Citation Nr: 1644988 Decision Date: 11/30/16 Archive Date: 12/09/16 DOCKET NO. 95-35 067 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to service connection for a neuropsychiatric disorder, to include organic brain syndrome with personality disorder and depressive syndrome. REPRESENTATION Veteran represented by: Kenneth L. Lavan, Attorney WITNESSES AT HEARINGS ON APPEAL The Veteran and R. S. ATTORNEY FOR THE BOARD L. Pelican, Associate Counsel INTRODUCTION The Veteran had active military service with the Army from April 1968 to May 1971. He had subsequence service with the Texas National Guard from November 1977 to May 1980 and from July 1982 to January 1984. The Veteran's National Guard service included periods of active duty for training (ACDUTRA) from June 3, 1978 to June 17, 1978, and from March 16, 1979 to April 25, 1979. For the sake of clarity the Board will recount this case's lengthy procedural history. This matter comes to the Board of Veterans Appeals (the Board) from a May 1994 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which denied service connection for organic brain syndrome. During the course of the appeal, the Veteran's disability has been recharacterized as a neuropsychiatric disorder, to include organic brain syndrome with personality disorder and depressive syndrome. The Board denied the Veteran's service connection claim in a February 2000 rating decision. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (the Court), which, upon an April 2001 joint motion by the Veteran-Appellant and the Secretary of Veterans Affairs, vacated the Board's decision, and remanded the case to the Board for further proceedings, to include compliance with the Veterans Claims Assistance Act of 2000. Following a remand by the Board for compliance with the April 2001 order, the Board issued a decision denying the Veteran's claim in March 2002. The Veteran appealed that decision to the Court. Upon an October 2004 joint motion by the Veteran-Appellant and the Secretary of Veterans Affairs, the Court vacated the March 2002 decision and remanded the case for further proceedings. The Board subsequently remanded the Veteran's case in April 2005, March 2007, and November 2007 for additional development and to ensure compliance with the prior remand directives. Upon completion of the requested development, the Board denied the Veteran's claim in a May 2009 decision. In a statement received by the Board in June 2009, the Veteran wrote that he had evidence he felt should not be overlooked by adjudicators, and requested that his claims file be returned to the RO in Waco, Texas. In a November 2009 statement, the Veteran requested reconsideration of the May 2009 Board decision, and submitted private medical records from Dr. J. B. Meanwhile, the Waco RO treated the Veteran's November 2009 statement and submission of additional medical records as a petition to reopen the previously denied service connection claim, characterizing the Veteran's claim as one for service connection for traumatic brain injury (TBI). In a June 2010 rating decision, the RO denied the Veteran's petition to reopen. The Veteran filed a timely appeal of the June 2010 rating decision, and in a July 2014 decision, the Board issued a decision denying the petition to reopen. The Veteran filed a timely appeal. In January 2015, the Board considered the Veteran's November 2009 motion for reconsideration of the May 2009 Board decision, and denied it. In April 2015, the Veteran appealed the Board's May 2009 decision. In a September 2015 Order, the Court determined that the Veteran's April 3, 2015 Notice of Appeal of the Board's May 2009 decision was timely. This was because the operative effect of the Board's denial of the Veteran's November 2009 motion for reconsideration was to toll the finality of the May 2009 Board decision. This tolling rendered the June 2010 rating decision and subsequent July 2014 Board decision null. In a December 2015 order, the Court upon a joint motion vacated the Board's May 2009 decision and remanded the case to the Board for further proceedings, to include consideration of the Veteran's direct service connection theory of entitlement, and to more fully address the adequacy of various VA examination reports. In a separate December 2015 order, the Court dismissed the Veteran's appeal of the Board's July 2014 decision. The Veteran testified at local RO hearings in January 1995, April 1996, and November 2006, and at Board hearings in May 1997 and September 2012. Transcripts of those proceedings have been associated with the claims file. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND In advancing the terms of the December 2015 JMR, the Court found that 1) the Board's May 2009 decision did not provide an adequate discussion of the Veteran's direct-service-connection theory or acknowledge his second in-service head injury, and 2) that the decision erred in determining that the VA medical examination reports were adequate to support a denial of the claim. With respect to the first error, the parties observed that the Board focused on whether there was in-service aggravation of a pre-service head injury during the Veteran's National Guard service. However, the Board had previously recognized the Veteran's contention that his neuropsychiatric disorder was related to a head injury sustained during his active duty service in the Army from April 1968 to May 1971. See JMR, pg. 2; see also, April 1996 RO Hearing Transcript, pp. 1; June 2011 VA Form 9. As to the second error, the parties found that the Board inadequately explained whether the January 14, 1999, March 7, 2006, and April 7, 2006 VA examination reports were sufficient to deny the Veteran's claim on a direct basis. They also found that the Board did not adequately explain whether the medical evidence was sufficient to find that the presumption of soundness had been rebutted by clear and unmistakable evidence of non-aggravation. The parties reasoned that not all of the examiners commented on the issue of aggravation or applied a standard that equated to "clear and unmistakable evidence," citing the January 14, 1999, March 7, 2006, and July 2007 VA examination reports in support of this finding. In light of the parties' determinations, the Board finds that remand for a new VA medical opinion is appropriate. However, before the Board can do so, additional development is required. Preliminarily, the Veteran advances two theories of entitlement to service connection for a neuropsychiatric disorder. He asserts that his National Guard service aggravated the residuals of his May 1976 head injury. See, e.g., March 1994 claim, November 1994 VA Form 9, and January 1995 RO Hearing Transcript, pp. 7-8. Alternatively, the Veteran and his representative assert that the Veteran's condition began during active duty service, as a result of his day-to-day military stress and "unfortunate incidents" that befell the Veteran, including an in-service personal assault. See April 1996 RO Hearing Transcript, pg. 1; May 1997 Board Hearing Transcript, pg. 11; and January 2015 Motion for Reconsideration. The Veteran also reported that he had mental health, memory, and anger problems prior to his May 1976 car accident. See September 2012 Board Hearing Transcript, pg. 6. As noted above, the Veteran's representative asserted that the Veteran's claim encompassed a claim for service connection for a mental disorder due to a personal assault. See January 2015 Motion for Reconsideration, pg. 2, and April 1996 DRO Hearing Transcript, pg. 5. To date, the Veteran has not been provided the appropriate VA Form 21-0781(a), Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD) Secondary to Personal Assault. Accordingly, on remand the Veteran should be provided with the required notice. Review of the Veteran's testimony suggests that the service treatment records from his period of active service may be incomplete. During the April 1996 RO hearing, the Veteran reported seeing a psychiatrist who told the Veteran that "he just did not like the Army." He also reported that he was later sent to a psychiatrist while stationed at Fort Gordon, Georgia. See April 1996 Hearing Transcript, pp. 4, 5. The Veteran later testified that he had one visit with a psychiatrist during service in April or May 1968. Id. at 10. Additionally, the Veteran testified that he saw a psychiatrist for the October 1969 incident that occurred while he was stationed in Germany. See May 1997 Hearing Transcript, pp. 6-9. The Veteran's service treatment records contain a note dated in September 1970 from Dispensary #6 at Fort Gordon. The note indicates the Veteran reported having a nerve problem that caused him to feel chills, and that his symptoms began a week ago. The Veteran also reported feeling very tense and nervous while in school. He was prescribed Librium, 10 milligrams (mg). There are no other in-service psychiatric records in the claims file. The M21-1 states that clinical records and mental health records are stored separately from service treatment records. M21-1, III.iii.2.A.1.e. Given the inconsistencies between the dates of the Veteran's reported psychiatric treatment and the lack of psychiatric treatment records contained in the Veteran's service treatment records at present, remand is appropriate to obtain any inpatient clinical records and mental health records from the Veteran's military service. If the Veteran's personnel records would be helpful in identifying which medical facilities the Veteran received treatment during service, they should be obtained and associated with the record. Similarly, contact the Veteran and request his assistance if necessary. Additionally, during his November 2006 RO hearing, the Veteran reported seeing a psychiatrist, Dr. W., after he stopped seeing Dr. S. G. L. See November 2006 Hearing Transcript, pg. 2. It does not appear that records from Dr. W. have been requested or otherwise obtained. On remand, the RO should request the Veteran to identify and authorize the release of any private medical records not already associated with the claims file, to include those from Dr. W., and attempt to obtain those records. Thereafter the Veteran's claims file should be reviewed by an appropriate clinician to identify any neuropsychiatric disorder diagnosed from March 1994 to present and to opine whether any such disorder is related to service. If the clinician determines that a TBI examination would be helpful in assessing the nature of the Veteran's diagnosed conditions, one should be provided. To assist the clinician in rendering the requested opinions, the Board will provide a brief summary of pertinent laws and medical evidence. This summary should not be construed as a substitute for careful review of the entire claims file. Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110 (West 2014). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b) (2015). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2015). A Veteran is presumed to have been sound upon entry into the military, except as to conditions noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111 (West 2014). "Clear and unmistakable evidence" means that which cannot be misunderstood or misinterpreted; it is that which is undebatable. Vanerson v. West, 12 Vet. App. 254 (1999). A preexisting injury or disease will be considered to have been aggravated by active military service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. Where a preservice disability underwent an increase in severity in service, there is a presumption of aggravation; clear and unmistakable evidence is required to rebut the presumption of aggravation. 38 U.S.C.A. § 1153 (West 2014); 38 C.F.R. § 3.306 (2015). The Court has held that temporary or intermittent flare-ups of a preexisting condition during service are not sufficient to be considered "aggravation in service" unless the underlying condition, as opposed to its symptoms, has worsened. See Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The Veteran had active duty service with the Army from April 1968 to May 1971. He had subsequence service with the Texas National Guard from November 1977 to May 1980 and from July 1982 to January 1984. The Veteran's National Guard service included periods of active duty for training (ACDUTRA) from June 3, 1978 to June 17, 1978, and from March 16, 1979 to April 25, 1979. The Board notes that the record contains no entrance examinations for the Veteran's two periods of ACDUTRA in 1978 and 1979. The Veteran's April 1968 entrance examination noted normal head, neurologic, and psychiatric systems; a scar over his right eye was observed. On his contemporaneous report of medical history, the Veteran endorsed previously having mumps but denied currently having or ever experiencing all other listed conditions; he also reported he was in good health. A July 8, 1968 service treatment record from Fort Huachuca, Arizona indicates the Veteran reported experiencing headaches after bumping his head. His pupils were equal, round, regular, and reacted to light and accommodation. He was assessed with headaches and treated with aspirin. On August 23, 1968, the Veteran was treated after he fell down stairs and was knocked unconscious the previous night. He reported feeling weak and dizzy. His vision was noted as "okay," and he did not exhibit nausea or vomiting. He reported pain all over his head and left jaw, and stated his neck was stiff. His pupils were equal, round, regular, and reacted to light and accommodation, and exhibited full range of motion. The clinician noted that the Veteran's tympanic membranes were "5" as was his "neural." The clinician noted facial swelling over the left jaw and head, and that the Veteran's neck hurt a little to turn. The Veteran was alert and oriented. The clinician determined that the Veteran had no fracture of his skull, jaw, or cervical spine, and recommended the Veteran return to duty. An October 5, 1969 note indicated that the Veteran had been drinking and was found undressed in a building near the airstrip. The Veteran reported being hit over his head, but examination revealed no deformities or bruises of his face and neck. The Veteran was noted to be oriented, aware, and cooperative. No pathology was detected. The clinician assessed the Veteran with simple drunkenness. A September 9, 1970 note indicates the Veteran reported having a nerve problem that caused him to feel chills, and that his symptoms began a week prior. The Veteran also reported feeling very tense and nervous while in school. He was prescribed Librium, 10 mg. The March 1971 separation examination showed normal head, neurologic, and psychiatric systems; however, the Veteran reported frequent or terrifying nightmares, depression or excessive worry, loss of memory or amnesia, and nervous trouble. The Veteran denied experiencing frequent or severe headaches. An October 27, 1976 discharge summary from Brackenridge Hospital noted that the Veteran was admitted to the hospital on May 15, 1976 with massive injuries following a car accident. It noted the Veteran had severe head injuries, including a hematoma in the left temporal lobe region with a left to right midline shift. The summary indicated the Veteran was treated by Dr. E. B. for his injuries, and was also seen by Dr. T. S., a psychiatrist, for a psychiatric evaluation. The summary concluded noting that the Veteran made a remarkable recovery mentally, appeared to be alert, had a good memory for recent events, but still had a clouded memory for the events surrounding the accident and his early postoperative phase in intensive care. The Veteran's November 1977 enlistment examination revealed normal head, neurologic, and psychiatric systems. The November 1977 report of medical history noted broken bones; the Veteran denied all other symptoms, including headaches, dizziness or fainting spells, head injury, trouble sleeping, depression or excessive worry, loss of memory, nervous trouble of any sort, and periods of unconsciousness. He reported his health was "good." A notation from the physician indicated that in May 1976 the Veteran was involved in a car accident and was treated by Dr. J. B., and sustained a right femur fracture and a tracheostomy to facilitate adequate breathing. The note also indicated Dr. J. B. indicated the Veteran's duty should be clerical and not in the field for present. The Veteran's July 1982 enlistment examination showed normal head, neurologic, and psychiatric systems. His report of medical history noted broken bones but denied all other symptoms, including headaches, dizziness or fainting spells, head injury, trouble sleeping, depression or excessive worry, loss of memory, nervous trouble of any sort, and periods of unconsciousness. He reported he was in good health. According to a February 1988 psychological evaluation, the Veteran requested vocational rehabilitation to help him get a job. He reported that during a car accident 12 years ago he had sustained head injuries and a broken leg. He also reported receiving psychiatric care and being prescribed Desyrel. The clinician did not render an Axis I diagnosis, but noted an Axis II diagnosis of borderline personality disorder, explaining that the Veteran had schizophrenic characteristics and characteristics of some other personality disorders. A September 1991 Total and Permanent Disability note from Dr. J. C. indicated the Veteran had a diagnosis of organic brain injury and severe depression. He noted that the Veteran's present illness or injury began on May 16, 1976. According to a February 1992 examination performed in conjunction with the Veteran's claim for housebound status, the Veteran reported some confusion from organic brain syndrome resulting from an old head injury. The clinician noted the Veteran had some slight dizziness and loss of memory secondary to a closed head injury and organic brain syndrome. The clinician diagnosed the Veteran with chronic organic brain syndrome. A VA psychiatric consultation performed as part of the claim noted diagnoses of organic brain syndrome by history and personality disorder, not otherwise specified with antisocial and borderline traits. A March 1992 computed axial tomography (CAT) scan revealed a small area of encephalomalacia in the left frontal region consistent with residuals of old trauma. A July 1994 letter from the Veteran's treating psychiatrist, Dr. S. G. L, noted that based on a close review of the Veteran's history, there was a high probability that parental abuse and neglect caused a considerable portion of the Veteran's current mental health problems, and therefore these problems began prior to military service. A December 1994 letter from Dr. S. G. L. reported that the Veteran's May 1976 car accident formed a "significant clinical background" upon which the Veteran's depressive syndrome existed, and that injuries sustained in that accident included brain injuries limiting his memory and general cognitive ability as well as predisposing him to depressive illness. Dr. S. G. L. further observed that the Veteran's National Guard service beginning in 1977 appeared to have exacerbated his depressive symptoms and worsened the course of his illness. A January 7, 1999 VA mental disorders examination noted diagnoses of dementia due to head trauma (mild to moderate) and personality disorder, not otherwise specified with prominent antisocial features. The examiner noted that the Veteran had a longstanding character disorder which predated his entry into service, and that it was impossible to determine whether the Veteran's current cognitive / intellectual deficits reflected congenital as opposed to acquired deficits. The examiner opined that there was no evidence to support a claim that the Veteran's problems, either organic or psychiatric, were exacerbated by military service. The examiner observed that the Veteran's history and records suggested that he had a personality disorder prior to service entry, as indicated by problems in school and legal involvements prior to enlistment. Though the examiner noted that evidence of cognitive deficits prior to service entry was unclear, she opined that the history clearly supported the opinion that the current deficits reflect residuals of the car accident which did not occur during his period of military service. She found no evidence that the Veteran's National Guard duty following this accident in any way exacerbated cognitive deficits. She concluded that there was no evidence that any of the Veteran's current difficulties, organic or psychiatric, are related to a disease or injury sustained during active service or periods of active duty training. In a January 14, 1999 VA brain and spine examination report, the clinician observed that the Veteran's history of a head injury with brain hemorrhage in 1976 seemed to be an adequate explanation for his reported memory problems. Based on the examiner's review of the records, he could not conclude or even strongly suspect that anything happened to the Veteran while in the military service that contributed to his memory problems. The Veteran was afforded a VA mental disorders examination in March 2006. The examiner reviewed the January 7, 1999 VA examiner's opinion and completely agreed with it. The clinician stated that none of the current evidence suggested an Axis I psychiatric disorder and that a review of the claims file and past VA examination reports provided no information to support the Veteran's contention that his alleged neuropsychiatric problems were related in any way to his military service. According to the April 2006 VA brain and spine examination report, the examiner found that there was no basis or evidence to conclude that the injury and sequelae of the car accident in 1976 had anything to do with events that happened in service. The Veteran was afforded a VA psychiatric examination in July 2007. The examiner stated that a diagnosis could not be provided, and that the evidence of record did not allow the examiner to make any connection between any in-service experience and any present neuropsychiatric condition. The Veteran submitted private records from Dr. J. B. dated in September 2009. Dr. J. B. reviewed the claims file, and observed that although the Veteran reported a significant head injury in his early days of military service, he did not see clear medical documentation supporting such an allegation. Dr. J. B. stated that the Veteran's significant cognitive impairments may be attributable to the clearly documented car accident in 1976, and that the available records did not allow him to comment definitively on any significant alleged head injury in 1968. The Veteran was afforded a VA TBI examination in May 2011. The examiner stated that the Veteran's claimed memory loss and confusion were not caused by or a result of any service-related injury, noting that the Veteran had no memory loss or confusion, or any other residuals related to the in-service injuries. The examiner stated that the neuropsychology test report showed findings consistent with the car accident in 1976. The examiner opined that the Veteran's history of head injury with a brain hemorrhage in 1976 would seem to be an adequate explanation for his reported memory problems, and was certainly consistent with the memory loss and confusion problems. In August 2016, the Veteran's representative submitted a private medical report from Dr. P. H. Dr. P. H. provided two opinions, the first addressing whether the Veteran's claimed neuropsychiatric disorder and organic brain syndrome was directly related to his period of active duty service from April 1968 to May 1971, and the second addressing whether the Veteran's condition was aggravated during his National Guard service from November 1977 to May 1980 and from July 1982 to August 1984. With respect to the direct opinion, the clinician explained that TBIs can be caused by even a slight bump of the head and that the symptomatology can manifest immediately or be delayed by days, weeks, or even years. He also noted patients that sustain a single major TBI, or multiple compounded minor TBIs, begin the pathophysiological processes of tissue degradation and weakening thereby becoming more susceptible to brain injuries. Returning to the evidence of record, the Dr. P. H. stated that the Veteran's 1968 and 1969 head injuries were consistent with the initial onset of slow mild encephalomalacia, which was diagnosed on the March 1992 VA radiographic report. The clinician then summarized the pertinent medical evidence of record and concluded that it was at least as likely as not that the initial onset of the Veteran's pathophysiological processes responsible for his organic brain syndrome was his in-service head injuries in 1968 and 1969. As for the aggravation opinion, Dr. P. H. noted the Veteran's inability to pass classes in defense information during his National Guard service resulted in "despair, disgrace, sadness, and major disappointment," and was compounded by his chronic pain. He concluded that based on those experiences, the Veteran's "predisposed psychiatric disorders" were at least as likely as not aggravated during the Veteran's National Guard service. Given the aforementioned inconsistencies regarding the existence of a neuropsychiatric disorder during the pendency of the appeal, the VA examiner is asked to address the conflicting medical diagnoses and medical nexus opinions in rendering the opinions requested below. Under VA regulations, personality disorders are not diseases or injuries and therefore are not disabilities for which service connection can be granted. 38 C.F.R. § 3.303(c) (2015). However, service connection may be granted if an acquired psychiatric disorder was incurred or aggravated in service and superimposed upon the preexisting personality disorder. 38 C.F.R. §§ 4.9; 4.127 (2015); Carpenter v. Brown, 8 Vet. App, 240 (1995). Additionally, for any condition that may have resolved during the pendency of the appeal period, an etiological opinion is still requested. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (noting that the requirement of current disability is satisfied when the disability is shown at any point during the pendency of the claim, even if the disability subsequently resolves). With respect to these opinions, the Board stresses that the presumption of soundness under 38 U.S.C.A. § 1111 (West 2014) does not apply when a claimant or Veteran, has not been examined contemporaneous to entering a period of ACDUTRA. Smith v. Shinseki, 24 Vet. App. 40, 45 (2010). Moreover, the presumption pertaining to chronic diseases under 38 U.S.C.A. § 1112 (West 2014) and the presumption of aggravation under 38 U.S.C.A. § 1153 (West 2014) do not apply to ACDUTRA service. Id.; see also Acciola v. Peake, 22 Vet. App. 320 (2008); Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998); Paulson v. Brown, 7 Vet. App. 466, 470 (1995). With respect to a claim of aggravation of a preexisting condition during ACDUTRA, the claimant must prove both that a worsening of the condition occurred during the period of ACDUTRA and that the worsening was caused by the period of ACDUTRA. Smith, 24 Vet. App. at 48. Accordingly, the case is REMANDED for the following actions: 1. Send the Veteran a notice letter in connection with his claim for a neuropsychiatric disorder, to include a disorder based, in part, on an alleged in-service personal assault. The letter must (1) inform him of the information and evidence that is necessary to substantiate the a service connection claim based on personal assault; (2) inform him about the information and evidence that VA will seek to provide; and (3) inform him about the information and evidence that he is expected to provide. Under 38 C.F.R. § 3.304(f)(5) the RO should advise the Veteran of potential secondary sources tending to substantiate his claim of personal assault. Examples of such evidence include, but are not limited to: Records from law enforcement authorities, mental health counseling centers, hospitals, or physicians; and 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. The Veteran should be asked to submit evidence from any secondary sources, and if he requests assistance in obtaining same, all assistance due him should then be provided by the RO. 2. Take all appropriate steps to verify the Veteran's claimed stressor, to include those pertaining to his reports of personal assault in accordance with 38 C.F.R.§ 3.304 (f)(5). The RO should also forward a copy of the Veteran's military personnel records, together with the stressor information, to the Joint Services Records Research Center (JSRRC). Ask the JSRRC to provide any additional information available regarding the Veteran's stressor. The Veteran should also be invited to submit any supporting evidence, including lay evidence from fellow service members who witnessed the Veteran's stated stressors. All actions to verify the alleged stressors should be fully documented in the claims file. If the information provided by the Veteran lacks sufficient specificity to be verified, the AOJ should make a formal finding to that effect. 3. Ask the Veteran to provide the names and addresses of all medical care providers who have treated him for his claimed neuropsychiatric disorder, including Dr. W. After securing the necessary releases, request any relevant records identified that are not duplicates of those already contained in the claims file. If any requested records cannot be obtained, the Veteran should be notified of such. 4. Request in-service psychiatric treatment records through official sources. If additional information is needed from the Veteran to request such records, the Veteran should be asked to provide it. All efforts to obtain such records should be documented in the claims file. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile. This determination should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records. 5. After the above development has been completed to the extent possible and any records received have been associated with the claims file, forward the Veteran's claims file to an appropriate clinician or clinicians for a medical opinion on the nature and etiology of the Veteran's claimed neuropsychiatric disorders. The clinician is requested again to review the claims folder, to include this remand. Unless the examiner finds that a new examination is required, the Veteran need not be examined again. Following review of the claims file, the examiner should provide an opinion on the following: a. Identify any neuropsychiatric disorder present at any time since March 1994, even if such disorder resolved during the pendency of the appeal. b. Whether it is clear and unmistakable (obvious, manifest, and undebatable) that any neuropsychiatric disorder preexisted active service. c. If so, is it clear and unmistakable (obvious, manifest, and undebatable) that any preexisting neuropsychiatric disorder WAS NOT aggravated (i.e., permanently worsened) during the Veteran's active service or is it clear and unmistakable (obvious, manifest, and undebatable) that any increase was due to the natural progress. d. If it is not clear and unmistakable that any diagnosed neuropsychiatric disorder preexisted service and was not aggravated by service, whether it is at least as likely as not (a probability of 50 percent or greater) that any currently diagnosed disorder is related to the Veteran's active duty service, to include the documented head injuries on July 8, 1968, August 23, 1968, October 5, 1969, individually or collectively; the Veteran's September 9, 1970 nerve problem; or the Veteran's reported in-service personal assault, if verified. e. If the Veteran is diagnosed with a personality disorder, is it at least as likely as not (a probability of 50 percent or greater) that there is additional disability due to aggravation of the personality disorder by a superimposed disease or injury sustained in service, to include the documented head injuries on July 8, 1968, August 23, 1968, October 5, 1969, individually or collectively; the Veteran's September 9, 1970 nerve problem; or the Veteran's reported in-service personal assault, if verified. f. Did the Veteran have a neuropsychiatric disorder(s) at entrance into National Guard service in November 1977. g. If the Veteran had a neuropsychiatric disorder that preexisted one or both entrances into National Guard service, is it at least as likely as not (a probability of 50 percent or greater) that the underlying condition, as opposed to its symptoms, was worsened during periods of ACDUTRA service from June 3, 1978 to June 17, 1978 and from March 16, 1979 to April 25, 1979. The examiner is reminded that "clear and unmistakable evidence" means that which cannot be misunderstood or misinterpreted; it is that which is undebatable. The phrase "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. Any opinions offered should be accompanied by the underlying reasons for the conclusions. If the examiner is unable to offer any of the requested opinions, it is essential that the he or she offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2011). 6. Review the examination report for compliance with the Board's directives. If necessary, any corrective action should be undertaken prior to recertification to the Board. 7. After receipt of the above, undertake any additional development necessary in light of the evidence received. Then readjudicate the Veteran's claim. If a complete grant of the benefit requested is not awarded, issue a Supplemental Statement of the Case (SSOC) to the Veteran and his representative, and provide them an opportunity to respond before returning the case to the Board. 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). 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 2014). _________________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), 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) (2015).