Citation Nr: 21011761 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 181107-1333 DATE: March 2, 2021 ORDER An initial 70 percent rating for other specified trauma and stressor related disorder, prior to January 22, 2013, is granted. A 70 percent rating for other specified trauma and stressor related disorder, since January 22, 2013, is granted. Entitlement to service connection for posttraumatic stress disorder (PTSD) is granted. REMANDED Entitlement to service connection for hypertension (claimed as high blood pressure) is remanded. FINDINGS OF FACT 1. The Veteran died in October 2020. The Veteran’s wife filed a timely request to be substituted as the appellant in his place. 2. During the period on appeal, the Veteran’s service-connected other specified trauma and stressor related disorder resulted in occupational and social impairment with deficiencies in most areas. 3. The Veteran’s PTSD was related to his in-service combat experiences. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 70 percent rating, but no higher, for other specified trauma and stressor related disorder, during the period on appeal, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9413. 2. The criteria for service connection for PTSD have been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1968 to December 1972. He died in October 2020. The Veteran’s wife filed a timely request to be substituted as the appellant in his place. The rating decision on appeal was issued in August 2018. In May 2018, the Veteran elected the modernized review system. 84 Fed. Reg. 138, 177 (Jan. 18, 2019) (to be codified at 38 C.F.R. § 19.2(d)). The Veteran selected the Higher-Level Review lane when he opted into the Appeals Modernization Act (AMA) review system by submitting a Rapid Appeals Modernization Program (RAMP) election form. His legacy appeal was withdrawn. The August 2018 AMA rating decision considered the evidence of record as of the date VA received the RAMP election form (May 2, 2018). The Veteran timely appealed this rating decision to the Board and requested the evidence submission review lane, allowing him 90 days to submit evidence pertinent to his claim. In May 2019, the Board remanded the issues of entitlement to service connection for diabetes mellitus type II and for entitlement to service connection for chronic kidney disease. The Board additionally denied entitlement to an increased rating for a generalized anxiety disorder between October 1, 2010 to January 21, 2013 and granted an increased rating of 50 percent, but no higher, for a generalized anxiety disorder beginning January 22, 2013. The Board also denied service connection for PTSD and a claim for entitlement to service connection for hypertension (claimed as high blood pressure). Thereafter, the Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In an April 2020 Joint Motion for Remand (JMR), the Secretary of VA and the Veteran (the parties) moved the Court to vacate, in part, the May 2019 decision to the extent that it denied entitlement to an increased rating in excess of 30 percent prior to January 21, 2013 and a rating in excess of 50 percent thereafter. The Court additionally vacated the Board’s denial of entitlement to service connection for PTSD and entitlement to service connection for hypertension. These issues are now again before the Board. The Board notes that development as to the issues of entitlement to service connection for diabetes mellitus and entitlement to service connection for a chronic kidney was conducted. In a March 2020 rating decision, the RO granted service connection for diabetes mellitus, type II, associated with herbicide exposure and entitlement to service connection for chronic kidney disease. These issues are no longer in appellate status. Evidence was added to the claims file during a period of time when new evidence was not allowed. As the Board is deciding the claims of entitlement to increased ratings for the Veteran’s psychiatric disability and entitlement to service connection for PTSD, it may not consider this evidence in its decision. 38 C.F.R. § 20.300. The appellant may file a Supplemental Claim and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. With respect to the claim for entitlement to service connection for hypertension, evidence was added to the claims file during a period of time when new evidence was not allowed. As the Board is remanding this claim for further development, this additional evidence will be considered by the RO in the adjudication of this claim. Increased Ratings 1. Entitlement to an initial rating in excess of 30 percent for other specified trauma and stressor related disorder, prior to January 22, 2013. 2. Entitlement to a rating in excess of 50 percent for other specified trauma and stressor related disorder, since January 22, 2013. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. The Board should consider only those factors contained in the rating criteria. Massey v. Brown, 7 Vet. App. 204 (1994). The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran’s other specified trauma and stressor related disorder has been rated pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9413, as 30 percent disabling prior to January 22, 2013 and as 50 percent disabling since that date for the remainder of the appeal period. As noted above, the only evidence the Board can consider in its analysis is evidence of record at the time of the Veteran’s opt-in to RAMP (May 2, 2018) and within 90 days of his submission of his appeal (October 30, 2018 VA Form 21-4138). Based on a review of the record during the appeal period, the Board finds that a 70 percent rating is warranted for his other specified trauma and stressor related disorder. Under this diagnostic code, a 30 percent rating is warranted if there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, DC 9413. A 50 percent rating is warranted when there is occupational and social impairment, but with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, 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 task); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. The maximum rating of 100 percent requires 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; and memory loss for names of close relatives, own occupation, or own name. Id. The specified factors for each incremental psychiatric rating are not requirements for a particular rating but are examples providing guidance as to the type and degree of severity, or their effects on social and work situations. Thus, the analysis should not be limited solely to whether the symptoms listed in the rating scheme are exhibited; rather, consideration must be given to factors outside the specific rating criteria in determining the level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The classification outlined in the portion of VA’s Schedule for Rating Disabilities that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, of the American Psychiatric Association (DSM-5). 38 C.F.R. § 4.130. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996). Effective August 4, 2014, the DSM-IV was superseded by a new fifth edition that significantly changed diagnostic metrics for mental illnesses. In pertinent part, the DSM-5 eliminated the GAF scores used in the DSM-IV. It was recommended that the GAF be dropped from DSM-5 for several reasons, including its lack of clarity (i.e., including symptoms, suicide risk, and disabilities in its descriptors) and questionable psychometrics in routine practice. A review of the evidence reflects that a rating of 70 percent is warranted for the entire period on appeal. In a statement signed in August 2012, and received by the RO in January 2013, the Veteran reported having suicidal thoughts for many years. He stated that he had thoughts of committing suicide but never carried out any of those thoughts. He reported he would wonder what it would feel like to be dead and thought of ways to commit suicide, but did not go through with these plans because he would consider how this would affect his family. The Veteran underwent a VA examination in January 2013. The Veteran reported that he did not have close friends or voluntarily attend social functions, though he indicated that he had a good relationship with his wife and sometimes accompanied her to church events. The Veteran endorsed passive suicidal ideation. The examiner noted that the Veteran had symptoms of depressed mood; anxiety; suspiciousness; chronic sleep impairment; and the inability to establish and maintain effective relationships. A January 2014 VA treatment record reflected that testing revealed severe depression. In a February 2014 VA treatment record it was noted that the Veteran had feelings of worthlessness, recurrent thoughts of death, feelings of hopelessness and helplessness and isolation and social withdrawal. It was also noted that the Veteran had difficulty with anger management. In a statement received in March 2014, the Veteran reported symptoms including anxiety, depression, panic attacks, a chronic sleep impairment, impairment with memory, disturbances of motivation and mood, feeling of worthlessness and helplessness, and thoughts of death or suicide. The Veteran reported participating in treatment for his psychiatric issues. In a June 2014 letter from the Veteran’s VA treating physician it was noted that the Veteran had a depressed mood with intermittent suicidal ideation (no intent), anxious mood, hypervigilance, intrusive memories of combat, nightmares, sleep disturbance, irritability and social isolation. Significantly, the VA treating psychiatrist completed his letter noting that the Veteran shows definite occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking, mood due to symptoms as outlined above. He noted that the Veteran has difficulty in establishing and maintaining effective work and social relationships. The Veteran underwent an additional VA examination in July 2015. The examination notes that the Veteran was referred to a psychiatrist in 2014 for treatment, who referred him to an outpatient PTSD program. The examiner noted that the Veteran was prescribed medication and attended 30 to 35 PTSD-related group therapy sessions until health issues forced him to terminate his care. The examination indicates that the Veteran had symptoms of depressed mood, anxiety, chronic sleep impairment, and mild memory loss. After a review of the Veteran’s claims file and an in-person assessment, the examiner opined that the Veteran had occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during period of significant stress, or; symptoms controlled by medication. The examiner indicated that the Veteran had sub-threshold PTSD symptoms that warrant a current DSM-5 diagnosis of Other Specified Trauma- and Stressor-Related Disorder. An October 2015 medical treatment record, authored by a social worker, reflects that the Veteran reported feeling depressed, agitated and angry, a lack of interest in things he used to enjoy, a lack of energy, intrusive thoughts, nightmares, sleeping difficulty, worry that his kidneys may stop working and that he might die, nervous or anxious, avoidance of thoughts related to combat, hyper startle response, and hypervigilance. The note indicates that the Veteran was casually dressed and his hygiene was okay. He was cooperative and pleasant, anxious or depressed; his speech was within normal limits; thought process was logical and goal directed; insight and judgement were fair. The Veteran denied suicidal or homicidal ideation. The social worker noted diagnoses of PTSD and major depressive disorder. A February 2016 treatment record, signed by a clinical pharmacy specialist, indicates a diagnosis of PTSD and anxiety disorder. The Veteran reported he was sleeping better, worked in the garage on projects, and his energy level and mood were up. He noted that he snapped at his wife a couple of times. He denied suicidal and homicidal ideation. His appearance was noted as neat and clean; attitude was cooperative; speech was normal; mood was depressed; perception was within normal limits; affect was congruent with mood; thought process was linear and logical; insight and judgment were good; and cognition was grossly intact. In a March 2018 report by a licensed clinical psychologist, it was noted that based on his clinical interview, professional experience, and records review it was his professional evaluation that during the period on appeal the Veteran’s psychiatric disabilities had resulted in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking and mood due to such symptoms as suicidal ideation, difficulty in adapting to stressful circumstances (including work or a work like setting), and neglect of personal appearance and hygiene. The Board has also considered a March 2018 statement from the Veteran. He reported that he had suffered from mental problems since service and used alcohol to cover up his problems for many years. He reported that once he stopped drinking his symptoms became overwhelming and he began treatment around 2013. The Veteran reported trouble sleeping because of nightmares. He reported that he did not like to stand in line with people and did not like a lot of people around him. He reported being suspicious of people and did not trust hardly anyone. He stated that he checked the locks around his house three times a night and when driving he would continuously look in the rearview mirror thinking somebody was following him. He reported only leaving his house about once a week and sometimes less than that. The Veteran reported that he tended to distance himself from people, even his own family and had very few people that he considered friends. The Veteran reported tending to flareup or get angry about small things that he could not control or getting upset with his wife when he should not have. He reported feeling totally worthless and was on the verge of considering suicide. He reported still having these thoughts whenever he became depressed and had thoughts of suicide on and off. The Board has additionally considered a March 2018 statement from the Veteran’s son. He reported that the Veteran did not like being around crowds and was easily irritable. He reported that his father was always suspicious of other people and when they did go out, he had to sit with his back against a wall and was always watching entrances. The Veteran’s wife additionally submitted a March 2018 statement. She reported that she had been married to the Veteran for forty-five years. She reported that he had trouble sleeping, tended to have mood swings and when he would get angry, he used to throw things. She reported that he was very suspicious of other people and did not trust anyone. Following a review of the evidence, to include the statements of the Veteran, the Board finds that the Veteran’s service-connected psychiatric disability was most consistent with a 70 percent disability rating, not the 30 and 50 percent disabilities ratings currently assigned. Although some treatment records appear to reflect milder psychiatric symptomatology, the evidence as a whole is most consistent with a 70 percent disability rating. Accordingly, and based on these findings, the Board finds that a 70 percent rating is warranted. Nevertheless, the Board finds that a rating in excess of 70 percent is not warranted for any period during the pendency of the claim, as the Veteran’s symptomatology did not manifest as total occupational and social impairment, due to such symptoms as (for example only): 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. Id. The Veteran’s reported social functioning was fairly consistent throughout the period on appeal, with social isolation and some interaction. Thus, while limited, he was still able to continue relationships with some people, including some family. Although he experienced unemployment during the appeal period, a rating of 100 percent is only warranted for both total social and total occupational impairment. Although the Board notes that a February 2014 VA treatment record noted symptoms of hallucinations, the evidence as a whole in no way supports a finding that these reported hallucinations were persistent in nature. The Board concludes the criteria for a 100 percent rating for the Veteran’s service-connected psychiatric disability were not met at any point during the period on appeal. 38 C.F.R. § 4.130, DC 9413. His own reports at various evaluations regarding how his service-connected psychiatric disability impacted him, overall, would provide additional evidence against this claim, clearly indicating the level of symptomatology cited within the 100 percent rating were not met at any point during the period on appeal. In summary, while the Veteran was significantly socially limited by his service-connected psychiatric disability, the evidence fails to show that this impairment was “total” so as to warrant a 100 percent rating. Based on the foregoing discussion, the Board finds that Veteran’s other specified trauma and stressor related disorder, more nearly approximated the rating criteria for a 70 percent rating. As such, a rating of 70 percent is granted, but a rating in excess of 70 percent is not warranted. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Finally, 38 U.S.C. § 1154(a) requires that VA give ‘due consideration’ to ‘all pertinent medical and lay evidence’ in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Specifically, ‘[l]ay 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.’ Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). 3. Entitlement to service connection for PTSD. Prior to his death, the Veteran was already service connected for other specified trauma and stressor related disorder. He additionally contended that he should be service connected for PTSD. The Veteran alleged various wartime stressors found in statements submitted in January 2013. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with § 4.125(a) of this chapter; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). The Board notes that the Veteran was awarded the Republic of Vietnam Campaign Medal with Device. Additionally, personnel records reflect that the Veteran was entitled to special pay due to hostile fire. Pursuant to 38 U.S.C. § 1154(b) and 38 C.F.R. § 3.304(d), for any Veteran who engaged in combat with the enemy, VA shall accept lay or other evidence as proof of a disease or injury being incurred or aggravated by such service, even if there is no official record of such incurrence, so long as the evidence is consistent with the circumstances of such service. In view of the Veteran’s personnel records and the circumstances described by the Veteran, the Board finds that the Veteran is entitled to the combat presumption because the claimed stressors are consistent with the circumstances, and conditions of the Veteran’s service. Accordingly, the Board accepts as credible the Veteran’s report of in-service stressors. In support of his claim, the Veteran submitted a March 2018 report from a licensed psychologist. He noted that he had held a videoconference interview with the Veteran. He also summarized the Veteran’s mental health/behavioral issues since 2000. The examiner noted the Veteran’s symptomatology and examples supporting these symptoms. The private psychologist noted that there were no psychiatric problems or nervous conditions noted upon the Veteran’s entrance examination. He stated that he was sound upon entrance into service. Based on a record review, his professional experiences, and clinical interview, he stated that it was his professional opinion that the Veteran met the DSM-5 criteria diagnosis of PTSD and a secondary major depressive disorder moderate recurrent. He also stated that it was his professional opinion that the Veteran’s stressors are more than sufficient to support a diagnosis of PTSD. The examiner also noted that he strongly disagreed with the results of the January 2013 VA examination which noted no diagnosis of PTSD. The examiner considered that the Veteran had been diagnosed with PTSD by three VAMC mental health providers after that VA examination. He also noted disagreement with the July 2015 VA examiner who stated that PTSD was not diagnosed. He summarized his findings noting that based on his clinical interview and his professional experience that the Veteran continues to clearly meet the DSM-V diagnostic criteria for a diagnosis of PTSD. He stated that the Veteran met the DSM criteria for a diagnosis of PTSD since his combat related stressors during active duty. The private examiner also noted that several of the Veteran’s PTSD and depression symptoms overlap and the symptoms are inextricably intertwined, and as a result, it is impossible to differentiate what portion of his occupational and social impairment is caused by depressive disorder as opposed to PTSD. In weighing these opinions, the Board finds that the question of whether the Veteran is diagnosed with PTSD (that is related to his in-service combat stressors) in accordance with the applicable regulation is at least in equipoise. Accordingly, resolving all reasonable doubt in his favor, the Board determines that the criteria for service connection for PTSD have been met. As noted above, the record reflects that the Veteran was already service connected and compensated for other specified trauma and stressor related disorder. While the Veteran filed a claim for service connection for PTSD, the practical effect of this Board decision is that all psychiatric symptomatology and social and occupational impairment, including those PTSD like symptoms, have been attributed by competent evidence to the service-connected other specified trauma and stressor related disorder, which now also includes PTSD. Under the VA rating criteria, all psychiatric disabilities other than eating disorders are rated under one General Rating Formula detailed at 38 C.F.R. § 4.130. The practical effect of this Board decision is that all psychiatric symptomatology and social and occupational impairment will be recognized as originating from the now service-connected acquired psychiatric disorders of PTSD and other specified trauma and stressor related disorder. As such, the Board finds this to be a full grant of the benefit sought on appeal with respect to the service connection psychiatric issues. REASONS FOR REMAND 4. Entitlement to service connection for hypertension (claimed as high blood pressure). The issue of entitlement to service connection for hypertension is remanded to correct a duty to assist error that occurred prior to the rating decision on appeal. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. VA’s duty to assist includes providing a medical examination when is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Prior to his death, the RO did not provide the Veteran with hypertension examination. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or recurrent symptoms of disability, (2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence indicates that there may be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). Prior to his death, the Veteran stated that he had suffered from blood pressure issues since his time in service. See January 2013 and March 2014 statements. The Veteran’s March 2014 statement can also be construed as a secondary claim for hypertension based on his service-connected psychiatric disability. Treatment records confirm that he was subsequently diagnosed with hypertension. The Board finds that the AOJ committed a pre-decisional duty to assist error by failing to obtain a VA medical opinion. As such, a remand is necessary. The Board observes that potentially favorable medical evidence (June 2020 positive nexus independent medical opinion) has been added to the claims file since the evidence of record considered in the August 2018 RAMP Higher-Level Review rating decision, and outside the 90 days of receipt of his appeal. The Board is legally precluded from considering this evidence. The matters are REMANDED for the following action: Forward the Veteran’s claims folder to an examiner for addendum opinion regarding the Veteran’s hypertension disability. The examiner is requested to review the claims folder, to include this remand. Following review of the claims file the examiner should provide an opinion on the following: Whether it is at least as likely as not (a probability of 50 percent or greater) that the Veteran’s hypertension disability began in, or is otherwise etiologically linked to, his time in service. Whether it is at least as likely as not (a probability of 50 percent or greater) that the Veteran’s hypertension was caused by his service-connected acquired psychiatric disability. Whether it is at least as likely as not (a probability of 50 percent or greater) that the Veteran’s hypertension was aggravated by his service-connected acquired psychiatric disability. The term “aggravated” in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. Rationale for all requested opinions must be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. (Continued on the next page)   In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). C. CRAWFORD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. M. Clark, 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.