Citation Nr: 18145941 Decision Date: 10/30/18 Archive Date: 10/30/18 DOCKET NO. 17-17 008 DATE: October 30, 2018 ORDER For the entire period on appeal, an initial rating higher than 20 percent for a right carpal tunnel syndrome (CTS), is denied. For the entire period on appeal, an initial rating higher than 30 percent for a left carpal tunnel syndrome (CTS), is denied. For the entire period on appeal, an initial rating of 50 percent, but not higher, for migraine headache disability, is granted. REMANDED Entitlement to increased rating higher than 10 percent for status-post dorsal wrist ganglion excision scar is remanded. Entitlement to increased rating higher than 10 percent for status-post left dorsal wrist ganglion excision scar is remanded. Entitlement to increased rating higher than 10 percent for status-post dorsal ganglion left ring finger metacarpal head excision scar is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include idiopathic hypersomnia and posttraumatic stress disorder (PTSD), also as due to military sexual trauma, is remanded. Entitlement to a total rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. For the entire initial period on appeal, the Veteran’s right CTS symptoms more nearly approximates moderate incomplete paralysis; severe incomplete paralysis or complete paralysis is not shown. 2. For the entire initial period on appeal, the Veteran’s left CTS symptoms more nearly approximates moderate incomplete paralysis; severe incomplete paralysis or complete paralysis is not shown. 3. Resolving any doubt in the Veteran’s favor, for the entire initial period on appeal, she had very frequent, completely prostrating, and prolonged migraine headache attacks, productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. The criteria for an initial rating higher than 20 percent for a right CTS have not been approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.6, 4.7, 4.20, 4.27, 4.123, 4.124a, Diagnostic Code 8515 (2017). 2. The criteria for an initial rating higher than 30 percent for a left CTS have not been approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.6, 4.7, 4.20, 4.27, 4.123, 4.124a, Diagnostic Code 8515 (2017). 3. For the entire period on appeal, the criteria for an initial 50 percent disability rating, but not higher, for migraine headaches have been approximated. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.21, 4.124a, Diagnostic Code 8100 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1999 to April 2006. The issue of entitlement to service connection for a dental disability is part of a different appeal stream that is currently being developed at the RO and is not yet certified to the Board. Increased Rating Disability evaluations are determined by comparing a veteran’s present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in 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 evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran’s condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Where the veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Right and Left Carpal Tunnel Syndrome The Veteran asserts that her bilateral CTS warrants a higher rating. Her left wrist is currently evaluated as 30 percent disabling; her right, 20 percent. A. Rating Criteria The Veteran’s CTS is rated under DC 8515 for paralysis of the median nerve. Ratings are for mild, moderate, severe, and complete based on involvement of the major hand (in this case, the left) or the minor hand (right). The following ratings are applicable: mild incomplete paralysis warrants a 10 percent rating on both the major and minor sides; moderate incomplete paralysis warrants 30 percent on the major side and 20 percent on the minor side; severe incomplete paralysis warrants 50 percent on the major side and 40 percent on the minor side; and complete paralysis warrants 70 percent on the major side and 60 percent on the minor side. Complete paralysis of the median nerve contemplates the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscle of the thenar eminence, the thumb in the plane of the hand (ape hand), pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm, flexion of wrist weakened; and pain with trophic disturbances. The term “incomplete paralysis” with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. 38 C.F.R. § 4.123. Similarly, neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. Words such as “mild,” “moderate,” and “severe” are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. B. Discussion This appeal stems from a July 2013 rating decision that assigned the initial rating for the Veteran’s right and left CTS. The Veteran is a left-hand dominant. For the reasons expressed below, the Board finds that for the entire period on appeal, symptoms of the Veteran’s bilateral CTS more nearly approximate moderate incomplete paralysis of the median nerve for each hand, which is properly contemplated by the currently assigned disability rating. The criteria for an increased rating is not more closely approximated for either hand. Turning to the evidence, a VA electrodiagnostic test dated in June 2011 indicates that the Veteran reported increased symptom severity despite treatment with conservative treatment such as splints and physical therapy. It was noted that symptoms worsened more on the right hand in comparison to the left. The study revealed electrodiagnostic evidence of right moderate median nerve entrapment at the level of the wrist, which the medical professional indicated “deteriorated significantly on right hand compared to last year’s study which correlates clinically with patient’s symptoms.” Thereafter, in March 2012, the Veteran reported that she was experiencing increasing problems with her CTS. In a September 2012 statement, the Veteran’s spouse indicated that she was unable to grip objects such as a mayonnaise jar, pick up heavy items with her fingers, or do their daughter’s hair tight enough that it won’t loosen every few days. He noted that sometimes she could not even turn on the shower, because she could not grip the handles properly. In another September 2012 statement, the Veteran’s friend reported that she complained of numbness, swelling, loss of grip, and intense pain when she had to write parking lot logs for work, count money, shift reports for work, wash dishes, comb her daughter’s hair or her own hair, and do other regular activities. In a September 2012 correspondence, the Veteran reported that she had chronic pain and numbness in her fingertips and lower wrist area. She indicated that she started to have difficulty opening jars when cooking, and was taking Motrin 800mg for pain and inflammation of her fingers, wrist, and inner part of her knuckles. In September 2012, the Veteran underwent a VA Examination for peripheral nerves, at which time the examiner confirmed a diagnosis of bilateral CTS. The Veteran reported that in 2004, she noticed tingling and numbness in both hands. She was later (in 2010 and 2011) evaluated by EMG tests, and reported that she noticed decreased grip strength and difficulty opening bottles and all activities requiting grip strength. Symptoms attributed to the Veteran’s CTS included moderate constant pain, moderate paresthesias, and moderate numbness, bilaterally. Muscle strength testing was normal on flexion and extension throughout, but revealed active movement against some resistance (4/5) for grip and punch (thumb to ring finger), bilaterally, with no evidence of muscle atrophy. Reflex examination was hypoactive (1+) for biceps and triceps, bilaterally. Sensory examination was decreased in the hand/fingers, but otherwise normal, with normal vibration, bilaterally. There was no evidence of any trophic changes. It was noted that the Veteran was using a brace regularly at work for her wrists. The examiner concluded that the severity of the Veteran’s CTS approximated mild incomplete paralysis of the median nerve, bilaterally. Impact on ability to work was described as difficulty with hand use that involved grip and difficulty with opening bottles. In an additional statement received later in September 2012 from another one of the Veteran’s friends, it was noted that her bilateral CTS caused her to lose her grip strength and made her unable to make “tight fist” or do anything that required the squeezing of her hands. VA treatment records dated later in September 2012 indicate that the Veteran’s bilateral CTS warranted nonsteroidal anti-inflammatory drug (NSAIDS), physical therapy, and splints. In September 2016, the Veteran underwent an additional VA examination for peripheral nerves, at which time the examiner confirmed the diagnosis of bilateral CTS. The Veteran reported constant bilateral hand numbness, weakness, and tingling sensation. She also reported partial improvement when using cock-up splint at night. Symptoms attributed to the Veteran’s CTS included moderate constant pain, moderate paresthesias, and moderate numbness, bilaterally. Muscle strength testing was normal on flexion and extension throughout, but revealed active movement against gravity (3/5) for grip, bilaterally. Reflex examination was normal throughout and sensory examination was decreased in hands and fingers, bilaterally. There was no evidence of any trophic changes. It was noted that the Veteran constantly used a resting wrist splint at night due to bilateral hand numbness and tingling sensation. The examiner concluded that the severity of the Veteran’s CTS approximated moderate incomplete paralysis of the median nerve, bilaterally. During the same time, the Veteran was also provided with a VA muscle examination, where she reported muscle atrophy of the left wrist; however, upon examination, the examiner concluded that there was no objective evidence of muscle atrophy. In a correspondence dated in March 2017, the Veteran indicated that she disagreed with the decision made regarding her right wrist, because although she wrote with her left hand, she utilized both hands, and used her right hand a lot to do many functions, and noted that both hands were used in a dominant capacity. She further indicated that her hands were not the hands of an average 34-years old, and her grip strength of her left hand in therapy was two-pounds, but a female is supposed to have a grip of 25-pounds. She further stated that she was ashamed that she had to ask her daughter or a coworker to open a bottle of water. She added that her pain level was noted as mild in 2012 and moderate in 2016, but in fact, her pain was severe, and every morning she woke up with throbbing and numbness in her wrist and fingertips, as well as the “fleshy part” of her hands. She indicated that she had a hard time opening the gas tank and needed to ask that the attendant help her. She further indicated that during her last therapy, her grip in her left hand increased from two-pounds to five-pounds, and from five-pounds to seven-pounds, but noted that she could not make “strong fist.” She concluded that her flexion of her wrist was weakened and pain level was severe. After a careful review of the evidence, lay and medical, the Board finds that the Veteran’s bilateral CTS symptoms more nearly approximate moderate incomplete paralysis of the median nerves, which is consistent with a 30 percent disability rating for her dominant CTS, and a 20 percent disability rating for her minor left CTS. The criteria for severe incomplete paralysis have not been more closely approximated for either had. Specifically, aside from lay reports of severe pain, no other severe symptoms were identified by objective medical evidence throughout the pendency of the appeal. In addition, the decrease in sensation and hand grip was not severe (3/5) and does not more nearly approximate severe symptoms, and there was no evidence of muscle atrophy. There is no evidence of muscle atrophy or trophic changes on either wrist. Regarding the Veteran’s assertion that both her hands are equally dominant, the Board notes that only one hand shall be considered dominant, and the injured hand, or the most severely injured hand, of an ambidextrous individual will be considered the dominant hand for rating purposes. See 38 C.F.R. § 4.69. Furthermore, the Veteran is in receipt of separate 10 percent disability ratings for each of her three scars related to the same disability. Accordingly, the Board finds that a rating in excess of 30 percent disability rating for the Veteran’s dominant CTS, and a 20 percent disability rating for her minor left CTS, are not warranted. As the preponderance of the evidence is against the claims, the benefit-of-the-doubt rule does not apply, and the Veteran’s claims must be denied. Migraine Headaches The Veteran asserts that her migraine headache disability, currently evaluated as 30 percent disabling, warrants a higher rating. A. Rating Criteria Migraine headaches are rated under Diagnostic Code 8100. 38 C.F.R. § 4.124a. Migraine headaches with characteristic prostrating attacks occurring on an average once a month over last several months are rated 30 percent disabling. Migraine headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability are rated 50 percent disabling. The term “prostrating attack” is not defined in regulation or case law, but can be defined as extreme exhaustion or powerlessness. Fenderson v. West, 12 Vet. App. 119, 126-127 (1999). Further, “severe economic inadaptability” is also not defined in VA law. See Pierce v. Principi, 18 Vet. App. 440 (2004). The Board may not deny entitlement to a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). B. Discussion This appeal stems from a ¬¬¬¬¬¬¬¬¬July 2013 rating decision that assigned the initial rating for the migraine headache disability. For the reasons expressed below, the Board finds that for the entire period on appeal, symptoms of the Veteran’s migraine headache disability more nearly approximate the criteria for a 50 percent disability rating. Turning to the evidence, VA treatment records in December 2011 indicate that the Veteran complained of increasing migraine headaches. Thereafter, in March 2012, the Veteran reported that she had migraines at least eight times per month, and stated that she developed fevers with each migraine. In an additional treatment note later in March 2012, the Veteran reported chronic headaches since 2002. The medical professional indicated that the pain was “aborted” with Sumatriptan, but the Veteran did not like the side effects of the medication. It further noted that the headaches were getting worse with photophobia. A MRI of the brain in April 2012 was negative, but the report noted that the Veteran was not taking the Inderal she was prescribed as prophylactic treatment in order to abort migraines. In a September 2012 statement, the Veteran’s spouse indicated that since 2003, when they were stationed in Ft. Leonard Wood, he noticed that she was getting severe chronic migraines, which would often cause her to “lash out or simply just shut down completely because the pain was so severe.” He further stated that despite years of treatment and medication, nothing seemed to help, and even in 2012, her chronic migraines still existed as if they were back in 2003. He noted that the medication she took made her high and unable to function, despite resolving the headache. He added that when taking her medications, she was unable to do much around the house or at work. In an August 2012 letter, the Veteran’s employer at the United States Department of the Interior, National Park Service, indicated that she was informed of the Veteran’s medical conditions, to include migraine headaches, as a result of her inquiries and concerns regarding the Veteran’s difficulty in performing her duties, sudden illnesses, and excessive use of leave. She further noted that her medical conditions were confirmed by receipt of documentation from physicians who treated her. In an additional September 2012 “buddy statement,” a friend of the Veteran indicated that he never saw someone cry from having chronic migraines or someone who had it as comfortable as she (the Veteran) did. The friend noted that since he learned of her headaches, he noted that she was getting them more often and that they lasted more than a day to a week with little to no relief. He added that he visited her at work and she was wearing shades and stated that she had to take her pills, but once she did, she was unable to stay at work. He indicated that that she was very resilient and attempted to go to work even when she did not feel well, but often had to leave work as early as ten in the morning after only two hours. Lastly, the friend noted that he saw the effect of her headache medications, which left her unable to do anything, to include taking care of her daughter. In a September 2012 correspondence, the Veteran reported that her migraine headaches that began in 2003, started out as sporadically and then progressed throughout the years to a point of lasting an entire day, and later she experienced two-day episodes and at times the headaches even lasted longer, sometimes as long as a full-week. She reported that she was at work when she had to take pills for her headaches, but then had to leave, because the pills numbed her from throat to head and made her feel high. She admitted that taking Sumatriptan resolved the headache, but immediately after, she was not in a condition where she could do any work or be “children friendly.” She identified difficulties caused by her migraines at work, such as inability to concentrate when giving people change, and difficulties at home, such as inability to cook, clean, or help her daughter with anything. The Veteran underwent a VA examination for her headaches in September 2012, at which time the examiner confirmed a diagnosis of migraine including migraine variants headaches. The Veteran reported that she started suffering from headaches in 2003, which improved, but in 2006 began again. She described her headaches as throbbing pain or pressure sensation in the frontal area, with irradiation to the back, and associated phonophobia and photophobia. The examiner noted that the headaches occurred about three-times per month, but they may last a few days at a time, and were usually prostrating. The examiner further noted that treatment plan included taking medications. Symptoms of the headaches included pulsating or throbbing head pain on both side of the head, as well as non-headache symptoms of sensitivity to light and sound. The examiner noted that the duration of a typical headache was between one and two days with characteristic prostrating attacks more frequently than once per month. Though, the examiner stated that the Veteran did not have very frequent prostrating and prolonged attacks of migraine headache pain. Lastly, the examiner noted that the Veteran was able to obtain, perform, and secure substantial gainful employment, but with restriction to light, sedentary and/or semi-sedentary duty work, with several precautions, such as making sure she always has her migraine medication nearby. In an additional statement received later in September 2012 from another one of the Veteran’s friends, it was noted that the Veteran often complained of migraines since service, but at the time just attributed it to the demanding training, without seeking medical attentions. Though, the friend noted that once her migraines intensified and caused excruciating pain, she was forced to seek medical help. In her June 2014 notice of disagreement (NOD), the Veteran stated that she believed her migraine headaches should have been rated as 50 percent disabling. She noted that even with her prescribed medications, when her migraine “hit,” she is unable to function as a “regular person,” and is unable to do her house work, cook, wash clothes, tolerate sunlight or artificial light, or help her daughter with her homework. In a correspondence attached to her NOD, she indicated that she was grateful she was granted a 30 percent rating, but for the “pain or lack of sex life,” her headaches should be rated as 50 percent disabling. She further stated that when she had migraines, which sometimes lasted a whole week, she was unable to have sexual intercourse due to the pain, pressure, and throbbing. She added that she was happy to have an understanding boss that might have been able to deal with her conditions, but stated that she had to stay home or leave work due to her migraines. VA treatment records dated in September 2014 indicate that the Veteran reported constant headaches that were described as frontal or occipital, throbbing or pressure-like, that lasted from three to seven days and were six to ten out of ten in severity. In a March 2017 correspondence, the Veteran indicated that her headaches caused her a financial burden and hardship on her life and work. She indicated that she received negative evaluation reports, because she was later to work due to her migraines and feeling sick. She added that she suffered from severe migraines that forced her to leave work, which was evidence by 32-leave slips between August 2004 and December 2016. Throughout the initial period on appeal, VA treatment records show that the Veteran was prescribed a number of medications for her headaches, to include Ibuprofen 800mg, Sumatriptan Succinate 100mg, Propranolol HCL 20mg, and Fioricet 40mg. Based on the foregoing, the Board finds that the Veteran’s headaches more nearly approximate a 50 percent disability rating. In this regard, the Board notes that for the 30 percent criteria, evidence must show headaches with characteristic prostrating attacks occurring on average once a month. Here, the Veteran reported severe headaches that occurred at least eight times per month or more frequently. As such, at the least, she had severe headaches that occurred four times a month, which is more frequent than required by the 30 percent rating criteria. Notably, the headaches were always referred to as “severe headaches,” and the Veteran’s lay reports and the above mentioned medical evidence suggests that these headaches were very frequent, completely prostrating, and prolonged. Here, the lay assertions made by the Veteran, her employer, and family and friends, all suggest that her headaches were so severe that they interfered with her ability to work. Therefore, the fact that she was still working does not indicate that her headaches were not productive of severe economic inadaptability. As noted above, the Board analysis is focused on whether the disability is capable of producing severe economic inadaptability, regardless of whether the condition was actually causing such inadaptability. Pierce, 18 Vet. App. at 440. Based on this body of evidence, the Board finds that the Veteran’s headaches more nearly approximate the criteria for a 50 percent disability rating, the highest available rating for this disability under the rating schedule, from the beginning of the claim. REASONS FOR REMAND A remand is necessary to provide the Veteran with a VA examination to determine the current severity of her numerous scars and the nature and etiology of any currently diagnosed psychiatric disorder. Increased Rating for Scars Notably, while the Veteran is rated for three scars, assigned a 10 percent disability each, she asserts that she has five scars as a result of her surgeries. She also asserted that the scars are more painful that described by the May 2016 VA examination. Service connection for an Acquired Psychiatric Disorder The Veteran’s service treatment records contain complaints of sleeping too much and lay assertions support post-service diagnosis of idiopathic hypersomnia. Subsequent VA treatment records show reports of daily sleepiness since 1999, which progressively worsened. Nevertheless, during a September 2012 mental health examination, the VA examiner concluded that the Veteran did not meet the criteria for a diagnosis of any mental health disorder. Specifically, the examiner stated that the Veteran did not fulfill the DSM-IV criteria for a sleep disorder, since the sleep disturbance did not cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. It does not appear however, that the examiner considered the competent lay assertions of Veteran, her spouse, and friends, indicating that she would fall asleep suddenly, to include in the middle of conversations. On remand, the examiner should consider those statements and discuss the significance; specifically, whether those statements show significant distress or impairment in social or occupational functioning. Further, in May 2017, the Veteran filed a formal claim for PTSD due to military sexual trauma. This claim was not noted by the RO, and while usually the Board will refer such claim to the RO for further development, here, the Board recharacterized the Veteran’s claim to include all psychiatric disorders, however diagnosed. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). Accordingly, the Board finds that a new VA examination is warranted, to further consider the Veteran’s current diagnoses, reported symptoms, and their potential relationship to service. In addition, further development is necessary regarding the Veteran’s claim for PTSD due to military sexual trauma. TDIU The issue of potential entitlement to a TDIU is an element of all increased rating requests. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Here, the Board finds that the record is replete with information suggesting that the Veteran’s service-connected disabilities preclude her from obtaining and/or maintaining employment. In light of the Board’s decision herein increasing the Veteran’s migraine headache disability to 50 percent, and the remanded claims for increased rating for the Veteran’s service-connected scars, the issue of a TDIU is inextricably intertwined with the issues being remanded and adjudication of TDIU must be deferred pending the proposed development, and the RO’s assignment of disability ratings for the service-connected depression based on the Board’s decision herein. The matters are REMANDED for the following action: 1. Ensure that all outstanding VA treatment records since the February 2017 SOC are associated with the claims file. 2. Develop the Veteran’s claim for service connection for PTSD, to include as due to military sexual trauma, in accordance with those special alternative evidentiary development procedures associated with personal assault claims as noted in 38 C.F.R. § 3.304(f)(5). 3. Thereafter, provide the Veteran with a VA examination to determine the nature and etiology of her service-connected scars. The claims file and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials. After a review of the record and examination of the Veteran, the examiner is asked to respond to the following: (a) Provide measurements of each related scar (including scar length and width at its widest part). (b) Indicate whether any associated scar causes loss of function. (c) Indicate whether any associated scar is superficial, deep, nonlinear, unstable, or painful. (d) Elicit from the Veteran all symptoms she attributes to her service-connected scars, if any symptom is related to another disability such her service-connected carpal tunnel syndrome, please explain such relationship. A complete rationale for all opinions. 4. Only after directive #2 above is completed, provide the Veteran with an appropriate VA examination to determine the nature and etiology of any currently diagnosed psychiatric disorders, to include idiopathic hypersomnia or any other currently diagnosed sleep disorder. The claims file and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials. After a review of the record and examination of the Veteran, the examiner is asked to respond to the following: (a) Identify all currently diagnosed psychiatric disorders, to include idiopathic hypersomnia, other sleeping disorders, PTSD, and/or other psychiatric disorders that resulted from the Veteran’s reported military sexual trauma. (b) For each currently diagnosed psychiatric disorder, provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) that it had its onset during service or is otherwise causally or etiologically related to it, to include as due to the Veteran’s reported military sexual trauma. (c) specifically related to the Veteran’s currently diagnosed idiopathic hypersomnia, if the examiner concludes that the criteria for a sleeping disorder was not met, he or she is asked to explain what symptoms of any are required and not present to support such diagnosis. In providing the opinion, the examiner should consider and discuss as necessary, the following VBMS entries: (i) CAPRI 08/18/2012 showing reports of excessive daytime sleepiness since 1999 and a history of depression (see for example p.93 and p.98, and, (ii) Buddy/Lay Statements, statement in support of claim, third party correspondence, and correspondence on 08/31/2012, 09/28/2012, 06/03/2014, and 03/14/2017. A complete rationale for all opinions. 5. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the TDIU. M.E. Larkin Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Yaffe, Associate Counsel