Citation Nr: 21063357 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 17-47 409 DATE: October 14, 2021 ORDER Entitlement to service connection for a personality disorder is denied. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), depressive disorder, and dysthymic disorder, is granted. REMANDED The issue of entitlement to service connection for a left wrist condition is remanded. The issue of entitlement to service connection for a gastrointestinal condition, claimed as irritable bowel syndrome (IBS), is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran has a current diagnosis of a personality disorder. 2. The Veteran has current diagnoses of PTSD, depressive disorder, and dysthymic disorder, and the claims file contains credible supporting evidence of in-service stressors that are related to the Veteran's PTSD, depressive disorder, and dysthymic disorder. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a personality disorder have not been met. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.304. 2. The criteria for entitlement to service connection for an acquired psychiatric disorder, to include PTSD, depressive disorder, and dysthymic disorder, have been met. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1988 to October 1989. This matter is on appeal from an August 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which denied entitlement to service connection for a left wrist disability, IBS, and personality disorder. The Veteran timely perfected an appeal. See September 2016 Notice of Disagreement; July 2017 Statement of the Case; September 2017 VA Form 9. This claim has previously been developed as two separate issues involving psychiatric disorders, i.e., personality disorder and an acquired psychiatric disorder, to include PTSD, depressive disorder, and dysthymic disorder. The Board notes that a claim for a disability includes any disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). However, a claim for one diagnosed disease or injury cannot be prejudiced by a prior claim for a different diagnosed disease or injury, when it is an independent claim based on distinct factual bases. Boggs v. Peake, 520 F.3d 1330 (Fed. Cir. 2008). In reconciling these holdings, the United States Court of Appeals for Veterans Claims (Court) held that when varying diagnoses are involved, in considering whether the claim presented is one to reopen or is a new claim to be adjudicated on the merits, "the focus of the Board's analysis must be on whether the evidence presented truly amounts to a new claim 'based upon distinctly diagnosed diseases or injuries' or whether it is evidence tending to substantiate an element of a previously adjudicated matter." Velez v. Shinseki, 23 Vet. App. 199, 204 (2009) (quoting Boggs, 520 F.3d at 1337). Here, the Veteran was initially denied service connection for a "psychological problems," which the RO characterized as separate claims for a personality disorder and dysthymic disorder, in a February 1993 rating decision. In October 2000, the Veteran filed a claim of entitlement to service connection for a nervous condition, which the RO construed as a request to reopen the previously denied claim. Thereafter, in a February 2001 rating decision, the RO denied the claim because new and material evidence was not submitted. Both decisions became final. 38 U.S.C. § 7105 (c), 38 C.F.R. §§ 3.104, 20.302, 20.1103. The Veteran subsequently filed a claim for dysthymic disorder and personality disorder in March 2016, which the RO construed as a request to reopen his previously denied claims. After a thorough review of the record, the Board finds that the Veteran's current claim of entitlement to service connection for a psychiatric disability, to include personality disorder, PTSD, and dysthymic disorder, constitutes the same claims that were denied in the February 1993 and February 2001 rating decisions. In this regard, the Veteran has continued to seek service connection for a psychiatric disability, however variously claimed and diagnosed, as due to traumatic events he experienced in service. Thus, the Board is broadening the scope of the present claim because it turns upon essentially the same history, factual bases, and claimed symptomatology that were considered in the prior final rating decisions - that the Veteran experiences a psychiatric disorder as a result of his active service. Accordingly, under Boggs and Velez, new and material evidence would generally be required to reopen the Veteran's claim of entitlement to service connection for a psychiatric disorder. However, under 38 C.F.R. § 3.156 (c), if at any time after VA issues a decision on a claim, VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim. In this case, the Veteran's service personnel records, which had not previously been requested or obtained by VA, were associated with the claims file in April 2016. These records, which existed and had not been previously considered by the RO in its previous denials, contain the Veteran's enlistment examination, which was apparently not contained in the Veteran's service treatment records. See August 1993 Rating Decision (noting that service medical records were reviewed but that "entry examination and medical history are not of record"). As such, the Board finds that they are relevant to the Veteran's claim of entitlement to service connection for a psychiatric disorder. Thus, the claim of entitlement to service connection for a psychiatric disorder must be reconsidered on a de novo basis, without regard to the previous final denials. 38 C.F.R. § 3.156 (c). The issues have been recharacterized accordingly. Similarly, the RO denied entitlement to service connection for IBS and a left wrist condition in the final August 1993 and February 2001 rating decisions. However, as discussed in detail below, the Veteran's newly received enlistment examination is highly relevant to his current claims because the claims were denied due to a finding that both conditions preexisted service. Thus, the claim of entitlement to service connection for IBS and a left wrist condition must also be reconsidered on a de novo basis, without regard to the previous final denials. 38 C.F.R. § 3.156 (c). On the Veteran's September 2017 VA Form 9, he requested a Board hearing. Thereafter, several letters informed the Veteran that his requested hearing had been scheduled for May 2021. However, according to the Veterans Appeals Control and Locator System, the Veteran failed to appear for his scheduled hearing. When a Veteran fails to appear for a scheduled hearing and a request for postponement has not been received and granted, the case will be processed as though the request for a hearing had been withdrawn. 38 C.F.R. § 20.704 (d). Under these circumstances, the Board finds that the Veteran has been afforded his opportunity for a hearing and that his request to testify before the Board has been withdrawn. Service Connection The Veteran seeks service connection for a personality disorder and an acquired psychiatric disorder, including PTSD, depressive disorder, and dysthymic disorder. A. Legal Criteria Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires competent evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Establishment of service connection for PTSD requires: (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304 (f); see also Cohen v. Brown, 10 Vet. App. 128 (1997). If a PTSD claim is based on in-service personal assault, evidence from sources other than a veteran's service records may corroborate his account of the stressor incident. 38 C.F.R. § 3.304 (f)(5). Examples of such evidence include but are not limited to records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Id. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include but are not limited to a request for a transfer to another military duty assignment; deterioration in work performance, substance abuse, episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. Moreover, it is well established that if a PTSD claim is based on an in-service personal assault, medical opinion evidence may be submitted for use in determining whether the occurrence of a stressor is corroborated. Menegassi v. Shinseki, 638 F.3d 1379, 1382 (Fed. Cir. 2011). Specifically, 38 C.F.R. § 3.304 (f)(5), allows Veterans claiming PTSD from an in-service military assault to submit evidence other than in-service medical records to corroborate the occurrence of a stressor, and this includes medical opinion evidence. Menegassi, 638 F.3d at 1382; see also 67 Fed. Reg. 10,330, 10,330-31 (Mar. 7, 2002). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Factual Background During the Veteran's November 1987 enlistment examination, he denied any prior history of psychiatric symptoms, and his psychiatric status was evaluated as clinically normal. A September 1989 Medical Board Report shows that the Veteran reported that he was married just prior to his enlistment and that he was homesick and missed his wife. He was psychiatrically hospitalized and diagnosed with dysthymic disorder that existed prior to service. It was also noted that the precipitating stress for his dysthymic disorder was "[r]outine military service." A March 2009 private treatment record shows that the Veteran reported a chronic, long history of insomnia. A September 2009 private treatment record shows that the Veteran was diagnosed with chronic depression. The Veteran was afforded a VA examination in August 2016. He reported no problems growing up with family, friends, school, work, substance use, health, or the law. He reported that he married a month before he enlisted in the Navy. The Veteran indicated that during training, he was upset by being pressured into joining in with his peers to give a struggling black recruit a blanket party. He also reported that he saw another unpopular sailor kill himself. The Veteran reported that he was harassed and stalked by a woman during his "A" school and that he was traumatized by homosexual behavior onboard ship, which led to his stomach pain and depression. The Veteran reported that after he was discharged, his mother told him that he had become "mean, cold, and distant." The examiner indicated that the Veteran's stressors, including being forced to participate in a blanket party, seeing another recruit jump out of a window, being stalked by a woman, and witnessing his bunk mates engaging in homosexual activity, were all adequate to support a diagnosis of PTSD, i.e., meet Criterion A, and that they were related to personal assault. The examiner also indicated that the evidence of the Veteran becoming more anxious and depressed about becoming vulnerable to attack by others, to include his in-service psychiatric hospitalization, were markers that substantiate his stressors. The examiner indicated that the Veteran also met the remaining criteria for a PTSD diagnosis. The examiner diagnosed the Veteran with PTSD and recurrent depressive disorder (dysthymia). The examiner also indicated that the Veteran's depressive disorder was secondary to or interacts with the PTSD and cannot be separated. The examiner opined that the Veteran's acquired psychiatric disorder was at least as likely as not related to service. The examiner explained as follows: It is as likely as not that the [V]eteran's military service led to symptoms of PTSD...and a recurrent depressive disorder (or dysthymia) due to a series of stressful events. The [V]eteran was forced to beat up a peer, saw a peer kill himself, was harassed by an out of wedlock girl friend and then had to sleep next to men who were having sex on board ship. This led to being hospitalized for IBS and depression and getting an early medical discharge. This is support by the social/industrial history, current mental status, reports by his fiancée, and objective personality measures. C. Analysis-Personality Disorder In this case, the Board finds that the preponderance of the evidence is against a finding that the Veteran has a current diagnosis of a personality disorder. Post-service treatment records do not reflect such a diagnosis. Moreover, the August 2016 VA examiner did not diagnose a personality disorder. In sum, the Veteran has not satisfied the necessary element of a present disability for a personality disorder, and thus, further discussion of the in-service incurrence or nexus elements is not necessary. Absent a showing of a current disability, service connection cannot be granted. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). Accordingly, the Board concludes that the preponderance of the evidence is against the claim of service connection for a personality disorder, and the benefit of the doubt rule does not apply. See 38 U.S.C. § 5107. D. Analysis-Acquired Psychiatric Disorder Based on a careful review of the evidence, the Board finds that service connection for an acquired psychiatric disorder, to include PTSD, depressive disorder, and dysthymic disorder, is warranted. Initially, the Board finds that the Veteran has current diagnoses of PTSD, depressive disorder, and dysthymic disorder. See August 2016 VA Examination Report; Private Treatment Records (showing a diagnosis of depression). Next, with respect to the claimed stressor, although the Veteran's service records do not document any of the reported stressors, the Board finds sufficient corroborating evidence that the reported events occurred. The current PTSD regulation relating to personal assault reflects VA's judgment that unreported personal assaults occur frequently in the military. Here, the Veteran has provided consistent statements describing his traumatic experience, and there is nothing in the record to directly contradict these assertions or that would indicate that he is not credible. While the events in question have not been specifically verified in the military records, other evidence, including those of in-service behavior changes and the fiancée's statements, tend to corroborate the events. Moreover, in the context of personal assault claims, the U.S. Court of Appeals for the Federal Circuit has specifically held that 38 C.F.R. § 3.304 (f)(5) specifically contemplates medical opinions as probative evidence that may corroborate a past assault stressor. Menegassi v. Shinseki, 638 F.3d 1379 (2011). In this case, the August 2016 examiner found that the events did meet the stressor criterion to support a diagnosis of PTSD and that the evidence of record was objectively consistent with symptoms often reported by individuals who have a history of physical and sexual assault, which serves to further substantiate the claimed events. Accordingly, the Board finds that the Veteran's cited stressors are corroborated. Turning to the question of whether there is a nexus, or link, between the currently shown disability and service, the evidence indicates that the Veteran's current psychiatric disability is attributable to his military traumas. The August 2016 VA examiner opined that the Veteran's PTSD and depressive disorder were at least as likely as not causally related to military events, and there are no contrary opinions of record. Therefore, all three elements of 38 C.F.R. § 3.304 (f) have been met, and service connection on a direct basis for an acquired psychiatric disorder, including PTSD, depressive disorder, and dysthymic disorder, is warranted. REASONS FOR REMAND Outstanding Records The record indicates that there may be Social Security Administration (SSA) records not associated with the claims file. See August 2016 VA Examination Report (noting that the Veteran "went on SSDI for physical and mental disorders" in 2003). When VA has actual notice of the existence of relevant SSA records, the duty to assist includes requesting those records from the SSA. See Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010) (finding that VA must seek to obtain relevant records under 38 U.S.C. § 5103A when "there exists a reasonable possibility that the records could help the veteran substantiate his claim for benefits"); see also Murincsak v. Derwinski, 2 Vet. App. 363, 370 (1992) (finding VA's duty to assist specifically includes requesting information from other Federal departments). On remand, any relevant SSA records should be obtained. Left Wrist Condition The Veteran seeks service connection for a left wrist condition. During the Veteran's November 1987 enlistment examination, he reported that he fractured his left wrist in 1982; however, on the associated enlistment examination report, no defects were noted. An October 1988 service treatment record shows that the Veteran reported left wrist pain after dropping a 30-pound pot on his wrist. He was diagnosed with left wrist contusion. The Veteran continued to report left wrist pain in November 1988 and June 1989. The Veteran was afforded a VA examination in August 2016. The examiner noted diagnoses of left wrist carpal metacarpal (CMC) arthritis, osteoarthritis, and resolved left wrist navicular (scaphoid bone) fracture. The examiner opined that the Veteran's left wrist condition, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service event, injury, or illness. The examiner noted that X-rays showed "age related and occupation related" degenerative changes. The examiner also indicated that November 1988 service treatment records show "no disability and [V]eteran fit for full duty." Therefore, the examiner concluded that "the claimed condition which clearly and unmistakably existed prior to military service was not aggravated beyond its natural progression by the military service injury." Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111. Thus, when no preexisting condition is noted upon entry into service, the veteran is presumed sound. See Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). However, if a preexisting disorder is noted upon entry into service, the veteran cannot bring a claim for service connection for that disorder, but the veteran may bring a claim for service-connected aggravation of that disorder. Jensen v. Brown, 19 F.3d 1413 (Fed. Cir. 1994). Where a preexisting disease or injury is noted on the entrance examination, section 1153 of the statute provides that "[a] preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease." 38 U.S.C. § 1153; 38 C.F.R. § 3.306 (a). The Court has held that lay statements by an appellant concerning a preexisting condition are not sufficient to rebut the presumption of soundness. See Paulson v. Brown, 7 Vet. App. 466, 470 (1995) (stating that a lay person's account of what a physician may or may not have diagnosed is insufficient to support a conclusion that a disability preexisted service); Crowe, 7 Vet. App. at 246 (1994) (finding that supporting medical evidence is needed to establish the presence of a preexisting condition). Moreover, the Court has held that the presumption of soundness upon entry into service may not be rebutted without "contemporaneous clinical evidence or recorded history" in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). In this regard, a higher court has subsequently explained the Miller decision by noting that "[n]othing in the court's opinion suggests that without such evidence the presumption can never be rebutted," emphasizing that any such determination must consider "how strong the other rebutting evidence might be." Harris v. West, 203 F.3d 1347, 1351 (Fed. Cir. 2000). Here, the Board finds the opinions and rationale of the August 2016 VA examiner that the Veteran's left wrist disability clearly and unmistakably preexisted service to be inadequate to rebut the presumption of soundness. In this regard, the Veteran's reports that he previously experienced a left wrist injury in childhood does not constitute the "clear and unmistakable evidence" needed to rebut the presumption of soundness upon entry into service. Indeed, lay statements by a Veteran concerning a preexisting condition are not sufficient to rebut the presumption of soundness; rather, supporting medical evidence is needed to establish the presence of a preexisting condition. The fact remains that no defects were noted at the time of the Veteran's November 1987 enlistment examination. Therefore, the Veteran is presumed sound as to his left wrist, and the burden is on VA to rebut the presumption by clear and unmistakable evidence that a left wrist condition both pre-existed and was not aggravated by service. In light of the foregoing, the Board finds that an addendum opinion is necessary to assist the Board in rendering the appropriate legal determinations in this case. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (stating that once VA undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). Gastrointestinal Condition The Veteran seeks service connection for a gastrointestinal condition, claimed as IBS, which he contends started in service. During the Veteran's November 1987 enlistment examination, the Veteran denied any relevant symptoms, and no defects were noted on the associated examination report. Service treatment records reflect that the Veteran reported stomach cramps and diarrhea on numerous occasions. See February 1989 Service Treatment Record (stomach cramps for four days); June 1989 Service Treatment Record (stomach cramps and diarrhea); June 1989 Service Treatment Record (stomach cramps); July 1989 Service Treatment Record (stomach cramps for three weeks); August 1989 Service Treatment Record (diagnosis of gastroenteritis). A September 1989 Medical Board report shows that the Veteran reported a past history of stomach problems, and he was diagnosed with psychological factors affecting physician condition manifested by gastrointestinal distress, which was noted as existing prior to service. He was also diagnosed with irritable bowel syndrome, treated, improved. In numerous lay statements, the Veteran reported that he continued to experience IBS/gastrointestinal symptoms since service. See February 1993 Correspondence; August 2016 VA PTSD Examination Report (noting chronic stomach pain). To date, the Veteran has not been afforded a VA examination regarding his claimed gastrointestinal condition. In light of the evidence discussed above, the Board finds that the Veteran should be afforded a VA examination to address the etiology of his gastrointestinal condition. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board also notes that, by way of the decision above, the Veteran is currently service connected for an acquired psychiatric disorder and that stomach symptoms have been noted to be a component of his psychiatric disorder. This issue should also be addressed by the examiner to determine whether the Veteran's gastrointestinal condition is related to service or to his service-connected acquired psychiatric disorder. The matters are REMANDED for the following action: 1. Obtain and associate with the Veteran's claims file all outstanding VA treatment records documenting treatment for the issues on appeal. The Veteran should also be given the opportunity to identify and/or submit any additional private treatment records pertinent to his claim. 2. Request from SSA any records relevant to the Veteran's claim of entitlement to service connection for a left wrist condition and IBS. All attempts to fulfill this development should be documented in the claims file. If the search for these records is negative, that should be documented in the claims file, and the Veteran must be informed of this in writing in accordance with 38 C.F.R. § 3.159(e). 3. After all available records have been associated with the claims file, obtain a VA medical opinion to determine the etiology of the Veteran's left wrist condition. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. The entire claims file and a copy of this Remand must be made available to the reviewing examiner and the examiner shall indicate in the report that the claims file was reviewed. After reviewing the claims file, and if necessary, examining the Veteran, the examiner should address the following: (a.) For each diagnosed left wrist condition, to include left wrist osteoarthritis and left wrist carpal metacarpal arthritis, the physician should opine as to whether that disability clearly and unmistakably (i.e., highest degree of medical certainty) pre-existed military service. If pre-existence is demonstrated clearly and unmistakably, the physician should then opine whether the disorder was clearly and unmistakably not aggravated (i.e., not permanently worsened beyond the natural progression of the disease) during military service. If necessary, and to the extent possible, reconcile this opinion with service treatment records showing complaints and treatment relating to left wrist symptoms and the Veteran's lay statements regarding onset and continuity of left wrist symptoms. If it is found that there is clear and unmistakable evidence that the Veteran's left wrist condition existed prior to service AND that there is clear and unmistakable evidence that the condition was not aggravated by service, the examiner should clearly indicate the clear and unmistakable evidence supporting his/her conclusions. (b.) If, however, the examiner cannot clearly and unmistakably determine that a left wrist condition pre-existed military service, or that any preexisting disability was not aggravated in service, the physician must take as conclusive fact that the Veteran's left wrist was sound on entrance into the military. After presuming such, the physician should then opine as to whether it is at least as likely as not (i.e., 50 percent or greater probability) that the Veteran's currently diagnosed left wrist conditions are related to his active military service. The physician should especially review and comment on service treatment records showing treatment for left wrist pain after dropping a 30-pound object. The examiner's report must reflect consideration of the Veteran's entire documented medical history and assertions and all lay evidence. A rationale for all requested opinions shall be provided. The reasons and bases for each opinion are to be fully explained with a complete discussion of the evidence of record and sound medical principles, including the use of any medical literature (if deemed warranted), which may reasonably explain the medical guidance in the study of this case. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. 4. After all available records have been associated with the claims file, schedule the Veteran for an appropriate VA examination to determine the nature, onset, and likely etiology of the Veteran's gastrointestinal condition. The entire claims file and a copy of this Remand must be made available to the examiner and the examiner shall indicate in the report that the claims file was reviewed. Any tests or studies deemed necessary should be conducted, and the results should be reported in detail. After review of the claims file and examination of the Veteran, the examiner should render an opinion as to whether it is at least as likely as not (i.e., 50 percent probability or greater) that any currently diagnosed gastrointestinal condition, to include IBS, had its onset in service or is related to any in-service disease, event, or injury, to include the in-service complaints and treatment. The examiner should also offer an opinion as to whether the Veteran's gastrointestinal condition is at least as likely as not (i.e., 50 percent probability or greater) is proximately due to or caused by the Veteran's service-connected acquired psychiatric disorder. If not, is it at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's gastrointestinal condition was aggravated (worsened in severity beyond a natural progression) by the Veteran's service-connected acquired psychiatric disorder? If the examiner determines that the Veteran's gastrointestinal condition was aggravated by his acquired psychiatric disorder, the examiner should report the baseline level of severity of the gastrointestinal condition prior to the onset of aggravation. If some of the increase in severity of the gastrointestinal condition is due to the natural progress of the disease, the examiner should indicate the degree of such increase in severity due to the natural progression of the disease. The examiner's report must reflect consideration of the Veteran's entire documented medical history and assertions and all lay evidence. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. The examiner must provide a rationale for each opinion given. 5. After completing the requested actions, and any additional notification and/or development deemed warranted, re-adjudicate the Veteran's claim. If the claim remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and be allowed an appropriate period of time for response. The case should be returned to the Board for further appellate review, if otherwise in order. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Kipper, 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.