Citation Nr: 21074671 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 18-10 550 DATE: December 16, 2021 ORDER Service connection for obstructive sleep apnea is granted. Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder other than PTSD is remanded. FINDINGS OF FACT 1. Resolving any reasonable doubt in the appellant's favor, the Veteran had symptoms of obstructive sleep apnea during active duty service and ever since service separation. 2. The Veteran did not have combat service and does not meet the diagnostic criteria for a valid diagnosis of PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for obstructive sleep apnea are met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 2. The criteria for service connection for PTSD are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.309, 4.125 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant in this case, served on active duty from January 1967 to November 1986. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2014 rating decision of a Department of Veterans' Affairs (VA) Regional Office, the agency of original jurisdiction (AOJ). In August 2021, the Veteran testified during a virtual Board hearing before the undersigned Veterans Law Judge (VLJ). A copy of the hearing transcript is of record and has been reviewed. During the August 2021 Board hearing, the VLJ agreed to hold the record open for 30 days to allow for the submission of additional evidence in support of the Veteran's claims. See Board hearing transcript dated August 16, 2021 (Hearing Transcript) at pg. 7. Following the hearing, the Veteran submitted additional evidence for consideration in the adjudication of his claim for service connection for obstructive sleep apnea. Thereafter, the Veteran's representative filed a motion requesting an additional 30 days to allow for submission of new evidence. See Representative's correspondence received September 30, 2021. On October 13, 2021, the VLJ granted a 30 day extension, noting that good cause was found for the extension. See Board correspondence dated October 13, 2021. Additional evidence, a psychiatric evaluation and medical opinion by a private psychologist, was timely submitted and has been associated with the electronic claims file. As the additional evidence was received after the January 2018 Statement of the Case, the AOJ has not had the opportunity to consider it in adjudicating the Veteran's claim for service connection for a psychiatric disorder. However, because the evidence was submitted after the filing of the February 2018 substantive appeal (VA Form 9), initial AOJ consideration of the evidence is automatically waived unless the Veteran or his representative requests in writing that the AOJ initially review such evidence. 38 U.S.C. § 7105(e). No such request has been received. Nevertheless, since the issuance of the January 2018 Statement of the Case, additional VA treatment records have been associated with the Veteran's claims file. Having reviewed this evidence, the Board finds that it is relevant to the claim of entitlement to service connection for a psychiatric disorder. Automatic waiver does not apply to VA treatment records, as the evidence is VA-generated, and there is no signed waiver of AOJ review of the evidence from the Veteran or his representative. Therefore, a remand is necessary for consideration of the evidence of record by the AOJ. 38 C.F.R. § 20.1304(c); 38 U.S.C. § 7105. Moreover, for reasons set forth below, additional development of the claim for service connection for an acquired psychiatric disorder is necessary on remand. The Board now finds it appropriate to bifurcate the issue of entitlement to service connection for PTSD into separate claims for entitlement to service connection for PTSD and for an acquired psychiatric disorder other than PTSD, to include an anxiety disorder. See Roebuck v. Nicholson, 20 Vet. App. 307, 315 (2006) (acknowledging that the Board can bifurcate a claim and address different theories or arguments in separate decisions); Locklear v. Shinseki, 24 Vet. App. 311 (2011) (bifurcation of a claim generally is within VA's discretion); see also Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Preliminary Matter The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Service Connection Applicable Laws and Regulations Generally, service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed aggravation of a disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Where a veteran served 90 days or more of active service, and certain chronic diseases, including psychosis, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. Here, neither obstructive sleep apnea nor PTSD are among the diseases enumerated under 38 C.F.R. § 3.309(a) and the record does not reflect a diagnosis of psychosis during or after service. Therefore, presumptive service connection under 38 C.F.R. § 3.303(b) is not for application. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57(1990). Competency of evidence differs from weight and credibility. A lay person is competent to report on the onset and reoccurrence of current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). The Board must determine, on a case by case basis, whether a veteran's particular disability is the type of disability for which lay evidence may be competent. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). When all the evidence is assembled, 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 a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Obstructive Sleep Apnea The Veteran had a current diagnosis of obstructive sleep apnea (OSA) since at least April 2014. See VA Respiratory Therapy Diagnostic Study dated April 9, 2014. The Veteran generally asserted that his OSA is related to or onset during a period of active duty service. After a careful review of all the evidence, lay and medical, the Board finds that symptoms of the currently diagnosed OSA had their onset during active duty service. The Veteran's service treatment records do not reflect symptoms, diagnosis, or treatment of OSA. Post-service treatment notes reflect that during an August 2013 VA outpatient appointment, the Veteran reported that his wife told him he snores a lot and stops breathing at intervals. See VA Ambulatory Care Note dated August 22, 2013. In September 2013, the Veteran was seen for a VA pulmonary consultation, at which time it was noted that "he is waking up gasping sometimes, wife states that he stops breathing." See VA Pulmonary Consult dated September 23, 2014. The Veteran endorsed loud disruptive snoring, apneas, gasping and choking arousals, and excessive daytime somnolence. Based on the Veteran's endorsement of these symptoms, a VA physician's assistant noted possible sleep apnea and recommended a sleep study. Id; see also VA Primary Care Note dated March 21, 2014. A sleep study was completed thereafter, and the Veteran was clinically diagnosed with OSA in April 2014. See VA Respiratory Therapy Diagnostic Study dated April 9, 2014. During the August 2021 Board hearing, the Veteran stated that during active duty his spouse told him he had loud snoring and he would stop breathing when he was asleep, but he did not seek treatment until after he retired from service. See Hearing Transcript at pgs. 7-9. He said he remembered his spouse telling him the same thing during service when he was stationed in Germany and that they have been married 54 years as of the time of the Board hearing. Id. An August 2021 statement from the Veteran's spouse W.C. describes how she noticed while the Veteran was stationed in Hawaii that throughout the night the Veteran would snore continuously, and he would stop breathing while asleep and then catch his breath again and resume breathing. See Statement of W.C. received August 20, 2021. W.C. noted that not knowing it was a medical condition the Veteran did not seek medical help or inform his doctor of these symptoms. Id. The Board notes that the Veteran was not afforded a VA examination to determine the likely etiology of his OSA. While a medical opinion could be requested to consider the question of etiology, the current evidence is sufficient to decide the claim. On appeal, the Veteran indicated through his statements and those of his spouse that he experienced loud snoring and breathing cessation during active duty service, and that he continued to experience these symptoms from their onset during active duty service and thereafter, which is consistent with the Veteran's post-service treatment records. The Veteran and his spouse are competent to report that the Veteran experienced sleep disturbances, including snoring and paused or stopped breathing. See Layno, supra. Furthermore, the Board finds the statements of the Veteran and his spouse with respect to such symptoms both competent and credible. In fact, there is nothing in the record that contradicts these lay assertions. The Board additionally notes that proof of symptoms in service that are later diagnosed may be evidence of service "incurrence." See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303(a), (d); Jandreau, 492 F.3d at 1377 (lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). The finding that the Veteran had OSA symptoms, particularly to include snoring and nighttime breathing difficulties dating from active service, as well as the competent and credible statements of his snoring and paused or stopped breathing that continued thereafter, is supportive of the claim overall, because it tends to show that the same symptoms that began in service were the basis for the later diagnosed OSA. See Horowitz v. Brown, 5 Vet. App. 217, 221-22 (1993) (lay statements are competent as to in-service and post-service symptoms). Accordingly, based on the competent and credible lay and medical evidence of record, and resolving all reasonable doubt in favor of the Veteran, the Board finds that his OSA had its onset during active service. See 38 C.F.R. §§ 3.102, 3.303(d). Given the Board's grant of service connection on a direct basis based on the Veteran's symptoms of OSA during service and continuing after his separation from active duty, all other theories of entitlement are rendered moot. PTSD Service connection for a psychiatric disorder, to include PTSD, requires the following three elements: (1) a current medical diagnosis of a psychiatric disorder, to include PTSD, (2) credible supporting evidence that the claimed in-service stressor(s) actually occurred, and (3) medical evidence of a causal relationship between current symptomatology and the specific claimed in-service stressor(s). See 38 C.F.R. § 3.304(f). VA regulation 38 C.F.R. § 4.125 requires PTSD diagnoses to conform to the Diagnostic and Statistical Manual of Mental Disorders (DSM) as the governing criteria for diagnosing PTSD. Parenthetically, the Board notes VA implemented DSM-V, effective August 4, 2014 and DSM-V applies to claims certified to the Board on and after August 4, 2014. 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). Here, a VA examination was conducted in August 2014 pursuant to DSM-V. Accordingly, the Board recognizes that the examination was correctly rendered pursuant to the criteria in effect at the time. In adjudicating a claim for service connection for PTSD, the Board is required to evaluate evidence based on places, types, and circumstances of service, as shown by the veteran's military records and all pertinent medical and lay evidence. Hayes v. Brown, 5 Vet. App. 60, 66 (1993); see also 38 U.S.C. § 1154(a); 38 C.F.R. § 3.304(f). The evidence necessary to establish the occurrence of an in-service stressor for PTSD will vary depending on whether or not the veteran "engaged in combat with the enemy." Id. The question of whether a veteran was exposed to a stressor in service is a factual one, and VA adjudicators are not bound to accept uncorroborated accounts of stressors or medical opinions based upon such accounts. Wood v. Derwinski, 1 Vet. App. 190 (1991), aff'd on reconsideration, 1 Vet. App. 406 (1991). Hence, whether a stressor was of sufficient gravity to cause or support a diagnosis of a psychiatric disorder, to include PTSD, is a question of fact for medical professionals and whether the evidence establishes the occurrence of stressors is a question of fact for adjudicators. Here, the threshold question is whether the Veteran actually has the disability for which service connection is sought, PTSD. The Board finds that the Veteran does not met the criteria for a valid diagnosis of PTSD during the course of the appeal. The Veteran's claim for PTSD was received in September 2013. A month earlier in August 2013, the Veteran reported having PTSD, but a PTSD screening was negative. See VA primary care nursing note dated August 22, 2013. During an October 2013 consultation with a VA psychiatrist, the Veteran asserted having PTSD that had gone untreated for a long time, noting symptoms of being startled easily and becoming easily irritated and feeling road rage. He added that he served in Vietnam for three months "working on missions of recovery [of dead] people from the tunnels. He does not think [he] killed anyone, but [he] fired his rifle." He noted that he suffered anemia and received a medical profile. Upon review, the VA psychiatrist concluded, "Patient has no criteria for PTSD" and diagnosed anxiety disorder. See VA mental health consultation dated October 29, 2013. A May 30, 2014 VA PTSD screening was negative. A July 2019 VA PTSD screening was positive; however, the Veteran declined further evaluation or intervention. An August 2014 VA PTSD examination applying DSM-V criteria reflects that there was no basis for a mental disorder diagnosis, including PTSD. See VA Initial PTSD examination dated August 20, 2014. The examiner stated that the Veteran identified and detailed a stressor that meets Criterion A, specifically, the Veteran's report that he "pulled bodies out of the tunnels" in Vietnam. However, the examiner also stated that the Veteran "does not meet diagnostic criteria for PTSD." Specifically, the examiner noted that was negative for all PTSD symptoms listed in the VA examination form. Id. at pgs. 5-9. The Board finds the August 2014 VA opinion that the Veteran did not meet the criteria for a diagnosis of PTSD to be highly probative. The August 2014 VA examiner reviewed relevant medical records, the opinion was consistent with DSM-V criteria, and the examiner also provided insight into why the Veteran's symptoms did not satisfy DSM-V criteria. The examiner noted reviewing the Veteran's pertinent medical records, and set forth a sufficient rationale, primarily that while the Veteran reported a stressor that arose from his experiences in Vietnam, he did not satisfy DSM-V criteria sufficient to establish a diagnosis of PTSD. Notably, the VA examiner conducted an in-person interview of the Veteran in reaching conclusions about the veracity of his claims of having PTSD symptoms, relying on the examiner's personal knowledge and expertise in psychiatry. The August 2014 examination findings are also consistent with the October 2013 VA evaluation discussed above. The Board notes that a September 2021 evaluation by private a psychologist concurs with the August 2014 VA examiner's finding that the Veteran does not meet the diagnostic criteria for PTSD. See Psychiatric evaluation dated September 2, 2021 by Q.A.S. Ph.D. As indicated above, lay persons are competent to provide opinions on some medical issues; however, in this case the question of whether the Veteran has PTSD falls outside the realm of common knowledge of any lay person. See Young v. McDonald, 766 F.3d 1348, 1353 (Fed. Cir. 2014). Therefore, while the statements of the Veteran are duly considered by the Board, they, respectfully, are not competent to render a diagnosis or a medical opinion with respect to the issue of entitlement to service connection for PTSD. To summarize, the Board finds the October 2013 VA mental health consultation and the August 2014 VA PTSD examination report to be highly probative. Therefore, the Board finds that the most probative evidence of record shows that the Veteran has not had a valid diagnosis of PTSD at any time during the pendency of the appeal. Accordingly, the Board concludes that entitlement to service connection for PTSD must be denied because the weight of the evidence is against the claim. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND Acquired Psychiatric Disorder other than PTSD Remand is necessary to ensure that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. Generally, the degree of probative value which may be attributed to a medical opinion of record takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Nieves-Rodriguez, 22 Vet. App. at 304 (the probative value of a medical opinion comes from its being factually accurate, fully articulated, and having a sound reasoning for the conclusion). Also significant is whether the examiner had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999). Here, the September 2021 evaluation by a private psychologist reflects diagnoses of other specified stressor disorder, adjustment disorder due to general medical conditions, and alcohol use disorder in sustained remission pursuant to DSM-V criteria. See Psychiatric evaluation by Q.A.S. dated September 2, 2021 at pg. 5. Q.A.S. opined that the Veteran's "other specified stressor disorder more likely than not, is related to military service events in Vietnam. His adjustment disorder, more likely than not, is related as a secondary condition to his already service-connected medical conditions." Id. at pg. 6. Q.A.S. explained that, the Veteran "experienced considerable trauma in Vietnam. He was part of active combat, as clearly documented in the records. He found patrols terrifying. He saw friends get killed and wounded. He was engaged in active firefights and fears he may have killed Vietnamese soldiers." Id. at pg. 2. Q.A.S. further noted, "He was at a hospital and saw many injured and evacuated from Vietnam, this was further traumatic for him." Id. However, Q.A.S.'s characterization of the claimed in-service injuries is not credible and the supporting rationale for Q.A.S.'s opinion is inconsistent with the record. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based upon an inaccurate factual premise has no probative value). The Veteran's service treatment and personnel records reflect that four days after his deployment to Vietnam, he was admitted on August 18, 1967 to the Army 85th Evacuation Hospital where he was diagnosed with hemolytic anemia. See Abbreviated Clinical Record dated August 18, 1967; Clinical Record Cover Sheet dated August 18, 1967. On August 22, 1967, he was transferred from the evacuation hospital to an Army hospital in Japan where the diagnosis of hemolytic anemia was confirmed and attributed to antimalarial prophylactic medication the Veteran was issued by the Army. The Veteran was discharged from the Army hospital in Japan a month later, on September 21, 1967, and from there returned to the United States for assignment to Fort Dix, New Jersey, with a permanent profile warning against deployment to areas with malaria. See Medical evaluation from Commanding Officer of U.S. Army Hospital, Camp Zama, Japan dated September 20, 1967; Clinical Record/Narrative Summary dated September 21, 1967. The service personnel records appear to include an entry noting that the Veteran was assigned or involved in a Vietnam counteroffensive, Phase III, in 1967. See List of campaigns (VBMS entry with document type "Military Personnel Record," receipt date 09/26/2017, at pg. 47 of 122). However, the nature of the Veteran's assignment or involvement in the counteroffensive, if any, is not indicated in the personnel records. Although these records show that the Veteran qualified in the use of firearms and he was awarded the Vietnam Service Medal and Vietnam Campaign Medal, this evidence does not by itself indicate that the Veteran engaged in combat. Furthermore, the Board observes that despite VA's repeated efforts to obtain specific stressor information from the Veteran through the pendency of his claim, and the undersigned VLJ's specific request for such details during the August 2021 Board hearing, the Veteran persisted in providing only vague replies to these inquiries. Indeed, when asked during the Board hearing to specifically identify his in-service stressors, the Veteran vaguely mentioned pulling bodies out of tunnels during a one-week training and transportation by helicopter to a hospital. Notably, the Veteran's service personnel records reflect that he was in Vietnam less than a week, which would have precluded completing the one week training period he described. While Q.A.S. has broadened the Veteran's claimed stressors and described them in somewhat more detail, these characterizations of the in-service injuries are not consistent with the record and the Board is unable to assess the veracity of what the Veteran told Q.A.S. during the evaluation interview and upon which the opinion is based as the underlying statements are not of record. Accordingly, the Board finds the September 2021 opinion of low probative weight. The Board notes that in this case, the Veterans Claims Assistance Act of 2000 (VCAA) notice requirements were satisfied by way of the February 2014 and March 2014 VA notice letters. Further, on at least two occasions during the pendency of this claim, the AOJ requested that the Veteran provide specific information regarding his claimed stressors for purposes of developing the claim, as reflected in VA correspondence dated March 13, 2014 and September 20, 2017, providing a VA form for that purpose (VA Form 21-0781); however, the record does not reflect that the Veteran or his representative provided specific information responsive to either VA request. Indeed, the Veteran maintains the ultimate burden to establish entitlement to service connection. See Fagan v. Shinseki, 573 F.3d 1282, 1287-88 (2009). Moreover, VA's duty to assist is a two-way-street; if the Veteran wishes help, he cannot, as has occurred here, passively wait for it in those circumstances where he may or should have information that is essential in obtaining relevant evidence or adjudication of the claim. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The VCAA duty to assist has been satisfied in this case. The complete service records and all identified and available post-service private and VA treatment records appear to be associated with the record. As the AOJ made reasonable efforts to develop the claim, the duty to assist in obtaining records has been complied with and no further duty to assist is required. 38 C.F.R. § 3.159(c). Nevertheless, a March 2018 VA mental health chronic pain management note suggests that the Veteran's mood and pursuit of social and recreational engagements is impacted by low back pain. See VA Mental Health Chronic Pain Management Note dated March 7, 2018. As the Veteran is service-connected for status-post discectomy L5-S1, the March 2018 treatment notes suggest that the Veteran's psychiatric disorder may be secondary to this service-connected back disability. 38 C.F.R. § 3.310(a). Accordingly, remand is necessary to obtain a VA opinion addressing the likely etiology of the Veteran's currently diagnosed psychiatric disorders, to include as secondary to service-connected disabilities. See McLendon, 20 Vet. App. 79, 83 (2006) (recognizing that 38 C.F.R. § 3.159(c)(4) presents a low threshold for the requirement that evidence indicate that claimed disability may be associated with service or with another service-connected disability for purposes of obtaining an examination). The matter is REMANDED for the following action: 1. Implement the Board's decision herein granting service connection for obstructive sleep apnea. 2. Ensure that all outstanding VA treatment records are associated with the claims file. 3. Then, obtain an opinion from an appropriately qualified VA examiner, as to the nature and etiology of the Veteran's currently diagnosed psychiatric disorders (i.e., other than PTSD). The claims file, and a copy of this Remand, must be made available to and be reviewed by the examiner. *The examiner's review of the body of this Remand is recommended to assist in avoiding deficiencies that have rendered a prior opinion inadequate. *The need for another examination is left to the discretion of the medical professional offering the opinion. Should an examination be necessary, all indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a complete review of the claims file, the examiner is asked to provide opinions with complete rationale addressing the following: (a) Identify all currently diagnosed psychiatric disorders, to include anxiety disorder and adjustment disorder, that have been present at any point since the commencement of the claim period in September 2013. (b) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the currently diagnosed psychiatric disorder(s) was CAUSED or AGGRAVATED by the service-connected status post discectomy L5-S1, pain associated therewith, AND/OR the Veteran's other service-connected disorders. *Any increase/aggravation is sufficient; permanent aggravation is NOT required. See Ward v. Wilkie, 31 Vet. App. 233, 239-240 (2019) (permanent worsening is not a requirement for secondary service connection of a non-service-connected injury or disease). To ensure that the correct legal standard is applied, which is essential for adjudication of this claim, each opinion regarding secondary service connection MUST be stated in terms of whether the disorder was CAUSED or AGGRAVATED by the service-connected disorder. (c) If the answer to (b) is negative, provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) that the currently diagnosed psychiatric disorder(s) onset during service, or is otherwise etiologically related to service, to include the Veteran's deployment to Vietnam in 1967. Although the examiner must review the entire claims file, the examiner is requested to consider the following potentially relevant evidence, which is identified by VBMS label and receipt date in parenthesis: *VA mental health chronic pain management note suggesting that the Veteran's low back pain interferes with his mood and pursuit of social and recreational engagements (see VBMS entry with document type "CAPRI," receipt date 04/21/2018, at PDF pages 16-17 of 201). The Board's reference to evidence in this context should not be construed as a determination of its credibility. 4. Thereafter, ensure that the examiner has substantially responded to the questions posed by the Board, and if not, take corrective action. 5. Then, readjudicate the remanded claim. S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Farrell, 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.