Citation Nr: 1319536 Decision Date: 06/18/13 Archive Date: 06/27/13 DOCKET NO. 09-15 409A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for neuropathy of the lower extremities. 2. Entitlement to service connection for a psychiatric disorder. 3. Entitlement to service connection for hearing loss. 4. Entitlement to service connection for a thoracolumbar spine disability. 5. Entitlement to a total disability rating based on individual unemployability (TDIU) by reason of service-connected disabilities. REPRESENTATION Appellant represented by: Todd Hammond, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C.L. Krasinski, Counsel INTRODUCTION The Veteran, the appellant in this matter, served on active duty from March 1989 to October 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia, that denied entitlement to service connection for a back disability, bilateral legs disability, a psychiatric disorder to include depression, anxiety and bipolar disorder, and hearing loss. This matter was subsequently transferred to the RO in Portland, Oregon. Service connection for a back disability, a leg disability, a psychiatric disorder and hearing loss was initially denied in an August 2005 rating decision. The Veteran was notified of this decision and did not appeal. Thus, the Board is required to first consider whether new and material evidence has been presented before the merits of a claim can be considered; and the Board can make an initial determination as to whether evidence is "new and material." See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). However, on thorough review, the Board finds that the provisions of 38 C.F.R. § 3.156 (c) must be applied to the Veteran's advantage in this case. 38 C.F.R. § 3.156(c) provides that, at any time after VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim notwithstanding the requirements of 38 C.F.R. § 3.156(a) (which defines new and material evidence). The evidence received since the August 2005 rating decision includes official service clinical records and service personnel records. These records were associated with the claims folder in May, June, and August 2008 and are relevant to the claims for service connection. The records existed at the time of the August 2005 decision but were not associated with the claims file at that time. Thus, the earlier rating decision, accordingly, is not considered to be final for the purposes of the current appeal. The Board finds that 38 C.F.R. § 3.156(c) applies, and the claims for service connection must be reconsidered. These issues have been recharacterized as above on the title page. The Veteran testified at a hearing held at the RO before the undersigned Veterans Law Judge in March 2013. A transcript of the hearing is associated with the Veteran's virtual VA file. At the hearing before the Board in March 2013, the issue of entitlement to service connection for an elbow disability, a shoulder disability, and headaches have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over these issues, and the issues are referred to the AOJ for appropriate action. In evaluating this case, the Board has not only reviewed the Veteran's physical claims file, but has also reviewed the Veteran's file on the "Virtual VA" system to ensure a complete assessment of the evidence. The issues of service connection for a psychiatric disorder to include bipolar disorder, anxiety disorder, and major depression, hearing loss, a back disability, and TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Symptoms of right and left leg pain, numbness, and tingling were chronic in service and have been continuous since service separation. 2. The Veteran's current peripheral neuropathy of the bilateral lower extremities is related to the chronic symptoms in active service and the continuous symptoms since service separation and first manifested in active service. CONCLUSION OF LAW Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for peripheral neuropathy of the bilateral lower extremities are met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.385 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). As the Board is granting the claim for service connection for peripheral neuropathy of the bilateral lower extremities, the claim is substantiated, and there are no further VCAA duties. Wensch v. Principi, 15 Vet App 362, 367- 68 (2001); see also 38 U.S.C.A. § 5103A(a)(2) (secretary not required to provide assistance "if no reasonable possibility exists that such assistance would aid in substantiating the claim"). Service Connection Laws and Regulations Service connection will be granted for disability resulting from a disease or injury incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection requires competent evidence showing, (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); see also Caluza v. Brown, 7 Vet. App. 498 (1995). In this case, an organic disease of the nervous system are listed among the "chronic diseases" under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. 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. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as an organic disease of the nervous system, becomes manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). That notwithstanding, a veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.102, 4.3, 4.7. Analysis The Veteran contends that he incurred a neurological disability of the bilateral lower extremities during his period of active service. He asserts that his current disability first began in service. There is competent evidence that the Veteran currently has bilateral lower extremity peripheral neuropathy. See the VA examination reports dated in September 2009 and May 2008. The Board finds that the Veteran experienced "chronic" symptoms of lower extremity pain, numbness and tingling during service and continuous symptoms of pain since service so as to warrant presumptive service connection for bilateral lower extremity peripheral neuropathy under the provisions of 38 C.F.R. § 3.303(b). The Veteran's service enlistment examination report dated in September 1988 indicates that neurological and lower extremity examination was normal. A neurological disability of the lower extremity was not detected or diagnosed. Service treatment records show that in October 1989, the Veteran sought medical treatment for complaints of left heel pain. Service treatment records dated in August 1991 indicate that the Veteran reported having bilateral shin splints and he reported having pain in the bilateral tibia, fibula and calcaneous for two years. A February 1991 service treatment record indicates that the Veteran had pain in the left ankle for three years; the pain was extreme with running and the pain had returned. A November 1992 service treatment records indicates that the Veteran had pain in the feet and leg. The assessment was exercise inducted compartment syndrome. Another service treatment record dated in November 1992 indicates that the Veteran reported having leg pain for three years. He wore orthopedic braces. He stated that he has a sharp pain that radiated to his back. The diagnosis was chronic plantar fasciitis and hagland's deformity. The Veteran sought treatment for leg and foot pain in January 1993. A January 1993 orthopedic clinic record indicates that the Veteran had sharp pains in both legs. He had complaints of swelling and numbness with standing for long periods. In April 1993, the Veteran was placed on a physical profile because of back and bilateral lower extremity pain. It was noted that a Medical Board was pending. An April 1993 orthopedic evaluation record indicates that the Veteran reported having bilateral lower extremity pain. In June 1993, the Veteran was placed on a permanent physical profile due to chronic leg pain and chronic back pain. The Veteran was limited from prolonged standing, sitting or walking, overhead work, and jumping. A July 1993 electromyography was normal. An August 1993 service treatment record indicates that the Veteran reported having bilateral lower extremity complaints since July 1989. The record indicates that the impression was extremity pain with no evidence of nervous system injury. A Medical Board report is not of record and it is not clear whether the Veteran underwent a Medical Board proceeding. The Veteran's DD 214 indicates that the Veteran separated due to disability and was awarded severance pay. The RO made several attempts to locate additional records concerning the award of severance pay but additional records were not located. See the RO's letters to the National Personnel Records Center (NPRC) dated in June 2007, May 2008, and April 2012. In October 2012, the NPRC responded that the separation and severance information was not a matter of record. No additional records were found. In March 2005 and June 2012 letters, the RO asked the Veteran to submit information concerning his separation from service and severance pay. The Veteran did not submit any additional evidence. At the hearing before the Board in March 2013, the Veteran stated that he was discharged because of his leg and back disabilities. Although it is not clear which disability led to the Veteran's discharge from service, the competent and credible evidence of record shows that the Veteran had chronic symptoms of pain in the legs during service and at the time of service separation. There is competent and credible evidence that the Veteran continued to have symptoms of pain, numbness, and tingling in the legs continuously after separation from service. The Board finds that the Veteran experienced "chronic" symptoms of pain, numbness, and tingling in the legs during service and since service so as to warrant presumptive service connection for peripheral neuropathy of the bilateral lower extremities under the provisions of 38 C.F.R. § 3.303(b). The Board also finds that symptoms of pain, numbness, and tingling in the legs have been continuous since service separation, which also is a basis for a grant of presumptive service connection under 38 C.F.R. § 3.303(b). The Veteran reported having the symptoms of pain, numbness, and tingling in the legs in service and since service separation. See the VA treatment records dated in October 2004, the VA examination reports dated in May 2008 and September 2009, and the Veteran's testimony at the hearing before the Board in March 2013. The October 2004 VA neurology consult records indicate that the Veteran reported experiencing pain in the feet and cramps with pain moving up the lower legs in 1989 to 1990. The Veteran reported that the pain was constant and sharp and the pain and weakness had progressed over time. The Veteran is competent to report observable symptoms such as pain and numbness in the legs. See Jandreau, 492 F.3d at 1377. The Board finds that the Veteran's report of symptoms to be credible since his statements have been consistent. The Veteran has consistently reported having symptoms of pain in his legs since service. See the VA treatment records dated in November 2003, February 2004, October 2004, July 2006, and December 2007. There is competent and credible evidence that the Veteran's current peripheral neuropathy of the bilateral lower extremities had its onset in service. A May 2008 VA neurologic examination indicates that the Veteran reported the onset of bilateral lower extremity pain, paresthesias, and distal weakness in service in around 1990. The neurologist indicated that it was more likely than not due to small fiber neuropathy at that time. The record indicates that since leaving service, the Veteran developed bilateral foot drop, ascending paresthesias and pain to the knees. The Veteran had decreased pain and temperature sensation in these regions as well as lower extremity hyporeflexia and mild bilateral ankle dorsiflexion weakness which are consistent with a peripheral neuropathy. The neurologist noted that weakness was atypical for small fiber neuropathy and concern was raised for an infiltrative, inflammatory, and infectious etiology to some degree. The neurologist indicated that predominantly small fiber neuropathy is most commonly seen in diabetes but can also been seen as a result of HIV infection, antiretroviral treatments, vasculities, hereditary sensory autonomic neuropathy, fabry disease, and friedrich's ataxia. The neurologist indicated that many cases remain idiopathic despite all diagnostic evaluations. The neurologist stated that given that the Veteran's HIV diagnosis was not made until 2003, he has not been treated with antiretroval medications and the Veteran's symptoms began at least 13 years prior to this diagnosis being made, it was less likely that there was a relationship between the Veteran's diagnosis of HIV and neuropathy. The neurologist also indicated that it was less than likely that toxic exposure in service caused the current neuropathy. The neurologist indicated that the onset of the neuropathy was in service. A May 2009 VA infectious disease outpatient note indicates that the Veteran had chronic progressive neuropathy beginning in 1990. The record indicates that the Veteran had weakness, numbness, tingling and pain in his lower legs and feet. A September 2009 VA examination report shows a diagnosis of lower extremity bilateral peripheral neuropathy. The Veteran reported having pain from his knees down to his feet. The pain was constant and the pain in the feet was a burning type of pain. He also had a pins and needles type sensation with a dullness sensation from the knees down, foot drop on the left, and difficulty with balance. The examiner indicated that the Veteran's main complaints were related to his peripheral neuropathy. The Board finds that the evidence is at least in relative equipoise on the question of whether the Veteran's current peripheral neuropathy of the bilateral lower extremities had its onset in service. While the service treatment records indicate that a neurological disability or disease was not diagnosed, there is probative medical evidence of record which establishes that the onset of the peripheral neuropathy of the lower extremities was in service. Specifically, the neurologist who conducted the May 2008 VA examination indicated that the onset of the neuropathy was in service. There is competent and credible lay evidence of the onset of symptoms in service. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that the criteria for service connection for peripheral neuropathy of the bilateral lower extremities have been met. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. The claim of service connection for peripheral neuropathy of the bilateral lower extremities is granted. ORDER Service connection for peripheral neuropathy of the bilateral lower extremities is granted. REMAND The VCAA, specifically provides that the duty to assist includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d). In accordance with VCAA, VA is obligated to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The evidence of a link between current disability and service must be competent. Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). The Board finds that medical examination is necessary to determine whether the Veteran's claimed back disability had its clinical onset during service or is medically related to injury or another event or incident of active service. Service treatment records show that the Veteran experienced chronic back pain in service. A November 1991 service treatment record indicates that the Veteran reported having back pain and spasm after lifting parts. The assessment was right side muscle strain. He was later assessed as having mechanical back pain and musculoskeletal thoracic and lumbar muscle strain and spasm. An April 1993 permanent physical profile indicates that the Veteran was on the permanent profile due to back and lower leg pain. There is evidence that the Veteran still had back pain. See the VA treatment records dated in May 2008, February 2010, August 2012, and September 2012. The Veteran was afforded VA examinations in May 2008 and September 2009 but it does not appear that the back was examined and the examiner did not render an opinion as to whether any current back disability was related to the symptoms in service. Thus, the Board finds that a medical examination is necessary. The Veteran asserts that he has currently has bilateral hearing loss that was caused by noise exposure in service. At the hearing before the Board in March 2013, the Veteran stated that he was exposed to gunfire in service. Service audiometric testing shows that the Veteran experienced a threshold shift in the left and right ears as shown by testing in September 1988 and September 1992. The VA audiometric examination report dated in April 2005 indicates that for the right ear, the Veteran had a Maryland CNC word list of 92 percent and this meets the requirements of 38 C.F.R. § 3.385 for hearing loss. However the examiner did not provide an opinion as to the etiology of any current hearing loss since the examiner found no current hearing loss. The Board finds that additional audiometric examination is necessary to determine whether the Veteran's claimed hearing loss had its clinical onset during service or is medically related to injury or another event or incident of active service. The Board finds that additional medical examination is necessary with regard to the claim for service connection for a psychiatric disorder. The Veteran asserts that he has a psychiatric disorder due to the pain he experiences from the bilateral leg disability. See the May 2009 statement by the Veteran. The Veteran also asserts that he had a suicide attempt in service and this was a manifestation of his psychiatric disorder. No pre-existing psychiatric disorder was noted at entry into service. A service hospital record dated in July 1990 documents that the Veteran was treated for an overdose. Review of the record shows that the Veteran has diagnoses of major depression, anxiety, panic disorder, and agoraphobia. See VA mental health treatment records dated in September 2003, February 2004, November 2006, January 2012, and July 2012. There is medical evidence which suggests that the Veteran's psychiatric disorder may have existed prior to his entrance into service. A September 2003 VA mental health record notes that the Veteran had a long history of depression likely starting when he was a teenager. See also a February 2004 VA mental health treatment record. Secondary service connection is granted where a service-connected disability causes or aggravates a nonservice-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (a) (2012). Thus, the Board finds that a medical opinion and examination is necessary to determine whether the Veteran's claimed psychiatric disorder had its clinical onset during service or is medically related to injury or another event or incident of active service, whether any pre-existing psychiatric disorder was aggravated by active service, and whether any psychiatric disorder is caused or aggravated by the service-connected peripheral neuropathy of the lower extremity. The claim for TDIU is inextricably intertwined with the pending claims for service connection. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a veteran's claim for the second issue). The Board finds that, because adjudication of the Veteran's claims of entitlement to service connection will potentially affect his TDIU claim, adjudication of the Veteran's TDIU claim is deferred until the service connection claims have been decided. The record shows that the Veteran currently receives treatment for the claimed disorders at VA. The RO must make attempts to obtain any records of treatment of the claimed back disability, psychiatric disorder, and hearing loss dated from November 2012 from the VA healthcare system. VA has a duty to seek these records. 38 U.S.C.A. § 5103A(b)(1). The RO also must contact the Veteran in order to have him provide sufficient information, and if necessary authorization, to enable the RO to obtain any pertinent VA and/or non-VA records showing treatment of the claimed disabilities since service separation. The RO should make an attempt to obtain any treatment records identified by the Veteran that are not currently associated with the claims file. The Veteran also should be informed that he may submit evidence to support his claim including any evidence of in-service treatment for his claimed disability. Accordingly, the case is REMANDED to the RO for the following action: 1. Contact the Veteran in order to obtain all VA and non-VA medical records referable to his treatment of the claimed back disorder, psychiatric disorder, and hearing loss. The letter should request sufficient information to identify the health care providers, and if necessary, signed authorization, to enable VA to obtain any additional evidence. If the Veteran adequately identifies the health care providers and provides the completed authorizations, request legible copies of all pertinent clinical records that have not been previously obtained, and incorporate them into the Veteran's claims file. The letter should invite the Veteran to submit any pertinent medical evidence in support of his claim. 2. Obtain records of treatment of the claimed back disability, psychiatric disorder, and hearing loss dated from November 2012 from the VA healthcare system. 3. Schedule the Veteran for a VA examination in order to determine to determine nature and likely etiology of the claimed thoracolumbar spine disability. The claims folder must be made available to the examiner for review in connection with the examination. All appropriate tests and studies including x-ray examination of the thoracolumbar spine should be accomplished with all results made available to the examiner prior to the completion of his or her report, and all clinical findings should be reported in detail. The examiner should report all current diagnoses pertinent to the thoracolumbar spine. After examining the Veteran and reviewing the relevant evidence in the claims file, the VA examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that any the current thoracolumbar spine disability had its onset during service or is otherwise due to injury or other event of the Veteran's periods of active service. The examiner should consider the service treatment records dated in November 1992 which indicate that the Veteran experienced chronic back pain and spasm after lifting and right side muscle strain, mechanical back pain, and musculoskeletal thoracic and lumbar muscle strain and spasm were diagnosed. An April 1993 permanent physical profile indicates that the Veteran was on the permanent profile due to back and lower leg pain. The examiner should clearly outline the rationale for any opinion expressed. If any requested medical opinion cannot be given, the examiner should state the reason(s) why. 4. Schedule the Veteran for a VA audiometric examination to determine the nature and etiology of any current hearing loss. The Veteran's VA claims folder must be made available to the examiner for review in connection with the examination. The examination should include a controlled speech discrimination test (Maryland CNC) and a pure tone audiometry test. For each ear, pure tone audiometric thresholds, in decibels, should be recorded for each of the frequencies of 1,000, 2,000, 3,000 and 4,000 hertz, as well as controlled speech discrimination testing (Maryland CNC) (reported in percentages of discrimination). The examination of hearing impairment should be conducted without the use of hearing aids. The examiner should provide an opinion as to whether it is at least as likely as not that the Veteran has a current hearing loss disability due to noise exposure or another event or incident of his active service. The examiner should clearly outline the rationale for any opinion expressed. If any requested medical opinion cannot be given, the examiner should state the reason(s) why. 5. Schedule the Veteran for a VA psychiatric examination to determine the nature and likely etiology of any current psychiatric disorder. The claims folder, including a copy of this REMAND, must be made available to and reviewed by the examiner. All indicated studies, tests and evaluations deemed necessary should be performed. The examiner should report all current DSM-IV diagnoses. The VA examiner should express an opinion as to whether it is at least as likely as not (50 percent probability or more) that any current psychiatric disability clearly and unmistakably (obvious, manifest, undebatable) pre-existed the Veteran's period of service and if so, whether such psychiatric disorder clearly and unmistakably was not aggravated during his active service. If any current psychiatric disorder is not found to have pre-existed service, the VA examiner should express an opinion as to whether it is at least as likely as not (50 percent probability or more) that any current psychiatric disability had its clinical onset during the Veteran's period of active service or is related to incident or event in service. The examiner should indicate whether a post-service event or incident caused any current psychiatric disorder. The examiner should also address whether any current psychiatric disability is caused or aggravated by a service-connected disability, to include the service-connected peripheral neuropathy of the lower extremities. The examiner is requested to provide an opinion concerning whether it is at least as likely as not (50 percent probability or more) that any current psychiatric disorder is caused or aggravated by a service-connected disability, to specifically include his service-connected peripheral neuropathy of the lower extremities. If the examiner finds that a psychiatric disorder is aggravated by a service-connected disability, the examiner should indicate the degree of disability of the disability before it was aggravated and its current degree of disability, to the extent possible. The examiner should clearly outline the rationale for any opinion expressed. If any requested medical opinion cannot be given, the examiner should state the reason(s) why. 6. After completing all indicated development, readjudicate all claims remaining on appeal including the claim for TDIU. If any benefit sought on appeal remains denied, the RO should provide the Veteran and his representative with a fully responsive Supplemental Statement of the Case and afford them a reasonable opportunity for response. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs