, such related to spiders and snakes, which were present during his deployment. In June 2008, the Veteran was diagnosed with PTSD by the same physician who, in March 2008, found the Veteran's history to be inconsistent with PTSD. That diagnosis was predicated upon a PTSD checklist completed by the Veteran. However, as discussed further below, the Board finds that the Veteran's reported psychiatric symptoms are exaggerated and therefore, finds that PTSD diagnosis unpersuasive and not probative. Moreover, the record does not indicate that the diagnosis was based upon a specific stressor or the Veteran's fear of hostile military or terrorist activity, and subsequent VA treatment records do not support a definitive diagnosis of PTSD. In this regard, in July 2009, it was noted that a workup for TBI/PTSD was equivocal, and that the Veteran likely suffered from major depressive disorder. In October 2010 and March 2011, mental health treatment notes show treatment for depressive disorder not otherwise specified and a history of MDD; significantly, PTSD was not listed as a diagnosis. In April 2011, it was noted that the Veteran was depressed and possibly meets the criteria for PTSD, but that further assessment is needed. A diagnosis was offered that month of rule out PTSD. In February 2012, the Veteran's medical history was noted to include a diagnosis of PTSD. However, there is no evidence of a formal evaluation associated with that diagnosis, or the stressor upon which that diagnosis was made. In March 2012, the Veteran was afforded a second VA examination. Following a review of the claims file and a clinical evaluation, the examiner opined that the Veteran does not meet the diagnostic criteria for PTSD. The examiner found that the only service-related stressor that meets Criterion A for a PTSD diagnosis is the motor vehicle accident. However, with respect to that specific stressor, the Veteran denied symptoms associated with other PTSD criteria, such as reexperiencing and avoidance. Instead, the Veteran's reported symptoms are related to his guilt over being away from his family during deployment. The examiner diagnosed a generalized anxiety disorder. The Board finds the March 2012 VA examiner's opinion that the Veteran does not have PTSD to be of significant probative value, as that opinion was based on the examiner's expertise in psychology, a full clinical evaluation, a review of the claims file, and was supported by adequate rationale. Moreover, that finding took into account the Veteran's prior mental health treatment and is not wholly inconsistent with the other evidence of record showing that, while the Veteran has been noted to report symptoms of PTSD, a private psychologist, a prior VA examiner, and various VA mental health providers have generally declined, with limited exception, to provide a definitive diagnosis of PTSD; instead, these clinicians have diagnosed rule out PTSD, probable PTSD, possible PTSD, or other psychiatric disorders. In this regard, the unqualified diagnoses of PTSD in the record are not supported by any explanation or rationale, to include the specific trauma upon which the diagnosis is made. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). In contrast, the March 2012 VA examiner considered the Veteran's specific reported traumas and the symptoms reported by the Veteran and determined that a PTSD diagnosis was not warranted. Accordingly, the Board assigns great weight to the opinion of the VA examining psychologist. See Madden v. Gober, 123 F.3d 1477, 1481 (Fed. Cir. 1997) (the Board is entitled to discount the weight, credibility, and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence); see also Guerrieri v. Brown, 4 Vet. App. 467, 471 (1993) ("The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches."). To the extent that the Veteran himself believes that he currently meets the diagnostic criteria for PTSD, as a lay person, the Veteran has not shown that he has specialized training sufficient to render such a diagnosis. Accordingly, his opinion as to a diagnosis of PTSD is not competent medical evidence, as the diagnosis of psychiatric disorders requires medical expertise to determine. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Here, the most probative medical evidence demonstrates that the Veteran does not meet the diagnostic criteria for PTSD. The Board finds the opinion of the VA examiner to be of greater probative value than the Veteran's lay contentions. Furthermore, the Board finds that the Veteran's credibility with respect to the effects and nature of his reported stressors and PTSD symptoms is lacking. For example, while the Veteran has reported as a traumatic stressor his documented June 2005 motor vehicle accident in service, the Board notes that the Veteran did not report that stressor during his initial June 2006 private psychiatric treatment or his October 2006 VA examination, nor did he consistently report it as a stressor or relate psychiatric symptoms such as nightmares to the motor vehicle accident during his ongoing VA mental health treatment. Moreover, the Veteran submitted a photograph dated the day of the accident showing presumably himself (as identified by the name on the uniform worn by the male soldier in the photograph), standing next to the overturned automobile, notably smiling. The Board finds it likely that had the accident been as traumatic as the Veteran now asserts, he would not have been posing for a photograph with a smile following the accident, and would have reported it upon initially seeking mental health treatment and during his October 2006 VA examination. Additionally, the Veteran has provided inconsistent statements regarding the occurrence of traumatic events. For instance, while the Veteran reported in a March 2008 statement that he experienced traumatic events every day during his deployment, with some events more severe than others, he explicitly denied trauma in service during January 2006 VA treatment. That early report is consistent with the Veteran's November 2005 post-deployment questionnaire in which the Veteran affirmatively denied experiencing anything so frightening, horrible, or upsetting that, in the last month, he had nightmares, intrusive thoughts, avoidant symptoms, or feelings of detachment. Similarly, the Veteran did not report specific service-related traumatic events during his June 2006 private treatment, and in April 2008, he reported that while he was in constant fear, no specific traumatic event occurred. In contrast to those reports, the Veteran testified during his January 2009 Board hearing that there were two IED explosions in proximity to him, including one that rocked a tower on which he was stationed. Significantly, those explosions were not previously reported by the Veteran during his February 2008 RO hearing or his October 2006 VA psychiatric examination. The foregoing inconsistent accounts provided by the Veteran relating to his stressors calls into question his overall credibility. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore a veteran's testimony simply because the veteran is an interested party; personal interest may, however, affect the credibility of the evidence); Caluza v. Brown, 7 Vet. App. 498, 511 (1995) ("The credibility of a witness can be impeached by a showing of interest, bias, inconsistent statements, or, to a certain extent, bad character."). In any event, as the initial reports by the Veteran prior to his February 2007 claim were made in furtherance of treatment and/or not in conjunction with a claim for psychiatric disability benefits, they are accorded greater probative value. For the reasons set forth above, the Board finds that the most probative evidence reveals that the Veteran does not meet the diagnostic criteria for PTSD. Accordingly, service connection for PTSD is denied. ORDER Service connection for PTSD is denied. REMAND The Board's review of the claims file reveals that further action is necessary on the claim for service connection for a psychiatric disorder other than PTSD. The Veteran contends that he is entitled to service connection for a psychiatric disorder. In statements submitted during this appeal and in hearing testimony, he asserts that he has a current psychiatric disorder that first manifested during service or is otherwise related to service. In support of his claim, the Veteran has submitted a statement from S. Hartwell indicating that he served with the Veteran, and that the Veteran "had some depression when his mother died." Additionally, the record raises the issue of service connection for a psychiatric disorder as secondary to service-connected musculoskeletal disabilities, including back and left ankle disabilities. Therefore, the Board will consider whether service connection should be granted on a secondary basis. See 38 C.F.R. § 3.310 (2012). Service treatment records show that, while a depression screening on a November 2005 post-deployment questionnaire was negative, the Veteran reported potential conflict with family or friends, and indicated a desire to seek mental health treatment post-service. Post-service treatment records show that the Veteran has been variously diagnosed with an adjustment disorder, a depressive disorder (including major depressive disorder and a single depressive episode), bereavement, relational disorder not otherwise specified, and most recently, generalized anxiety disorder. The Veteran has also reported psychiatric symptoms related to events in service, to include a motor vehicle accident, his mother's death, not being able to contact his post while deployed, spiders and snakes, and witnessing injured or killed soldiers. Post service treatment records also show somatic complaints related to back pain. However, as noted above, the Board observes that the Veteran's reports regarding his stressors have generally not been consistent, and the Veteran was noted to be nebulous in his reporting of service stressors. Additionally, his symptoms, including nightmares and flashbacks, have been noted to not relate to actual events in service. Moreover, the Board notes that it appears the Veteran exaggerates his symptoms. For instance, while the Veteran has submitted written statements attesting to his severe back pain, submitted a log chronicling back pain, and reported functional limitations during his VA examinations and VA treatment related to his service-connected disabilities (to include an inability to run and play sports), the Board notes that post-service private and VA records show that at various times since leaving service, the Veteran played on two softballs teams, played ice hockey, and as recently as 2012, was going to the gym four to five times per week where he has performed weight lifting and aerobic exercise. Review of the record reveals that the Veteran was evaluated in October 2006 for the specific purpose of obtaining information regarding the nature and etiology of his claimed psychiatric disorder. At that time, the VA examiner found that no psychiatric diagnosis was warranted. The Veteran underwent further evaluation in March 2012, at which time he was diagnosed with a generalized anxiety disorder. The examiner found that the claimed condition was less likely as not related to service, noting that while the Veteran reported an onset of excessive worry during his deployment, there was no objective evidence of significant mental health symptoms until February 2007, more than one year post discharge. However, in an April 2012 addendum, the same VA examiner then indicated that the Veteran's depressive disorder was at least as likely as not related to an injury, event, or illness in service. However, the examiner's rationale does not support that conclusion, in that she appears to relate the Veteran's depressive disorder to his overall guilt over leaving his family, but not to an event, injury, or illness in service. Moreover, to the extent that the opinion suggests that the Veteran's depressive disorder manifested during service, the examiner did not adequately support such a conclusion, as there is no discussion of the Veteran's negative depression screening on his November 2005 post-deployment questionnaire, his negative depression screening in January 2006, his denial of depressive symptoms on September 2006, and the October 2006 VA examiner's findings that the Veteran did not have a psychiatric disorder. Finally, the examiner opined that the Veteran's depressive disorder is less likely than not proximately due to the Veteran's service-connected disabilities. However, the rationale for that opinion appears to contradict that conclusion or perhaps suggest aggravation, as the examiner notes that about 25 percent of the Veteran's depressive symptoms are related to his service-connected disabilities. Given the inconsistencies and inadequate rationale, the Board finds that additional medical evidence is necessary to adjudicate this claim. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 C.F.R. § 3.159(c)(4) (2012). See also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). As such, a remand is necessary to obtain a VA opinion. In addition, it does not appear that the Veteran has been provided VCAA notice concerning the information and evidence necessary to substantiate his claim for service connection for an acquired psychiatric disorder on a secondary basis. Such should be provided on remand. Relevant ongoing medical records should also be requested. 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, the case is REMANDED for the following action: 1. Send the Veteran a VCAA letter notifying him of the information and evidence necessary to substantiate his claim for service connection for an acquired psychiatric disorder on a secondary basis. 2. Obtain VA mental health treatment records dating since April 2012 from the White River Junction VA Medical Center to include the Keene outpatient clinic. 3. Schedule the Veteran for a VA mental health examination by a VA psychiatrist or psychologist to determine whether the Veteran suffers from an acquired psychiatric disorder other than PTSD that is related to service or service connected disability. The Veteran's claims file must be reviewed by the examiner in conjunction with the examination. All tests deemed necessary should be accomplished, including psychological testing. Following examination of the Veteran and review of the claims file, the examiner should provide the diagnosis of the psychiatric disabilities identified. The examiner should provide an opinion as to whether it is at least as likely as not (i.e., probability of 50 percent or greater) that any currently psychiatric disorder, other than PTSD, arose during service or is otherwise related to any incident during service, including the death of the Veteran's mother or his motor vehicle accident. If a psychiatric disorder other than PTSD did not arise during and is not otherwise related to any incident during service, the physician should provide an opinion as to whether any currently diagnosed psychiatric disorder was caused by or is aggravated (permanent worsening of the underlying disability beyond natural progress) by the Veteran's service-connected back or left ankle disability. If aggravation by a service-connected disability is found, then the physician should quantify the degree of such aggravation, if possible. In providing the requested opinions, the examiner should explain the medical basis for the conclusions reached. The examiner should consider and discuss the prior October 2006, March 2012, and April 2012 VA examination reports. 4. After the development requested above, as well as any additional development deemed necessary, has been completed, the RO/AMC should again review the record. If the benefit sought on appeal remains denied, then the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be provided an opportunity to respond. The case should then be returned to the Board for further appellate consideration. 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). The Veteran's 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). ____________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs