Citation Nr: 1330730 Decision Date: 09/25/13 Archive Date: 09/30/13 DOCKET NO. 09-31 129 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), anxiety disorder, depression, and dysthymia. 2. Entitlement to an initial disability rating in excess of 20 percent for lumbar spine degenerative disc disease. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D.S. Lee, Counsel INTRODUCTION The Veteran served on active duty from July through October of 2000 and from September 2001 through July 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio which, among other issues, granted service connection for lumbar spine degenerative disc disease, effective from July 10, 2008 with a 20 percent initial disability rating, and denied service connection for PTSD. A timely Notice of Disagreement (NOD), in which the Veteran contested the initial disability rating assigned for his lumbar spine disability and the denial of service connection for PTSD, was received in February 2009. After a Statement of the Case (SOC) was issued in August 2009, the Veteran perfected his appeal in August 2009, via VA Form 9 substantive appeal. With respect to the Veteran's claim for service connection for PTSD, the United States Court of Appeals for Veterans Claims (Court) has held that claims for service connection for PTSD encompass claims for service connection for all psychiatric disabilities. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). The evidence in this case, to include the Veteran's service treatment records and post-service treatment records, appear to indicate possible diagnoses of PTSD, depression, anxiety disorder, and dysthymia. In view of the same, the Board has expanded the issue previously characterized as service connection for PTSD to also include possible service connection for the other possible psychiatric disorders indicated in the record. The issue of entitlement to service connection for an acquired psychiatric disorder, to include PTSD, anxiety disorder, depression, and dysthymia, 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. FINDING OF FACT Since the July 10, 2008 effective date of the award of service connection, the Veteran's lumbar spine degenerative disc disease has been manifested by pain, stiffness, and reduced thoracolumbar range of motion that includes forward thoracolumbar flexion to no less than 50 degrees, and moreover, has not been productive of ankylosis of the spine, intervertebral disc syndrome (IVDS), or any neurological manifestations. CONCLUSION OF LAW The criteria for an initial rating in excess of 20 percent for lumbar spine degenerative disc disease have not been met or approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, General Rating Formula for Diseases and Injuries of the Spine (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011) and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical evidence or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VA's notice 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 v. Nicholson, 19 Vet. App. 473 (2006). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. Such notice should be provided to a claimant before the initial unfavorable decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). Regarding the issue of the Veteran's entitlement to a higher initial disability rating for his service-connected lumbar spine degenerative disc disease, a pre-rating July 2008 letter provided the Veteran with notice of the information and evidence needed to substantiate his claim for service connection for his claimed back condition, to include arthritis. This letter included notice of the process in which VA assigns disability evaluations and effective dates. This notification would also apply to the "downstream" issue of entitlement to a higher initial disability rating for lumbar spine degenerative disc disease. In that regard, the Court has held that once service connection is granted, the claim is substantiated. In such instances, additional VCAA notice is not required and any defect in the notice is not deemed prejudicial to the Veteran. Dunlap v. Nicholson, 21 Vet. App. 112, 119 (2007); Dingess, 19 Vet. App. at 491. Thus, because the VCAA notice that was provided before service connection for lumbar spine degenerative joint disease was granted was legally sufficient, VA's duty to notify in this case has been satisfied. In addition, VA has fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate the Veteran's claims. His service treatment records, service personnel records, claims submissions, lay statements, identified and relevant private treatment records, and VA treatment records have been obtained and associated with the record. VA examinations of the Veteran's spine was conducted in December 2008 and January 2013. Moreover, VA has not received any additional evidence since the more recent examination which indicates that the Veteran's low back condition has changed such as to warrant the scheduling of a new VA examination to reassess the associated symptoms and severity. Hence, these examinations, along with the other evidence of record, are fully adequate for the purposes of determining the extent of the Veteran's disability in light of the applicable diagnostic criteria. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. II. Higher Initial Disability Rating for Lumbar Spine Disability Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In cases where there is a question as to which of two ratings applies, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In every instance where the rating schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). In instances where the rating being appealed is the initial rating assigned with a grant of service connection, the entire appeal period is for consideration, and separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119 (1999). VA's defined and consistently applied policy is to administer the law under a broad interpretation; however, in a manner that is consistent with the facts shown in each case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. As noted in the introduction, a February 2009 rating decision granted service connection for lumbar spine degenerative disc disease effective July 10, 2008, with a 20 percent initial disability rating. Although the rating decision identifies 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5243 (criteria for rating disabilities due to intervertebral disc syndrome (IVDS)) as being the basis for the initial disability rating, a reading of the RO's rationale indicates that the initial disability rating was in fact based upon demonstrated loss of thoracolumbar motion. In that regard, the RO expressly identified diminished ranges of thoracolumbar motion; however, did not expressly find any IVDS or neurological impairment related to the Veteran's low back disability. Effective September 6, 2003, degenerative arthritis and IVDS are evaluated under the General Rating Formula for Diseases and Injuries of the Spine (to include consideration of separate ratings for orthopedic and neurological manifestations). IVDS is rated either under the General Rating Formula or the formula based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. Given the rationale stated by the RO in its February 2009 rating decision, and in the absence of any express findings of IVDS or neurological manifestations, the Board infers that the RO applied the General Rating Formula in rating the Veteran's service-connected lumbar spine degenerative disc disease. As discussed fully below, however, the evidence does not show the presence of IVDS. Accordingly, potential ratings for IVDS will not be considered in this case. The General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) provides for assignment of a 20 percent disability rating for spine disabilities resulting in forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, or when the combined range of motion of the thoracolumbar spine is not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. The next higher rating of 40 percent is warranted for disability of the thoracolumbar spine either where forward flexion of the thoracolumbar spine is 30 degrees or less, or where there is favorable ankylosis of the thoracolumbar spine. A 50 percent disability rating is warranted where there is unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted where there is unfavorable ankylosis of the entire spine. These criteria are to be applied with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by disease or injury. 38 C.F.R. § 4.71a. Under federal regulations, normal thoracolumbar motion consists of forward flexion to 90 degrees and extension, lateral flexion, and rotation to 30 degrees each. "Combined range of motion" refers to the sum of the ranges of forward flexion, extension, right and left lateral flexion, and right and left lateral rotation. Hence, full and normal combined range of motion of the thoracolumbar spine is 240 degrees. 38 C.F.R. § 4.71a, General Rating Formula, Note 2, and Plate V. When evaluating musculoskeletal disabilities, VA may, in addition to applying the foregoing schedular criteria, also consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). The provisions under 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). The Board acknowledges that, under Note (1) of the General Rating Formula, VA must consider whether combining ratings for orthopedic and neurological manifestations would result in a higher rating. As also discussed fully below, the evidence in this case does not indicate the presence of any neurological manifestations associated with the Veteran's lumbar spine disability. Accordingly, Note (1) is not applicable in this case. Also, there is no basis for separate and additional disability ratings for associated neurological manifestations. Although the Veteran has not urged the application of any other specific rating criteria for his renal dysfunction, the Board has also considered the potential application of the other provisions of 38 C.F.R., Parts 3 and 4. Schafrath, 1 Vet. App. 589. In doing so, the Board does not see other rating criteria that may be applied in this case. In view of the same, and as neither the provisions pertaining to IVDS or Note (1) are applicable here, the Veteran's lumbar spine disability will be rated under the General Rating Formula and based strictly upon demonstrated loss of thoracolumbar motion. The post-service evidence in this case includes records pertinent to private and VA treatment received by the Veteran from February 2007 through January 2012. These records, however, do not pertain to any treatment for the Veteran's back, nor do they contain any objective findings or subjective complaints relating to the back. During a December 2008 VA examination, the Veteran reported that he had been having intermittent but daily low back stiffness and pain since October 2004. He described the reported pain as being 10 out of 10 in severity and radiating upward into his upper back. He stated that his back symptoms were aggravated by periods of prolonged sitting and standing. Functionally, he reported that he was able to walk distances of up to a couple of blocks. During physical examination, the Veteran demonstrated a slight right-sided limp. It is unclear whether the demonstrated limp was attributable to the Veteran's back disability. The Board notes, however, that the Veteran did not expressly report an altered gain in association with his low back problem. Demonstrated thoracolumbar motion included flexion to 50 degrees, extension to 10 degrees (or loss of 20 degrees of extension), lateral flexion to 15 degrees bilaterally, and lateral rotation to 25 degrees bilaterally. Subjective complaints of pain during motion were not noted. Repetitive motion was not productive of further loss of motion or other loss of function. Neurologically, the Veteran complained during the examination that he was experiencing numbness and tingling in his lower extremities. Nonetheless, a neurological examination was grossly normal and not indicative of any neurological manifestations associated with the Veteran's lumbar spine disability. In January 2013, the Veteran underwent a VA spine examination to assess the current severity and manifestations of his lumbar spine disability. During the examination, the Veteran reported intermittent tenderness to touch of his back that had been present over the past year and occurred roughly once every two weeks and lasted periods of up to a few hours. He also reported that he was having episodes of sharp midback pain which also lasted for periods of up to a few hours. Occupationally, he stated that he worked as a maintenance worker at a powdered metal factory for the past two years and did not report any examples of work impairment. X-rays of the thoracic spine were normal. Although thoracolumbar spine x-rays indicated a defect at L5, there was no evidence of associated subluxation or loss of disc space. During physical examination of the spine, the Veteran complained of low back stiffness; however, demonstrated full and pain free thoracolumbar motion in all directions (i.e., flexion, extension, right and left lateral flexion, and right and left lateral rotation). Repetitive thoracolumbar motion also did not result in any loss of motion or other loss of function. Palpation over the spine did not produce any complaints of tenderness or pain. The Veteran also demonstrated a normal gait and did not require any assistive devices. A neurological examination of the spine was also grossly normal; indicating full muscle strength, full reflexes, and full sensation to light touch on both lower extremities. Straight leg raising tests were also normal. The Veteran also expressly denied having any other neurological manifestations, such as low of bowel or bladder function. Based upon the Veteran's subjectively reported history and the subjective findings from the examination, the examiner confirmed previous diagnoses of lumbar spine degenerative disc disease but opined that the Veteran's low back disability did not impact the Veteran's ability to work. Considering the evidence in light of the applicable legal authority, the Board finds that a rating in excess of 20 percent is not warranted at any point since the July 10, 2008 effective date for the award of service connection for lumbar spine degenerative disc disease. As indicated above, thoracolumbar range of motion testing performed over the course of this period has demonstrated some loss of thoracolumbar motion but has not reflected forward flexion that is limited to 30 degrees or less or any ankylosis of the spine. Indeed, a comparison of the thoracolumbar motion demonstrated at the Veteran's VA examinations appears to indicate improvement in that regard. As discussed above, VA may consider any demonstrated functional loss attributable to pain, weakness, excess fatigability, or incoordination, to include with repeated use or during flare-ups, in conjunction with criteria under the General Rating Formula. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 204-7. In this regard, the Board recognizes that during his VA examinations, the Veteran reported that one of the primary manifestations of his disability was low back pain. Nonetheless, given the extent of pain free thoracolumbar motion demonstrated by the Veteran during his VA examinations, the overall level of disability demonstrated by the Veteran is not commensurate to a loss of flexion to 30 degrees or less, nor is it akin to ankylosis. Moreover, repetitive motion testing has not been productive of any additional loss of motion. In view of the foregoing, even after taking into consideration the factors identified in DeLuca, a disability rating in excess of 20 percent may not be granted under the General Spine Rating Formula. The Board has also considered the provisions under 38 C.F.R. § 3.321(b)(1), which govern the assignment of extra-schedular disability ratings. However, in this case, the record does not show that the severity of the Veteran's lumbar spine disability is so exceptional or unusual such as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extra-schedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and, no extra-schedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular rating does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extra-schedular regulation (38 C.F.R. § 3.321(b)(1)) as "governing norms"(which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show that the Veteran's lumbar spine disability presents an exceptional disability picture that renders inadequate the available schedular ratings. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the General Rating Formula shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. As such, it cannot be said that the available schedular ratings for the Veteran's lumbar spine degenerative disc disease are inadequate. Based on the foregoing, the Board finds that the requirements for an extra-schedular evaluation for the Veteran's service-connected lumbar spine degenerative disc disease, under the provisions of 38 C.F.R. § 3.321(b)(1), have not been met. Thun, 22 Vet. App. 111; Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). The Board has also considered whether "staged" disability ratings, beyond those already provided, are warranted by the evidence. The symptomatology shown upon examination and treatment, however, has been essentially consistent and fully contemplated by the assigned disability rating. As such, there is no basis for further staged disability ratings in connection with the Veteran's lumbar spine degenerative disc disease. Overall, the Board finds that the symptomatology associated with the Veteran's lumbar spine degenerative disc disease is consistent with a 20 percent disability rating under the General Rating Formula. To that extent, this appeal is denied. ORDER An initial disability rating in excess of 20 percent for lumbar spine degenerative disc disease is denied. REMAND In support of his claim for service connection for an acquired psychiatric disorder, the Veteran has alleged that he experienced psychiatric symptoms during service and that he received a PTSD diagnosis. He alleged that his PTSD was related to stressors related to his service in Iraq, to include duty participating in convoys; an incident in which he was fired upon by an enemy sniper during guard duty; and repeated enemy mortar attacks on his duty station. The service department records corroborate the Veteran's service in Iraq, as well as service in Kosovo. Given the nature of his service, and his contentions, specific stressors in service need not be corroborated if it is determined by a VA psychiatrist or psychologist that fear of hostile military or terrorist activity in service is related to a current diagnosis of PTSD. 38 C.F.R. § 3.304(f)(3). In cases involving such stressors related to fear of hostile or military terrorist activity, the revised regulation requires that: (1) a VA psychiatrist or psychologist, or contract equivalent, must confirm that the reported stressor is adequate to support a diagnosis of PTSD; (2) the reported stressor be consistent with the places, types, and circumstances of the veteran's service; and (3) the veteran's symptoms be related to the reported stressor. 38 C.F.R. § 3.304(f)(3); Relaxation of Evidentiary Standard or Establishing In-Service Stressors in Claims for Posttraumatic Stress Disorder - 38 C.F.R. § 3.304(f)(3), (VBA) Fast Letter No. 10-05, at 1 (July 16, 2010) (on file with author). Consistent with the Veteran's assertions, a June 2006 service treatment record reflects that the Veteran complained of stress related to his deployment to Iraq. Subsequent service treatment records dated from 2006 through 2008 contain problem lists which continuously identify chronic PTSD, anxiety disorder, and dysthymia as known and ongoing conditions. Nonetheless, the service treatment records associated with the claims file do not pertain to any psychiatric treatment. Indeed, except for an isolated June 2006 Depression Outpatient Documentation which notes various psychiatric symptoms. The absence of psychiatric treatment records is particularly suspicious given the Veteran's contention, made during a January 2013 VA examination, that he received regular psychiatric counseling while stationed at Camp Roberts, California. Moreover, it is unclear from the record as to whether any requests for the Veteran's in-service mental health treatment records were ever made by VA. In view of the foregoing, the RO should undertake efforts to obtain the Veteran's complete in-service mental health treatment records. 38 C.F.R. § 3.159(c)(2). The Board also notes that the Veteran previously underwent VA psychiatric examinations in January 2009 and January 2013. Both examinations ultimately concluded that the Veteran did not meet the diagnostic criteria for any Axis I mental health disorders. Nonetheless, the Board points out that to the extent that the Veteran's complete in-service mental health treatment records were unavailable for review and consideration by either VA examiner, the January 2009 and January 2013 opinions are based upon an incomplete understanding of the Veteran's psychiatric history. Moreover, the January 2013 VA examiner failed to explain or discuss positive objective findings of depression and anxiety, determined according to Beck Depression Inventory-II and Beck Anxiety Inventory testing performed during that examination. The absence of such a discussion renders the January 2013 opinion incomplete, particularly in view of its ultimate conclusion that the Veteran does not have a diagnosable Axis I psychiatric condition. Accordingly, the Veteran should be arranged to undergo a new VA examination to determine the nature and etiology of his claimed acquired psychiatric disorder. 38 C.F.R. § 3.159(c)(4). Prior to arranging the examination ordered above, and in order to ensure that the most complete and up-to-date evidence has been associated with the claims file, the Veteran should also be asked to identify any other treatment providers who have rendered psychiatric treatment since January 2012. VA must then make efforts to obtain any treatment records that are identified by the Veteran. 38 C.F.R. § 3.159. Accordingly, the case is REMANDED for the following action: 1. A letter should be sent to the Veteran explaining, in terms of 38 U.S.C.A. §§ 5103 and 5103A, the need for additional evidence regarding his claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD, anxiety disorder, depression, and dysthymia. This letter must also inform the Veteran about the information and evidence that is necessary to substantiate his claim and provide notification of both the type of evidence that VA will seek to obtain and the type of evidence that is expected to be furnished by the Veteran. The letter must also notify the Veteran that VA is undertaking efforts to obtain his in-service mental health treatment records for psychiatric counseling received at Camp Roberts, California, and to arrange a VA psychiatric examination of his claimed psychiatric disability. The Veteran should be advised that it remains his responsibility to report for the scheduled VA examination and to cooperate with the development of his claim. The Veteran should also be provided a VA 21-4142 release and be asked to identify the name(s) and current address(es) for any private and/or VA treatment providers who have provided psychiatric treatment since January 2012. 2. Make efforts to obtain the Veteran's in-service mental health treatment records pertaining to psychiatric counseling received by the Veteran at Camp Roberts, California. Any records obtained as a result of such efforts should be associated with the claims file. If such efforts yield negative results, a notation to that effect should be inserted in the file. The Veteran and his representative are to be notified of unsuccessful efforts in this regard, in order to allow the Veteran the opportunity to obtain and submit those records for VA review. 3. Make efforts to obtain the records for any post-service psychiatric treatment identified by the Veteran. Any records obtained as a result of such efforts should be associated with the claims file. If such efforts yield negative results, a notation to that effect should be inserted in the file. The Veteran and his representative are to be notified of unsuccessful efforts in this regard, in order to allow the Veteran the opportunity to obtain and submit those records for VA review. 4. After the foregoing development has been performed to the extent possible, the Veteran should be afforded a VA psychiatric examination to determine the nature and etiology of his claimed psychiatric disorders. The Veteran's claims file should be made available to the examiner prior to the examination, and the examiner must review the entire claims file in conjunction with the examination. For purposes of this examination, the examiner should assume that the Veteran sustained in-service stressors that are related to fear of hostile military or terrorist activity. A full examination, to include an interview of the Veteran and any tests and studies deemed necessary by the examiner, should be conducted. The examiner should provide a multi-axial diagnosis that includes an Axis I diagnosis(es) based upon findings from the examination. For each provided diagnosis, the examiner should specifically discuss how the Veteran has met the DSM-IV criteria for each diagnosed disorder. The examiner should also comment upon the psychiatric diagnoses shown in the Veteran's service treatment records; the psychiatric symptoms and depression and dysthymia diagnoses shown in the VA treatment records; and the positive findings of anxiety and depression that are noted in the previous January 2013 VA examination report; and if appropriate, provide an explanation as to why he or she does or does not concur with these earlier findings and diagnoses. If PTSD is diagnosed, then the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's stressors are adequate to support a diagnosis of PTSD, and, that the Veteran's symptoms are related to the reported stressors. For any diagnosed psychiatric disorder, other than PTSD, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the disorder either began during or was otherwise caused by the Veteran's active duty service. If the examiner determines that the Veteran does not have a current psychiatric disorder, or, that a current psychiatric diagnosis cannot be given, then the examiner should provide rationale for such findings. If the examiner is unable to provide any of the opinions requested above without resort to speculation, he or she should explain the reasons for this inability and comment on whether any further tests, evidence or information would be useful in rendering an opinion. The examiner's opinions and rationale should be expressed in a typewritten and legible report. 5. If the Veteran fails to report to the scheduled examination, the RO must obtain and associate with the claims file a copy of any notice(s) of the date and time of the examination sent to the Veteran by the pertinent VA medical facility. 6. After completion of the above development, the issues of the Veteran's entitlement to service connection for an acquired psychiatric disorder, to include PTSD, anxiety disorder, depression, and dysthymia, should be readjudicated. If the determination remains adverse to the Veteran, he and his representative should be furnished with a supplemental SOC and be given an opportunity to respond. 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). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs