Citation Nr: 21041594 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 18-41 859 DATE: July 9, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and persistent depressive disorder, is remanded. Entitlement to an initial compensable rating for fifth metacarpal fracture residuals, to include arthritis, due to right hand trauma, is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1981 to February 1982 and from January 1983 to December 1988. This matter comes before the Board of Veteran's Appeals (Board) from an October 2016 rating decision that denied service connection for PTSD and a September 2017 rating decision that granted service connection for arthritis, fifth metacarpal fracture, in the right hand, issued by the Department of Veterans Affairs (VA) Regional Office (RO). In March 2021, the Veteran testified via videoconference before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the record. As the evidence of record suggests that the Veteran may suffer from more than one psychiatric disorder, to include PTSD and persistent depressive disorder, the Board has recharacterized the claim as it appears on the title page of this remand. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009) (holding that a claim for benefits for one psychiatric disability also encompassed benefits based on other psychiatric diagnoses and should be considered by the Board to be within the scope of the filed claim). 1. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and persistent depressive disorder, is remanded. The Veteran seeks service connection for an acquired psychiatric disorder, claimed as PTSD. In favor of his claim the Veteran asserts that his acquired psychiatric disorder is related to his service, specifically his service in Germany. The Veteran has submitted multiple statements pertaining to his PTSD stressors, as well as other evidence consisting of news articles and reports in support of his assertions. Additionally, his military personnel record, his service treatment records (STRs), and some of his post-service medical records have also been associated with the claims file. The Veteran's military personnel records show that he was stationed in Germany from February 1985 to August 1987. A Behavioral Health Evaluation, associated with the claims file in May 2016, noted a diagnosis of PTSD with persistent depressive disorder. This evaluation included a succinct mention of the Veteran's claimed stressors of being stationed in Germany, having to pull guard duty on missile sites, being locked-in for weeks at the time due to threats, and that other sites were attacked while he was there. See Behavioral Health Evaluation associated with the claims file in May 2016. The Board notes this evaluation report is signed by a professional counselor/therapist. In a Statement in Support of claim, associated with the claims file in May 2016, the Veteran noted he had been diagnosed with PTSD by VA in 1998 and described his in-service stressors. He mentioned being stationed on a Hawk missile site in Germany. He explained that while he was there, in October 6, 1985, one of the missile sister sites was attacked which caused all Hawk sites near the attack to heighten their security, to include a lock down. The heightened security was supported by continued foot patrols and "conditioning of an actual terrorist threat." The Veteran also asserted that eventually he was given down time to relax during which he visited a nearby town where he experienced what he describes as a "visual nuclear attack on the city" that took place in his "mind's eye." He reported that this event/experience resulted in an "emotional split" and a "numbing effect" that has been present since then and has affected every aspect of his life. He also noted that after this event, he experienced "multiple disassociations" during the continued heightened security measures at the missile sites. See Statement in Support of Claim, associated with the claims file in May 2016. In May 2016, the Veteran also submitted a narrative of events he believed relevant to his PTSD stressor and claim. In this narrative the Veteran noted that in September 6, 1985, terrorist infiltrated a Hawk Missile site, where they blew up radar units. The Veteran explained that this event caused a ripple effect and sister missile sites located at Giessen/Kirchgoens/Fulda were put on alert and locked down. He also noted that the responsibility of guarding the sites was very intense due to the number of places to be guarded and the number of available personnel to do so. He asserted that for 5 months, he and other soldiers were required to pull continual guard duty. The duty was very stressful for the Veteran who would often pull double duty. Additionally, the Veteran described how he felt while walking the perimeter and his state of mind while doing so. He explained that walking the perimeter made him feel like a target- as the fence was far away from buildings and illuminated. He explained that most of the time he was at the edge of panic when on the outside of the fence and could barely hold himself from running; in addition to thoughts of how it would be easy for someone to shoot someone doing the perimeter check and how that someone would not be found for a long time because the back of the fence was so far from other buildings. He also noted that he guarded the perimeter on another site, that was very similar but that there was only one way in and out of the concertina wire. He explained that when he was assigned to duty there, they would stay for days and take shifts pulling guard duty. He noted that his mind played a lot of scenarios out during that time as to what would he do if something were to happen and he began to not sleep. He also recounted a specific incident that happened while walking the perimeter with another soldier. He explained that they saw lights in the woods, outside the fence. They immediately dropped to the ground and tried to radio others. The radio did not work properly, and the Veteran thought it was an imminent attack and that the radio signals were being jammed. He sent the fellow soldier to run for assistance while he stayed behind and prepared for the imminent attack while running scenarios in his head. He noted that after a while of not seeing lights in the woods, and his fellow soldier not returning, he went back to the guard shack where he was informed that the other guards had confirmed with the guards outside the gates that there was no one in the woods. None of the guards that were aware that there was no threat had thought to get the Veteran or inform him. The Veteran stated that he was too embarrassed of his thoughts to say anything to the others. After this event, he was given free time, he went to a nearby town and thought he saw a nuclear missile shoot down from the sky and thought he only had a few more minutes to live. When he opened his eyes and saw everything normal, he went to the nearest bar and began to drink, thinking he had gone mad. Since then, he often has panic attacks, nightmares, and does not sleep long. See Statement, associated with the claims file in May 2016. In July 2016, medical records from a VA facility were associated with the claim file. These records show diagnoses of depression and PTSD in 1998. See medical records for October and December 1998. In September 2016, the Veteran presented another narrative with more details on his stressors. See Statement of September 2016. In October 2016, VA issued a formal finding of a lack of information to corroborate the stressors. In pertinent part VA noted having reviewed the May 2016 and September 2016 statements but determined that these statements did not contain sufficient information for corroboration. Additionally, it was noted that the Veteran was stationed in Germany from February 1985 to August 1987. However, VA found that as the Veteran did not indicate witnessing the death or injury of any individual and was not involved in direct combat action, further efforts to corroborate the Veteran's assertions would not likely provide verifiable supporting data. See Memorandum, dated September 2016 and associated with the claims file in October 2016. In March 2021, the Veteran provided testimony in favor of his claims. Pertinent to the claim of service connection for PTSD, the Veteran testified as to how terrorist attacks in Germany, such as a bombing of the Frankfurt Airport in June 1985 and the killing of a U.S. Solider in August 1985, resulted in heightened security and high stress levels in his duty station. He also mentioned patrolling the perimeter, the event of seeing lights in the woods, and his vision of seeing an attack on the city he was visiting. He also mentioned that as a result of all of these events, he was feeling burnt out, drinking to self-medicate and had a car accident in Germany while under the influence of alcohol- for which he was reprimanded. See hearing transcript. Additionally, that same month, the Veteran submitted a report on terrorist events and various news articles dating back to 1985 and 1986 that confirm the occurrence of some of the events the Veteran has asserted caused his PTSD; to include the bombing of the radar in 1985, the bombing of a base, and the killing of a U.S. soldier by terrorist who later used his identification documents to enter and carry out an attack in a base. See news articles and reports associated with the claims file in March 2021. Based on the above, the Board finds that the claim must be remanded for corroboration of the Veteran's stressors and a VA examination. Generally, 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, 1131; 38 C.F.R. § 3.303 (a). To establish a right to compensation for a present disability, a Veteran 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 - the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Notwithstanding the above, service connection for PTSD is subject to the following specific statutory requirements: (1) medical evidence establishing a diagnosis of the disorder, (2) credible supporting evidence that the claimed in-service stressor occurred, and (3) a link established by medical evidence between current symptoms and an in-service stressor. 38 C.F.R. § 3.304 (f). Notably, applicable regulation requires that the PTSD diagnosis be made in accordance with the criteria of Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 38 C.F.R. § 3.304 (f); 38 C.F.R. § 4.125 (a). In the present appeal, there is medical evidence of record that notes a diagnosis of PTSD. However, the PTSD diagnosis made by a VA psychologist in 1998 was not made in accordance with the DSM-5 criteria. Moreover, the Behavioral Health Evaluation, associated with the claims file in May 2016, which noted a diagnosis of PTSD with persistent depressive disorder, seems to have been prepared and signed by a professional counselor/therapist, not a psychologist or psychiatrist. Thus, it is unclear whether the Veteran's PTSD diagnosis meets or has met at any time during the appeal period the DSM-5 criteria, as required by the applicable regulation. The Board acknowledges that the Veteran reported receiving treatment for his psychiatric disorder from a non-VA provider- who passed away recently due to COVID. See hearing transcript page 22-23. The Board further notes that some private medical records from the Center for Counseling and Human Development were associated with the claims file in September 2016 and medical records from Fairview, dated March 2021, were submitted by the Veteran. There are no other medical records, VA or non-VA, related to PTSD or psychiatric treatment for recent years in the claims file. On remand, the RO must send the Veteran the necessary authorization forms so that VA may attempt to obtain any outstanding medical records on his behalf, if available. Moreover, the Veteran's claimed stressors and/or the circumstances surrounding such stressors have not been corroborated by VA. There are several avenues to document an in-service stressor, other than obtaining verification from an appropriate government records repository. In cases of in-service PTSD diagnosis, combat service, or prisoner of war status a Veteran's stressor may be verified by lay evidence. 38 C.F.R. § 3.304 (f)(1), (2), (4). Lay evidence of personal assault requires appropriate corroboration, and a stressor related to a Veteran's fear of hostile military or terrorist activity requires appropriate medical evidence. 38 C.F.R. § 3.304 (f)(3), (5). Based on the available evidence of record, the Board notes that the Veteran was not diagnosed with PTSD while in service, did not engage in combat, was not a prisoner of war nor has the Veteran asserted that his PTSD stems from personal assault. Thus, the provisions of 38 C.F.R. § 3.304 (f) (1), (2), (4), and (5) do not apply. However, the Veteran's stressors seem to be related to fear of hostile military or terrorist activity. Thus, 38 C.F.R. § 3.304 (f) (3) applies- which establishes a reduced evidentiary burden to establish a stressor related to a fear of hostile military or terrorist activity. Pertinently, 38 C.F.R. § 3.304 (f) (3) stablishes that if a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. For purposes of this paragraph, "fear of hostile military or terrorist activity" means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 38 C.F.R. § 3.304 (f)(3). Notably, the Veteran has not been afforded a VA examination and thus it is unclear if the Veteran's reported stressors are adequate to support a diagnosis of PTSD as required by VA regulation and/or are consistent with fear of hostile military or terrorist activity, as defined by VA. However, the Veteran has submitted evidence, consisting of news articles and reports that detail some of the events happening in Germany while he was stationed there, that resulted in the heightened security measures and increased stress levels, that the Veteran asserts are related to his PTSD. Thus, the Board finds that the matter must also be remanded so that the RO may attempt to verify the Veteran's stressors, in light of the new evidence he has submitted pertaining to the circumstances surrounding such stressors. The Board acknowledges that some of the Veteran's statements would be difficult to corroborate; however, the lock-down of a missile site in Germany or heightened security measures following an attack on a neighboring military site, could be corroborated through searches of the Veteran's military unit records or morning reports at the time. The Board notes that corroboration of every detail of the stressor is not required. Pentecost v. Principi, 16 Vet. App. 124, 128 (2002). Moreover, a veteran's actual presence during the stressor event need not be specifically corroborated if the evidence shows that he was assigned to and stationed with a unit that was present when a reported event that has otherwise been verified occurred; as such evidence strongly suggests actual exposure to the stressor event. Id. Additionally, regardless of whether the Veteran's claimed stressors or the circumstances related to such stressors are corroborated by the RO, the Veteran must be afforded a VA examination for his claimed acquired psychiatric disorders, to include PTSD and depression. In the present appeal, the evidence of record suggests that the Veteran has symptoms suggestive of a disability, has a diagnosis of an acquired psychiatric disorder, and the Veteran has competently reported in-service events that he asserts led to the development of the acquired psychiatric disorder. Furthermore, there is some medical evidence of record that suggests a possible relation between the Veteran's service and his current disorder. See medical records for 1998 and the evaluation associated with the claims file in May 2016. McLendon v. Nicholson, 20 Vet. App. 79, 81-83 (2006). However, the evidence of record is insufficient to adjudicate the claim. Accordingly, the Veteran must be afforded a VA examination and a medical opinion must be obtained regarding the Veteran's acquired psychiatric disorder, to include PTSD and depression. As previously noted, VA regulations allow for an award of service connection for PTSD based on a stressor related to a Veteran's fear of hostile military or terrorist activity, without corroboration, if such stressor is found to be consistent with the places, types, and circumstances of the veteran's service. 38 C.F.R. § 3.304 (f)(3). Moreover, only service connection for PTSD requires a stressor; as service connection for other acquired psychiatric disorders, such as depression, are subject to the Shedden service connection test- requiring only a current diagnosis, an in-service incurrence (as opposed to a stressor) and a nexus. Therefore, regardless of whether any of the Veteran's claimed stressors can be verified, he must still be provided a VA examination to determine whether any acquired psychiatric disorders, other than PTSD, are due to his active duty service and/or whether the Veteran's claimed stressors are sufficient to support a diagnosis of PTSD in accordance with VA regulation and whether such stressor are consistent or sufficient to meet the criteria of a stressor related to fear of hostile military or terrorist activity. 2. Entitlement to an initial compensable rating for fifth metacarpal fracture residuals, to include arthritis, due to right hand trauma, is remanded. The Veteran seeks an initial compensable rating for his right-hand trauma residuals, originally claimed as "arthritis due to trauma." He was initially granted service connection for arthritis, status post (s/p) open reduction internal fixation (ORIF), fifth metacarpal, on the right hand, at a noncompensable rating under diagnostic code 5003-5230. The Veteran disagreed and asserted that the noncompensable rating assigned does not reflect the severity of his condition. In favor of his claim the Veteran testified at the hearing that he is right handed, he does a lot of typing at work, and that his trauma residuals have become a hindrance as he has to sometimes wear a brace to avoid pain. He also noted taking ibuprofen for the pain when his disability flares-up, described as increased pain or throbbing that wakes him up at night. He also noted that the disability has affected his range of motion. See hearing transcript page 3. Additionally, the Veteran asserted that his condition is affecting his wrist movement as well because the pain travels to his wrist. Moreover, the Veteran asserted that he had to stop working as a mechanic because he could no longer turn wrenches but is now employed in a different field. See hearing transcript page 4. In terms of his range of motion, the Veteran explained that since his surgical intervention, that he has limited motion and it "pops." He also noted that sometimes the area swells up. See hearing transcript page 5. Furthermore, the Veteran asserted that his condition has worsened since the VA examination in 2017. See hearing transcript page 8. Medical records associated with the claims file in May 2016, show that the Veteran was examined by a private physician in September 2015. The results of that examination revealed right hand swelling, tenderness, and pain over the base of the fifth metacarpal. Normal tendon function was noted as the Veteran was able to make a full fist. However, the physician noted that the Veteran had loss of motion in the fifth carpometacarpal joint with motion of about 20 degrees as opposed to the "normal" 60 degrees. X-rays revealed advanced osteoarthritis secondary to the trauma at the base of the right fifth metacarpal and a surgical fusion, if the pain worsened, was recommended to the Veteran. See medical records dated September 2015, associated with the claims file in May 2016. In July 2017, a Hand and Finger Conditions Disability Benefits Questionnaire (Hand DBQ) completed by a private physician in April 2016, was associated with the claims file. This DBQ noted a diagnosis of post-traumatic arthritis in the right hand related to a 5th metacarpal fracture dislocation due to a crush injury. In terms of functional loss, the Veteran reported pain and weakness in his right hand and wrist- which limit his ability to perform work tasks. Abnormal ranges of motion for finger flexion in the right hand and wrist were noted. See Hand DBQ, associated with the claims file in July 2017. Notably, no description on the Veteran's functional limitation during a flare-up was included in this Hand DBQ. In November 2017, the Veteran was administered a Wrist Conditions Disability Benefits Questionnaire (Wrist DBQ) where a diagnosis of carpal metacarpal arthritis was noted on his right side. In pertinent part, this DBQ noted that the Veteran could not discriminate between his right wrist pain and right lateral hand pain. Abnormal range of motion for the right wrist was noted. See Wrist DBQ of November 2017. Based on the above, the Board finds that a remand is necessary to afford the Veteran an examination to determine the extent and severity of his right-hand trauma residuals, to include a description of all of his related symptomatology. Allday v. Brown, 7 Vet. App. 517, 526 (1995). Particularly, the Board notes the Veteran was not afforded a VA physical examination for his hand disability. Instead, it seems VA relied on the Hand DBQ dated April 2016, submitted by the Veteran in July 2017, to assign a noncompensable disability rating. Furthermore, the evidence of record suggests that the Veteran's right-hand trauma residuals affect not only his hand but his wrist as well. See Hand DBQ associated with the claims file in July 2017 (noting abnormal range of motion in the wrist and describing the functional loss as pain and weakness in the hand and wrist); see also Wrist DBQ of November 2017 (noting that the Veteran is unable to discriminate between his wrist and hand pain). The Veteran's right-hand trauma residuals are currently evaluated under DC 5003-5230. DC 5003 pertains to arthritis while DC 5230 pertains to painful motion of the small finger. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating. 38 C.F.R. § 4.27. DC 5003 dictates that degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, DC 5003. For the purpose of rating disability from arthritis in the hands/fingers, multiple involvements of the interphalangeal, metacarpal, and carpal joints of the upper extremities, are considered groups of minor joints, ratable on a parity with major joints. 38 C.F.R. § 4.45 (f) (emphasis added). DC 5230 establishes that any limitation of motion of the ring or little finger, for either the dominant or non-dominant hand, will be evaluated as zero percent disabling. 38 C.F.R. § 4.71A. In other words, there is no mechanism for rating limitation of motion of this finger greater than zero percent disabling under the rating schedule because a zero percent rating is explicitly assigned for the limitation of motion disability of that finger. 38 C.F.R. § 4.71a, DC 5230. The Board notes that VA has a duty to maximize benefits. Bradley v. Peake, 22 Vet. App. 280, 294 (2008). Additionally, Veterans are generally presumed to be seeking the maximum benefits allowed by applicable regulation. AB v. Brown, 6 Vet. App. 35, 38 (1993). Furthermore, the United States Court of Appeals for Veterans Claims (Court) held that "VA has powerful, ready-made schedular rating tools with which it can better adjudicate claims that include symptoms and effects not contemplated by an applicable diagnostic code." Morgan v. Wilkie, 31 Vet. App. 162 (2019). Here, the Veteran sustains, and the evidence of record suggests that his right-hand trauma residual symptomatology is more extensive than just his in-service 5th metacarpal fracture and the limited motion of his little finger. Particularly, the Veteran has consistently asserted that he suffers pain not only in his hand but his wrist as well, that the area swells, in addition to decreased range of motion, and the medical evidence of record seems to be consistent with those assertions. Thus, in light of VA's duty to maximize benefits and the holding in Morgan instructing the Board to exhaust all schedular alternatives to better adjudicate claims that include symptoms and effects not contemplated by an applicable diagnostic code, including but not limited to secondary service connection, the Board finds that all the symptomatology pertaining to the Veteran's right hand trauma must be clearly documented in the examination report. Particularly, the examiner is asked to address the Veteran's right wrist pain complaints, pursuant to the directives below. These medical findings will allow the RO to consider whether the Veteran's service-connected disability, and all of its associated symptomatology, is contemplated by the assigned diagnostic code, whether any symptomatology not contemplated should be granted service connection on a secondary basis, and whether the disability warrants an initial compensable disability rating. The Board acknowledges that in a November 2017 rating decision, the RO denied service connection for arthritis in the right wrist on a direct basis. However, that decision did not address entitlement to service connection for a wrist disability, secondary to the Veteran's service-connected arthritis, fifth metacarpal, right hand, which has been reasonably raised by the record in light of the Veteran's assertions pertaining to his symptomatology. See also Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The matters are REMANDED for the following actions: 1. Provide the Veteran an opportunity to identify any outstanding private treatment records in favor of his claims. After obtaining any necessary authorization from the Veteran, attempt to obtain such records. All obtained records should be associated with the evidentiary record. All attempts made must be documented, to include the unavailability of any identified records. If any such records are unavailable, inform the Veteran and afford him an opportunity to submit any copies in his possession. 2. Attempt to corroborate the Veteran's stressors, or the circumstances surrounding such stressors, via the appropriate channels, to include a review of the Veteran's unit reports. Submit multiple requests to cover the Veteran's entire period of service in Germany (February 1985 to August 1987), if necessary. See Gagne v. McDonald, 27 Vet. App. 397 (2015). All attempts to secure this evidence must be documented in the claim file by the RO. Particularly, the RO must attempt to corroborate the Veteran's assertion that the missile site where he was posted in Germany underwent a lock-down and increased security measures following terrorist activity- to include attacks on other military installations in the area. Consider the various news reports the Veteran submitted in March 2021 in support of these assertions, in addition to his statements pertaining his stressors. Thereafter, issue a Formal Finding outlining the steps taken to assist the Veteran, to include any requests for corroboration made through the appropriate channels, and notify the Veteran of VA's inability to verify the alleged stressors, if they remain uncorroborated, and whether there is alternative evidence that the Veteran may submit in favor of his stressors, such as buddy statements or other corroborating evidence, not of record. 3. Regardless of whether the Veteran's stressors are corroborated pursuant to the preceding directive, provide the Veteran with a VA examination to determine the likely etiology of the Veteran's acquired psychiatric disorder, to include PTSD and depression. Both, an Initial PTSD DBQ and a Mental Health Conditions DBQ, must be completed by the appropriate examiner. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail and correlated to a specific diagnosis. The examiner is asked to: a. Provide diagnoses for any acquired psychiatric disorder found to be present during the pendency of this appeal. b. Specifically state whether the Veteran has a current diagnosis of PTSD in accordance with the DSM-5. i. If a diagnosis of PTSD is appropriate in accordance with the DSM-5, the examiner must identify the specific stressor(s) underlying the PTSD diagnosis and opine whether the stressor involves fear of hostile military or terrorist activity. In so opining, the examiner must review and discuss the Veteran's statements, to include statements of May 2016, September 2016, and the Veteran's testimony at the hearing, describing his stressors and the circumstances surrounding those stressors. In particular, although not limited to, the examiner is asked to discuss the Veteran's assertions of feeling like a target and experiencing panic while patrolling the missile site perimeter in Germany, the event of seeing lights in the woods while patrolling and preparing in his mind for an imminent attack when his radio did not work, his vision of a nuclear attack on a civilian city, and the reported heightened stress levels due to terrorist activity in the area, and whether such assertions/stressors meet or involve fear of hostile military or terrorist activity. ii. If a diagnosis of PTSD is not deemed appropriate, explain why the Veteran's reported symptoms do not meet the diagnostic criteria for PTSD and reconcile those findings with the 1998 records showing a diagnosis of PTSD as well as the Behavioral Health Evaluation, associated with the claims file in May 2016. c. With respect to each acquired psychiatric disorder, other than PTSD, found to be present and/or diagnosed proximate to or during the pendency of the appeal (to specifically include a depressive disorder), the examiner is asked to opine whether it is at least as likely as not (50 percent or greater probability) that the disorder had its onset in, was caused by, or is otherwise related to, the Veteran's military service. In offering this opinion, the examiner must consider the Veteran's reports of stressful events while in Germany. In rendering the requested opinions, the examiner should consider all relevant treatment records and statements of record, to include service and personnel records, the Veteran's statements, and VA and private treatment records. A fully articulated medical rationale for each opinion expressed must be set forth in the medical report. If the examiner cannot provide the requested opinions without resorting to speculation, he/she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 4. Schedule the Veteran for an examination to determine the extent, symptomatology, and current severity of his arthritis due to right-hand trauma. The examiner is asked to elicit information from the Veteran pertaining to his symptomatology, to include decreased range of motion of the little finger, pain and swelling in the hand, and pain in the wrist. a. The examiner is asked to clarify the current diagnoses pertaining to the Veteran's right hand. Particularly, the examiner is asked to determine whether the Veteran's arthritis involves one or more joints in the hand, its current severity and note, if possible, whether the arthritis has progressed/worsened. If the examiner is unable to opine on whether the condition has progressed or worsened, he/she must explain why. Undertake any necessary testing to render these opinions, to include x-rays. b. Regarding the Veteran's reported right wrist pain: i. The examiner is asked to opine whether the Veteran's wrist pain is a progression of his right-hand arthritis, or ii. if otherwise, the pain is related to a separate diagnosable condition or disability. The examiner is reminded that pain alone that results in functional impairment may be considered a disability for VA purposes. See Saunders v. Wilkie, No. 2017-1466 (Fed. Cir. Apr. 3, 2018). iii. If a separate disability is diagnosed regarding the Veteran's wrist pain, as opposed to it being found a progression of the Veteran's service connected disability, the examiner is asked to opine whether the diagnosed wrist disability is caused by or aggravated by the Veteran's service-connected arthritis in the right hand. c. Regarding flare-ups: i. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). To the extent possible, the examiner should identify any symptoms and functional impairments due to the right-hand disability and discuss the effect of the Veteran's disability on any occupational functioning and activities of daily living. If the examiner is unable to estimate the functional loss in terms of degrees after physical examination and eliciting the pertinent information about the flareups, he or she must explain why, beyond the fact that such would require speculation. The examiner is asked to provide a complete rationale for all opinions expressed. If the examiner cannot provide the requested opinion(s) without resorting to speculation, the report should expressly indicate this, and the examiner should explain why an opinion cannot be provided without resorting to speculation. If the inability to provide an opinion is the result of a need for additional information, the physician must identify the additional information needed. 5. After completing the above requested actions, and any additional notification and/or development deemed warranted, readjudicate the issues on appeal. If the benefits sought on appeal remain denied, furnish to the Veteran and his representative an appropriate supplemental statement of the case that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Gonzalez-Maldonado 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.