Citation Nr: 21062013 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 97-34 767 DATE: October 6, 2021 ORDER Prior to October 15, 1999, an initial disability rating of 50 percent, but no higher, for the Veteran's major depressive disorder is granted. From October 15, 1999, a 100 percent disability rating for the Veteran's major depressive disorder is granted. REMANDED Entitlement to an effective date earlier than February 18, 2009, for special monthly compensation based on loss of use of a creative organ is remanded. FINDINGS OF FACT 1. Affording the Veteran the benefit of the doubt, prior to October 15, 1999, the Veteran's major depressive disorder was manifested by symptomatology more closely approximated by considerable impairment in the ability to establish or maintain effective or favorable relationships with people, and reduction in reliability, flexibility, and efficiency levels as to produce considerable industrial impairment. 2. Affording the Veteran the benefit of the doubt, from October 15, 1999, the Veteran's major depressive disorder has been manifested by symptomatology more closely approximated by virtual isolation in the community, totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality, or demonstrable inability to obtain or retain employment. CONCLUSIONS OF LAW 1. Prior to October 15, 1999, the criteria for an initial 50 percent rating, but no higher, for major depressive disorder have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.132, Diagnostic Code 9411 (1995); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.14, 4.130, Diagnostic Code 9411 (2020). 2. From October 15, 1999, the criteria for a 100 percent rating for major depressive disorder have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.132, Diagnostic Code 9411 (1995); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.14, 4.130, Diagnostic Code 9411 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1967 to June 1969. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2011 rating decision which granted service connection for major depressive disorder, evaluated as noncompensable from March 5, 1996, at 30 percent from November 7, 1996, and at 100 percent from August 22, 2003. As the Veteran is currently in receipt of the maximum schedular rating from August 22, 2003 to present, this rating is not currently before the Board. In August 2015, April 2018, and January 2021, the Board remanded the matter for further development, to include obtaining VA medical opinions and outstanding Social Security Administration and private treatment records. The Board must consider entitlement to special monthly compensation when fairly raised by the record. See Akles v. Derwinski, 1 Vet. App. 118 (1991). Entitlement to special monthly compensation based on loss of use of a creative organ due to a service-connected psychiatric disability prior to February 18, 2009 has been raised by the record and the Board has added the issue to the appeal. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Within that context, VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a "staged rating." See Fenderson v. West, 12 Vet. App. 119 (1999). Pertinent 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. Generally, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). The standard of proof to be applied in decisions on claims for veteran's benefits is set forth in 38 U.S.C. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Entitlement to an initial compensable disability rating for major depressive disorder prior to November 7, 1996, and in excess of 30 percent from November 7, 1996 to August 21, 2003. The Veteran contends that an increased rating is warranted for his major depressive disorder prior to August 22, 2003. Specifically, he contends that at least a 70 percent initial evaluation is warranted from March 5, 1996, and a 100 percent evaluation is warranted from October 15, 2001. See May 2021 appellate brief. The Veteran's major depressive disorder is currently rated as noncompensable from March 5, 1996 to November 6, 1996, and at 30 percent from November 7, 1996 to August 21, 2003 under Diagnostic Code (DC) 9411. See 38 C.F.R. § 4.132, Diagnostic Code 9411 (1995); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2021). The Board has considered the Veteran's claim under the laws and regulations that were in effect at the time of his claim in March 1996. In this regard, the Board notes that while it may apply the pre-November 7, 1996 rating criteria at all times from March 5, 1996, the post-November 7, 1996 rating criteria can only apply from November 7, 1996. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Prior to November 7, 1996, under the General Rating Formula for Psychoneurotic Disorders, a 10 percent rating was assigned with emotional tension or other evidence of anxiety productive of mild social and industrial impairment. A 30 percent rating was assigned where there was a definite impairment in the ability to establish or maintain effective and wholesome relationships with people. Psychoneurotic symptoms result in such reduction in initiative, flexibility, efficiency, and reliability levels as to produce definite industrial impairment. A 50 percent evaluation required considerable impairment in the ability to establish or maintain effective or favorable relationships with people, and psychoneurotic symptoms that result in such reduction in reliability, flexibility, and efficiency levels as to produce considerable industrial impairment. A 70 percent evaluation required severe impairment in the ability to establish and maintain effective or favorable relationships with people; the psychoneurotic symptoms are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. A 100 percent evaluation required virtual isolation in the community, totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality, or demonstrable inability to obtain or retain employment. These criteria provide three independent bases for granting a 100 percent disability evaluation. See Johnson v. Brown, 7 Vet. App. 95, 97 (1994). On November 7, 1996, the rating criteria for psychiatric disorders were revised and provides that such disability is evaluated pursuant to the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. Under the General Rating Formula, a 30 percent rating is warranted when the evidence shows occupational and social impairment with an 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, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted when the evidence shows 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 warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, 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 depressive disorder affecting the 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); inability to establish and maintain effective relationships. A 100 percent rating is warranted when the evidence shows 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. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates 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). When determining the appropriate disability evaluation to assign, however, the Board's "primary consideration" is the Veteran's symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). In reviewing the evidence, the Board has considered all of the above and has taken an expansive view as to which of the laws and regulations would provide the Veteran the highest benefit. Initially, the Board notes that this claim for a higher rating for an acquired psychiatric disorder has been pending since March 5, 1996. Therefore, the Board's adjudication of this claim can include a discussion of the Global Assessment of Functioning (GAF) scores found in the record. Turning to the evidence of record, in a February 1995 psychiatric evaluation by Dr. O.C. submitted with the Veteran's March 1996 claim, the Veteran reported suffering from recurrent nervous episodes during which he reexperienced traumatic events that occurred during service. He reported that his latest crises began nine months earlier with symptoms such as his mind going blank and sometimes passing out, permanent insomnia or awakening startled, hearing voices, constant irritability, panic attacks when at heights and fear of crowded spaces, sexual impotence, inability to watch films related to Vietnam, and fainting at noises resembling explosions. The Veteran reported working for the telephone company since 1976 and being married for two years in his third marriage, with his previous marriages ending due to his irritability. He denied alcohol or substance abuse. Upon examination, the Veteran was cooperative, approachable, and frank, without hostility or aggression. He was alert and oriented and affect was appropriate. He was well-nourished, casually dressed, and adequately groomed. He was highly anxious, and the clinician had to repeat questions. Speech was spontaneous but the Veteran talked very fast and was unclear at times. Thoughts were logical, coherent, and relevant, but due to anxiety, he seemed to lose his association trend and had to organize his thoughts. The Veteran described auditory hallucinations. Immediate memory was diminished but recent memory conserved. The clinician indicated that the Veteran could not control his impulses adequately. The clinician provided diagnoses of PTSD, insomnia related to PTSD, panic disorder associated with phobias, and histrionic personality disorder, and indicated that the Veteran's prognosis was poor. The Board notes that while the February 1995 psychiatric evaluation predates the Veteran's March 1996 claim, affording the Veteran the benefit of the doubt, it is relevant to show the severity of his disability at the time of his March 1996 claim. A February 1997 VA examination report reflects a panel of examiners reviewed the February 1995 psychiatric evaluation as well as a previous VA examination report. The Veteran reported working for the past twenty-one years with the telephone company. The Veteran denied psychiatric treatment or hospitalizations. The Veteran reported frequent anger spells, usually directed at his spouse and baby. He reported two previous marriages. He reported that in his spare time, he liked to sleep, watch television, and read. Upon examination, the Veteran appeared well-developed, clean, and casually dressed. His posture and gait were appropriate. He appeared a little tense but was expressive and some voluntary component was felt. His thoughts were coherent and relevant without evidence of a thought or perceptive disorder. He was well-oriented, memories were preserved, and recall, retention, intellect, and sensorium were clear. There were no depressive signs and no suicidal ruminations. Judgment was preserved and the Veteran was able to differentiate between right and wrong. After examining the Veteran, the panel indicated that the Veteran did not have a gross psychiatric disorder. In October 2001, the Veteran sought treatment from Dr. J.S. Upon examination, the Veteran appeared clean but poorly groomed and disheveled. He maintained eye contact and was cooperative, but motor behavior was slow, and the Veteran was isolated and withdrawn. He reported nightmares, audiovisual hallucinations, and suicidal and homicidal ideation. He appeared aggressive with poor impulse control, concentration and abstraction, judgment, and insight. His memory was adequate. Psychiatric treatment notes from November 2001 to September 2002 reflect severe psychosis, depression, and anxiety. The Veteran had insomnia with poor sleep and slow motor behavior. His condition was noted to be unchanged. A September 2002 psychiatric evaluation by Dr. J.S. reflects that the Veteran reported he had isolated himself, abandoned his appearance, did not eat or sleep well, and spent his time crying and depressed. The Veteran reported loss in all interest in physical, social, and sexual activities and had low self-worth. Upon examination, the Veteran appeared well-cared for and clean but disheveled. He was cooperative and his voice was low but articulated. His thoughts were illogical, motor behavior was slow, and he appeared sad. His mood was depressed and anxious, but affect was appropriate. He reported insomnia, audiovisual hallucinations, and suicidal and homicidal ideation. He appeared aggressive and had poor impulse control, concentration, abstraction, judgment, and insight, but memory was adequate. The clinician noted that his psychiatric symptoms began long ago and were exacerbated concomitantly with his physical symptoms. The clinician noted the Veteran could not tolerate stress as stress brought on psychotic, depressive crises and exacerbated his condition. His clinician indicated he was not competent to perform any kind of work and recommended a guardian as the Veteran could not manage his affairs. Psychiatric treatment notes from September 2002 to October 2003 show no change and stable condition. A December 2003 psychiatric evaluation associated with the Veteran's claim for Social Security Administration (SSA) benefits was summarized in a March 2006 determination letter. The determination report reflects the Veteran alleged disability beginning October 15, 1999 due to back pain, herniated discs, insomnia, loss of memory, a vision condition, and an emotional condition. He reported he had not worked since October 1999. The report noted the Veteran continued to suffer from significant physical and emotional limitations, including poor capacity to interact socially with others, maintain attention and concentration, handle intense stress, and adapt to changes in his environment or workplace. His daily activities were noted to be substantially restricted, he had limited social adaptability, and he did not participate in social or cultural activities. Upon examination in December 2003, the Veteran complained of auditory and visual hallucinations, hearing voices, irritability, memory loss, insomnia, isolation, and depression. He needed help with personal hygiene and did not participate in group activities. He presented with diminished psychomotor activities and recent and remote memory. He had low self-esteem and poor concentration. The clinician provided a diagnosis of undifferentiated chronic schizophrenia and assigned a global assessment score of 30 to 40 percent with poor prognosis and noted the Veteran needed help managing his funds. The Board notes that while the SSA determination report is associated with the record, an April 2017 response from SSA reflects that the medical records associated with his claim were destroyed. As such, additional attempts to obtain these records would be futile. A June 2004 VA examination report reflects that the examiner found that the Veteran had last sought psychiatric treatment in 1981 prior to seeking treatment in 1995. The Veteran reported that in 1999, he retired, and he started to see Dr. J.S. in October 2001. The Veteran reported that he was irritable most of the time, easily startled, and preferred to be alone. In April 2018 and January 2021, the Board remanded the matter to obtain retrospective opinions as to the severity of the Veteran's psychiatric disability from March 1996 to August 2003. In a January 2020 VA medical opinion, the examiner noted the Veteran worked until 1999 when he injured his back. The examiner noted the psychiatric evaluation with Dr. O.C. in 1995, but found that prior to 1999, the Veteran was able to complete courses and certifications, to work, was married, had a family, and lived a successful life. Thus, the examiner concluded that prior to 1999, the Veteran's psychiatric disability was not severe enough to interfere with his marital relationship, parenting, daily activities, family responsibility, and social and occupational functioning. The examiner further noted that the Veteran was referred to disability in 1999 due to a back injury, not a mental disorder. In a February 2021 VA medical opinion, the examiner noted that the Veteran's psychiatric treatment records were silent from 1976 until 1995 when Dr. O.C. evaluated the Veteran, and the next available treatment records were from a VA medical center in 2003. As to the severity of the Veteran's psychiatric disability from November 1996 to August 2003, the examiner indicated that there was no factual evidence of significant decrease in functionality, hospitalization, psychological crisis, or failure of pharmacologic treatment. Thus, the examiner indicated that the Veteran's psychiatric disability was stable. The Board gives some probative weight to the January 2020 VA medical opinion. While the January 2020 VA examiner indicated that the Veteran retired in 1999 due to his back disability alone, a review of the SSA determination report reflects that the Veteran's psychiatric disability and limitations were considered. However, the Board notes that the January 2020 VA medical opinion also appears to reflect a finding that the Veteran's psychiatric disability worsened in 1999. The Board gives little probative weight to the February 2021 VA medical opinion. The February 2021 VA examiner indicated that the Veteran did not seek treatment for his psychiatric disability from 1995 to 2003; thus, it is clear that the examiner did not consider psychiatric treatment records beginning in October 2001. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Although the Board could remand the claim for an additional VA medical opinion, the Board finds that a remand for an additional medical opinion is not necessary and would only serve to delay the Veteran's claim, which has been pending since March 1996. The evidence of record, including recently translated psychiatric treatment records from 2001, is sufficient to decide the Veteran's claim. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The Board emphasizes that it has afforded the Veteran the benefit of the doubt as to the severity of his disability and the dates that his disability increased in severity. The Court of Appeals for Veterans Claims has held that, "it is the information in a medical opinion, and not the date the medical opinion was provided that is relevant when assigning an effective date." Tatum v. Shinseki, 24 Vet. App. 139, 145 (2010) (discussing assignment of an effective date for a reduction in disability rating under Diagnostic Code 7528); see also Young v. McDonald, 766 F.3d 1348, 1352-53 (Fed. Cir. 2014) (holding that a medical opinion can diagnose the presence of the condition and identify an earlier onset date based on preexisting symptoms). Upon review of the evidence of record, the Board finds a 50 percent evaluation, but no higher, is warranted from March 5, 1996 to November 6, 1996 for the Veteran's major depressive disorder under the pre-November 7, 1996 ratings criteria. The evidence of record demonstrates that the Veteran's psychiatric disability was manifested by insomnia, irritability, some impairment of concentration and immediate memory, impaired impulse control, and auditory hallucinations. This symptomatology caused considerable impairment in the Veteran's ability to establish or maintain effective or favorable relationships with people and a reduction in reliability, flexibility, and efficiency levels resulting in considerable industrial impairment, and is more closely approximated by a 50 percent evaluation. The Board finds that a 70 percent evaluation is not warranted from March 5, 1996 to November 6, 1996 for the Veteran's major depressive disorder under the pre-November 7, 1996 ratings criteria. Despite two previous marriages, the Veteran was married and had maintained employment with the same employer for over 21 years. Furthermore, the Veteran appeared upon examination as cooperative, approachable, and frank, without hostility or aggression despite his impaired impulse control. As the overall evidence of record does not show symptoms of such severity and persistence more closely approximated by severe impairment in the ability to establish and maintain effective or favorable relationships or severe impairment in the ability to obtain or retain employment, a higher 70 percent evaluation is not warranted. From November 7, 1996, the Board can evaluate the Veteran's psychiatric disability under both the old and new criteria. From November 7, 1996 to October 14, 1999, the only additional relevant evidence of record is the February 1997 VA examination report, during which the Veteran reported frequent anger spells and appeared a little tense. However, the examination was otherwise normal such that the panel of examiners found that the Veteran did not have a diagnosable psychiatric disorder. The Board finds that this evidence does not warrant a change in the Veteran's 50 percent evaluation under the pre-November 7, 1996 ratings criteria. From November 7, 1996 to October 14, 1999, the Board finds that application of the post-November 7, 1996 ratings criteria would not allow for a rating in excess of 50 percent. The evidence of record shows that the Veteran's psychiatric disability was manifested by insomnia, irritability, and some impairment of concentration and immediate memory, symptomatology more nearly approximated by occupational and social impairment with reduced reliability and productivity associated with a 50 percent evaluation. Although the Veteran experienced impaired impulse control and auditory hallucinations, symptomatology associated with 70 percent and 100 percent ratings, respectively, the Board notes that the February 1997 VA examination report reflects that while the Veteran appeared a little tense and that he had anger spells, the examination was otherwise normal. The evidence also shows that the Veteran was married and employed. The overall evidence of record does not show symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depressive disorder affecting the ability to function independently, appropriately and effectively; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); or inability to establish and maintain effective relationships resulting in occupational and social impairment, with deficiencies in most areas, or symptoms such 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 resulting in total occupational and social impairment, such that 70 percent or 100 percent ratings, respectively, would be warranted. Affording the Veteran the benefit of the doubt, the Board finds that from October 15, 1999, a 100 percent evaluation is warranted. Under the pre-November 7, 1996 ratings criteria, a 100 percent evaluation required virtual isolation in the community, totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality, or demonstrable inability to obtain or retain employment. Here, the March 2006 SSA determination report reflects that beginning October 15, 1999 and continuing since, the Veteran had poor capacity to interact socially with others, maintain attention and concentration, handle intense stress, and adapt to changes in his environment or workplace. His daily activities were noted to be substantially restricted, he had limited social adaptability, and he did not participate in social or cultural activities. It is from this date that the January 2020 VA medical opinion appears to reflect that the Veteran's psychiatric disability worsened, and the evidence of record shows that the Veteran eventually sought psychiatric treatment in October 2001, when he presented with slow motor behavior and was found to be isolated, withdrawn, and aggressive with poor impulse control, concentration and abstraction, and judgment and insight. The Veteran also reported nightmares, audiovisual hallucinations, and suicidal and homicidal ideation. This symptomatology demonstrates virtual isolation in the community and a demonstrable inability to obtain or retain employment since October 15, 1999, symptomatology required for a 100 percent evaluation under the pre-November 7, 1996 ratings criteria. This is the maximum schedular rating available for a psychiatric disorder under both the pre- and post-November 7, 1996 ratings criteria; thus, the Board need not discuss whether a higher rating is warranted under the post-November 7, 1996 ratings criteria. In sum, and affording the Veteran the benefit of the doubt, the Board finds that from March 5, 1996 to October 14, 1999, a 50 percent rating, but no higher, is warranted for the Veteran's major depressive disorder, and from October 15, 1999, a 100 percent evaluation is warranted. To the extent that the Veteran argues a rating in excess of 50 percent is warranted prior to October 15, 1999, 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(b); 38 C.F.R. §§ 3.102, 4.3 (2019); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND Entitlement to an effective date earlier than February 18, 2009, for special monthly compensation based on loss of use of a creative organ is remanded. As part of his increased rating claim for his psychiatric disability, the Veteran contends that entitlement to special monthly compensation based on loss of use of a creative organ is warranted. For reasons discussed below, the Board finds that entitlement to special monthly compensation based on loss of use of a creative organ is raised by the record as part of his increased rating claim for his service-connected psychiatric disability. However, the Board is unable to make a fully-informed decision on entitlement to such at this time. The Veteran is currently in receipt of special monthly compensation based on loss of use of a creative organ from February 18, 2009 based on erectile dysfunction that, while not due to his service-connected diabetes mellitus, type II, was worsened due to his diabetes mellitus, type II. A July 2009 VA examination report notes onset of erectile dysfunction in the summer of 2007 that was most likely due to an endocrine disease. However, psychiatric treatment records dated in February 1995 reflect the Veteran reported sexual impotence and records dated in September 2002 reflect the Veteran reported loss in all interest in sexual activities. As such, the Board finds that a remand is necessary for an addendum opinion as to the nature and etiology of the Veteran's erectile dysfunction, to include whether it is proximately due to or aggravated by his service-connected psychiatric condition. The matter is REMANDED for the following actions: 1. Obtain an addendum opinion from an appropriate clinician as to the Veteran's erectile dysfunction. The examiner must review the claims file. An in-person examination is not required unless deemed so by the examiner. The examiner is asked to provide a response to the following: Is the Veteran's erectile dysfunction at least as likely as not (1) proximately due to service-connected disability, including his psychiatric disability, or (2) aggravated, i.e., worsened beyond its natural progression, by service-connected disability, including his psychiatric disability? 2. After completing the above, and any other development as may be indicated, the Veteran's claim should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case (SSOC). (Continued on next page) An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. K. Parakkal Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Owen, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.