Citation Nr: 1322388 Decision Date: 07/12/13 Archive Date: 07/18/13 DOCKET NO. 08-13 301A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder, due to personal assault. REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. WITNESS AT HEARINGS ON APPEAL Veteran ATTORNEY FOR THE BOARD J. D. Deane, Counsel INTRODUCTION The Veteran had active service from June 1973 to June 1976. This matter came before the Board of Veterans' Appeals (Board) on appeal from a decision of October 2007 by the Department of Veterans Affairs (VA) Muskogee, Oklahoma, Regional Office (RO). The appeal is remanded to the RO via the Appeals Management Center, in Washington, DC. REMAND The Veteran contends that she is entitled to service connection for an acquired psychiatric disorder, specifically posttraumatic stress disorder (PTSD), due to in-service personal assaults. She originally filed a service connection claim for PTSD in February 1986. The RO denied the claim of entitlement to service connection for PTSD in rating decisions dated in April 1986, July 1986, and September 1987. The Veteran sought to reopen her claim of entitlement to service connection for PTSD in February 1996. The RO denied the claim to reopen entitlement to service connection for PTSD in an April 1996 rating decision. The Veteran again sought to reopen her claim of entitlement to service connection for PTSD in May 2000. The RO denied the claim to reopen entitlement to service connection for PTSD in July 2000 and March 2002 rating decisions. The Veteran was notified of these decisions and provided her appellate rights, but did not perfect an appeal. Thus, each of these decisions is final. 38 U.S.C.A. § 7105. Most recently, the Veteran sought to reopen her claim of entitlement to service connection for PTSD in May 2006. The RO denied the claim to reopen entitlement to service connection for PTSD in a February 2007 rating decision on the grounds that the Veteran failed to submit new and material evidence. Specifically, the RO found that there was no diagnosis of PTSD related to her period of active military service. Following the submission of additional evidence, the RO reopened the Veteran's claim of entitlement to service connection for PTSD in an April 2007 rating decision. However, the RO denied the Veteran's service connection claim on the merits, noting that there was no evidence of a verifiable in-service stressor. An October 2007 rating decision confirmed and continued the RO's denial of service connection for PTSD due to personal assault on the basis that there was no evidence of personal assault in service and no diagnosis of PTSD due to personal assault. The Veteran was notified of these decisions and provided her appellate rights. She then perfected the current appeal. In March 2012, the Board reopened the Veteran's claim, recharacterizing the issue on appeal as listed on the title page above, and remanded this matter for additional development. As will be discussed below, the Board has found that further development for this matter is warranted. A longitudinal review of the record showed that the Veteran's service treatment records were negative for any diagnosis of or treatment for an acquired psychiatric disorder or personal assault and there was no evidence of such within one year after discharge from service. Service personnel records for the period from June 1973 to June 1976, including service in Germany from March 1974 to May 1976, reflected largely outstanding performance evaluations until February 1975, at which time the Veteran's performance evaluations declined. The Veteran was also fined and had her grade reduced in April 1976 after she operated a vehicle while intoxicated. Additional service personnel records in the claims file show that her military occupational specialty (MOS) was Armor Unit Supply Specialist. Other primary duties during active service included telephone switchboard operator and clerk typist. The record further reflects that the Veteran had a subsequent period of service in the Army National Guard from 1977 to 1980. Unfortunately, in a January 2013 memorandum, the RO issued a formal finding of the unavailability of National Guard and Defense Finance and Accounting Service Records (DFAS) records. The RO indicated that its attempts to retrieve the Veteran's records from the South Carolina State Adjutant General, Arizona National Guard, Oklahoma National Guard, and DFAS were unsuccessful, as these records were unavailable. Post-service VA treatment records indicated that the Veteran was hospitalized in August 1984 with a history of recent acute psychosis with agitation, paranoid delusions, and auditory hallucinations. The Veteran reported being under heavy stress at her job at a VA medical facility and having marital problems with her husband prior to admission. The impression was atypical paranoid disorder, inactive; adjustment disorder with depressed mood; and alcohol abuse, episodic. Private treatment records from Eastern State Hospital dated October 1984 revealed that the Veteran was admitted for psychiatric treatment after reporting that "[e]verything broke down" following her divorce and her inability to care for her child. The Veteran reported feeling suicidal for a period of two days. She had recently learned that her husband had a "girlfriend" and subsequently divorced him. The initial diagnosis was major depressive episode, but the discharge diagnosis was major depression without psychiatric features. The Veteran was readmitted to a VA medical facility for additional psychiatric care in February 1986 after reporting depression and constant tension-type headaches. The Veteran was relieved of her work duties and sent to a physician. The Veteran attributed her symptoms to being over-worked by her bosses, whom she felt were inconsiderate and excessively demanding. The Veteran also reported a past medical history significant for seizures after being struck in the back of the head by a piece of lumbar in 1980 while working in a barn. The impression was alcohol abuse, in remission, and borderline personality disorder. VA outpatient psychiatric treatment records dated June 1993 to December 1994 reflected treatment for bipolar disorder. During this time period, the Veteran was also noted to experience family problems and household stressors, including dealing with undisciplined and physically abusive children. In February 1996 statement, the Veteran detailed her claimed in-service stressors. She asserted that she was harassed by lesbians in service and threatened to be killed by fellow soldiers on at least three separate occasions, to include being held upside-down by her feet out of a second story window; having a loaded gun held to her head; and being threatened with a switchblade knife. The Veteran was afforded a VA PTSD examination in March 1996. She indicated that she enjoyed her work in service in "document security." However, she reported problems dealing with lesbians and drug addicts. In April 1975, the Veteran stated that a female soldier named T.N. pulled a knife on her and threatened her after thinking that the Veteran was responsible for a recent drug bust. She detailed that the same individual held her outside of a window before pulling her back inside. The impression was bipolar disorder and borderline personality disorder. Additional VA treatment records reflected that the Veteran was admitted for VA psychiatric care in May and December 1999 to manage her bipolar disorder. In December 1999, the Veteran reported three threats to her life while stationed in Germany. The Veteran reported being threatened at gunpoint and at knifepoint. She also reported an incident where she was held upside down by her feet out of a second story window. The Veteran was unsure why she was threatened in this manner, but speculated that it had something to do with her job as an intelligence clerk. In April 2000, the Veteran's treating VA psychiatrist submitted a statement in support of her claim in which the psychiatrist stated that the Veteran underwent several traumatic situations in service. According to the psychiatrist, the Veteran believed that her current psychiatric problems were related to these traumatic in-service events. A provisional diagnosis of PTSD was listed at that time. The Veteran was afforded another VA PTSD examination in September 2000. The Veteran again reported several in-service stressors related to her active duty service in the Army, including when a fellow soldier threatened to shoot the Veteran with a .38 pistol, when a female soldier pulled a knife on her and threatened to kill her, and when she was held upside down out of a two-story window. The impression was schizoaffective disorder, bipolar type. In a subsequently submitted stressor statement dated in May 2001, the Veteran reported that the claimed in-service stressful events occurred while she was stationed in Germany in summer 1974 or sometime from 1974 to 1976. The Veteran testified before the RO in May 2003. Specifically, the Veteran reported that she was stationed in Germany and worked as an intelligence clerk. Her primary responsibility included document protection and involvement in an investigation to determine who brought illegal drugs and weapons into the country. The Veteran stated that she was accosted by a bus driver outside of the Army Criminal Investigation Division office. She noted that this man drove a bus for "the baseball team in Berlin." She stated that this man held a loaded .38 caliber pistol to her head and forced her to escort him off of the base. She requested assistance from a military police officer, but stated that the police officer did not see him hold the gun to her head. The police officer noted that this man had a gun in his possession as he left the base, but the police officer advised the Veteran that he had a permit to carry it. The Veteran stated that neither she nor the police officer reported this incident. Thereafter, the Veteran reported a second incident in which she was threatened by a female soldier at knifepoint and subsequently held upside down by her feet out of a second story window. The Veteran reported a third incident in which she was again held at knifepoint in her office by a different female soldier. She stated that she did not report these incidents because of her prior negative experience with the military police officer and because she feared retribution or retaliation. The Veteran denied psychiatric problems in service and first sought psychiatric treatment in 1984. The Veteran's husband noted that bipolar disorder was diagnosed, but he expressed concern that the Veteran was misdiagnosed. He also testified about the manner in which her psychiatric symptoms affected their daily life. A March 2004 VA treatment note from VA clinical psychologist showed an assessment of symptoms of PTSD, secondary to trauma in the Army, and treatment of bipolar disorder and schizoaffective disorder. In January 2006, the Veteran reported sexual abuse in the military and a history of National Guard service from 1977 to 1980. Included in the claims file is a buddy statement from V. E. dated May 2006. According to V. E., she was friends with the Veteran and had personal knowledge of the in-service stressful events alleged by the Veteran. In particular, V. E. indicated that the Veteran was threatened by "Willie" and T.N. on two separate occasions, once by knifepoint and again by being held upside down outside of a window, given the Veteran's knowledge of drug use and drug dealing on base in Fliegerhurst, Germany. V. E. also stated that the Veteran was threatened by a male who held a gun to her head. Furthermore, V. E. overheard the Veteran being threatened by two females in service during a heated exchange about the Veteran's knowledge of the drug use and drug dealing on base. After overhearing this exchange, V. E. stated that she noticed a change in the Veteran. It was indicated that she observed the Veteran become withdrawn and worried and continue to have problems since discharge from service. The Veteran was readmitted to a VA medical facility in May 2006 for additional psychiatric care. Treatment notes associated with this episode of care indicated that the Veteran was taken to the emergency department in an altered state of consciousness, possibly due to an overdose of psychiatric medications. The Veteran reported several family stressors at that time and recalled two instances in service in which she was threatened while stationed in Germany, the gunpoint incident and the incident where the Veteran was held upside down outside of a window. In a follow-up VA treatment note dated October 2006, the Veteran reported continued family stress. In particular, it was noted that the Veteran was back together with her husband, who in the past emotionally, physically, and sexually abused her. It was also noted that her son had a history of substance abuse and illicit behavior, and that he also abused the Veteran emotionally and physically. The impression was schizoaffective disorder, unspecified. A provisional PTSD diagnosis was also listed. In January 2007, the Veteran's VA treating psychiatrist, M. K., M. D., diagnosed schizoaffective disorder, bipolar type. The psychiatrist also listed a provisional PTSD diagnosis based on the Veteran's account of her in-service stressful events in Hanau, Germany, to include having a gun pointed at her head and forced to escort a male off of the base, being threatened at knifepoint, and held upside down outside of a window. The Veteran reported that these events occurred because she thought the company/battalion commander was selling drugs. By the Veteran's own account, the individuals who perpetrated these claimed threats mistakenly believed that the Veteran ordered drug searches on base. In a November 2008 VA telephone treatment note, the Veteran stated that she was attacked four times in service and threatened with bodily harm. She also reported being raped in service. The Veteran testified before the Board at a video-conference hearing in December 2011. The Veteran denied having any psychiatric problems prior to service. She reported two instances of in-service assault in June 1975 while stationed in Hanau, Germany. In the first instance, the Veteran reported that a male soldier held a loaded gun to her head and threatened to kill her unless she escorted him off of the base. The Veteran stated that she asked for help from a military police officer as the incident occurred, but the police officer allowed the individual to leave the base because he had a permit for the gun. In the second case, the Veteran reported that she was threatened at knifepoint by a female soldier. She again testified that the same female soldier also held the Veteran upside down by her feet outside of a second story window. The Veteran indicated that she did not report these incidents and speculated that they occurred given her knowledge of drug use and drug dealing on base. The Veteran further testified that she worked at a VA medical facility after discharge from service and that she first received inpatient mental health treatment in 1984. In March 2012, the Board reopened the Veteran's claim, recharacterizing the issue on appeal as listed on the title page above, and remanded this matter for additional development. In light of the cumulative evidence of record, the Board determined that the Veteran should be afforded a VA examination to determine the etiology of her currently diagnosed psychiatric disabilities and their relationship to service, if any. Additional VA treatment records dated from 2009 to 2012, located in the Veteran's Virtual VA file, reflected continued findings of schizoaffective bipolar type, PTSD, PTSD with schizoaffective disorder, MST (military sexual trauma) - PTSD provisional, and unspecified schizoaffective disorder. In VA mental health notes dated from 2009 to 2011, the same VA treating psychiatrist, M. K., M. D., listed assessments of schizoaffective-bipolar type, provisional PTSD (based on the patient's reported trauma exposure), psychosis NOS - stable, and schizoaffective bipolar type (current mild depression). Multiple PTSD screenings were at times negative or positive between 2009 and 2011. VA mental health treatment notes dated in September 2009 and March 2010 showed the Veteran requesting that her VA treating psychiatrist remove the "provisional" portion of her PTSD diagnosis. The psychiatrist repeatedly explained the process of service connection to the Veteran as well as gave her options to see another VA treatment provider or to obtain a psychiatric evaluation from a non-VA provider. The Veteran was afforded a VA PTSD examination in March 2012. After reviewing the claims file and examining the Veteran, the examiner, a VA psychiatrist, first listed a diagnosis of schizoaffective disorder, commenting that the Veteran has many symptoms currently and chronically that overlap a variety of diagnostic categories. The examiner highlighted that when looking at the sequence of illness and symptoms, the Veteran's severity of psychosis was beyond what would typically be seen in PTSD. As such, the examiner noted that the pattern of symptoms and the treatment response were more consistent with a psychotic mood disorder. Additional listed diagnoses were self-reported alcohol abuse (in remission) and borderline personality disorder. Thereafter, the examiner listed a diagnosis of PTSD, commenting that the diagnosis was made at that time on the Veteran's self report of her current symptoms. The examiner acknowledged that there were some inconsistencies in the details of some aspects in the Veteran's reported stressors but that they could be documentation related. The examiner indicated that the major themes of the Veteran's stressors seemed to be consistent over the years. However, the examiner could not determine if those events actually occurred and the chart did not provide documentation of the asserted stressors. The examiner noted that reports of a "drug ring" could be reality based or could have been early prodromal phases of an underlying psychotic disorder exacerbated by stress, alcohol abuse, etc. It was noted that PTSD symptoms as well as schizoaffective symptoms could have latent phase or periods of remission. The examiner highlighted that the Veteran was in her early 30's when first hospitalized for psychosis. The examiner indicated that more than one mental disorder had been diagnosed and that it was possible to differentiate what symptoms were attributable to each diagnosis. The examiner presumed that the Veteran's current symptoms were related to schizoaffective disorder, as the veteran reported sobriety from alcohol. The examiner noted the following reported stressors by the Veteran: (1) having a gun pointed at her head and forced to escort a male off of the base; (2) being threatened at knifepoint by a female soldier; (3) being held upside down outside of a window by the same female soldier; and (4) being raped off base by an ex-boyfriend who was also a non-commissioned officer (NCO). The examiner indicated that stressors 1 - 3 were adequate to support the diagnosis of PTSD and were related to the Veteran's fear of hostile military or terrorist activity. In a June 2012 addendum report, the examiner acknowledged that an opinion as to whether the record credibly indicated that a personal assault occurred had been requested. On review of the claims file, the examiner noted that there was only the Veteran's self-report indicated an assault. The examiner noted that the rest of the file did not clearly reflect evidence/documentation of the four reported stressors. The examiner highlighted that if the claimed stressors were valid, then the Veteran's reported symptoms were consistent with a diagnosis of PTSD. It was noted that whatever the Veteran experienced in her Germany deployment did seem to have affect her ability to cope over the years and may have exacerbated her course of mental illness. The examiner could not say without speculation if the Veteran's schizoaffective disorder was related to your military experience, but indicated that the Veteran's experience may have had an impact on her mood disorder. The examiner further commented that the Veteran's alcohol abuse may have been related to military stressors as a way to manage, but military stressors would not cause alcohol abuse. The examiner reported that this was a complex case due to the complexity of symptoms, personality disorder, history of alcohol abuse, and self-reports of military stressor events. The examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness, noting that whether the stressor events occurred was speculation. However, the examiner indicated that based on the Veteran's reported symptoms, the criteria for the clinical symptoms of PTSD were met. In an additional March 2013 addendum report, it was noted that the examiner was requested to further clarify whether the Veteran's military service had an impact on her nonservice-connected schizoaffective mood disorder. As indicated in the June 2012 opinion/addendum, the examiner opined that "I cannot say without speculation if her Schizoaffective Disorder is related to her military experience, but her experience may have had an impact on her mood disorder". The examiner reported that it was mere speculation on the degree, if any, that the Veteran's service stressors had impacted her mood disorder, similar to how other life experiences (the barn incident in '80, her drinking, borderline character organization, etc.) could have impacted her resiliency and ability to cope with a psychotic mood disorder. It was highlighted that the Veteran had nearly 10 years of work history/employment at the VA prior to onset of her psychosis/mood disorder with her functioning during that time indicative of the ability to manage activities of daily living and the ability to function in government employment. The examiner was unable determine the "baseline level of mood disorder before it was aggravated by the service" since the onset of the mood disorder was years after the service stressors. The examiner concluded that there was no clear and convincing evidence that the Veteran's service stressors had any specific or direct impact on the mood disorder. It was further noted that there was no clear evidence that her service stressors had any specific impact on the course/progression of the schizoaffective disorder. In order for a VA examination to be considered adequate, the articulated reasoning must demonstrate that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board has found that the March 2012 VA examination with the June 2012 and March 2013 addendum reports are inadequate for purposes of determining service connection. Establishing service connection for PTSD requires that there be (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) a link, established by medical evidence, between current symptoms and an in-service stressor; (3) and credible supporting evidence that the claimed in-service stressor actually occurred. 38 C.F.R. § 3.304(f) (2012); see also, Cohen v. Brown, 10 Vet. App. 128, 138 (1997). The diagnosis of a mental disorder must conform to the Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) and be supported by the findings of a medical examiner. 38 C.F.R. § 4.125(a) (2012). There are special considerations for PTSD claims predicated on a personal assault. The pertinent regulation, 38 C.F.R. § 3.304(f)(5), provides that PTSD based on a personal assault in service permits evidence from sources other than a veteran's service records, including evidence of behavior changes, which may corroborate his or her account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. 38 C.F.R. § 3.304(f)(5) (2012). VA will not deny a PTSD claim that is based on in-service personal assault without first advising the claimant that evidence from sources other than the veteran's service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. In addition, VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. Id. In this case, the Board instructed the RO to submit evidence received in connection with this matter to a mental health professional for an opinion as to whether the evidence of record was indicative of a personal assault occurring. While the VA psychiatrist continually discussed the Veteran's reported stressors in the March 2012 VA examination report as well as the June 2012 and March 2013 addendum opinions, the psychiatrist never actually provided the requested opinion as to whether the evidence of record indicated that a personal assault occurred. Instead, the examiner noted that there was only the Veteran's self-report indicated an assault and commented that the record did not clearly reflect evidence/documentation of the four reported stressors. The examiner highlighted that if the claimed stressors were valid, then the Veteran's reported symptoms were consistent with a diagnosis of PTSD. In addition, the examiner marked that three of the Veteran's reported stressors were adequate to support the diagnosis of PTSD and were related to the Veteran's fear of hostile military or terrorist activity in the March 2012 VA examination report. However, the Federal Circuit has specifically held that § 3.304(f)(3) can apply only if a veteran's claimed in-service PTSD stressor relates to an event or circumstance that a veteran experienced, witnessed, or was confronted with and that was perpetrated by a member of an enemy military or by a terrorist. Thus, the regulation does not apply where a veteran alleges an in-service assault by a fellow service member. Hall v. Shinseki, ___ F.3d ___ (Fed. Cir. 2013) (2013 WL 2450628). "Once VA undertakes the effort to provide an examination, it must provide an adequate one or, at a minimum, notify the veteran why one will not or cannot be provided." Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In order to satisfy VA's duty to assist, the Board must again remanded the appeal in order to afford the Veteran an additional VA medical opinion to clarify the etiology of the Veteran's claimed acquired psychiatric disorder on appeal. 38 U.S.C.A. §§ 5107(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012). Accordingly, the case is remanded for the following actions: 1. The RO must contact the Veteran and afford her the opportunity to identify or submit any additional pertinent evidence in support of her claim for entitlement to service connection for an acquired psychiatric disorder, to include PTSD, due to personal assault. Based on her response, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. Regardless of the Veteran's response, the RO must obtain all relevant VA medical records pertaining to the Veteran, to include records from the Muskogee VAMC from March 2012. If, after making reasonable efforts to obtain this information the RO is unable to secure any of the identified records, the RO must notify the Veteran and her representative and (a) identify the information the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain that information; (c) describe any further action to be taken by the RO with respect to the claim; and (d) that the Veteran is ultimately responsible for providing information. The Veteran and her representative must then be given an opportunity to respond. 2. The RO must obtain a VA medical opinion from an appropriate psychiatrist, preferably the VA psychiatrist who conducted the March 2012 VA examination as well as executed the June 2012 and March 2013 addendum opinions, to clarify the etiology of the Veteran's claimed acquired psychiatric disorder. The claims file and all records on Virtual VA must be made available to the psychiatrist, and the psychiatrist must specify in the report that the claims file and Virtual VA records have been reviewed. The psychiatrist must specify the dates encompassed by the Virtual VA records that were reviewed. A copy of this REMAND should be made available to and reviewed by the VA psychiatrist. The RO must specify for the psychiatrist stressors that it has determined are established by the record. Regardless of the RO's response, the Board notes that the Veteran has consistently alleged the following in-service stressors: (1) having a gun pointed at her head and forced to escort a male off of the base; (2) being threatened at knifepoint by a female soldier; (3) being held upside down outside of a window by the same female soldier; and (4) being raped off base by an ex-boyfriend who was also a NCO. In reviewing the record, the psychiatrist should identify and examine all records indicating any signs/indicators of the claimed personal assault stressors alleged by the Veteran to have occurred during active service, and offer an opinion as to the clinical significance, if any, of such evidence. The Board is cognizant that the record does not show clear documentation of the Veteran's reported personal assault stressors. As discussed at length in 38 C.F.R. § 3.304(f)(5) above, VA regulations provide that evidence from sources other than the Veteran's service records can corroborate the occurrence of a claimed in service stressor based on personal assault. Based on the evidence of record, the psychiatrist must provide an opinion as to whether the record indicates that any in-service personal assault described by the Veteran occurred. Following a review of the evidence of record and with consideration of the Veteran's statements and all other lay statements of record, the psychiatrist must provide diagnoses for all psychiatric disorders found. The psychiatrist must integrate the previous psychiatric findings and diagnoses to obtain a true picture of the nature of the Veteran's psychiatric status. If the diagnosis of PTSD is deemed appropriate, the psychiatrist must specify (1) whether the Veteran's claimed stressors found to be established by the record were sufficient to produce PTSD; and (2) whether there is a link between the current symptomatology and the in-service stressors found to be established by the record and found sufficient to produce PTSD. The psychiatrist must provide a complete rationale for all opinions expressed. If the psychiatrist cannot provide the requested opinion without resorting to speculation, it must be so stated, and the psychiatrist must provide the reasons why an opinion would require speculation. The psychiatrist must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the psychiatrist must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. The report prepared must be typed. Another examination of the Veteran must only be performed if deemed necessary by the person providing the opinion. 3. The RO must notify the Veteran that it is her responsibility to report for any examination scheduled, and to cooperate in the development of the claim. The consequences for failure to report for any VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained and associated with the Veteran's claims file that shows that notice scheduling the examination was sent to her last known address. Documentation must be also be obtained and associated with the Veteran's claims file demonstrating any notice that was sent was returned as undeliverable. 4. After the development requested has been completed, the RO must review any medical opinion and/or examination report to ensure that it is in complete compliance with the directives of this Remand. If the opinion and/or report is deficient in any manner, the RO must implement corrective procedures at once. 5. Once the above actions have been completed, and any other development as may be indicated by any response received as a consequence of the actions taken above, the RO must re-adjudicate the Veteran's claim on appeal. If the benefit remains denied, a supplemental statement of the case must be provided to the Veteran and her representative. After she has had an adequate opportunity to respond, the appeal must be returned to the Board for further appellate review. No action is required by the Veteran until she receives further notice; however, the Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). _________________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).