Citation Nr: 18156620 Decision Date: 12/10/18 Archive Date: 12/10/18 DOCKET NO. 16-53 486 DATE: December 10, 2018 ORDER Entitlement to service connection for exposure to dioxin is denied. Entitlement to service connection for diabetes mellitus is denied. Entitlement to service connection for insomnia is denied. Entitlement to service connection for memory loss is denied. Entitlement to an initial rating of 70 percent, but no higher, for service-connected acquired psychiatric disorder to include PTSD with an anxiety disorder and depressive disorder is granted subject to controlling regulations governing the payment of monetary awards. REMANDED Entitlement to service connection for fibromyalgia is remanded. Entitlement to service connection for erectile dysfunction as secondary to service-connected PTSD is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The claimed exposure to dioxin is not, in and of itself, a disability for VA benefits purposes. 2. Diabetes mellitus did not have its onset in service and is not otherwise related to active duty, to include service in Southwest Asia and to include contaminated water at Camp Lejeune. 3. The Veteran’s sleeping difficulty/insomnia is a symptom of his service-connected psychiatric disability. 4. The Veteran’s mild memory loss is a symptom of his service-connected psychiatric disability. 5. Throughout the period on appeal, the evidence shows that the Veteran’s symptoms and overall impairment caused by the Veteran’s service-connected acquired psychiatric disorder to include PTSD with an anxiety disorder and depressive disorder more nearly approximate occupational and social impairment with deficiencies in most areas, but do not approximate total occupation and social impairment. CONCLUSIONS OF LAW 1. The criteria for service connection for exposure to dioxin are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303 (2018). 2. The criteria for service connection for diabetes mellitus are not met. 38 U.S.C. §§ 1110, 1131, 1117, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317 (2018). 3. The criteria for service connection for insomnia are not met. 38 U.S.C. §§ 1101, 1110, 1131, 1154, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309 (2018). 4. The criteria for service connection for mild memory loss are not met. 38 U.S.C. §§ 1101, 1131, 1110, 1154, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309 (2018). 5. The criteria for an initial rating of 70 percent, but not higher, for the Veteran’s service-connected acquired psychiatric disorder to include PTSD with an anxiety disorder and depressive disorder, have been met throughout the pendency of the claim. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.3, 4.130, Diagnostic Code (DC) 9411 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Marine Corps from February 1987 to February 1993. These matters come before the Board of Veterans’ Appeals (Board) on appeal from December 2013 and July 2016 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. In the December 2013 rating decision, the RO granted service connection for an acquired psychiatric disorder to include PTSD with an anxiety disorder and depressive disorder. In the July 2016 rating decision, the RO denied service connection for diabetes mellitus, erectile dysfunction, exposure to dioxin, fibromyalgia, insomnia, and memory loss. The Veteran timely filed notice of disagreements (NODs) to the RO decisions as well as timely substantive appeals, via a VA Form 9, appeal to the Board. During the pendency of the claim, a September 2015 rating decision granted a higher rating of 50 percent for his psychiatric disability, effective August 31, 2015. This created a staged rating. The Veteran timely appealed the effective date of the assigned 50 percent rating. Thus, the issue before the Board in this regard may be phrased in various manners. The issue may be phrased as entitlement to an earlier effective date for a 50 percent rating for the Veteran’s psychiatric disability. The issue may also be phrased as entitlement to a 50 percent rating for PTSD from prior to August 31, 2015. The Board notes that the grant of any compensation benefit necessarily includes implementation of an award and the selection of an effective date, since no award is granted in a legal vacuum. Here, the Board has phrased the issue as entitlement to an initial rating in excess of 50 percent for the Veteran’s service-connected psychiatric disability prior to August 31, 2015 because, as noted, the RO has granted a staged rating. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (where a veteran timely appeals a rating initially assigned when service connection is granted, the Board must consider entitlement to “staged” ratings to compensate for times since filing the claims when the disabilities may have been more severe than at other times during the course of the appeal). There is therefore no issue with regard to an impermissible freestanding claim for an earlier effective date. Cf. Rudd v. Nicholson, 20 Vet. App. 296 (2006). In July 2017, the Veteran testified before a Decision Review Office (DRO); a transcript of the hearing is of record. In his substantive appeals, the Veteran requested a Board hearing. However, in January 2018 correspondence, he withdrew his hearing requests. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In this case, no examination is necessary in order to adjudicate the Veteran’s claims of entitlement to service connection for diabetes mellitus, exposure to dioxin, insomnia, and memory loss. As indicated in the discussion below, there is no evidence that the Veteran’s diagnosed diabetes mellitus is associated with service. Furthermore, exposure to dioxin, in and of itself, is not a disability for VA purposes, and the Veteran is not entitled to the presumption of such exposure. Additionally, there is no current independent diagnosis of insomnia and memory loss and the evidence reflects that these are symptoms of the Veteran’s service-connected PTSD. To the extent that the Veteran has asserted that he his diabetes mellitus, any exposure to dioxin, and insomnia and memory loss are related to service, such a conclusory generalized lay statement alleging nexus between a current disability and service does not meet the standard to warrant a VA examination. Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010). 1. Entitlement to service connection for exposure to dioxin The Veteran contends that he was exposed to dioxin while serving in the Southwest Theater of Operations during the Persian Gulf War. A current disability is required to establish entitlement to compensation. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a). While a “disability” for the purposes of awarding VA disability benefits is not only a disease or an injury, but also any “other physical or mental defect,” 38 U.S.C. § 1701 (1); Allen v. Brown, 7 Vet. App. 439, 444-45 (1995) (applying the definition of disability in section 1701(1) to statutes describing “eligibility for disability compensation for service connected disabilities”), here the evidence does not establish a current disability. As such, entitlement to service connection for exposure dioxin, alon, is not warranted. Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007) (“Without a current disability, of course, there can be no service connection and, thus, no disability compensation”). In addition, the Veteran’s claims for service connection for disabilities due to exposure to environmental hazards are already being considered in connection with this claim. Entitlement to service connection for exposure to dioxin must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine is not for application. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for diabetes mellitus The Veteran contends that his diabetes mellitus is due to environmental hazards he was subjected to while stationed in Southwest Asia to include exposure to various chemicals and fumes, including burn pits and exposure to radioactive materials. Service treatment records (STRs) do not reflect diagnosis, treatment, or symptoms of diabetes mellitus. The Veteran underwent numerous blood tests throughout service which were normal. On separation, the report of medical examination reflects a normal endocrine clinical evaluation. Post-service, VA treatment records reflect that in October 2014, the Veteran was diagnosed with diabetes mellitus without mention of complication, type II or unspecified type. During the July 2017 DRO hearing, the Veteran reported that he was at Camp Lejeune. He also reported that he was in Desert Storm and exposed to a number of environmental hazards, all of which are known to contain dioxin, which is the active agent in Agent Orange. Accordingly, the Veteran asserts that he was exposed to herbicide. He reported that for a two-week period, he was in charge of making sure that burn barrels got burned and discarded medical waste. He reported that the hazmat suits were compromised. He stated that he was not wearing any protective clothing in the burn pits. He reported that it could take anywhere from four to eight hours, depending on how much equipment they had to burn. He stated that the smoke got in his face and eyes. Upon review of the evidence of record, the Board finds that service connection for diabetes mellitus is not warranted. Under 38 U.S.C. § 1117 (a)(1), compensation is warranted for a Persian Gulf Veteran who exhibits objective indications of a “qualifying chronic disability” that became manifest during service on active duty in the Armed Forces in the Southwest Asia Theater of operations during the Persian Gulf War, or to a degree of 10 percent prior to December 31, 2021 (for qualifying chronic disabilities that become manifest to a degree of 10 percent or more after active duty in the Southwest Asia Theater of operations). See 81 Fed. Reg. 71382 (Oct. 17, 2016). Furthermore, the chronic disability must not be attributed to any known clinical disease by history, physical examination, or laboratory tests. See 38 C.F.R. § 3.317 (a)(ii). The Board notes that Congress revised 38 U.S.C. § 1117, effective March 1, 2002. In the revised statute, the term “chronic disability” was changed to “qualifying chronic disability,” and the definition of “qualifying chronic disability” was expanded to include (a) undiagnosed illness; (b) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders) that is defined by a cluster of signs or symptoms; or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. Effective June 10, 2003, VA promulgated revised regulations to, in part, implement these statutory changes. See 38 C.F.R. § 3.317 (a)(2). Because the Veteran served in the Southwest Asia Theater of operations from December 1990 to April 1991, he is a Persian Gulf veteran within the meaning of the applicable statute and regulation. It must now be determined whether the Veteran’s diabetes mellitus is associated with an undiagnosed illness or medically unexplained chronic multisymptom illness other qualifying chronic disability that became manifest either during the Veteran’s Persian Gulf War service or to a degree of 10 percent or more after separation from service. The Board finds that the Veteran does not have a qualifying chronic disability pursuant to 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, i.e., one due to an undiagnosed illness or a medically unexplained chronic multi-symptom illness. Diabetes mellitus is a known clinical diagnosis. As such, awarding service connection pursuant to 38 U.S.C. § 1117 is not warranted. Additionally, the Veteran contends that he was exposed to environmental hazards at Camp Lejeune. His service personnel records confirm that he was stationed at Camp Lejeune, at the earliest, in January 1988. However, the Veteran reported that he served at Camp Lejeune from October 1987 to February 1993. Service connection may also be granted on a presumptive basis for certain diseases associated with exposure to contaminants (defined as the volatile organic compounds trichloroethylene (TCE), perchloroethylene (PCE or PERC), benzene, and vinyl chloride) in the on-base water supply located at Camp Lejeune, even though there is no record of such disease during service, if they manifest to a compensable degree at any time after service, in a veteran, former reservist, or a member of the National Guard, who had no less than 30 days (consecutive or nonconsecutive) of service at the United States Marine Corps Base Camp Lejeune and/or Marine Corps Air Station New River in North Carolina, during the period beginning on August 1, 1953, and ending on December 31, 1987. Diseases Associated with Exposure to Contaminants in the Water Supply at Camp Lejeune, 82 Fed. Reg. 4,173 (Jan. 13, 2017) (to be codified at 38 C.F.R. pt. 3). This presumption may be rebutted by affirmative evidence to the contrary. Id. As the Veteran’s military personnel records do not reflect consecutive or nonconsecutive service at Camp Lejeune during the period beginning on August 1, 1953 and ending December 31, 1987, he is not presumed to have been exposed to contaminated water. Nevertheless, even if the Veteran did serve during the required period, service connection for diabetes mellitus on a presumptive basis could not be granted. The following diseases are deemed associated with exposure to contaminated water at Camp Lejeune: kidney cancer, liver cancer, Non-Hodgkin's lymphoma, adult leukemia, multiple myeloma, Parkinson's disease, aplastic anemia and other myelodysplastic syndromes, and bladder cancer. Id. As such, diabetes mellitus is not a disease for which presumptive service connection based on exposure to contaminated water at Camp Lejeune may be granted. Id. However, the Veteran may still establish service connection on a direct or secondary basis. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994); 38 U.S.C. § 1113 (b). The STRs are silent as to any complaints, treatments, or diagnoses of diabetes mellitus. The Veteran was not diagnosed with diabetes mellitus until 2014—more than 20 years following separation from service. Furthermore, the Veteran has not made any statements, and the medical evidence of record does not reflect, symptomatology or a continuance of symptomatology of diabetes mellitus before his diagnosis. As such, service connection on a direct basis is not warranted as there is no in-service injury or event. The Board has also considered the Veteran’s statements concerning the etiology of his diabetes mellitus. While the Veteran is competent to report his symptoms, the question of whether diabetes mellitus was a result of disease or injury that is due to service, to include contaminated water at Camp Lejeune and exposure to environmental hazards in Southwest Asia, relates to an internal medical process that extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Jandreau, 492 F.3d at 1377, n. 4 (“sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer”). Thus, the Veteran’s own assertions as to the etiology of diabetes mellitus are not competent. Based on the evidence of record, the weight of the competent and credible evidence demonstrates no relationship between the Veteran’s diabetes mellitus and active duty service. For these reasons, the Board finds that the preponderance of the lay and medical evidence of record is against the Veteran’s claim of service connection for diabetes mellitus, to include as due to exposure to environmental hazards in the Southwest Asia arena and contaminated water at Camp Lejeune, on a direct, presumptive, or any other basis, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to service connection for insomnia STRs reflect that in November 1991, the Veteran was seen for a psychiatric consultation. The Veteran reported that he experienced insomnia among a number of other psychiatric symptoms. He was diagnosed with marital problems, alcohol abuse, and antisocial traits. Post-service, the Veteran was diagnosed with an acquired psychiatric disorder to include PTSD with an anxiety disorder and depressive disorder. During his December 2011, September 2013, August 2015, and October 2017 VA examinations, the Veteran reported difficulty sleeping. During the July 2017 DRO hearing, the Veteran testified that his insomnia is because of his nightmares and hypervigilance which were due to his PTSD. VA treatment records reflect difficulty sleeping in connection with his psychiatric disabilities. Upon review of the evidence of record, the Board finds that a separate grant of service connection for insomnia is not warranted. The weight of the above evidence reflects that the Veteran does not have a stand-alone sleep disability due to causes other than his service-connected psychiatric disorder. While a “disability” for the purposes of awarding VA disability benefits is not only a disease or an injury, but also any “other physical or mental defect.” 38 U.S.C. § 1701(1); Allen v. Brown, 7 Vet. App. 439, 444-45 (1995) (applying definition of disability in section 1701(1) to statutes describing “eligibility for disability compensation for service connected disabilities”). Here the evidence reflects that the Veteran’s sleep difficulties have already been attributed to his PTSD and the Veteran is compensated accordingly. As the Veteran does not have a separate and distinct sleep disability, entitlement to service connection is not warranted. Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007) (“Without a current disability, of course, there can be no service connection and, thus, no disability compensation”). For the foregoing reasons, the preponderance of the evidence is against the claim for service connection for insomnia. The benefit of the doubt doctrine is not for application, and entitlement to service connection for insomnia is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 4. Entitlement to service connection for memory loss STRs do not reflect diagnosis, treatment, or complaint of memory loss. Post-service, as noted above, the Veteran was diagnosed with an acquired psychiatric disorder to include PTSD with an anxiety disorder and depressive disorder. The September 2013 VA examination report reflects mild memory loss. During the July 2017 DRO hearing, the Veteran reported that he has a lot of issues bringing parts together and remember the people he served with. He reported that he has forgotten a lot of things. Upon review of the evidence of record, the Board finds that a separate grant of service connection for memory loss is not warranted. The weight of the above evidence reflects that the Veteran does not have a separate and distinct memory disability. See Allen, 7 Vet. App. 439 at 445 (1995) (applying definition of disability in section 1701(1) to statutes describing “eligibility for disability compensation for service connected disabilities”). Here the evidence reflects that the Veteran’s mild memory loss has already been accounted for in the rating assigned for the service-connected psychiatric disability. As the Veteran does not have a separate and distince memory loss disability, entitlement to service connection is not warranted. Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007) (“Without a current disability, of course, there can be no service connection and, thus, no disability compensation”). For the foregoing reasons, the preponderance of the evidence is against the claim for service connection for memory loss. The benefit of the doubt doctrine is not for application, and entitlement to service connection for insomnia is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102 Increased Rating Disability evaluations are determined by the application of 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. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the evidence since the grant of service connection and consideration of the appropriateness of a “staged rating” (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). 5. Entitlement to an initial rating in excess of 30 percent prior to August 31, 2015 and in excess of 50 percent thereafter for his service-connected psychiatric disability The Veteran contends that he is entitled to a higher evaluation for his service-connected psychiatric disability. His psychiatric disability is currently rated as 30 percent disabling prior to August 31, 2015 and 50 percent disabling thereafter under 38 C.F.R. § 4.130, DC 9434-9400. Under the General Rating Formula, a 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is assigned 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; in difficulty establishing effective work and social relationships. Id. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relationships, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals 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. A 100 percent rating is warranted when there is evidence 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 and place; memory loss for names of close relatives, own occupation or name. Id. 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 of adjustment during periods of remission. The rating agency shall assign a rating 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 will also consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126(b). When determining the appropriate disability rating to assign, the Board’s primary consideration is the veteran’s symptoms, but it must also make findings as to how those symptoms impact the veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because 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, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to ward a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-24 (Fed. Cir. 2004). 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 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. During the December 2011 VA examination, the Veteran denied suicidal ideation. However, he reported that he did have homicidal ideation about once per month, but denied any acting out. He did not indicate that he had made plans on occasion but had no intent on killing anyone. He reported that he felt totally confident of his control. The Veteran reported that he worked about five years as a carpenter, and then became a housekeeping manager at a nursing home for about two years. He reported that he was a school bus driver where he has worked on and off since August 2011. He reported that he enjoyed his job and enjoyed his life more. He reported reasonable satisfaction with his marriage. He reported that he spent time working on his computer, woodworking, fishing, and does most of the cooking in his house. The Veteran reported awakening but could not attribute a cause to the awakenings per night. He reported dreams once per week but says he could not recall them. He reported intrusive memories, perhaps one or two times per week. He did not report any identifiable avoidance of emotionality. He reported that there was some effort to limit memories, although there was little focus to avoid them. He did not overtly report numbing, although he did say that a primary emotional change has occurred in that he now believed God gave him a second chance at life. He reported that there was some social estrangement in limitation, but it appeared more secondary to his hypervigilance than it is to his memories. He reported that sleep was not of optimal quality, but the big problem seemed to be initial insomnia rather than awakening. He claimed vigilance. He reported that his startle was essentially within normal limits, but reported that due to vigilance, he could not be surprised. He did not report any problems with concentration. On examination, the Veteran’s grooming and hygiene was adequate; eye contact was good; speech was within normal limits; thought content was relevant and coherent; no evidence of psychosis; euthymic mood; appropriate range of affect; and was oriented in all three spheres. The examiner reported that overall, attention, concentration, and executive function appeared intact. Judgment indicated a relatively restrictive kind of thinking but did not indicate poor impulse control. The examiner noted 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 a September 2013 VA examination report, the examiner found that the Veteran had occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or, symptoms controlled by medication. On examination, psychiatric symptoms included anxiety; suspiciousness; panic attacks that occur weekly or less often; mild memory loss; and the inability to establish and maintain effective relationships. The Veteran reported a hot temper. He reported that he would curse out drivers and destroy mail when he was frustrated while working for USPS. He reported that he threatened to kill the children next door for throwing rocks at ducks. He reported that he was extremely anxious and suspicious of people. He reported that he scanned the area at all times. An August 2015 examination report reflects that the examiner found that the Veteran had occupational and social impairment with reduced reliability and productivity. The Veteran continued to live with his wife and described his marriage as “shaky.” He reported that he was fully estranged from his two biological children due to his psychiatric symptoms. He reported that he saw his stepchildren regularly and described fair relationships with them. The Veteran reported that he had a few hobbies. He reported increased anxiety and reported that he only had one friend who he saw once or twice per month. He reported that he formerly had friends, but had become more withdrawn over the years. The Veteran was unemployed and spent his day with his wife gardening, playing games, and watching television. The Veteran reported that he had flashbacks, especially when he went outside in the heat. He reported that he had nightmares, he was always on guard, restless, had triggers, and would freeze. He reported that he avoided shopping as he would feel “on edge” if he was unaware of his surroundings. He reported awakening, nightmares, night sweats, and general restlessness. He reported his interests decreased, energy decreased, concentration decreased. As to suicidal ideation, the Veteran endorsed occasional existential apathy but was asked directly and flatly denied any desire, plan, or intent to self-harm. The Veteran’s psychiatric symptoms included depressed mood; anxiety; suspiciousness; and chronic sleep impairment. The Veteran maintained good eye contact and responded appropriately throughout the examination. There were no obvious difficulties with speech, concentration, orientation, or fund of knowledge were observed. During the July 2017 DRO hearing, the Veteran reported that he was on social security for PTSD since 2014 (back dated to 2013). The Veteran reported that he has not worked since then. The Veteran reported that he was doing construction work where he would get flashbacks and heat was a trigger for him. Additionally, he could not follow behind vehicles really closely or sit in the passenger seat. The Veteran reported that he experienced numerous flashbacks and triggers. He reported panic attacks “all the time” from different triggers. He reported that he tried to avoid the triggers that he knew he had, but would still have about three or four panic attacks a week and this occurred before 2015. He reported that he had nightmares every night and experienced hypervigilance. He reported that he “knocked out” a coworker off a second story window because he called him the wrong name. He reported that he does not speak to his biological children anymore due to his PTSD. He reported his first wife divorced him due to his PTSD. He reported that he remarried and that relationship is “shaky” at times. He reported startle behavior and described an incident where he gave his wife a black eye once because she scared him. He reported that he had to withdraw socially frequently. In the October 2017 VA examination report, the examiner found occupational and social impairment with reduced reliability and productivity. The Veteran’s psychiatric symptoms included depressed mood; anxiety; suspiciousness; chronic sleep impairment; flattened affect; impaired judgment; disturbances of motivation and mood; difficulty adapting to stressful circumstances; impaired impulse control; and neglect of personal appearance and hygiene. His affect was appropriate for the situation; his speech was fluent and clear; he made good eye contact; his thoughts were goal-directed. There was no indications of the presence of hallucinations or delusional thinking. Upon review of the evidence of record, throughout the entire period on appeal, the Board finds that the Veteran’s psychiatric disability more nearly approximates the criteria required for a 70 percent disability rating, but not higher. As noted above, the evidence of record reflects that the Veteran had suicidal ideation; homicidal ideation; anxiety; near-continuous panic attacks; neglect of personal appearance and hygiene; and difficulty with intimate and social relationships. Additionally, he had, low motivation and energy, and chronic sleep impairment. The Court recently reiterated, “VA must 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). As such, the Board finds that the Veteran exhibited symptoms of such type, severity, and frequency as to more closely approximate a disability rating of 70 percent for his service-connected psychiatric disability. See Id. at 20 (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). The Board has also considered whether the evidence supports a rating of 100 percent. The Veteran’s symptoms and overall level of impairment did not, however, more nearly approximate the total occupational and social impairment required for a 100 percent rating. The Veteran maintained a relationship with his wife and stepchildren, remained oriented to time and place, had hobbies, and was consistently able to perform activities of daily living. The Veteran never reported any delusion or hallucination. There were no other symptoms listed in the criteria for a 100 percent rating. For the foregoing reasons, an initial rating of 70 percent, but no higher, for acquired psychiatric disorder to include PTSD with an anxiety disorder and depressive disorder, is warranted. In this regard, the Board finds that there is no time period during which the Veteran’s symptoms warrant a different rating. Additionally, at no time during the period covered by this claim have the criteria been met or approximated for the assignment of a 100 percent rating for the service-connected psychiatric disorder. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3 REASONS FOR REMAND 1. Entitlement to service connection for fibromyalgia is remanded. The Veteran contends that he has fibromyalgia that was caused by his service, to include his service in the Gulf War, as a result of exposure to various chemicals and fumes, including burn pits and exposure to radioactive materials. Military records reflect that the Veteran served in operation Desert Shield in the Southwest Asia Theater of Operations from December 13, 1990 to January 16, 1991 and from January 17, 1991 to April 1991. As the Veteran served in Southwest Asia Theater of Operations during the Persian Gulf War, 38 U.S.C. § 1117 (2012) and 38 C.F.R. § 3.317 (2017) are therefore potentially applicable. The Veteran was counseled that there was a potential health hazard as he was exposed to heavy atmospheric smoke generated as a result of numerous oil-well fires. In October 2017, the Veteran underwent a VA examination to determine if he had a diagnosis of fibromyalgia. The Veteran reported that he was at home when he had a headache, aching pain in both elbows, and aching pain in shoulder blades and mid back area. The current symptoms he experienced were muscle aches, bilateral front neck, upper trapezius, under both shoulder blades, and both medial elbows. The examiner found that the Veteran does not have a diagnosis of fibromyalgia. However, a VA examination is necessary to address the nature and likely etiology of the Veteran’s chronic pain. For veterans with service in the Southwest Asia Theater of operations during the Persian Gulf War, service connection may be established under 38 U.S.C. § 1117 (2012) and 38 C.F.R. § 3.317 (2017). Under that statute and regulation, service connection may be warranted for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of operations during the Persian Gulf War, or to a degree of 10 percent or more. A “qualifying chronic disability” may be one that results from an “undiagnosed illness” or a “medically unexplained chronic multisymptom illness.” 38 U.S.C. § 1117(a)(2)(A), (B); 38 C.F.R. § 3.317(a)(2)(ii). The term “medically unexplained chronic multisymptom illness” means “a diagnosed illness without conclusive pathology or etiology that is characterized by overlapping symptoms and signs.” 38 C.F.R. § 3.317(a)(2)(ii). Unlike other disability compensation claims, claims based on a qualifying chronic disability under section 1117 and § 3.317(a) do not require a nexus linking the condition to service; rather, they are presumptively service related when the requirements of the statute and the regulation are met. See Gutierrez, 19 Vet. App. at 8. The signs and symptoms that may be manifestations of a medically unexplained chronic multisymptom illness include, but are not limited to, muscle and joint pain. 38 U.S.C. § 1117(g)(4), (5); 38 C.F.R. § 3.317(b)(4), (5). Therefore, the Board finds that a remand is necessary to obtain an opinion to address the nature and etiology of the Veteran’s chronic pain. 2. Entitlement to service connection for erectile dysfunction as secondary to service-connected PTSD is remanded. The Veteran contends that he has erectile dysfunction due to his service-connected PTSD. Specifically, he claims that medication he takes for PTSD contributes to his erectile dysfunction. VA treatment records reflect frequent complaints of impotence and erectile dysfunction. In accordance with the duty-to-assist provisions codified at 38 U.S.C. § 5103A (d) and by regulation found at 38 C.F.R. § 3.159(c)(4), a medical opinion or examination is required if the information and evidence of record does not contain sufficient evidence to decide the claim, but there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies; and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability. McLendon v. Nicholson, 20 Vet. App. 79 (2006). It is well established that certain medications can have various side effects, including erectile dysfunction. Further, as the Veteran is competent to report his erectile dysfunction symptoms and VA treatment records reflect that the Veteran has been on numerous medication for his PTSD symptoms, the Board finds that a remand for a medical evaluation and nexus opinion is warranted to decide the claim. 3. Entitlement to a TDIU is remanded During his July 2017 hearing, the Veteran testified that he stopped working in 2013 and he believed his psychiatric symptoms contributed to his decision to stop working. As the Veteran was seeking the highest rating possible for his psychiatric disability and there was evidence of unemployability due to this disability, the issue of entitlement to TDIU has been raised as part and parcel of the claim for a higher disability rating for his service-connected psychiatric disability. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). The matters are REMANDED for the following action: 1. Schedule a VA examination with an appropriate physician to determine the nature and etiology of the Veteran’s constant pain. All indicated tests and studies should be performed. Thereafter, the physician should address the following: a) Indicate all current disabilities which are manifested by the pain located in both elbows, shoulder blades, mid back area, muscle aches, bilateral front neck, upper trapezius, and under both shoulder blades. Specifically indicate whether the Veteran has had fibromyalgia at or any time since approximately April 2016 when he filed the claim on appeal. b) If the Veteran does not have a diagnosis of fibromyalgia, please opine as to the likely etiology of the Veteran’s chronic pain, to include whether any such disability, as likely as not, had its onset during service or is otherwise related to service. c) Indicate whether there are any symptoms that are due to an undiagnosed illness or medically unexplained chronic multisymptom illness. In providing the requested opinions, the physician should specifically consider and discuss all pertinent medical evidence and lay assertions and the service treatment records. All finding results, along with complete, clearly-stated rationale for the conclusions reached, must be provided. 2. Schedule the Veteran for a VA examination with an appropriate clinician in order to determine the etiology of the Veteran’s erectile dysfunction/impotence. The clinician should identify all penile disorders that have existed since the date of the claim. The claims folder must be made available to and reviewed by the examiner prior to completion of the opinion, and the opinion must reflect that the claims folder was reviewed. The physician should indicate whether it is at least as likely as not (at least a 50 percent probability) that erectile dysfunction/impotence was either (a) caused or (b) aggravated by service-connected PTSD, to include whether it is caused or aggravated by medications taken for the service-connected psychiatric disorder or any other service-connected disability. If aggravated, the physician should specify the baseline of disability prior to aggravation, and the permanent, measurable increase in disability resulting from the aggravation. 3. Develop and adjudicate the issue of entitlement to a TDIU to include giving the Veteran an opportunity to submit evidence of his unemployability, education, and work history. L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Laroche, Natalie