Citation Nr: 22044451 Decision Date: 08/04/22 Archive Date: 08/04/22 DOCKET NO. 17-16 866A DATE: August 4, 2022 ORDER Entitlement to an initial rating of 70 percent, but not higher, for the appeal period prior to April 26, 2017 for an acquired psychiatric disorder is granted. REMANDED Entitlement to an initial rating in excess of 10 percent for irritable bowel syndrome is remanded. Entitlement to a total rating based on individual unemployability due to service-connected disabilities (TDIU) for the appeal period prior to April 26, 2017 is remanded. FINDING OF FACT For the appeal period prior to April 26, 2017, the Veteran's acquired psychiatric disorder most closely approximated occupational and social impairment with deficiencies in most areas without total occupational and social impairment. CONCLUSION OF LAW The criteria for a rating of an initial 70 percent for an acquired psychiatric disorder, for the appeal period prior to April 26, 2017 have been met. 38 U.S.C. § 1155, 5107; 8 C.F.R. §§ 3.102, 4.14.14, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Navy from July 1988 to July 1992. These matters come to the Board of Veterans' Appeals (Board) on appeal from August 2015, December 2016, and November 2017 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). Jurisdiction of this appeal is currently with the RO in Little Rock, Arkansas. The Veteran testified at a video conference hearing before the undersigned Veterans Law Judge of the Board in April 2021. A transcript of the hearing has been associated with the claims file. The record was held open for 60 days following the hearing to allow for the submission of additional evidence; this requested extension period has now expired. In addition, in a September 2018 rating decision, the AOJ granted entitlement to a TDIU effective April 26, 2017. However, as this does not represent a full grant of the benefits sought on appeal, the claim remains before the Board, and the Board has reframed the issue to reflect the grant of entitlement to a TDIU and effective date. Increased Rating Acquired Psychiatric Disorder The Veteran seeks a higher initial rating for his service-connected acquired psychiatric disorder. In this regard, the Veteran asserts that instead of the disability becoming more severe at any particular point during the appellate period, the disability has instead been inadequately rated since the initial rating. See e.g., Notice of Disagreement, January 12, 2017; see also VA Form 9, April 21, 2017. More specifically, the Veteran limited his argument to an initial 70 percent rating, but no higher, throughout the appellate period. See Board hearing transcript, April 12, 2021. The Veteran has consistently asserted that a 70 percent rating is warranted under Diagnostic Code 9413. The Board agrees and awards a 70 percent rating for the appeal period prior to April 26, 2017 herein. At the Board hearing, the Veteran testified that his psychiatric symptoms manifested with nightmares; flashbacks; hospitalizations for psychiatric matters in 2014 and 2016; anxiety; depression; panic attacks daily; irritability; marital stress; estrangement from one of his sons; limited interactions with his other son; periods of homelessness; and severe or serious impairment throughout the period on appeal. A claimant may "limit a claim or appeal to the issue of entitlement to a particular disability rating which is less than the maximum disability rating allowed by law" via "clearly expressed intent to limit the appeal to entitlement to a specific disability rating for the service-connected condition." See AB v. Brown, 6 Vet. App. 35, 39 (1993) (citing Hamilton v. Brown, 4 Vet. App. 528, 544 (1993)). The Board accepts the Veteran's limitation accordingly, as it has been consistent throughout the period on appeal up to his sworn hearing testimony. The Board construes a 70 percent rating for the acquired psychiatric disorder as a full grant of the Veteran's claim on appeal, and so grants his claim in full. Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Board must also consider staged ratings. Hart v. Mansfield, 21 Vet. App. 505, 50910 (2007). The veteran's entire history is considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A review of the recorded history of a disability is necessary to make an accurate rating. 38 C.F.R. §§ 4.2, 4.41. The regulations do not give past medical reports precedence over current findings where such current findings are adequate and relevant to the rating issue. Francisco v. Brown, 7 Vet. App. 55 (1994); Powell v. West, 13 Vet. App. 31 (1999). The Board will 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); Hart v. Mansfield, 21 Vet. App. 505 (2007). The assignment of a particular diagnostic code is dependent on the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. In reviewing the claim for a higher rating, the Board must consider which diagnostic code or codes are most appropriate for application in the veteran's case and provide an explanation for the conclusion. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. When there is an approximate balance of positive and negative evidence as to any issue material to the determination of a matter, VA will resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc). Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran's claim. The Veteran's acquired psychiatric disorder is rated under the General Rating Formula for Psychiatric Disabilities (General Formula). 38 C.F.R. § 4.130. Psychiatric disabilities are rated based on the General Rating Formula codified in 38 C.F.R. § 4.130, which provides disability ratings are based on a spectrum of symptoms. "A Veteran may qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of a similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) and (5th ed. 2013) (DSM-5). See Mauerhan v. Principi, 16 Vet. App. 436, 44243 (2002). VA is to engage in a holistic analysis in which it assesses the severity, frequency, and duration of the signs and symptoms of the veteran's service-connected mental disorder; quantifies the level of occupational and social impairment caused by those signs and symptoms; and assigns an evaluation that most nearly approximates that level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). Under the General Rating Formula for Mental Disorders per 38 C.F.R. § 4.130, a 70 percent rating is warranted if the disability is productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9413. A schedular maximum 100 percent rating is warranted if the disability is productive of total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. In addition, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the lengths of remissions, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation on the basis of social impairment. The Board notes that with regard to the use of the phrase "such as" in 38 C.F.R. § 4.130 (General Rating Formula for Mental Disorders), ratings are assigned according to the manifestations of particular symptoms. However, the use of the phrase "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve only as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment. The Board acknowledges that psychiatric examinations frequently include assignment of a global assessment of functioning (GAF) score. The American Psychiatric Association has released the Diagnostic and Statistical Manual of Mental Disorders (5th Ed.) (DSM-5), and 38 C.F.R. § 4.130 has been revised to refer to the DSM-5. The DSM-5 does not contain information regarding GAF scores. Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders to remove outdated references to the DSM-IV and replace them with references to the DSM-5. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). VA adopted as final, without change, the interim final rule and clarified that the provisions of the final rule did not apply to claims that were pending before the Board, this Court, or the U.S. Court of Appeals for the Federal Circuit on August 4, 2014, even if such claims were subsequently remanded to the agency of original jurisdiction. See 80 Fed. Reg. 14,308 (Mar. 19, 2015). In Golden v. Shulkin, 29 Vet. App. 221 (2018), the Court held that given that the DSM-5 abandoned the GAF scale and that VA has formally adopted the DSM-5, the Board errs when it uses GAF scores to assign a psychiatric rating in cases where the DSM-5 applies. This appeal was certified to the Board in March 2019. As such, the DSM-5 applies, and the GAF scores will not be considered. Turning to the evidence, the Veteran was afforded a VA examination in August 2013. At that time, the VA examiner opined his acquired psychiatric disorder manifested in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. In August 2013, the Veteran reported he had four brothers and one sister, that he was married to his wife of 10 years without violence, that he one separation in 2004 but described his marriage as "good"; and had two sons. He reported his relationships with his siblings were distant until his mother became ill and they talked on a regular basis and saw each other occasionally. He reported a "good" relationship with his mother and talked to her daily. He reported that he did not have many friends and saw his friends approximately twice a month to smoke marijuana together and played cards or dominos. He also reported that he spent his free time watching TV, eating out two or three times a month, but was not a people person and tried to sit in the corner of restaurants. He reported that he did his own gardening, landscaping, listened to music, read, and watched news and sports clips and that he would watch local sporting events across the street. The Veteran described his occupational history as having many jobs, the longest of 13 years as a lab technician, getting along mostly well with coworkers, but sometimes having to call in sick due to inability to sleep or feeling amotivation to work. He denied problems at work, but indicated his attendance was a problem due to his stomach or difficulty sleeping. He denied having problems with truck driving course work. In August 2013, the Veteran denied suicidal thoughts since a year prior, but that he was protected by his two children, wife, and mother who loved him or needed him. He denied attempting suicide. He did not have psychiatric hospitalizations. He endorsed difficulty initiating and staying asleep, nightmares, strange appetite, stomach problems, feeling tired, having low energy during the day, that he was still interested in pleasurable activities but lacked energy or motivation to participate in them, irregular crying spells and managed hygiene only two or three times a week. The Veteran endorsed feeling depressed. Symptoms attributable to his acquired psychiatric disorder included a depressed mood, chronic sleep impairment, difficulty in adapting to stressful circumstances including work or a worklike setting and a rush of emotions when thinking about his stressor. An April 2014 VA treatment record indicates the Veteran reported severe depression, thoughts of suicide by cop, nightmares, intrusive thoughts and significant issues with sleep that contributed to his depressive symptoms. The Veteran also reported hearing people screaming that they would die, crackling noises, and gun shots. The Veteran reported feeling very "strange" lately, difficulty focusing, hearing things, irritability, agitation, anhedonia, a poor memory and significant marital stress and impairment in their relationship. A June 2014 VA treatment record indicates the Veteran denied suicidal and homicidal ideation, feared he would lose his job, and complained about gastritis. The Veteran was afforded a VA examination in April 2016. At that time, the VA examiner opined his acquired psychiatric disorder manifested in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. In April 2016, the Veteran reported continuing impairment of social relationships, amotivation with work and home and not being a "people person," independent as to activities of daily living but would have some difficulty with medication management. He reported difficulty communicating with his wife, losing train of thought, irritation and watching sports on TV and enjoying sports, but disliked crowds. He did not like his job but kept working to pay his bills. The Veteran reported anxiety, suspiciousness, anger and negative/dysphoric mood, intrusive recollection and physiological arousal, as well as some depression. He reported a gradually worsening dysthymia/depression that progressed from occasional low mood to depressed mood most days, more days than not. The anxiety was described as ongoing inability to relax, irritability, suspiciousness, unwanted intrusive thoughts, some hypervigilance, tension interfering with sleep (independent of other factors affecting sleep), and occasional nightmares. He reported always feeling tense with interference in sleep, inability to relax, and feeling like a miserable person. He indicated he had difficulty with seeing blood due to his in-service stressor. He was not pervasively avoidant of the trauma. The Veteran reported a loss of interest, always being alert, easily irritated, always irritable, anxiety every day in public to include work and a low mood. He reported depression, anxiety, being guarded, suspiciousness and some auditory hallucination but denied frank hallucinations. He reported transient thoughts of suicide in the past, but denied any recent intentions or plans. He denied homicidal ideation, intent, or plans. Symptoms attributable to his acquired psychiatric disorder in April 2016 included a depressed mood, anxiety, suspiciousness, chronic sleep impairment and difficulty in establishing and maintaining effective work and social relationships. Behavioral observations showed the Veteran was casually dressed, that his grooming was fair and hygiene and his eye contact within normal limits. Psychomotor was found to be unremarkable function and he was found to be cooperative, reasonable, attentive, calm and not hostile, threatening, or bizarre or unusual behaviors apparent. He was found to be alert, oriented to all spheres and grossly intact mental status with spontaneous and normal speech. Affect was found to be slightly constricted and congruent with dysphoric or anxious mood. He was found to be coherent, logical, and without auditory or visual hallucinations in thought processes and content. Any current suicidal or homicidal ideation, intent or plans were denied. Insight and judgment were fair and reliability was acceptable. Of record are VA treatment records from April 2014, July 2016, and September 2016 that show the Veteran reported suicidal and homicidal ideations, marital strain, significant stressors of deaths in the family, anxiety and hospitalizations due to his psychiatric symptoms. Significantly, during his hospitalizations, the Veteran was shown to have a dysfunctional relationship with his wife, an inability to participate in gainful employment (in September 2016), depression, a low mood, low energy, anhedonia, difficulty sleeping, and decreased functional tolerance. The Veteran had thoughts of provoking his wife or the police to shoot and kill him. In addition, September 2016 VA treatment records indicate the Veteran felt paranoia and suspiciousness toward his wife, that he acknowledged were not warranted; and reported past suicidal ideation. Moreover, VA treatment record from April 2016 through August 2016 showed the Veteran reported depression, suicidal thoughts, anxiety, significant marital stress, a low mood and anxiety. Of record is an April 2017 private psychiatric evaluation completed by Dr. Y.O. At that time, Dr. Y.O. found the Veteran's acquired psychiatric disorder manifested with occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. Symptoms attributable to his acquired psychiatric disorder included depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood and difficulty adapting to stressful circumstances, including work or a worklike setting. Behavioral observations showed the Veteran was pleasant, cooperative, a reliable historian and motivated to present an accurate account of his history and symptoms. His effort was found to be adequate and appeared motivated to perform well. The Veteran was last employed in 2016 as a custodian and resigned after four and a half months due to stress, family issues, and conflicts with others. The Veteran was able to manage activities of daily living, hygiene, grooming, light meals, and snacks without assistance. However, he relied on others for housekeeping, full meals, shopping for groceries, and managing household finances. He felt capable of managing his own finances. He did not attend church. He occasionally visited with friends and relatives, watched television, sat outside, and occasionally exercised. Dr. Y.O. found the Veteran had marginal skills in activities of daily living. The Veteran was shown to have meaningful relationships in his life but did not socialize often and he did not have adequate pleasurable activities. Mental status examination in April 2017 showed the Veteran was neatly dressed, that his hygiene and grooming were adequate, that no physical restrictions observed and that his psychomotor activity within normal limits. His speech was organized, goal-directed, and adequate and mood and affect were congruous and within normal limits. He denied current suicidal and homicidal ideation with historical suicidal attempts and related inpatient treatment in 2014 and 2016. Some auditory hallucinations in the form of gunshots and soldiers marching were reported as well as four to five crying spells per month. He reported feelings of sadness, worthlessness, conflict in marriage and with children, panic attacks once or twice weekly, frequent anxiety in crowds and being away from home, difficulty with sleep, nightmares and inconsistent appetite. There were no indications of thought disorder or delusional thinking and adequate insight and judgment. The Veteran presented as oriented to time, place, and person; and his fund of knowledge, common sense, and abstract reasoning skills were adequate. Some limitations were observed in memory and concentration. In April 2017, Dr. Y.O found the Veteran had mild limitations in understanding and remembering and would have difficulty with concentration and focus and his performance would be inconsistent. The provider found that his attendance maybe inconsistent, would require frequent rest breaks and that impairment was moderate for concentration, persistence, and pace; and mental illness would be exacerbated by stress of routine work and he would likely overreact to minor conflicts with peers and supervisors. Dr. Y.O. found the Veteran would have difficulty acquiring new information and/or applying previous learning in novel circumstances; thus, he had marked impairment in social interacting and adapting to changes in work settings and requirements. Therefore, Dr. Y.O. found the Veteran's acquired psychiatric symptoms most closely approximated occupational and social impairment with reduced reliability and productivity. The Board notes that a review of the record shows that the Veteran has received treatment for his acquired psychiatric disorder from both VA Medical Centers and private providers. However, there is no indication from the record that the Veteran's symptoms are worse than those reported in the various records discussed above. Based on the foregoing, and resolving all doubt in favor of the Veteran, the Board finds that the Veteran is entitled to an initial rating of 70 percent for his acquired psychiatric disorder for the appeal period prior to April 26, 2017. In this regard, the Board notes that the Veteran had occupational and social impairment with deficiencies in most areas. Impairment to mood was demonstrated as the Veteran consistently reported anxiety and depression. Impairment to thinking was demonstrated as the Veteran endorsed some auditory hallucinations on occasion and admitted to hearing screaming, drums, and gunshots. Significant impairment to family relations was demonstrated as the Veteran endorsed having only a few friends whom he saw on occasion, being close with his mother, being estranged from one son, and having significant marital stress and strain. Significantly, the Veteran reported he would have periods of irritability, paranoia, and suspiciousness toward his wife, which he acknowledged were not always warranted; and he felt his sons were afraid of him. In addition, the Veteran endorsed suicidal ideation, that consistently worsened in frequency and manifested with two inpatient treatment periods due to the severity of his suicidal ideation. Moreover, the Veteran reported significant difficulty with his employment, to include irritability and anxiety, and was unemployed for a significant period on appeal. Therefore, occupational and social impairment with deficiencies in most areas was demonstrated. While the Board recognizes that the Veteran is competent to provide statements regarding his observable symptomatology, he is not competent to provide an opinion regarding the severity of her symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Rather, the Board finds the medical evidence in which professionals with medical expertise examined the Veteran, acknowledged his reported symptoms, and described the manifestations of such disability considering the rating criteria to be more persuasive than the Veteran's reports regarding the severity of his condition. Despite the foregoing, the Board acknowledges the Veteran's assertions that his various symptoms and functional impairments warrant a higher rating and have considered them herein. The Board has considered whether a staged rating under Fenderson v. West, supra is appropriate; however, the Board finds that his symptomatology was been stable throughout the period on appeal. Therefore, assigning a staged rating is not warranted. The Veteran nor his representative have not raised any other issues, nor have any other issues been reasonably raised by the record in regard to the increased rating claim adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Accordingly, the Board finds the evidence supports the assignment of an initial 70 percent rating for an acquired psychiatric disorder for the appeal period prior to April 26, 2017. To that extent, the appeal is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, supra. REASONS FOR REMAND 1. Increased Rating Irritable Bowel Syndrome The Veteran was most recently afforded an examination for his irritable bowel syndrome in July 2014. At his April 2021 Board hearing, it was indicated that the irritable bowel syndrome had worsened since his VA examination. In this regard, the Veteran testified that he experienced worsening symptoms of irritable bowel syndrome, to include constant pain, regular treatment, medication, severe diarrhea with foul odor, and results in being essentially homebound. In addition, September 2020 VA treatment records indicate the Veteran's bloating and gas had worsened due to his irritable bowel syndrome. As the above evidence indicates a possible worsening of that the Veteran's irritable bowel syndrome since his last VA examination, an additional examination should be afforded to gauge the current level of severity of his disability. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (VA has a duty to provide the Veteran with a thorough and contemporaneous medical examination); Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (an examination too remote for rating purposes cannot be considered "contemporaneous"). 2. Entitlement to a TDIU Prior to April 26, 2017 Regarding the TDIU issue, the Board notes that the issue of entitlement to a TDIU is inextricably intertwined with the claim remanded herein. Harris v. Derwinski, 2 Vet. App. 180, 183 (1991). Hence, a determination on the claim for TDIU should be deferred pending final dispositions of the claim of entitlement to an increased initial rating for irritable bowel syndrome. The matters are REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, schedule the Veteran for a VA examination to determine the current nature and severity of his service-connected irritable bowel syndrome. The record, to include a copy of this Remand, should be made available to the examiner, and all indicated tests should be conducted. The examiner should identify the nature and severity of all current manifestations of the Veteran's service-connected irritable bowel syndrome. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). (Continued on the next page) The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resorting to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mariah N. Sim, 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.