Citation Nr: 1341691 Decision Date: 12/17/13 Archive Date: 12/31/13 DOCKET NO. 08-36 353 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for an acquired psychiatric disorder other than PTSD. REPRESENTATION Appellant represented by: Colin E. Kemmerly, Attorney WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD A. Spector, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1969 to May 1971. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2007 rating decisions by the Jackson, Mississippi Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran filed a notice of disagreement (NOD) with these determinations in April 2008, and timely perfected his appeal in November 2008. The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge in September 2011. A transcript of this hearing was prepared and associated with the claims file. In January 2012, the Board reopened the Veteran's claims of service connection for PTSD and an acquired psychiatric disorder, other than PTSD, and remanded these issues for further examination. Regrettably, as outlined below, further development is necessary before the Board can proceed with the issue of entitlement to service connection for an acquired psychiatric disorder, other than PTSD. The issue of service connection for PTSD is ready for review. The Board notes that, in addition to the paper claims file, there is a Virtual VA paperless claims file associated with the above claims. A review of the documents in such file reveals that there are additional VA treatment records related to the Veteran's claims on appeal. These records have been reviewed and considered by the Board. The issue of entitlement to service connection for an acquired psychiatric disorder, other than PTSD, is addressed in the REMAND portion of the decision below and is REMANDED to the Department of Veterans Affairs Regional Office. FINDING OF FACT The Veteran does have a diagnosis of PTSD, pursuant to the DSM-IV criteria. CONCLUSION OF LAW The criteria for a grant of service connection for PTSD have not been met. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist The VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA 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 in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Here, the duty to notify was satisfied by way of letters sent to the Veteran in August and November 2011 that fully addressed all notice elements and was sent prior to the initial AOJ decision in this matter. The letters informed the Veteran of what evidence was required to substantiate the claims and of the Veteran's and VA's respective duties for obtaining evidence. The letters also provided notice regarding how disability ratings and effective dates are assigned. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). VA must also make reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate the claim for the benefit sought unless no reasonable possibility exists that such assistance would aid in substantiating the claim. This duty includes assisting with the procurement of relevant records, including pertinent treatment records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Veteran has indicated that he received treatment at a private facility in New Orleans. He stated that the records from that facility were destroyed in Hurricane Katrina in 2005. Thus, a remand to attempt to obtain those records would result in unnecessarily imposing additional burdens on VA, with no additional benefit flowing to the appellant. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). The VA has also done everything reasonably possible to assist the Veteran with respect to his claim for benefits, such as obtaining VA and private medical records and Social Security Administration disability records, and providing the Veteran with VA examinations September 1979, August 2003, and April 2013. The Veteran has not indicated that he has received additional treatment for PTSD. The Board thus concludes that there are no additional treatment records outstanding with respect to that claim. Consequently, the duty to notify and assist has been satisfied as to the claim now being finally decided on appeal. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). II. Service Connection Legal Criteria Service connection may be granted for a disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110. Service connection may also be granted for any disease 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). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303(a). However, the absence of a documented disability while in service is not fatal to a claim for service connection. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). When a Veteran does not meet the regulatory requirements for a disability at separation, he can still establish service connection by submitting evidence that a current disability is causally related to service. Hensley v. Brown, 5 Vet. App. 155, 159-60 (1993). Service connection for PTSD requires medical evidence establishing a diagnosis of the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., the diagnosis must comply with the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders, 1994 (DSM-IV)); credible supporting evidence that the claimed in-service stressor occurred; and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. See 38 C.F.R. §§ 3.304(f), 4.125; see also Cohen v. Brown, 10 Vet. App. 128, 140 (1997). The evidence necessary to establish the occurrence of a stressor during service to support a diagnosis of PTSD will vary depending upon whether the Veteran engaged in "combat with the enemy" as established by official records. If VA determines that the Veteran engaged in combat with the enemy and an alleged stressor is combat-related, then the Veteran's lay testimony or statement is accepted as conclusive evidence of the stressor's occurrence and no further development or corroborative evidence is required providing that such testimony is found to be "satisfactory," i.e., credible, and "consistent with the circumstances, conditions, or hardships of service." See 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(f); Dizoglio v. Brown, 9 Vet. App. 163, 164 (1996); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). Moreover, the Board notes that, effective July 13, 2010, the regulations governing service connection for PTSD were amended to relax the adjudicative evidentiary requirements for determining what happened in service where the Veteran's claimed stressor is related to "a fear of hostile military or terrorist activity during service." Specifically, the new 38 C.F.R. § 3.304(f)(3) provides that, if a stressor claimed by a Veteran is "related to the Veteran's fear of hostile military or terrorist activity," and a VA psychiatrist or psychologist (or a psychiatrist or psychologist with whom VA has contracted), confirms that the claimed stressor is 1) adequate to support a diagnosis of PTSD, and 2) that the Veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the places, types, and circumstances of the Veteran's service, the Veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(3). Moreover, the amendment provides that, "fear of hostile military or terrorist activity" means that a Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the Veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Id. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for the evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the Veteran. Background The Veteran contends that he suffers from PTSD as a result of his active duty. The Board points out that throughout the record, the Veteran has claimed different stressors for PTSD. He claimed that he was attacked by the Vietcong, and was exposed to numerous dead bodies. In April 2007, the RO made a formal finding that these stressors were unverifiable. Veteran also contends that his acquired psychiatric disorder is related to an in-service incident where he was hit on the head with a pipe while serving in Thailand, suffering from trauma to his head. In this particular case, the Board does not reach the question of whether the Veteran sustained a verified in-service stressor, as the preponderance of the competent medical evidence does not indicate that he has a diagnosis of PTSD for service connection purposes. As noted above, a threshold requirement for the granting of service connection is evidence of a current disability. In the absence of evidence of a current disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). A May 1971 psychological evaluation performed in-service noted diagnoses of personality disorder: anti-social type; paranoid and immature personality traits, chronic, moderate; and acute hostile anxiety, moderate, and ruled out early acute psychotic reaction. The Veteran was afforded a VA examination in September 1979. Upon examination, the examiner stated that psychological testing strongly suggested the presence of a schizophrenic disorder, paranoid type, in partial remission. The Veteran was noted to be competent and employable. Additionally, VA hospital records show that the Veteran was admitted and treated for nervousness and hearing voices in November and December 1979. He was diagnosed with Schizophrenia. He subsequently underwent a December 1979 Psychiatric Evaluation, where he was again diagnosed with Schizophrenia. The Veteran was again admitted for VA treatment from October to November 1981, with a diagnosis of Schizophrenia, paranoid type. September 1986 admission records show that the Veteran was diagnosed with unspecified substance delirium, dementia with alcoholism, and alcohol abuse. The Veteran underwent a psychiatric evaluation in March 2003. The physician noted that the Veteran served in Vietnam, but was not exposed to a combat-related trauma that met the stressor criterion for PTSD. He had multiple traumatic experiences that met the stressor criterion, assault with head injury, loss of consciousness, and concussion in the military, subsequent armed robbery, shot at several times, ect. However, he did not articulate PTSD symptoms as deriving from any of these traumas. Rather, the Veteran presented most prominently currently with symptoms of depression and interpersonal suspicion and distrust of paranoid, but not delusional proportions. By his report, he had been diagnosed as paranoid schizophrenic in the past and described command hallucinations; however, he indicated that he had not experienced hallucinations in several years and did not manifest psychotic symptoms currently. History of head injury with concussion and long-term alcohol abuse, presently in early remission, raised at least the possibility of an organic component to the clinical picture. Given the Veteran's clinical presentation and lack of a combat stressor, he did not meet eligibility requirements for the PTSD Program and was referred to the Mental Hygiene Clinic. A June 2003 VA record noted that the Veteran was referred by the PTSD program after his PTSD evaluation in April 2003. The physician noted that Veteran's reports of in-service incidents while servicing in Vietnam. The Veteran was diagnosed with Schizophrenia, PTSD, and ETOH dependence, early remission. VA Mental Health records continue to list diagnoses of schizophrenia and depression with psychotic features. Additionally, SSA records obtained, show a diagnosis of schizophrenia. The Veteran was afforded a VA mental disorders examination in August 2003. The examiner noted that the record contained a March 2003 PTSD evaluation. The Veteran did not experience a combat-related stressor or any other stressor which would meet the criteria "A" for PTSD. The examiner diagnosed the Veteran with anxiety and depression, not otherwise specified, which were both situational. VA treatment records contain January 2009, July 2009, January 2010, August 2010, and December 2010 PTSD screening reports. The PTSD screenings results were negative, with a score of 0. The Veteran was afforded another VA examination in April 2013. The examiner noted that the Veteran did not have a diagnosis of PTSD because the Veteran's symptoms did not meet the diagnostic criteria for PTSD under DSM-IV criteria. In more detail, the examiner noted that Veteran's stressor included when he was knocked unconscious by a pipe in the military, which met Criterion A to support a PTSD diagnosis. The Veteran experienced, witnessed or was confronted with an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. However, for Criterion B, the examiner noted that the traumatic event was not persistently re-experienced by the Veteran. Additionally, for Criterion C, there was no persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness. For Criterion D, there were no persistent symptoms of increased arousal. Additionally, the stressor was not related to the Veteran's fear of hostile military or terrorist activity. The examiner concluded that the Veteran did not meet full criteria for PTSD. The examiner diagnosed the Veteran with Schizophrenia, CPT under the DSM-IV criteria. After considering the in-service blow to the head with a pipe as possible PTSD stressor and considering his Chronic Alcohol Dependency along with apparent lateralized tremors, the examiner determined that Schizophrenia, Paranoid was the most likely diagnosis. The examiner concluded that the data did not support PTSD or any other link to military service. Analysis Based on the foregoing, the Board finds that the preponderance of the evidence weighs against the claim of service connection for PTSD. A review of the competent medical evidence of record does not show that the Veteran currently has a diagnosis of PTSD within the meaning of VA regulations. The Board acknowledges that in a June 2003 VA treatment record, the Veteran was diagnosed with PTSD. However, as discussed below in greater detail, this evidence does not reflect a comprehensive mental health evaluation and does not show that the PTSD diagnosis meets the requirements of 38 C.F.R. § 4.125. In contrast, the Board points out that prior to the June 2003 diagnosis, the Veteran underwent a psychiatric evaluation in March 2003. The physician noted that the Veteran served in Vietnam, but was not exposed to a combat-related trauma that met the stressor criterion for PTSD. He had multiple traumatic experiences that met the stressor criterion, assault with head injury, loss of consciousness, and concussion in the military, subsequent armed robbery, shot at several times, ect. However, he did not articulate PTSD symptoms as deriving from any of these trauma. Rather, the Veteran presented most prominently currently with symptoms of depression and interpersonal suspicion and distrust of paranoid, but not delusional proportions. By his report, he had been diagnosed as paranoid schizophrenic in the past and described command hallucinations; however, he indicated that he had not experienced hallucinations in several years and did not manifest psychotic symptoms currently. Given the Veteran's clinical presentation and lack of a combat stressor, he did not meet eligibility requirements for the PTSD Program and was referred to the Mental Hygiene Clinic. Additionally, the Board finds that the most complete assessment of the Veteran's mental condition was made in the April 2013 PTSD VA examination. The examiner did not diagnose him with PTSD; rather he was diagnosed with Schizophrenia, when evaluated under the DSM-IV. The VA examiner specifically examined the Veteran for PTSD under DSM-IV criteria, but found that he did not meet all of the criteria for a PTSD diagnosis. Specifically, the examiner noted that Veteran's stressor included when he was knocked unconscious by a pipe in the military, which met Criterion A to support a PTSD diagnosis. The Veteran experienced, witnessed or was confronted with an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. However, for Criterion B, the examiner noted that the traumatic event was not persistently re-experienced by the Veteran. Additionally, for Criterion C, there was no persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness. For Criterion D, there were no persistent symptoms of increased arousal. Additionally, The stressor was not related to the Veteran's fear of hostile military or terrorist activity. The examiner concluded that the Veteran did not meet full criteria for PTSD. Overall, the Board finds that the preponderance of the competent medical evidence of record does not indicate that the Veteran has a DSM-IV diagnosis of PTSD to warrant service connection in this case. The Board recognizes that the record contains conflicting medical evidence as to the diagnosis of the Veteran's mental condition. The Board must thus determine how much weight to afford the opposing opinions. See Guerrieri v. Brown, 4 Vet. App. 467, 471 (1993). The Board may weigh one medical professional's opinion over another, depending on factors such as the reasoning employed by the medical professionals and whether or not, and the extent to which, they reviewed prior evidence. Id. at 470-71. ("The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusions that the physician reaches."). The Board must provide adequate reasons and bases if it adopts one medical opinion over another. Owens v. Brown, 7 Vet .App. 429, 433 (1995) (noting that the Board may "favor the opinion of one competent medical expert over that of another when the Board gives an adequate statement of reasons and bases"). In assessing evidence such as medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight of the credibility of the evidence in the adjudication of the merits. See Hernanadez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Although the Veteran received a PTSD diagnosis in June 2003, the associated records did not contain any information about the bases of the diagnosis, such as what assessment methods were used or which symptoms the Veteran exhibited for each major Criteria (B, C, and D). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Additionally, the evidence does not indicate that the Veteran was diagnosed with PTSD by a mental health professional in conformance with the criteria of DSM-IV. Throughout the Veteran's treatment records, he was consistently diagnosed with depression, anxiety, and Schizophrenia. As the May 2003 VA psychiatric evaluation and April 2013 VA examination reports provided the more in depth analyses of the Veteran's mental condition by mental health practitioners, the Board finds these opinions to be of greater probative value. The VA psychiatric evaluation and examination reports were conducted in accordance with DSM-IV, as is required by 38 C.F.R. § 4.125. Additionally, they clearly diagnosed the Veteran's current mental disorders and provided greater detail as to how the PTSD determination was made. The VA examiners' opinions were based on review of the claims folder, including the Veteran's service treatment records. The examiners offered a detailed explanation of the rationale for his opinions that incorporates both the facts of the Veteran's case and the pertinent medical principles. Thus, the May 2003 VA psychiatric evaluation and April 2013 VA examination reports are found to be of greater probative value. Under these circumstances, for the Board to conclude that the Veteran has PTSD related to his military service would be speculation, and the law provides that service connection may not be granted on a resort to speculation or remote possibility. 38 C.F.R. § 3.102; Obert v. Brown, 5 Vet. App. 30, 33 (1993). Simply put, in the absence of a present disability that is related to service, a grant of service connection is clearly not supportable. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board has carefully considered the Veteran's assertions that he has PTSD that is related to his active service. However, as a layperson, he is not competent to give a medical opinion on diagnosis, causation, or aggravation of a medical condition. See Bostain v. West, 11 Vet. App. 124 (1998); Routen v. West, 142 F.3d. 1434 (Fed. Cir. 1998); Espiritu v. Derwinski, 2 Vet. App. 492 (1992). The Board acknowledges that the Veteran is competent to give evidence about the symptoms that he has experienced. Layno v. Brown, 6 Vet. App. 465 (1994). Competency must be distinguished, however, from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67 (1997). There can be no doubt from review of the record that the Veteran rendered honorable and faithful service for which the Board is grateful, and the Veteran is sincere in his belief that he has PTSD that is related to his military service. While the Board has carefully reviewed the record in depth, it has been unable to identify a basis upon which service connection may be granted. The Board has also carefully considered the benefit of the doubt rule, but as the preponderance of the evidence is against the claim, the evidence is not in equipoise, and there is no basis to apply it. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for PTSD is denied. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The Veteran was afforded a VA examination in April 2013 to determine the etiology of his acquired psychiatric disability. The VA examiner diagnosed the Veteran with Schizophrenia. He concluded that the data did not support PTSD or any other link to military service. However, his Schizophrenia diagnosed after the military was totally disabling. The examiner noted that the Veteran's in-service head trauma could have provided vague accelerant to his Schizophrenia which likely as not predated 1979, but without a clear link to the military. However, the VA examiner did not provide a medical opinion addressing the specific legal criteria of "clear and unmistakable evidence," which is necessary to satisfy the applicable legal standards when addressing whether a disability pre-existed military service. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (stating that once VA undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). Therefore, this VA opinion is inadequate for rating purposes. An addendum opinion was obtained in July 2013. The VA examiner noted 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. According to the Initial PTSD C&P Examination (dated April 30, 2013) it was noted, "Data does not support PTSD or any other link to military service. However, his Schizophrenia diagnosed after the military is Totally Disabling." Also, in that exam, the Veteran's mental disorder was not the result of military experiences. Veteran's C-File did not document evidence indicative of occurrence of mental diagnosis due to Veteran's military service (as noted in the April 30, 2013 exam), nor do records from the Veteran STRs of psychiatric evaluation (dated May 5, 1971) suggest that mental disorder is due to military service. However, the examiner failed to state a clear rationale for the etiology opinion given in reference to the Veteran's acquired psychiatric disorders. It appears the examiner basically restated the previous inadequate April 2013 VA examiner's opinion. The Board notes that a medical opinion that contains only data and conclusions without any supporting analysis is accorded no weight. A review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Additionally, it is unclear if the examiner considered the Veteran's extensive psychiatric medical history dating back to his time in-service when rendering an opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (stating that when the Secretary undertakes to provide a medical examination or obtain a medical opinion, he must ensure that the examiner providing the report or opinion is fully cognizant of the claimant's past medical history). Without further clarification, the Board is without medical expertise to determine whether the onset and/or etiology of the Veteran's acquired psychiatric disability is related to his active military service, to include an in-service head injury. Godfrey v. Brown, 7 Vet. App. 398 (1995); Traut v. Brown, 6 Vet. App. 495 (1994); Colvin v. Derwinski, 1 Vet. App. 171 (1991). Therefore, VA medical opinion should be obtained. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the case is REMANDED for the following action: 1) Ensure that all VA treatment records are up to date. 2) The RO should obtain a VA medical opinion from someone who has not previously examined the Veteran, to determine the nature and etiology of his acquired psychiatric disorder, other than PTSD. The VA examiner should thoroughly review the Veteran's claims file and a complete copy of this Remand and note this has been accomplished in the VA examination report. The VA physician should note all of the Veteran's acquired psychiatric disorder(s), other than PTSD. Did the Veteran's acquired psychiatric disorder(s) clearly and unmistakably (obvious or manifest) pre-exist his entry into active duty? A. If there is clear and unmistakable evidence that the Veteran's acquired psychiatric disorder(s) pre-existed service, the examiner is asked to opine as to whether there is clear and unmistakable evidence that the pre-existing disorder(s) did not undergo an increase in the underlying pathology during service. If there was an increase in the severity of the Veteran's disorder(s), the examiner should offer an opinion as to whether such increase was clearly and unmistakably due to the natural progress of the disease. B. If there is no clear and unmistakable evidence that any current disorder pre-existed service, then the examiner is asked whether it is at least as likely as not that the Veteran's acquired psychiatric disorder(s) had its onset in service or is related to any in-service disease, event, or injury, to include an in-service incident where the Veteran was hit over the head with a pipe, resulting in head trauma. Specifically, the VA examiner should review and discuss the Veteran's service treatment records (April 1971 head trauma and May 1971 Psychiatric Evaluation), VA treatment records (March 2003 Psychiatric Evaluation), the September 1979, August 2003, April 2013, and July 2013 VA examination and opinion reports, September 2011 hearing testimony, and any other relevant information. Furthermore, the examiner should also discuss the Veteran's lay statements regarding chronicity of symptomatology when discussing the offered opinion. The reviewer must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. 3) Thereafter, the AMC/RO must review the claims file to ensure that the foregoing requested development has been completed. In particular, review the requested medical opinion to ensure that it is responsive to and in compliance with the directives of this remand and if not, implement corrective procedures. See Stegall v. West, 11 Vet. App. 268 (1998). 4) Following the completion of the foregoing, the AMC should readjudicate the Veteran's claims. The AMC should then provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board for further appellate review, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs