Citation Nr: 18148668 Decision Date: 11/08/18 Archive Date: 11/07/18 DOCKET NO. 16-39 389 DATE: November 8, 2018 ORDER Service connection for fatigue is granted. A disability rating of 70 percent, but no higher, for persistent depressive disorder with other specified trauma and stressor-related disorder (previously rated as posttraumatic stress disorder (PTSD) and major depressive disorder) (hereinafter “psychiatric disability”), is granted. REMANDED Entitlement to service connection for gout (claimed as pain all over) is remanded. Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for a skin disability is remanded. Entitlement to service connection for cluster headaches is remanded. FINDINGS OF FACT 1. The Veteran served in the Southwest Asia theater of operations, in Saudi Arabia, during his second period of active service in April 1991 and is a Persian Gulf Veteran. 2. The Veteran’s fatigue is attributable to a symptom of his service-connected psychiatric disability. 3. The Veteran’s psychiatric disability has been manifested by depressed mood and suicidal thoughts or ideations and more nearly approximated by occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. With resolution of reasonable doubt in the Veteran’s favor, the criteria for entitlement to service connection for fatigue, as a symptom of service-connected psychiatric disability, have been met. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2018). 2. The criteria for a disability rating of 70 percent, but no higher, for psychiatric disability have been met. 38 U.S.C § 1155 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.21, 4.126, 4.130, Diagnostic Code 9411 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1983 to January 1988 and from August 1988 to August 1991, followed by a period of service in the Navy Reserve. This matter comes to the Board of Veterans’ Appeals (Board) from a June 2011 rating decision which denied service connection for a body rash, cluster headaches, gout, sleep apnea, and fatigue. This matter also comes to the Board from a May 2014 rating decision which continued a 50 percent evaluation for persistent depressive disorder with other specified trauma and stressor-related disorder (formerly rated as posttraumatic stress disorder and major depressive disorder) (hereinafter “psychiatric disability”). In June 2016, the Regional Office (RO) issued a statement of the case for the increased rating claim for a service-connected psychiatric disability. In August 2016, the Veteran filed a timely substantive appeal by VA Form 9 (Appeal to the Board of Veterans’ Appeals) and in attached correspondence, indicated that he was appealing the rating of his mental health condition. This issue was not certified to the Board, but by treating a claim as if it is part of a timely filed substantive appeal, VA effectively waives all objections to the procedural adequacy of the appeal with respect to that issue. See Percy v. Shinseki, 23 Vet. App. 37, 46 (2009). Therefore, the Board has jurisdiction over the claim. Service Connection Service connection may be granted for 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). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service-connected disability. In such an instance, a veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish entitlement to service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). In addition to direct service connection, statutes provide for a presumption of service connection for undiagnosed illnesses and medically unexplained chronic multi-symptom illnesses for Persian Gulf veterans. 38 U.S.C. § 1117. The statutes are implemented at 38 C.F.R. § 3.317. Review of the Veteran’s service personnel records shows that he served in the Southwest Asia theater of operations, in Saudi Arabia, during his second period of active service in April 1991. As a result, the Veteran in this case is a Persian Gulf Veteran. Entitlement to service connection for fatigue The Veteran asserts that service connection is warranted for fatigue. Specifically, he contends his fatigue started soon after his return from the Gulf and has continued since. At a July 2010 VA general medical examination, the Veteran reported always being tired and having trouble sleeping for many years. Following the clinical evaluation, the VA examiner provided diagnoses of depression and chronic fatigue as part of depression. At a July 2010 VA general medical examination, the Veteran reported always being tired and having trouble sleeping for many years. Following the clinical evaluation, the VA examiner provided diagnoses of depression and chronic fatigue as part of depression. In September 2014, the Veteran underwent a VA Disability Benefits Questionnaire (DBQ) examination for chronic fatigue syndrome. The VA examiner evaluated the Veteran and determined that, while he experienced subjective symptoms of fatigue, he did not have a diagnosis of chronic fatigue syndrome. Further, the examiner opined that the Veteran’s fatigue was most likely due to a combination of sleep apnea and depression. At the outset, the Board acknowledges that the evidence of record does not show a current diagnosis for chronic fatigue syndrome nor that the Veteran’s symptoms of fatigue are attributable to an undiagnosed illness or otherwise related to his Persian Gulf service. Nevertheless, the Board finds that the Veteran’s fatigue has been attributed as due to his service-connected psychiatric disability. For the reasons and bases discussed above and after resolving all reasonable doubt in favor of the Veteran, service connection is warranted for fatigue as secondary to his service-connected psychiatric disability. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.310. Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Any reasonable doubt regarding a degree of disability will be 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, such as for the service-connected psychiatric disability in this case, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. 38 C.F.R. § 4.2; Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Generally, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). The standard of proof to be applied in decisions on claims for veteran’s benefits is set forth in 38 U.S.C. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Entitlement to a disability rating in excess of 50 percent for psychiatric disability On December 5, 2013, the Veteran requested a higher rating for his service-connected psychiatric disability. The Veteran’s psychiatric disability is currently evaluated as 50 percent disabling under Diagnostic Code (DC) 9411 of the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, DC 9411. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran’s capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the 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. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, VA also will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Under the applicable rating criteria, a 50 percent disability rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9411. A 70 percent disability rating is warranted for 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 work-like setting); inability to establish and maintain effective relationships. Id. Finally, a 100 percent disability rating, the maximum available, is warranted when there is 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. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is a Veteran’s symptoms, but it must also make findings as to how those symptoms impact a Veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan, 16 Vet. App. at 436. Thus, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442. Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran’s impairment must be “due to” those symptoms; a Veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. In Golden v. Shulkin, No. 16-1208 (U.S. Vet. App. April 19, 2017), the Court held that, given that the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) abandoned the Global Assessment of Functioning (GAF) scale and that VA has formally adopted the DSM-5, GAF scores are inapplicable to assign a psychiatric rating in cases where the DSM-5 applies when the appeal was certified after August 4, 2014. Although this issue was not formally certified to the Board, the substantive appeal was filed after August 4, 2014, thus in this case, the DSM-5 applies and GAF scores are inapplicable. 80 Fed. Reg. 14, 308 (March 19, 2015). In this case, the Board considers whether a disability rating in excess of 50 percent for psychiatric disability is warranted at any time since or within one year prior to the date of claim on December 5, 2013. Turning to the evidence of record, a May 2013 VA treatment record reflects that the Veteran reported feeling ok, but when questioned further, stated that he was having passive thoughts of suicide and wondered if he would die if he hit a tree, but he denied that he would follow through. The Veteran complained of memory issues and racing thoughts due to stress from his coworkers, and the examiner noted that the Veteran had difficulty providing accurate information. In July 2013, the Veteran reported passive suicidal ideation with plan, but denied intent. While pleasant and cooperative, the Veteran was noted to have little spontaneous speech and answered opened ended questions with very short answers. The Veteran reported self-esteem issues and poor sleep, appetite, energy and concentration and was noted to have significant psychosocial stressors, including estrangement from one of his children. The examiner indicated that a suicide prevention safety plan was established, and that the Veteran would be closely monitored. Review of VA treatment records from mid- to late-2013 and into early 2014 reflects that the Veteran reported overall improvement in his mood and sleep. The Veteran’s affect was brighter and his eye contact better. The Veteran appeared alert and oriented, appropriately groomed, speech normal, thought processes were linear and goal-oriented, memory intact, and judgment and insight were fair. Mood ranged from depressed to okay. The Veteran denied suicidal or homicidal ideations and hallucinations. The Veteran was afforded a VA examination in April 2014. The Veteran reported significant suicidal ideation subsequent to his divorce in 2008 after being married for 20 years. He reported that he rarely saw his two sons due to their schedule and his social withdrawal. He reported that he tended to avoid most social and leisure activities, that he only had one friend whom he had known since elementary school. The Veteran reported working on aircraft for 16 years, but that work was stressful due to arguments with his coworkers. The Veteran reported recent thoughts of hurting himself, but denied taking action or having access to a gun. Upon examination, the Veteran appeared appropriately dressed and groomed. He was cooperative, engaged, and focused, but his affect was flattened. Speech was normal and thought processes were linear and logical. The examiner found symptoms of depressed mood, chronic sleep impairment, flattened affect, and suicidal ideation, resulting in occupational and social impairment with occasional decrease in work efficiency and intermittent periods in inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. In May 2014, the Veteran’s employer issued him a letter of caution which noted incidents of slamming clipboards, banging lockers, slamming the wall with his fists, and kicking doors, and such behavior could be construed as workplace violence, threatening, and harassment. The Veteran was advised to seek assistance for anger management and that further incidents could result in formal disciplinary action. In June and July 2014, the Veteran reported that his symptoms often waxed and waned, but that his symptoms continued to bother him, even if he had not been reporting them. He reported difficulty identifying his emotions, but could identify disgust, anger, and sadness. The Veteran reported problems at work. He appeared alert and oriented, but his mood was depressed and his affect ranged from flat to constricted. Speech was normal and thought processes logical and goal-directed, but the Veteran endorsed suicidal thoughts without intent. In March 2016, the Veteran denied feelings of hopelessness or thoughts about taking his life, but reported a previous suicide attempt. After personally evaluating the Veteran, the examiner recommended intervention, but the Veteran refused and declined mental health treatment at the time. Based upon the evidence of record, including that specifically discussed above, the Board concludes that a disability rating of 70 percent is warranted. Specifically, the evidence reflects that the Veteran reported depressed mood, decreased concentration or memory problems, difficulty maintaining effective work and social relationships, and often reported passive suicidal ideation or thought, sometimes with a plan but without intent to act. The Board notes that thoughts of suicidal ideation are only considered in a 70 percent disability evaluation. There are no analogues at the lower evaluation levels. See Bankhead v. Shulkin, 29 Vet. App. 10, 20-21 (2017) (precedential panel decision). Thus, under the General Formula for Rating Mental Disorders at 38 C.F.R. § 4.130, “the presence of suicidal ideation alone, that is, a veteran’s thoughts of his or her own death or thoughts of engaging in suicide-related behavior, may cause occupational and social impairment with deficiencies in most areas.” Bankhead v. Shulkin, 29 Vet. App. at 20 (2017). Evidence of more than thought or thoughts of ending one’s life to establish the symptom of suicidal ideation, is not required. In other words, a veteran need not be at a risk, whether a high or low risk, of self-harm in order to establish the criteria of suicidal ideation. Bankhead, 29 Vet. App. 20-21. Accordingly, the Board finds an increased 70 percent evaluation is warranted. While the frequency and severity of the symptoms of the Veteran’s psychiatric disability fluctuates and there are times which suggest the condition may not even rise to the level contemplated by a 70 percent rating, resolving all doubt in the Veteran’s favor, the 70 percent evaluation is appropriate. A higher 100 percent schedular rating is not warranted at any time during the appeal period. The Veteran’s psychiatric disability manifested a range of symptoms, but those most frequently emphasized by the Veteran were depressed mood and suicidal ideation and thoughts. The evidence does not show any indication of total social or occupational impairment that more nearly approximates a 100 percent disability rating due to his psychiatric symptomatology based on review of treatment records, VA examination reports, and the Veteran’s lay statements. Objective examinations and treatment records document the Veteran has demonstrated appropriate dress and grooming, alertness and orientation, and fair insight and judgment. Additionally, he denied hallucinations and while he presented with thoughts of death or suicide, he was never described as being a danger to himself or others. The Veteran’s symptoms have never been shown to be so frequent or disabling that they rise to the level of total occupational or social impairment, which is a level of severity so disabling that some of the examples of symptoms include not knowing one’s own name or posing a persistent threat of danger to self or others. See Mauerhan, 16 Vet. App. at 442 (finding that symptoms contained in rating schedule criteria are “not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating”). Thus, the Board finds that an increased disability rating of 70 percent, but no higher, is warranted for the service-connected psychiatric disability in this case. See 38 C.F.R. § 4.130, Diagnostic Code 9411. REASONS FOR REMAND In April 2011, the RO made a formal finding of unavailability of the Veteran’s service treatment records from his periods of active service from 1983 to 1991. Treatment records from the Veteran’s service in the Naval Reserve from 1997 to 1999 reflect that the Veteran was transferred to the Individual Ready Reserve in 1999 and a January 2000 note from the Naval Reserve Personnel Center reflects that his health records were terminated by reason of expiration of enlistment. While the RO made a request for the Veteran’s records from the Records Management Center (RMC), it is not clear whether the RO requested the Veteran’s records from the Naval Reserve Personnel Center or with his reserve unit. 1. Entitlement to service connection for gout (claimed as pain all over) At this time, the Board cannot make a fully-informed decision on the issue of entitlement to service connection for gout, claimed as all over body pain. The Veteran was afforded VA examinations in July 2010 and September 2014. While the July 2010 VA examiner indicated that the Veteran reported subjective pain in his knees and elbows for 10 years, the examiner found no objective evidence of a knee or elbow disability and opined that the Veteran did not have an undiagnosed illness or medically unexplained chronic multi-symptom illness of unknown etiology. The September 2014 examiner noted the Veteran reported injuring his knees and elbows prior to service in a motorcycle accident, but that the pains did not start until after service. The examiner found that the Veteran was diagnosed with gout in 2012, with flares in his right knee and large toe every two months, but that the Veteran denied any current elbow or left knee problems. The examiner found that the Veteran’s gout developed after leaving service and there was no connection between gout and the Gulf War. Thus, the examiner opined that the Veteran’s gout was less likely as not caused by, incurred in, or a result of military service or the Gulf War. While the September 2014 VA examiner indicated that there was no known connection between the Gulf War and gout, the examiner did not provide an adequate rationale or basis for service connection on a direct or presumptive basis under 38 C.F.R. § 3.309(a). Thus, the Board finds that a remand is warranted for an additional VA medical opinion as to the nature and etiology of the Veteran’s gout, claimed as pain all over. 2. Entitlement to service connection for sleep apnea At this time, the Board cannot make a fully-informed decision on the issue of entitlement to service connection for sleep apnea. The Veteran was afforded a VA examination in September 2014. The September 2014 examiner noted the Veteran was diagnosed with sleep apnea in 2012. However, the examiner found that there was no known relationship between burn pits, fuel fires, and sleep apnea and opined that the Veteran’s sleep apnea was less likely as not caused by, incurred in, or a result of military service or the Gulf War. In light of the Veteran’s reported onset of sleep apnea with his fatigue, the Board finds that a remand is warranted for an additional VA medical opinion as to the nature and etiology of the Veteran’s sleep apnea on a secondary basis to his now service-connected fatigue as well as psychiatric disability. 3. Entitlement to service connection for a skin disability At this time, the Board cannot make a fully-informed decision on the issue of entitlement to service connection for a skin disability, to include a rash. In a July 2010 statement, the Veteran reported having developed intermittent body rash on his back, stomach, chest, and under arms. At the July 2010 VA general medical examination, the Veteran reported eczema as a child and that he would currently have intermittent rashes on his body. Upon examination, the examiner found no rashes, concluded there was no current disease of eczema, and did not provide a current diagnosis of a skin disability. At the September 2014 VA DBQ examination for skin diseases, the examiner noted the Veteran’s childhood history of eczema, and provided a current diagnosis of contact dermatitis. The examiner opined that the Veteran’s contact dermatitis was less likely than not caused by, incurred in, or a result of military service or the Gulf War, but was rather due to exposure to aircraft fuel due at his current job. The Board finds it is not clear whether the September 2014 VA examiner considered a November 1997 Naval Reserve enlistment examination which noted dry, flaky skin. Thus, the Board finds that a remand is warranted for an additional VA medical opinion as to the nature and etiology of the Veteran’s current skin disability. gout, claimed as pain all over. 4. Entitlement to service connection for cluster headaches At this time, the Board cannot make a fully-informed decision on the issue of entitlement to service connection for headaches. The Veteran was afforded VA examinations in July 2010 and September 2014. While the July 2010 VA examiner indicated a diagnosis of cluster headaches and found that the Veteran did not have an undiagnosed illness or medically unexplained chronic multi-symptom illness of unknown etiology, the examiner did not opine as to whether the Veteran’s headaches were caused by or a result of his active service, to include environmental exposures in the Gulf. The September 2014 examiner noted the Veteran reported onset of headaches after returning from his tour of duty in Iraq, and that a 2012 VA neurology report noted onset of headaches in 1992. However, the examiner found that there was no known relationship between the Gulf War and cluster headaches and opined that the Veteran’s cluster headaches were less likely as not caused by, incurred in, or a result of military service or the Gulf War. While the September 2014 VA examiner indicated that there was no known connection between the Gulf War and cluster headaches, the examiner did not provide an adequate rationale or basis for service connection on a direct or presumptive basis under 38 C.F.R. § 3.309(a). Thus, the Board finds that a remand is warranted for an additional VA medical opinion as to the nature and etiology of the Veteran’s cluster headaches. The matters are REMANDED for the following actions: 1. Request the Veteran’s complete service treatment records for the period from 1983 to 1991 from the Naval Personnel Reserve Center and the Veteran’s naval reserve unit. 2. Then, return the Veteran’s claims file to the examiner who conducted the September 2014 VA DBQ examination for non-degenerative arthritis so a supplemental opinion may be provided. If that examiner is no longer available, provide the Veteran’s claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. A new examination is only required if deemed necessary by the examiner. The examiner must opine whether any diagnosed gout disability, claimed as pain all over, at least as likely as not (1) began during active service, to include related to an in-service injury, event, or disease, including environmental exposures in the Gulf War, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. The examiner is advised that service treatment records are missing due to no fault on the part of the Veteran. The examiner is requested to accept as true the Veteran’s account of the disability unless there is a medical reason to reject the description as being true. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 3. Return the Veteran’s claims file to the examiner who conducted the September 2014 VA DBQ examination for sleep apnea so a supplemental opinion may be provided. If that examiner is no longer available, provide the Veteran’s claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. A new examination is only required if deemed necessary by the examiner. The examiner must opine as to the following: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s sleep apnea was proximately due to or the result of his service-connected fatigue or psychiatric disability. (b.) Whether it is at least as likely as not that the Veteran’s sleep apnea was aggravated beyond its natural progression by his service-connected fatigue or psychiatric disability. 4. The examiner is advised that service treatment records are missing due to no fault on the part of the Veteran. The examiner is requested to accept as true the Veteran’s account of the disability unless there is a medical reason to reject the description as being true. 5. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 6. Return the Veteran’s claims file to the examiner who conducted the September 2014 VA DBQ examination for skin diseases so a supplemental opinion may be provided. If that examiner is no longer available, provide the Veteran’s claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. A new examination is only required if deemed necessary by the examiner. The examiner must opine as to whether any it is at least as likely as not that the Veteran’s contact dermatitis is related to an in-service injury, event, or disease, to include any environmental exposures in the Gulf War and consideration of the 1997 Naval Reserve entrance examination noting dry, flaky skin. The examiner is advised that service treatment records are missing due to no fault on the part of the Veteran. The examiner is requested to accept as true the Veteran’s account of the disability unless there is a medical reason to reject the description as being true. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 7. Return the Veteran’s claims file to the examiner who conducted the September 2014 VA DBQ examination for headaches so a supplemental opinion may be provided. If that examiner is no longer available, provide the Veteran’s claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. A new examination is only required if deemed necessary by the examiner. The examiner must opine whether any diagnosed headache disability at least as likely as not (1) began during active service, to include related to an in-service injury, event, or disease, including environmental exposures in the Gulf War, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. 8. The examiner is advised that service treatment records are missing due to no fault on the part of the Veteran. The examiner is requested to accept as true the Veteran’s account of the disability unless there is a medical reason to reject the description as being true. 9. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 10. Then, review the medical opinions and examination reports (if provided) to ensure that the requested information was provided. If any report or opinion is deficient in any manner, the RO must implement corrective procedures. 11. After completing the above, and any other development as may be indicated, the Veteran’s claims should be readjudicated based on the entirety of the evidence. If any claim remains denied, the Veteran, and his representative if one is appointed, should be issued a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. T. Blake Carter Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Owen, Associate Counsel