Citation Nr: 1812977 Decision Date: 03/01/18 Archive Date: 03/13/18 DOCKET NO. 17-11 177 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUES 1. Entitlement to service connection for Parkinson's disease, to include as due to exposure to contaminated water at Camp Lejeune, North Carolina. 2. Entitlement to service connection for essential tremors, to include as due to exposure to contaminated water at Camp Lejeune, North Carolina. 3. Entitlement to service connection for a low back disorder. 4. Entitlement to service connection for an acquired psychiatric disorder claimed as depression, to include as secondary to Parkinson's disease. REPRESENTATION Veteran represented by: Pennsylvania Department of Military Affairs ATTORNEY FOR THE BOARD Patricia Kingery, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from October 1980 to March 1981. The Veteran also had various periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) through April 1986. This appeal comes before the Board of Veterans' Appeals (Board) from a February 2015 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky, which, in pertinent part, denied service connection for chronic back pain, essential tremors, and depression. A claim for service connection for tremors based on exposure to contaminated drinking water at Camp Lejeune, North Carolina was received in August 2011. A claim for service connection for chronic back pain and depression was received in November 2013. A motion to advance this appeal on the Board's docket has been raised by the Board's Acting Vice Chairman based on interpretation of law of general application reflected in recent amendments to VA regulations. Effective March 14, 2017, 38 C.F.R. §§ 3.307 and 3.309 were amended to add eight diseases to the list of diseases associated with contaminants present in the water supply at U.S. Marine Corps Base Camp Lejeune, North Carolina, from August 1, 1953, to December 31, 1987. 82 Fed. Reg. 4173 (January 13, 2017). The undersigned is granting the motion and advancing the appeal on the docket based upon the interpretation of law of general application affecting claims for benefits related to exposure to contaminated water at Camp Lejeune. 38 C.F.R. § 20.900(c) (2017). The issue of service connection for an acquired psychiatric disorder is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran served at Camp Lejeune, North Carolina for over 30 days from January to March 1981. 2. The Veteran has currently diagnosed Parkinson's disease, a disease presumed to be associated with Camp Lejeune water contaminants under VA regulatory criteria. 3. The Veteran has currently diagnosed essential tremors and lumbar strain. 4. A neurologic or low back injury or disease was not sustained in service or during a period of ACDUTRA or INACDUTRA. 5. The essential tremors first manifested after service separation and are not causally or etiologically related to active service, to include in-service exposure to contaminants in the water supply at Camp Lejeune. 6. Service connection is precluded for disability due to alcohol or drug abuse. 7. The lumbar strain first manifested after service separation and is not causally or etiologically related to active service. CONCLUSIONS OF LAW 1. The criteria for service connection for Parkinson's disease have been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). 2. The criteria for service connection for essential tremors have not been met. 38 U.S.C. §§ 105(a), 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.1(m), 3.102, 3.159, 3.303 (2017). 3. The criteria for service connection for a low back disorder have not been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159 (2017). The Board is granting service connection for Parkinson's disease, constituting a full grant of the benefit sought on appeal. As there remains no aspect of the claim to be further substantiated, there is no further VCAA duty to notify or assist, or to explain compliance with VCAA duties to notify and assist with respect to this issue. With respect to the issues of service connection for essential tremors and a low back disorder, neither the Veteran nor the representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Service Connection Laws and Regulations Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Generally, service connection for a disability requires evidence of: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Effective March 14, 2017, 38 C.F.R. §§ 3.307 and 3.309 were amended to add eight diseases to the list of diseases associated with contaminants present in the water supply at U.S. Marine Corps Base Camp Lejeune, North Carolina, from August 1, 1953, to December 31, 1987. The amendments apply to claims received by VA on or after January 13, 2017, and claims pending before VA on that date. 82 Fed. Reg. 4173 (Jan. 13, 2017). In order to establish presumptive service connection for a disease associated with exposure to contaminated water at Camp Lejeune, a veteran, former reservist, or member of the National Guard must show the following: (1) that he or she served at U.S. Marine Corps Base Camp Lejeune, North Carolina for no less than 30 days (either consecutive or nonconsecutive) from August 1, 1953 to December 31, 1987; (2) that he or she currently suffers from a disease associated with exposure to contaminants in the water supply at Camp Lejeune enumerated under 38 C.F.R. § 3.309(f); and (3) that the current disease process manifested to a degree of 10 percent or more at any time after service. 38 C.F.R. §§ 3.307(a)(7), 3.309(f). In this case, the Veteran has been diagnosed with essential tremors and a lumbar strain, neither of which is listed as a "chronic disease" under 38 C.F.R. § 3.309(a) (2017); therefore, the presumptive provisions based on "chronic" symptoms in service and "continuous" symptoms since service at 38 C.F.R. § 3.303(b) or manifesting within one year of service separation at 38 C.F.R. § 3.307 (2017) do not apply. Active military, naval, or air service includes any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in line of duty. 38 U.S.C. § 101(21), (22) (2012), (24); 38 C.F.R. § 3.6(a), (c) (2017); Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). ACDUTRA is defined as full-time duty in the Armed Forces performed by Reserves for training purposes, and includes full-time duty performed by members of the National Guard of any State. 38 U.S.C. § 101(22); 38 C.F.R. § 3.6(c)(1). Service connection for INACDUTRA is permitted only for injuries, not diseases, incurred or aggravated in line of duty. See Brooks v. Brown, 5 Vet. App. 484, 485 (1993). VA's General Counsel has interpreted that it was the intention of Congress when it defined active service in 38 U.S.C. § 101(24) to exclude inactive duty training during which a member was disabled or died due to nontraumatic incurrence or aggravation of a disease process. VAOPGCPREC 86-90. Service Connection for Parkinson's Disease The Veteran contends that Parkinson's disease was caused by exposure to contaminated drinking water at Camp Lejeune. The Veteran has confirmed service at Camp Lejeune from January to March 1981. See service personnel records. Next, the evidence reflects currently diagnosed Parkinson's disease, which is included on the list of diseases associated with exposure to contaminants in the water supply at Camp Lejeune under 38 C.F.R. § 3.309(f). See October 2017 Parkinson's disease disability benefits questionnaire. Further, ratings for Parkinson's disease, known in VA regulations as "paralysis agitans," are assigned pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8004 (2017). Under this Diagnostic Code, a minimum 30 percent rating is warranted when there are "ascertainable residuals" of the disability. The evidence of record reflects multiple manifestations associated with the Parkinson's disease including stooped posture, balance impairment, and speech changes among others, see October 2017 Parkinson's disease disability benefits questionnaire; therefore, Parkinson's disease has manifested to a degree of at least 10 percent (i.e., 30 percent) since service separation. 38 C.F.R. § 4.124a, Diagnostic Code 8004. Based on the above, presumptive service connection for Parkinson's disease, as a disease associated with exposure to contaminants in the water supply at Camp Lejeune under the regulatory provisions at 38 C.F.R. § 3.309(f), is warranted. The grant of presumptive service connection renders moot all other theories of service connection. Service Connection for Essential Tremors The Veteran essentially contends that the claimed essential tremors are related to active service, specifically exposure to contaminated drinking water at Camp Lejeune, North Carolina. In August 2011, the Veteran claimed service connection for tremors in both hands based on exposure to contaminated drinking water at Camp Lejeune. See also November 2013 and September 2016 written statement. Alternatively, the Veteran contends the essential tremors onset during active service. See June 2015 notice of disagreement (contending that service treatment records specifically list the presence of constant tremors). In an October 2017 written statement, the Veteran contended that the service treatment records make specific mention of constant tremors prior to discharge. First, the evidence of record demonstrates that the Veteran has current diagnosed essential tremors. See July 2009 private neurobehavioral assessment report, November 2011 private treatment record. In a May 2016 letter, Dr. T.W.L. noted diagnoses of both essential tremor and Parkinson's disease (for which service connection has been established herein). Next, the Veteran and representative have contended that the Veteran was diagnosed with tremors during active service. See e.g., June 2015 notice of disagreement. The Board finds that the weight of the evidence demonstrates that the Veteran did not experience an injury or disease, to include tremors, related to the neurologic system during active service or during a period of ACDUTRA or INACDUTRA. The notation of constant tremors referenced by the Veteran was not during a period of active service, but rather was noted on a March 1984 annual physical examination report related to Reserve service. Service treatment records from the period of active service (October 1980 to March 1981) do not reflect any injury, complaint, diagnosis, or treatment for tremors or neurologic disorder or otherwise reflect a reported history or findings of tremors. On a March 1981 service separation physical examination report, the neurologic system was noted as clinically normal. The Veteran did not endorse any neurologic symptoms or tremors on an associated report of medical history. The in-service history of symptoms is more contemporaneous to service, so is of more probative value, than the more recent assertions made many years after service separation and for compensation purposes. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (upholding a Board decision assigning more probative value to a contemporaneous medical record report of cause of a fall than subsequent lay statements asserting different etiology); Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (upholding Board decision giving higher probative value to a contemporaneous letter the veteran wrote during treatment than to subsequent assertion years later). During the time period in which the Veteran served on periods of ACDUTRA and INACDUTRA (March 1981 to April 1986), review of the evidence of record does not reflect any neurologic disease or injury during any such period. A March 1982 annual physical examination report (associated with Reserve service) notes that the neurologic system was clinically normal. No history of tremor is noted on the associated report of medical history. In a March 1984 report of medical history (associated with Reserve service), the reviewing physician noted that the Veteran had a constant tremor, but does not indicate that said tremor was incurred in or aggravated during a period of ACDUTRA, that the Veteran sustained a neurologic injury or disease during a period of ACDUTRA, or that the Veteran sustained a neurologic injury during a period of INACDUTRA. Despite the Veteran's contention that this notation was made during a period of active service, such contention is directly contradicted by the contemporaneous service records. The Board finds that the evidence of record reflects no neurologic injury or disease during service and/or during a relevant period of ACDUTRA or INACDUTRA. Service treatment records, and treatment records from the relevant periods of ACDUTRA and INACDUTRA, convey no such injury or disease. The Veteran has also not noted any such injury or disease, other than recent statements in which it was advanced that tremors onset during service. For the reasons discussed above, the Board does not find this assertion supported by the evidence. Turning to the contention that the essential tremors were caused by in-service exposure to contaminated water while the Veteran was stationed at Camp Lejeune, essential tremors are not included on the list of diseases associated with exposure to contaminants in the water supply at Camp Lejeune under 38 C.F.R. § 3.309(f). Based on the law, the Veteran cannot benefit from this presumption, regardless of whether he was exposed to contaminants in the water supply at Camp Lejeune during service. Notwithstanding the foregoing, service connection for claimed residuals of exposure to contaminated water at Camp Lejeune during service may also be established by showing that a disorder is, in fact, causally linked to such exposure. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). After a review of all the evidence, the Board finds that the weight of the evidence is against a finding that the essential tremors are causally related to exposure to contaminants in the water supply at Camp Lejeune during service. Generally lay evidence is competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). Lay evidence can be competent and sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau, 492 F.3d at 1376-77. Additionally, a lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. Id. A veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); Jandreau at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"); see 38 C.F.R. § 3.159(a)(2). While the Veteran is competent to relate tremor symptoms, under the facts of this case that includes medical opinions (discussed below), the Board finds that the Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of the medically complex essential tremors. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011) (recognizing ACL injury is a medically complex disorder that requires a medical opinion to diagnose and to relate to service or differentiate from in-service symptoms and diagnosis); see Jandreau at 1977, n. 4. The etiology of the current essential tremors is a complex medical etiological question involving internal and unseen system processes, some of which are unobservable by the Veteran. The Board does not find the Veteran competent to provide an etiological nexus between the in-service exposure to contaminated water at Camp Lejeune and the essential tremors, especially in this case where the disability, as discussed below, has specifically been attributed to non-service connected causes. In an October 2013 central nervous system and neuromuscular disease disability benefits questionnaire (submitted by the Veteran), Dr. G.C. noted a long history of progressively worsening essential tremor that began at age 25. Dr. G.C. opined that the essential tremor is as likely as not causally related to exposure to contaminants in the water supply at Camp Lejeune. Dr. G.C. did not provide a rationale for the opinion. A medical opinion that is unsupported and unexplained is purely speculative and does not provide the degree of certainty required for medical nexus evidence. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Further, the Board finds the October 2013 medical opinion report outweighed by the other evidence of record, specifically the January 2015 VA medical opinion report and a July 2009 private neurobehavioral assessment. A July 2009 private neurobehavioral assessment report notes that the Veteran reported developing a tremor in his early 20s or late teens that he attributed to alcohol. The Veteran reported that alcohol intoxication helped reduce tremor symptoms. The Veteran reported an extensive history of alcohol use beginning at 12 years of age and continuing until 1988. The Veteran was noted to have begun using intranasal methamphetamine at age 18 as well as cocaine and valium. The July 2009 private neurobehavioral assessment noted that the essential tremor had worsened over the previous two years without a particular trigger with the exception of head trauma. In a January 2015 VA medical opinion report, the VA examiner opined that the essential tremor is less likely as not caused by or the result of the Veteran's exposure to contaminated water at Camp Lejeune. The VA examiner opined that essential tremor is not associated with solvent exposure. The January 2015 VA examiner noted that essential tremor is the most common of the movement disorders affecting an estimated five million people in the U.S. with a genetic link present in about 50 percent of cases, including in the case of this Veteran because his mother also had a severe essential tremor. The VA examiner noted the Veteran's history of alcohol and drug use (detailed in the July 2009 private neurobehavioral assessment report) and opined that both alcohol and drug use are associated with tremor. The VA examiner further noted that the Veteran has a Chiari I malformation with neurological symptomatology, had nuchal cord at birth, and has a history of head trauma - all of which can be associated with neurological symptomatology. The reasonable inference of this opinion is that the essential tremor is more likely related to these risk factors. The Board finds the January 2015 VA medical opinion report to be highly probative evidence that the essential tremors are not related to the in-service exposure to contaminated water at Camp Lejeune. The VA examiner reviewed the claims file, had the requisite medical expertise to render a medical opinion, had sufficient and accurate facts, factual assumptions, and data on which to base conclusions, and stated the bases supporting the opinion. The Board further finds that the weight of evidence of record shows that the currently diagnosed essential tremors have been partially attributed to alcohol use disorder. Direct service connection for disability resulting from a claimant's own drug or alcohol abuse is precluded for all VA benefit claims filed after October 31, 1990 (including in this case with the service connection claim received in August 2011). See VAOPGCPREC 7-99; VAOPGCPREC 2-98. Compensation cannot be awarded pursuant to 38 U.S.C. § 1131 and 38 U.S.C. § 105(a) either for primary alcohol abuse disabilities or for secondary disabilities that result from primary alcohol abuse. Allen v. Principi, 237 F.3d 1368, 1376 (Fed. Cir. 2001). Primary alcohol abuse disability means an alcohol abuse disability arising from voluntary and willful drinking to excess. Id. VA regulations state that no compensation shall be paid if a disability is the result of alcohol abuse. 38 C.F.R. § 3.301. For the purpose of this regulation, alcohol abuse means the use of alcoholic beverages over time, or such excessive use at any one time, sufficient to cause disability to or death of the user; drug abuse means the use of illegal drugs (including prescription drugs that are illegally or illicitly obtained), the intentional use of prescription or non-prescription drugs for a purpose other than the medically intended use, or the use of substances other than alcohol to enjoy their intoxicating effects. 38 C.F.R. § 3.301(d). See also 38 U.S.C. § 105; 38 C.F.R. § 3.1(m). In the June 2015 notice of disagreement, the representative contended that, because the Veteran did not use drugs during service and consumption of alcohol alone would not constitute willful misconduct, service connection for essential tremors should be granted. In a September 2016 written statement, the representative contended that the Veteran did not abuse drugs during active service and should not have been denied service connection for essential tremors. The level of the Veteran's alcohol and/or drug use during service is not at issue here. Rather it is the fact that the essential tremors have been partially attributed to alcohol/drug abuse. As noted above, the January 2015 VA examiner noted the Veteran's history of alcohol and drug use (detailed in the July 2009 private neurobehavioral assessment report) and opined that both alcohol and drug use are associated with tremor. VA regulations preclude compensation for disabilities that are the result of alcohol abuse. To the extent that the essential tremors have been attributed to alcohol abuse, service connection is precluded as a matter of law. For the reasons discussed above, the Board finds that the weight of the evidence demonstrates that essential tremors were not incurred in active service or a relevant period of ACDUTRA or INACDUTRA, to include in-service exposure to contaminated water at Camp Lejeune, North Carolina. As such, service connection for essential tremors is not warranted. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Service Connection for a Low Back Disorder The Veteran essentially contends that the claimed low back disorder onset during active service. In a November 2013 written statement, the Veteran contended that back pain began during active service and has continued to bother him since service separation. The Veteran references a March 1984 notation of back pain as evidence that the back pain began prior to service separation. See also June 2015 notice of disagreement. First, the evidence of record demonstrates that the Veteran has current diagnosed lumbar strain. See November 2008 private treatment record. Private treatment records note ongoing treatment for chronic low back pain and strains. See November 2008 to June 2011 private treatment records. In this case, the Board finds that the weight of the evidence demonstrates that the Veteran did not experience an injury or disease related to the low back during active service or during a period of ACDUTRA or INACDUTRA. The notation of low back pain referenced by the Veteran was not during a period of active service, but rather was noted on a March 1984 annual physical examination report related to Reserve service. Service treatment records from the period of active service (October 1980 to March 1981) do not reflect any injury, complaint, diagnosis, or treatment for a low back disorder or otherwise reflect a reported history or findings related to the low back. On a March 1981 service separation physical examination report, the spine was noted as clinically normal. On an associated report of medical history, the Veteran denied recurrent back pain. The in-service history of symptoms is more contemporaneous to service, so is of more probative value, than the more recent assertions made many years after service separation and for compensation purposes. See Harvey, 6 Vet. App. at 394; Madden, 125 F.3d at 1481. During the time period in which the Veteran served on periods of ACDUTRA and INACDUTRA (March 1981 to April 1986), review of the evidence of record does not reflect any low back disease or injury during any such period. A March 1982 annual physical examination report (associated with Reserve service) notes that the spine was clinically normal. On an associated report of medical history, the Veteran denied recurrent back pain. A March 1984 annual physical examination report (associated with Reserve service) notes that the spine was clinically normal. In a March 1984 report of medical history (associated with Reserve service), the Veteran endorsed recurrent back pain. The reviewing physician noted that the Veteran had back pain status post a motor vehicle accident one and one half years prior (1982 or 1983) requiring traction for two weeks and use of a brace for six months. Occasional residual lumbar pain was noted. The March 1984 report of medical history does not indicate that the motor vehicle accident and resultant back injury was incurred in or aggravated during a period of ACDUTRA, that the Veteran sustained a back injury or disease during a period of ACDUTRA, or that the Veteran sustained a back injury during a period of INACDUTRA. Despite the Veteran's contention that this notation was made during a period of active service, such contention is directly contradicted by the contemporaneous service records. The Board finds that the evidence of record conveys no back injury or disease during service and/or during a relevant period of ACDUTRA or INACDUTRA. Service treatment records, and treatment records from the relevant periods of ACDUTRA and INACDUTRA, convey no such injury or disease. The Veteran has also not noted any such injury or disease, other than recent statements in which it was advanced that the low back disorder onset during service. For the reasons discussed above, the Board does not find this assertion supported by the evidence. As the element of in-service incurrence is not demonstrated, the claim for service connection for a low back disorder is denied on a direct basis. For the reasons discussed above, the Board finds that the weight of the evidence demonstrates that a low back disorder was not incurred in active service or a relevant period of ACDUTRA or INACDUTRA. As such, service connection for a low back disorder is not warranted. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for Parkinson's disease is granted. Service connection for essential tremors is denied. Service connection for a low back disorder is denied. REMAND Service Connection for an Acquired Psychiatric Disorder Throughout the course of this appeal, the Veteran has contended, in pertinent part, that his depression is exacerbated by the essential tremors (for which service connection has been denied herein). However, pursuant to this decision, the Board grants service connection for Parkinson's disease - which has also been manifested by tremors. An October 2017 Parkinson's disease disability benefit questionnaire notes that the Veteran has mental manifestations of depression due to Parkinson's disease or its treatment. An April 2009 private treatment record notes that the Veteran reported being treated for depression and possible posttraumatic stress disorder (PTSD). The Board finds it unclear from the evidence of record what acquired psychiatric disorders the Veteran has been diagnosed with to include whether the Veteran has a diagnosed depressive disorder separate from the service-connected Parkinson's disease that may have been caused or aggravated by Parkinson's disease. Based on the above, the Board finds that a VA opinion is necessary because there remains some question as to etiology of the claimed acquired psychiatric disorder. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). Accordingly, the issue of service connection for an acquired psychiatric disorder is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Schedule a VA examination(s) to assist in determining the etiology of the claimed acquired psychiatric disorder. The VA examiner should review the evidence associated with the record. The examiner should diagnose all current acquired psychiatric disorders and offer the following opinions with supporting rationale: Is it at least as likely as not (50 percent or greater probability) that each current acquired psychiatric disorder was incurred in or caused by active service? Is it at least as likely as not (50 percent or greater probability) that each current acquired psychiatric disorder was caused by the service-connected Parkinson's disease? Is it at least as likely as not (50 percent or greater probability) that each current acquired psychiatric disorder was aggravated (worsened in severity beyond a natural progression) by the service-connected Parkinson's disease? 2. Then, readjudicate the issue on appeal in light of all pertinent evidence. If any part of the appeal remains denied, provide the Veteran and the representative with a supplemental statement of the case and allow an appropriate time for response. 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. §§ 5109B, 7112 (2012). ______________________________________________ TANYA SMITH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs