Citation Nr: 1827447 Decision Date: 05/03/18 Archive Date: 05/14/18 DOCKET NO. 10-40 743 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to an initial evaluation in excess of 10 percent prior to June 15, 2012 and in excess of 30 percent from June 15, 2012 to April 18, 2017, for an acquired psychiatric disorder, to include adjustment disorder with depressed mood. 2. Entitlement to service connection for migraine headaches, to include as secondary to service-connected disabilities. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD LM Stallings, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1971 to September 1971, with a period of active duty for training (ACDUTRA) from April 11, 1982 to April 23, 1982. This matter is before the Board of Veterans' Appeals (the Board) on appeal from a December 2009 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). A hearing was held before the undersigned in February 2011. A transcript of the hearing is of record. In September 2011 and February 2017, the appeal was remanded for further evidentiary development. In a March 2015 rating decision, the RO assigned a 30 percent disability rating effective June 15, 2012 and in a July 2017 rating decision the RO assigned a 70 percent rating effective April 19, 2017. The Veteran indicated in an August 2017 correspondence that he was not seeking a rating in excess of 70 percent from April 19, 2017 for an acquired psychiatric disorder, but is arguing that he is entitled to a rating of 70 percent prior to that date. As the Veteran has expressed satisfaction with the 70 percent rating assigned, the Board has recharacterized the issue on appeal as reflected on the title page. See AB v. Brown, 6 Vet. App. 35 (1993). The March 2017 VA headaches examination raised a question as to whether the Veteran's migraine headaches may be secondary to his service-connected acquired psychiatric disorder. As such, the issue of service connection for migraines, to include as secondary to right shoulder impingement has been recharacterized as service connection for migraines, to include as secondary to service-connected disabilities. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (holding that claims for service connection for psychiatric disorders may encompass claims for service connection for all diagnosed psychiatric disorders). The issue of service connection for migraine headaches, to include as secondary to service-connected substance abuse disorder and anxiety, is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT For the entire appeal period prior to April 19, 2017, the Veteran's service-connected acquired psychiatric disorder was manifested by symptoms that most nearly approximated occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. CONCLUSION OF LAW The criteria for an initial rating of 30 percent for an acquired psychiatric disorder, but no higher, prior to April 19, 2017, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.21, 4.126, 4.130, Part 4, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist Neither the Veteran nor his 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 a duty to assist argument). Legal Standards and Analysis As noted in the introduction, the Veteran claims he is entitled to an initial rating in excess of 10 percent prior to June 15, 2012 and a rating in excess of 30 percent from June 15, 2012 to April 18, 2017. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C. § 1155. Ratings of a service-connected disability require review of the entire medical history regarding the disability. 38 C.F.R. §§ 4.1, 4.2. If there is a question that arises as to which rating to apply, the higher rating is assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2008). As noted above, the Veteran is in receipt of three different staged ratings. The Veteran has expressed satisfaction with the rating assigned from April 19, 2017; therefore, that period of time will not be discussed further. In general, all disabilities, including those arising from a single disease entity, are rated separately, and disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes. However, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259 (1994). The regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function, will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, irrespective of whether the Veteran raised them, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Veteran's psychiatric disorder is rated pursuant to Diagnostic Code 9440. The criteria for rating psychiatric disabilities other than eating disorders are set forth in a general rating formula. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. A 10 percent rating is warranted with the evidence demonstrates occupational and social impairment due to mile or transient symptoms with decrease in work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A 30 percent rating is warranted when the evidence demonstrates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events. A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Ratings are assigned according to the manifestation of particular symptoms. The use of the term "such as" in 38 C.F.R. § 4.130 indicates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. VA must consider all symptoms of a Veteran's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (DSM). Because of the symptom-driven nature of the General Rating Formula, a Veteran may qualify for a disability rating under 38 C.F.R. § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. The symptomatology should be the fact-finder's primary focus when deciding entitlement to each disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). Reasonable doubt will be resolved in favor of the claimant when there is an approximate balance of positive and negative evidence. When a Veteran seeks benefits and the evidence is in relative equipoise, the Veteran prevails. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. Alemany v. Brown, 9 Vet. App. 518 (1996). The Board notes that it has reviewed all of the evidence in the record, with emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F. 3d 1378, 1380-81 (Fed. Cir. 2000). The Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim being decided. The Veteran filed his claim for service connection for an acquired psychiatric disorder in September 2009 and was granted a 10 percent disability rating in a December 2009 rating decision. A September 2009 private treatment record notes depression as due to his service-connected shoulder injury. The Veteran denied anxiety, insomnia, suicidal ideation or plan. In an October 2009 VA Form 21-4138, Statement in Support of Claim, the Veteran reiterated that his shoulder injury caused loss of work and loss of social time. The Veteran underwent a VA mental disorders examination in November 2009. The Veteran reported that he gets angry and frustrated when he cannot do what he used to, which manifested in withdrawal. He reported that he works for the local housing authority, and has for the past six years, but has been written-up for missing work secondary to his pain. The Veteran also reported that he works at the food pantry at his church, has a friend he sometimes visits, lives alone as his two previous wives are deceased, and does not date. He also reported that he ate about one or one and a half meals per day and slept four to five hours per night with periods of wakefulness. The Veteran also reported anger three to four times a week, not enjoying things he used to, and denied suicidal or homicidal ideation. Upon evaluation, the Veteran was cooperative, well-groomed, speech was within normal limits, mood was depressed, affect was appropriate, thought processes and associations were logical and tight, memory was intact, he was oriented in all spheres, and there were no delusions or hallucinations. The examiner indicated the Veteran's symptoms were mild. They did not preclude employment, did not cause gross impairment in social functioning, and did not preclude activities of daily living. A January 2010 VA depression screen was negative. Regardless, the Veteran reported little or no interest or pleasure in doing things and reported feeling down, depressed, or hopeless more than half the days. A VA treatment note from December 2010 reflects depressive disorder, which needs to be monitored. The Veteran testified at a Board hearing in February 2011. He testified that he experienced symptoms of low appetite and chronic sleep disturbances for which he is on medication. The Veteran also testified that he seeks treatment with a family doctor and would like to seek specific mental health treatment. He testified that his symptoms have worsened since being granted service connection; specifically, his sleeping was difficult and he struggled with driving or being around people. A VA treatment record from February 2011 reflects psychiatric symptoms of insomnia. The VA physician noted that anxiety, sleep disturbances, delusions, depression, hallucinations, inability to concentrate, mood changes, panic attacks, and suicidal ideation or intent were not present. A March 2011 statement from a private physician reported that the Veteran has a diagnosis of depression which does not require medication but does include periods of mood variances and anxiety. He also had intermittent periods of not being able to do daily activities, experienced depressive symptoms at least once weekly, and had chronic sleep disturbances. A March 2011 VA psychiatry note reflected anxiety problems and nervousness, which caused him to stop working. The VA treating provider noted diagnoses of depressive disorder, generalized anxiety disorder, and substance abuse disorder. The Veteran reported no motivation, social isolation, and daily substance use. Another March 2011 VA treatment note reflects that the Veteran experienced severe anxiety when driving over bridges on the interstate, along with symptoms of depressed mood, decreased appetite, decreased motivation, isolation, and avoidance. An April 2011 VA psychiatry note reflects that the Veteran is attempting to limit his substance use. The Veteran appeared alert and had low and even speech. The VA examiner noted a diagnosis of depressive disorder with panic attacks and social isolation. An April 2011 VA medication list reflects active medication for depression and anxiety. A VA treatment record from December 2011 reflects psychiatric symptoms of insomnia. In a VA Form 21-4138 in December 2011, the Veteran complained of depression and reported he was on medication. The Veteran underwent another VA examination in June 2012. The VA examiner noted that the Veteran had social and occupational impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The examiner noted the Veteran had symptoms of depressed mood, anxiety, panic attacks that occur weekly or less, chronic sleep impairment, and difficulty in establishing and maintaining effective work and social relationships. The examiner noted that the Veteran presented well-groomed with good social skills and logical thought processes that are coherent and relevant. Affect was anxious, the Veteran was restless, well-oriented to time, place, person, and situation, and reasoning and judgment were intact. The Veteran described subjective difficulties with concentration and short-term memory but no issues with long term memory. The Veteran denied suicidal or homicidal ideation, and denied psychosis or mania. The examiner noted that the Veteran's adjustment disorder included symptoms of insomnia, dysphoria, feelings of worthlessness, and irritability. He also reported panic attacks, particularly while driving, and increasing social isolation/agoraphobia. A June 2016 VA depression screening was negative for depression. In an October 2016 Brief, the Veteran's representative argued that due to the Veteran's current symptomatology, he is entitled to a rating in excess of 30 percent for his acquired psychiatric disorder. An October 2016 VA treatment note reflects a choice to return to treatment after urging by family as his depression and anxiety had not improved. The Veteran reported that he still has problems driving, panic attacks, sleep disturbances, and no motivation. The Veteran underwent another VA examination in April 2017. The VA examiner noted diagnoses of adjustment disorder with depressed mood and anxiety disorder, not otherwise specified with symptoms of anxiety and panic attacks. The Veteran endorsed symptoms of depressed mood, anxiety, impaired judgment, alcohol abuse, and impaired impulse control, such as unprovoked irritability with periods of violence. The Veteran was on time, was cooperative, and demonstrated a wide range of affect that changed with the conversation, was alert and oriented, with adequate grooming and hygiene. The Veteran's speech was pressured and tangential, was somewhat difficult to redirect, and his thought processes were logical. The examiner noted that while he had been asked to provide a baseline for the Veteran's conditions and opine on any increase from there, he had insufficient evidence to establish a baseline without speculation. The VA examiner opined that the Veteran's substance abuse disorder is at least as likely as not aggravated beyond its natural progression by his adjustment disorder and his anxiety is also likely a symptom of his adjustment disorder. In an August 2017 VA form 21-0958, Notice of Disagreement, the Veteran argued that he is now happy with the rating he has but believes it should have the effective date of February 2, 2010, the date on which he first appealed the decision. A September 2017 VA Form 27-0820, Report of General Information, in a phone call with the Veteran he reiterated this argument. In a March 2018 Brief, the Veteran's representative argued that the Veteran's entire record be evaluated in order to determine the appropriate rating for his service-connected acquired psychiatric disorder. The Board notes that the VA examiner in April 2017 indicated that the Veteran's substance abuse disorder is at least as likely as not aggravated by his service-connected adjustment disorder and that his diagnosed anxiety disorder is also a symptom of his adjustment disorder. Therefore, the Board must consider all of the Veteran's psychiatric symptoms in conjunction with his service-connected adjustment disorder and the analysis below will so follow. See Mittleider v. West, 11 Vet. App. 181 (1998) (holding that if it is not medically possible to distinguish the effects of service-connected and nonservice-connected conditions, the reasonable doubt doctrine mandates that all signs and symptoms be attributed to the veteran's service-connected condition). Prior to June 15, 2012 The Veteran claims he is entitled to a rating in excess of 10 percent for adjustment disorder prior to June 15, 2012. Considering all of the evidence of record, the Board finds that the Veteran's service-connected acquired psychiatric disability has been manifested by the symptoms contemplated by the higher 30 percent rating pursuant to the General Rating Formula for Mental Disorders. Specifically, the Veteran's symptoms have shown occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. A September 2009 private treatment record reflects depression and denied anxiety, insomnia, or suicidal ideation. The Veteran's November 2009 VA examination reflected anger and frustration when he is limited by his service-connected disability; he has a low appetite, and angry outbursts. Further, that he works and volunteers with his church, but has been written-up for missing work due to his pain. The Veteran denied suicidal ideation. VA treatment records from January 2010 to February 2011 reflect feelings of hopelessness and insomnia. At the February 2011 Board hearing the Veteran testified to a low appetite, sleep disturbances, and difficulty driving or being around people. March 2011 private and VA treatment records reflect mood disturbances, anxiety, social isolation, and chronic sleep disturbances and an April 2011 VA medication list reflects daily medication for depression and anxiety. Based on the evidence during the staged period on appeal, the Board finds that the Veteran's acquired psychiatric disorder symptoms are like those contemplated by the criteria for a 30 percent rating. Overall, his symptoms show occupational and social impairment with occasional decrease in work efficiency and inability to perform occupational tasks. Accordingly, the Board concludes that throughout the period prior to June 15, 2012, the evidence of record most nearly approximates the criteria for a 30 percent rating for an acquired psychiatric disorder, and the claim is granted to that extent. 38 U.S.C. § 5107; Gilbert, 1 Vet. App. 49. As the Board has found the Veteran is entitled to a higher rating of 30 percent for the period prior to June 15, 2012, which is the same as the evaluation for the period from June 15, 2012 to April 18, 2017, the analysis for a rating in excess of 30 percent for the entire period of appeal prior to April 19, 2017, will be considered in the next section. Prior to April 19, 2017 Considering all of the evidence of record, the Board finds that the Veteran's service-connected acquired psychiatric disability has not been manifested by the symptoms contemplated by the higher, 50 percent, rating pursuant to the General Rating Formula for Mental Disorders for the period prior to April 19, 2017. Specifically, the Veteran's symptoms have shown occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks and have not been manifest by occupational and social impairment with reduced reliability and productivity. In a March 2011 VA treatment note, the Veteran reported panic attacks when he attempted to drive over bridges on the interstate. An April 2011 VA treatment note reflects appropriate speech patterns, panic attacks, and feelings of social isolation. In the June 2012 VA examination, the VA examiner noted that the Veteran had social and occupational impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The Veteran endorsed symptoms of depressed mood, anxiety, panic attacks that occur weekly or less, chronic sleep impairment, and difficulty in establishing and maintaining effective work and social relationships. He denied psychosis, hallucinations, suicidal ideations, and homicidal ideations. The Veteran endorsed difficulty with concentration, mild short-term memory loss, feelings of worthlessness, and irritability. The Veteran again sought treatment for his acquired psychiatric disability in October 2016. The Veteran reported that his depression and anxiety had not improved since his last treatment and that he had difficulty driving, panic attacks, sleep disturbances, and disturbances of motivation. Based on the evidence during the period on appeal, the Board finds that the Veteran's acquired psychiatric disorder symptoms are most like those contemplated by the criteria for a 30 percent rating. Overall, his symptoms show occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Under Diagnostic Code 9440, the next higher rating of 50 percent for an acquired psychiatric disability is described as a condition with manifestations and symptoms that cause occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. The medical and lay evidence of record does not reflect flattened affect, circumlocutory speech, panic attacks more than once a week, impaired judgment, or impaired abstract thinking. The Veteran's symptoms during this time have consistently been chronic sleep impairment, irritability, mild short-term memory loss, depression, and anxiety, symptoms that are considered by the assigned 30 percent rating. The Veteran's representative's October 2016 brief argued that he is entitled to a rating in excess of 30 percent, but did not present additional argument or evidence supporting a 50 percent disability evaluation. The Veteran's symptomatology is better approximated by the criteria outlined under the 30 percent rating prior to April 19, 2017. Specifically, he has always appeared on time to his appointments, he has been appropriately groomed and responsive and has not indicated difficulty in understanding complex commands. Considering all the evidence of record, the Board finds that frequency, duration, and severity of symptoms of the Veteran's service-connected acquired psychiatric disability does not more nearly approximate the criteria for a 50 percent rating pursuant to the General Rating Formula for Mental Disorders as occupational and social impairment with reduced reliability due to an acquired psychiatric disability is not shown. Similarly, the Veteran is not entitled to a rating of 70 percent prior to April 19, 2017 as his disability picture does not more nearly approximate occupational and social impairment with deficiencies in most areas due to near continuous panic attacks, impaired impulse control, spatial disorientation, neglect of personal appearance or hygiene, or suicidal ideation. The Veteran has consistently appeared on time and appropriately dressed with adequate hygiene; he has not endorsed near continuous panic attacks, has consistently denied suicidal ideation, and has not indicated issues with spatial disorientation or impulse control during this period on appeal. Therefore, a rating of 70 percent pursuant to the General Rating Formula for Mental Disorders is also not shown. Finally, the Veteran is also not entitled to a rating of 100 percent prior to April 19, 2017 as his disability picture does not reflect total occupational and social impairment due to symptoms such as delusions or hallucinations, grossly inappropriate behavior, or persistent danger in hurting oneself. The Veteran has consistently denied delusions and hallucinations, denied suicidal ideation, and has not demonstrated or indicated periods of grossly inappropriate behavior. To the contrary, the Veteran has been able to work and volunteer, live alone (albeit with increasing social isolation), and has managed his acquired psychiatric disorder with medication and sought treatment with the VA where he learned and applied some coping mechanisms. Therefore, the Veteran's symptoms also do not warrant a 100 percent rating prior to April 19, 2017. Therefore, prior to April 19, 2017, the evidence does not reflect a rating in excess of 30 percent and as the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 54-56. ORDER Entitlement to an initial rating of 30 percent, but no higher, prior to April 19, 2017, for an acquired psychiatric disorder, is granted, subject to regulations governing the payment of monetary awards. REMAND Unfortunately, the Board has determined that additional development must occur for the remaining issue before appellate review can proceed. The Veteran has asserted that he has a migraine condition, to include as secondary to his service-connected right shoulder condition. The appeal was remanded in February 2017 in order to obtain an opinion which could reconcile conflicting evidence regarding the likely cause or aggravating factors of the Veteran's claimed migraine headaches. The Veteran was provided a VA examination in March 2017 to determine the nature of his claimed migraine headaches. The VA examiner opined, in part, that the Veteran's nonservice-connected conditions, including alcohol abuse, illicit drug use, and anxiety disorders could have headaches as symptoms and may contribute to his claimed headache condition. As discussed above, the Veteran was provided a VA examination in April 2017 to determine the nature and severity of his service-connected anxiety disorder. Upon VA mental health examination, the VA examiner opined that the Veteran had a substance abuse disorder at least as likely as not aggravated by his adjustment disorder with depressed mood and that his noted anxiety is likely a symptom of his adjustment disorder with depressed mood, which is now considered part in parcel of his service-connected acquired psychiatric disorder pursuant to Mittleider, 11 Vet. App. 181. As the Veteran's adjustment disorder now includes substance abuse disorder and anxiety, and considering the March 2017 VA examiner's opinion which was stated in speculative terms, but indicated that headaches could be caused by substance use disorder and anxiety, it is necessary to remand for an opinion to evaluate secondary service connection for migraine headaches as due to substance abuse disorder and anxiety. In the March 2018 Appellant's Post-Remand Brief, the Veteran's representative argued that the Veteran's claim for service-connection for migraine headaches should be evaluated for secondary service connection, considering the benefit of the doubt. In addition, the most recent VA treatment records are from October 2017. Therefore, any updated pertinent VA records should be obtained and associated with the claims file on remand. Accordingly, the case is REMANDED for the following actions: 1. Obtain the Veteran's VA treatment records from October 2017 to the present. 2. After any records obtained have been associated with the electronic claims file, forward the complete file to an appropriate clinician to evaluate his claim for service connection for a migraine condition, to include as secondary to the service-connected acquired psychiatric disorder, to include adjustment disorder, anxiety, and substance abuse disorder. The claims file must be made available to the clinician for review in conjunction with the opinion. Only if the clinician deems it necessary, schedule the Veteran for a VA examination to assist in providing the opinion. Based on review of the pertinent evidence of record, (and any tests, studies or examination deemed necessary) the examiner should provide the following opinion: Is it at least as likely as not (50 percent or better probability) that a migraine condition is caused or aggravated by (where aggravation is any increase in severity beyond the natural progress of the disability) his service-connected acquired psychiatric disorder, to include adjustment disorder, anxiety, and substance abuse disorder? A complete rationale for all opinions must be provided, to include consideration of the arguments made in the Veteran's representative's October 2016 and March 2018 briefs and lay and medical evidence previously submitted by the Veteran. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to decide. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the examiner. 3. Finally, after undertaking any other development deemed appropriate, readjudicate the issues remaining on appeal, to include consideration of all medical evidence added to the record because of this remand. If any benefit sought is not granted, furnish the Veteran and his representative with a SSOC and afford him an opportunity to respond before the record is returned to the Board for further review. 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 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. ______________________________________________ M. Sorisio Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs