Citation Nr: 18159129 Decision Date: 12/19/18 Archive Date: 12/18/18 DOCKET NO. 17-06 888 DATE: 1. Entitlement to service connection for body aches, to include as due to an undiagnosed illness based upon Gulf War service. 2. Entitlement to service connection for diabetes mellitus, type II. 3. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and/or unspecified depressive disorder. December 19, 2018 REMANDED Entitlement to service connection for body aches is remanded. Entitlement to service connection for diabetes mellitus, type II, is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and/or unspecified depressive disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from January 1989 to February 1993. The Veteran's service personnel records verify service in Saudi Arabia from January 1991 to June 1991. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a September 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. As to the claim for service connection for an acquired psychiatric disorder, in Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the United States Court of Appeals for Veterans Claims (Court) clarified how the Board should analyze claims, specifically to include those for an acquired psychiatric disorder. As emphasized in Clemons, though an appellant may only seek service connection for PTSD, the appellant's claim "cannot be a claim limited only to that diagnosis, but must rather be considered a claim for any mental disability that may be reasonably encompassed...." Id. Given that the Veteran has applied for service connection for PTSD, but was diagnosed by a VA examiner with unspecified depressive disorder, the Board has combined and recharacterized the different claims into one acquired psychiatric claim accordingly as noted on the first page of this decision. 1. Entitlement to service connection for body aches is remanded. The Veteran was afforded a VA Gulf War general medical examination in April 2015. The Veteran reported experiencing joint pain. The examiner noted that these symptoms impact the Veteran’s ability to work due to fatigue, depression and general body aches with interfere with the Veteran’s ability to maintain work. However, the examiner concluded that “[t]here is a lack of sufficient clinical evidence to establish [a] chronically disabling condition of an unknown etiology”, noting that the examination revealed normal findings. The examiner stated that “the veteran has the diagnoses of Diabetes mellitus, Hypogonadism, Hypothyroidism, Lumbar Degenerative Disc [and] Obesity that can singly or collectively present as joint/leg/foot pain as reported by the veteran.” With regard to the Veteran's claimed body aches without a definite underlying diagnosis, the Board notes that in Saunders v. Wilkie, 17-1466 (Fed. Cir. April 3, 2018), the Federal Circuit held that pain, a symptom, may constitute a disability if it produces functional limitation or impairment without identification of the underlying cause of pain. As such, the Board remands this matter for an examination. An opinion must also be provided as to whether the Veteran has pain associated with his claimed disorders that causes functional impairment such that it may qualify as a disability in the event an underlying diagnosis is not provided. 2. Entitlement to service connection for diabetes mellitus, type II is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for diabetes mellitus, type II, because no VA examiner has opined whether the Veteran’s currently diagnosed diabetes mellitus, type II, is related to his military service. 3. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD and/or unspecified depressive disorder, is remanded. The Veteran was afforded a VA PTSD examination in April 2015. A diagnosis of unspecified depressive disorder was noted, with the examiner stating that it is unclear “exactly how and to what extent the Veteran’s multiple serious health problems, and medications, are impacting his mood.” The examiner further stated that “problematic personality characteristics, including rigidity, are complicating symptoms of mental disorder.” The examiner found that the Veteran does not have PTSD and opined that his unspecified depressive disorder is less likely than not related to his military service, noting that his first mental health treatment was almost 18 years after his discharge and that his general focus during the examination was on his numerous physical health problems and their impact on his employment and finances. Here, the examiner places considerable weight on the length of time between the Veteran’s first seeking treatment for his mental health and did not address the January 2015 statement from the Veteran’s wife that suicide is something she and the Veteran deal with on a daily basis. As such, the Board finds this examination to be inadequate. In a May 2018 private medical opinion, Dr. N. S. stated that the Veteran has a diagnosis of PTSD. The psychiatrist noted that the Veteran “becomes more anxious when he talks about his traumatic events that have taken place when he was at the combat zone.” The Board notes that there are currently no corroborated stressors linked to the diagnosis provided in the private medical opinion. As such, the diagnosis alone is not sufficient to establish service connection for PTSD. Indeed, 38 C.F.R. §§ 3.304 (f) and 4.125 (a) require not only a diagnosis, but also credible supporting evidence that the claimed in-service stressor occurred, in other words, corroborated stressor(s), and a link between the current symptomatology and the claimed in-service stressor(s). Even under the liberalized standards of 38 C.F.R. § 3.304 (f)(3) for a stressor related to the Veteran's fear of hostile military or terrorist activity, a VA psychiatrist or psychologist is still required to confirm that the claimed stressor is adequate to support a diagnosis of PTSD. The evidence is still insufficient to decide the claim in this regard. There are diagnostic impressions of the PTSD, but there is not an opinion from a VA psychiatrist or psychologist confirming that the claimed stressor related to the Veteran's fear of hostile military activity is adequate to support a diagnosis of PTSD. Here, a remand is necessary to confirm the Veteran's stressor and to afford him a VA examination to determine the nature and etiology of his acquired psychiatric disorder, to include PTSD and/or unspecified depressive disorder. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from May 2015 to the Present. 2. After, and only after, completion of step one above, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any body aches. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease. All opinions provided must be thoroughly explained, and a complete and detailed rationale for any conclusions reached should be provided (a bare conclusory statement will be deemed inadequate). The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. It is not sufficient to base an opinion on a mere lack of documentation of complaints in the service or post-service treatment records. 3. After, and only after, completion of step one above, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his diabetes mellitus, type II. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease. All opinions provided must be thoroughly explained, and a complete and detailed rationale for any conclusions reached should be provided (a bare conclusory statement will be deemed inadequate). The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. It is not sufficient to base an opinion on a mere lack of documentation of complaints in the service or post-service treatment records. 4. After, and only after, completion of step one above, and after the Veteran’s reported stressors have been developed, schedule the Veteran for a psychiatric examination to determine the nature and etiology of any posttraumatic stress disorder (PTSD). If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor. If the Veteran is diagnosed with a personality disorder and PTSD, the examiner must opine whether the PTSD was at least as likely as not superimposed on a personality disorder during active service and resulted in additional disability. If any other acquired psychiatric disorders are diagnosed, the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease. All opinions provided must be thoroughly explained, and a complete and detailed rationale for any conclusions reached should be provided (a bare conclusory statement will be deemed inadequate). The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. It is not sufficient to base an opinion on a mere lack of documentation of complaints in the service or post-service treatment records. 5. After completing the requested actions, and any additional development deemed warranted, readjudicate the claims in light of all pertinent evidence and legal authority. If the benefits sought remain denied, furnish to the Veteran a Supplemental Statement of the Case and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. Michael Pappas Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. P. Keeley, Associate Counsel