Citation Nr: 18161036 Decision Date: 12/28/18 Archive Date: 12/28/18 DOCKET NO. 16-47 685 DATE: December 28, 2018 ORDER Service connection for irritable bowel syndrome (IBS) is granted. Service connection for idiopathic thrombocytopenic purpura, including as due to Gulf War service, is denied. Service connection for migraine headaches is granted. An evaluation of 70 percent for posttraumatic stress disorder (PTSD) is granted. REMANDED Service connection for a back disorder, including as due to Gulf War service, is remanded. Service connection for a left knee disorder, including as due to Gulf War service, is remanded. Service connection for a right knee disorder, including as due to Gulf War service, is remanded. Service connection for tinea versicolor, including as due to Gulf War service, is remanded. Service connection for obstructive sleep apnea, including as due to Gulf War service, is remanded. Entitlement to a total disability rating based upon individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran’s IBS manifested to a degree of at least ten percent and chronically persisted for at least six months after a period of active duty service in the Gulf War. 2. Idiopathic thrombocytopenic purpura was not manifest in service, is not attributable to service, and may not be presumed to be attributable to Gulf War service. 3. A migraine headache disorder manifested to a compensable degree within one year of separation from service. 4. Obstructive sleep apnea was not manifest in service, is not attributable to service, and may not be presumed to be attributable to Gulf War service. 5. Posttraumatic stress disorder (PTSD) was productive of occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. The criteria for service connection for IBS due to Gulf War service are met. 38 U.S.C. §§ 1110, 1117, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.317, 4.114, Diagnostic Code 7319 (2017). 2. Idiopathic thrombocytopenic purpura was not incurred in or aggravated during service and may not be presumed to have been incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1117, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2017). 3. A migraine headache disability is presumed to have been incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1117, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 4. Obstructive sleep apnea was not incurred in or aggravated during service and may not be presumed to have been incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1117, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2017). 5. The criteria for an evaluation of 70 percent for PTSD have been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1989 to September 1994. Service department records show the Veteran served in Southwest Asia. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from March 2015 and February 2017 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). Originally, the Veteran sought service connection for idiopathic thrombocytopenic purpura and later expanded the claim to include a rash on his back. The evidence indicates that these are two separate disorders. Accordingly, the Board has bifurcated the issue into two. The Veteran’s attorney has raised issues related to the adequacy of VA examinations. He also phrases the issue of adequate examinations as a failure to develop the evidence in accordance with VA policy. The Board interprets this as being the same issue, namely, relating to adequacy of the examinations. The attorney’s arguments relating to the examinations’ adequacy is addressed in each individual section below. Neither the Veteran nor his attorney have raised any other issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active 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) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be established under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 because the Veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War. Under these provisions, service connection may be granted 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. For disabilities due to undiagnosed illness and medically-unexplained chronic multisymptom illness, the disability must have been manifest either during active military service in the Southwest Asia Theater of Operations or to a degree of 10 percent or more not later than December 31, 2021. 38 C.F.R. § 3.317 (a)(1). There are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi-symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. 1117 (d) warrants a presumption of service connection. An undiagnosed illness is a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness, unlike in claims for direct service connection, there is no requirement of competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more, the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. 38 C.F.R. § 3.317 (a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). A medically unexplained chronic multisymptom illnesses is one defined by a cluster of signs or symptoms and specifically includes chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases), as well as any other illness that the Secretary determines meets the criteria for a medically unexplained chronic multisymptom illness. A “medically unexplained chronic multisymptom illness” means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317 (a)(2)(ii). 1. Service connection for irritable bowel syndrome including as due to Gulf War service. The Veteran seeks service connection for IBS, including as related to his service in Southwest Asia. The Veteran was diagnosed with IBS in 2014, as reported in the February 2015 VA examination. Irritable bowel syndrome is considered a medically unexplained chronic multisymptom illness, qualifying the Veteran for the Gulf War service presumptions. See 38 C.F.R. § 3.317(a)(2)(i)(B)(3). The next question before the Board is whether the Veteran’s illness has met the chronicity requirement and the requirement that the disorder manifest to a compensable degree at any time after service. The February 2015 VA examination’s report of a diagnosis of IBS in 2014, along with treatment records showing IBS as an active problem dating into 2016, satisfy the 6-month chronicity requirement. With respect to the compensable evaluation requirement, under Diagnostic Code 7319, for irritable colon syndrome (spastic colitis, mucous colitis, etc.), a noncompensable evaluation is warranted for mild irritable colon syndrome, with disturbances of bowel function with occasional episodes of abdominal distress. A 10 percent evaluation is warranted for moderate irritable colon syndrome, with frequent episodes of bowel disturbance with abdominal distress. Here, at the February 2015 VA examination, the Veteran reported having diarrhea for a day or so every week or two weeks. A February 2016 VA treatment record noted the Veteran reported having difficulty with IBS and requested medication, which the treatment professional prescribed. The Board finds that these symptoms more nearly approximate a compensable evaluation. Specifically, the Board finds that having diarrhea for a day or so every week or two weeks more nearly approximates frequent episodes of bowel disturbance with abdominal distress. Accordingly, the compensable evaluation requirements for a medically unexplained chronic multisymptom illness are met. The Board notes that, although a February 2015 VA medical opinion held that the current disorder is separate from the events in service, the Gulf War presumption regulations take precedence over the examiner’s opinion. The examiner was apparently opining as to a direct relationship between service and the current disorder, which is inapplicable here. 2. Service connection for idiopathic thrombocytopenic purpura (ITP), including as due to Gulf War service. The Veteran claims service connection for ITP including as due to his Gulf War service. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease, including due to his Gulf War service. The Board acknowledges that the Veteran has a current ITP disorder. As to whether the disorder can be service-connected under the law and regulations pertaining to Gulf War service, the Board finds that it cannot. 38 C.F.R. § 3.317. The February 2015 VA examiner indicated that the idiopathic thrombocytopenic purpura was a known diagnosis. As the disorder is attributed to a known clinical diagnosis, service connection based on the presumption concerning undiagnosed illnesses is not warranted in this case. Id. The Board further finds that the disorder cannot be service-connected based upon the provisions relating to a medically unexplained chronic multisymptom illness. In that regard, the Veteran’s reported symptoms were a rash on the back. The March 2015 VA skin examination reported that the rash on the back (diagnosed as tinea versicolor) and ITP are different disorders. The examiner explained that ITP manifests as tiny spots of blood all over the body, not as scaling and itching on the back. Thus, the symptoms relevant to ITP are spots of blood all over the Veteran’s body. The rash symptoms are analyzed as a separate issue. The regulations affording service-connection relate to medically unexplained symptoms. 38 C.F.R. § 3.317(a)(2)(i)(B). Here, the symptoms of bloody-like spots all over the body, are explained by the diagnosis of idiopathic thrombocytopenic purpura. Although the term “idiopathic” means “of unknown cause or spontaneous origin,” see Dorland’s Illustrated Medical Dictionary, 912 (32nd ed. 2012), the Board interprets “idiopathic” as it relates to ITP to mean an unknown cause for the cause for the disease as a whole. Here, the Veterans symptoms themselves are not unexplained. Additionally, they are not overlapping, another requirement of the Gulf War presumption regulations. Moreover, the Veteran currently has no symptoms. The February 2015 VA hematologic and lymphatic conditions examination reported treatment with steroids in 2003 after which the condition has been static, and that the Veteran was asymptomatic currently. The March 2015 VA examination showed normal skin on the Veteran’s back. The Veteran’s attorney asserts that the examination report is insufficient because the examiner did not give the etiology of the diagnosis. However, finding against an undiagnosed illness or a medically unexplained chronic multisymptom illness does not require identification of the etiology of the disorder. It merely requires that there is a diagnosis or a medical explanation, apart from limited exceptions not applicable here. Turning to direct service connection, the Board concludes that, while the Veteran has a diagnosis of ITP, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Service treatment records show the Veteran was treated in service for a rash on his back on two occasions. In August 1992, he was treated for pimple-like bumps all over his back. It was assessed as heat rash or malaria, and calamine lotion was prescribed. In May 1993, the back rash was assessed as a form of tinea. For the reasons explained above, the March 2015 VA examiner opined that the skin disorder in service was not ITP, but rather tinea versicolor, which the Board evaluates separately below. The February 2015 VA examiner opined that there was no evidence indicating the Veteran had a low platelet count in service. An April 2014 private treatment note reported thrombocytopenia was diagnosed around ten years prior. Ten years prior could place the diagnosis within the Veteran’s period of service. The Board, however, finds the report that the diagnosis occurred “around” ten years ago is too vague to give more than negligible credibility as to the time the disorder manifested. Additionally, the Veteran’s statements supporting the claim describe symptoms of a rash, and the statements relate to his tinea versicolor. See September 2015 Statement in Support of Claim. Furthermore, the Veteran does not contend that he acquired ITP in service. As the VA examiner has reviewed service treatment records, the Board gives more probative value to the examiner’s opinion that there was no indication of a blood disorder in service. 3. Service connection for headaches, including as due to Gulf War service. The Veteran claims service connection for headaches including as due to his Gulf War service. He reported having headaches for several years, every day lasting two to four hours, aggravated by light and sound, and relieved by rest. See February 2015 VA examination. In an August 2015 VA treatment record, he reported daily frontal headaches since the 1990s. In a September 2015 statement, the Veteran reported having headaches in service and self-treating them. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease, including due to his Gulf War service. The February 2015 VA examiner diagnosed the Veteran with migraine headaches. Thus, he has a current disability. For certain disabilities, the nexus requirement may be satisfied by evidence that a chronic disease subject to presumptive service connection manifested itself to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. This includes organic diseases of the nervous system. The VA Adjudication Procedures Manual (M21-1) is not binding on the Board. See Overton v. Wilkie, No. 17-0125, 2018 U.S. App. Vet. Claims LEXIS 1251. However, the Board must “…discuss any relevant provisions contained in the M21-1 as part of its duty to provide adequate reasons or bases, but because it is not bound by those provisions, it must make its own determination before it chooses to rely on an M21-1 provision as a factor to support its decision.” Id. at *13-14. The M21-1 provides that migraine headaches are considered to be organic diseases of the nervous system for the purposes of presumptive service connection under 38 U.S.C. §§ 3.307 and 3.309. M21-1, III.iv.4.N.1.d. An organic disease is one where there are detectable physical or biochemical changes within he cells, tissues, or organs of the body. “Migraine” is defined as “an often familial symptom complex of periodic attacks of vascular headache…[a]ttacks are preceded by constriction of the cranial arteries….” Dorland’s Illustrated Medical Dictionary, 1166 (32nd ed. 2012). The medical definition of migraines is consistent with it being an organic disease of the nervous system as migraines involve constriction of arteries. In an August 2015 VA treatment record, he reported daily frontal headaches since the 1990s. He underwent a CT scan of his head and it was unremarkable. He asserts in the September 2015 statement that he began having migraine headaches in a chronic manner while on active duty and self-treated. A 10 percent evaluation is warranted for migraines with characteristic prostrating attacks averaging one in 2 months over the last several months. 38 C.F.R. § 4.124a, Diagnostic Code 8100. “Because D[iagnostic] C[ode] 8100 specifically governs migraine headaches, the phrase ‘characteristic prostrating attacks’ plainly describes migraine attacks that typically produce powerlessness or a lack of vitality.” Johnson v. Wilkie, No. 16-3808, 2018 U.S. Vet. App. Claims 1253. VA treatment records show that he reported that he needed to rest sometimes to relieve his daily headaches. Interpreting this evidence in the most favorable light, the Board finds that service connection for migraines is granted under the provisions set forth in 38 C.F.R. §§ 3.307 and 3.309. The Veteran has asserted that his migraines are due to his Gulf War service. Because service connection has been granted based upon another theory, no further discussion of the Gulf War presumptions is needed. 4. An evaluation in excess of 50 percent for posttraumatic stress disorder. The Veteran submitted his claim for an increased evaluation for PTSD in December 2016. The appeal period, therefore, begins in December 2015. The Veteran has been assigned a 50 percent rating for his PTSD pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. All psychiatric disorders are evaluated under the General Rating Formula for Mental Disorders, which provides for a noncompensable evaluation when a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. A 10 percent rating is warranted when there is 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 continuous medication. 38 C.F.R. § 4.130. A 30 percent rating is warranted when there is 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; mild memory loss (such as forgetting names, directions, recent events). 50 percent rating is warranted for 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; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to 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, or 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; and the inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for 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; 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. Use of the term “such symptoms as” in § 4.130 indicates that the list of symptoms that follows is non-exhaustive, meaning that VA is not required to find the presence of all, most, or even some of the enumerated symptoms to assign a particular evaluation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013); see Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). During the appeal period, a January 2017 VA examination was conducted. The examiner opined that the Veteran experienced occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily. The Veteran denied having any problems with caring for his basic physical needs. The Veteran described a good relationship with his wife of over twenty years and his five sons. He taught middle school, but eventually quit due to the “kids and noise.” He then became a minister at church between 2001 to 2015. He was then asked to leave by the elders and deacons. He acknowledged making threatening remarks and having physical altercations at home. The examiner reported that symptoms for VA rating purposes were depressed mood, anxiety, disturbances of mood and motivation, and difficulty in adapting to stressful circumstances, including work or a worklike setting. The Veteran reported that concentration was good, but worse when he was tired. An April 2016 VA treatment intake note showed the Veteran was isolating from his family, was avoiding large groups of people, had difficulty falling asleep, was hypervigilant, and avoided reminders of trauma. He stated he either feels anxious or depressed and has difficulty accepting his current mental state because he perceives it as a sign of weakness. He stated he is involved with his church and occasionally preaches and ministers. May 2016 VA treatment showed a continued depressed mood, with the Veteran carrying the burden of wearing a mask around others to hide his sadness. He reported isolating himself in his “man cave” at home and being disconnected. June 2016 treatment records show the Veteran was not enjoying being around people including his family. He reported not being happy “like everyone else.” He reported sleep of 3 to 4 hours per night with interruptions. He was dressed appropriately and his mood was euthymic. In September 2017 VA treatment, the Veteran reported continued efforts to avoid and distract himself from his internal experiences of anxiety and sadness. He continued to isolate in his room and watch television. He avoided thinking about his relationship with his wife as it continued to suffer from his avoidance. His mood was dysphoric with restricted affect. Thought processes were clear, logical, and goal-directed. The Veteran denied suicidal ideation, homicidal ideation, and auditory and visual hallucinations. No psychosis or delusional content was noted. Insight and judgment were good. In July 2017, the Veteran submitted an affidavit, in which he attested to becoming extremely anxious and nervous around large groups of people; being terminated from his church position for missing work; and having sleep impairment, the inability to concentrate, and flashbacks. He attested to having interpersonal problems with the church elders and verbal altercations. Furthermore, he reported feeling as though he was unravelling due to PTSD since leaving work in 2015. A November 2017 treatment note additionally reported that thought processes were clear, logical, and goal-directed. Insight and judgment were good. A February 2018 affidavit from the Veteran’s wife reported that the Veteran gets in slumps where he will not shower, change his clothes or brush his teeth for weeks at a time and he neglects the cleanliness of the home. The Veteran’s wife is worried that his anger may blind him to the point of becoming physical. She further reported that he becomes very aggressive and inconsolable when angry or irritated. He once lashed out at her employer necessitating a call to security. Furthermore, he has terrible road rage, she attested. A February 2018 affidavit from a friend reported that the Veteran has difficulty concentrating, is easily startled, and “lives his life constantly on edge and looking over his shoulder.” The friend reported witnessing the Veteran experience a panic attack once during Fourth of July fireworks. The friend further discussed the Veteran’s social isolation, and lashing out in social situations. The friend also reported other symptoms based on the Veteran’s report to the friend. The Board finds that the latter symptoms are not competent evidence as they are not based on personal knowledge. Based on the evidence of record, the Board finds an evaluation of 70 percent is warranted because the Veteran has deficiencies in most areas. Specifically, the Veteran has deficiencies with work in his difficulty in adapting to stress in a worklike setting. He has deficiencies in family relations because he keeps heavily isolated from his family. He has deficiencies in mood as he is frequently depressed and/or anxious. The deficiencies with school criterion is not applicable in this case. There were no deficiencies with thinking or judgment. When reconciling the several reports into a consistent disability picture, the Board finds that both total occupational and social impairment is not present. “Total” is defined as “whole, not divided; full; complete,” and “utter, absolute.” Black’s Law Dictionary, 1498 (7th ed. 1999). The most probative evidence of record does not show that the Veteran’s PTSD causes utter and absolute social and occupational impairment. Even if on remand TDIU were to be granted based upon PTSD, total social impairment still is not shown, and both are required for the 100 percent rating. A 100 percent evaluation is not warranted because, while the Veteran may have difficulty adapting to stress in a worklike setting and resulting absences in his chosen profession, as well as sleep impairment, and irritability with his employer (church elders), see July 2017 affidavit from the Veteran, PTSD symptoms are not severe enough to totally impair the Veteran’s occupational functioning. In treatment records, memory is often reported as being “good,” although on occasion memory impairment is noted. See March 2013 and September 2017 VA treatment records. The Veteran’s thought processes are intact, and “executive functioning” was described as being intact. See October 2015 VA treatment records. Although the Veteran reported decreased energy and concentration in October 2015, thought processes were generally clear, logical and goal directed. See December 2016 VA treatment records. As to social functioning, the record shows that the Veteran has maintained long terms relationships with his wife and sons. He is active in his church and always attended sons’ football games. See October 2015 VA treatment record. He has remained married for 23 years and had a few friends, though his symptoms sometimes result in isolative periods. At his January 2017 VA examination, he described his relationship with his wife and five children as “good.” The records show that the Veteran consistently denied suicidal and homicidal ideation. Additionally, the Veteran’s reports of impaired sleep are reduced in probative weight because he has sleep apnea, therefore, the Board reasons that some portion of the sleep difficulties are due to sleep apnea. Finally, the Board gives greater probative weight to medical records than it does to the lay statements because the medical records are the recordations of objective observations made by professionals. Although the Veteran’s attorney argues that the Veteran experiences a lack of ability to concentrate; a heightened emotional state; flashbacks; irritability; memory loss; and suicidal thoughts, the Board finds that a preponderance of the evidence shows these symptoms are not present, or that they are mild to moderate. Memory loss has been discussed above. The heightened emotional state and irritability appear to be present only mildly or infrequently. The Board acknowledges the road rage reported by the Veteran’s spouse, but finds that it is infrequent in comparison to twenty-four hours per day, seven days per week life. Similarly, the friend reported only one incidence of a panic attack. The Veteran’s wife indicates the Veteran has not gotten physically violent, and that security was called on him only once. The Veteran overwhelmingly denied suicidal and homicidal ideation in treatment visits and the VA examinations. The preponderance of the evidence does not show that he is a danger to himself or others. While the Veteran avoided events that reminded him of his trauma, the reports of flashbacks do not indicate a frequency, that when combined with other symptoms, would produce total occupational and social impairment. Moreover, to the extent the evidence is presented in the affidavits from the Veteran, his wife and friend, the Board places greater probative weight on the assessments of the medical professionals as to whether the Veteran’s memory and concentration are intact, and whether the Veteran is hypervigilant due to PTSD. The Board’s severity conclusion is supported by the VA examiner’s opinion that the Veteran’s occupational and social impairment is accompanied by occasional decrease in work efficiency with intermittent periods of inability to perform occupational tasks. For these reasons, a 70 percent rating is the most appropriate for the Veteran’s PTSD. REASONS FOR REMAND 1. Service connection for a back disorder, including as due to Gulf War service, is remanded. The Board cannot make a fully-informed decision on the issue of service connection for a back disorder because no VA examiner has opined whether the current spine disorder is related to a motor vehicle accident sustained in service, other than as due to Gulf War service. Service treatment records show the Veteran was treated for spine pain in May 1994 due to a motor vehicle accident. Thus, the Veteran had an injury in service. In a private treatment visit in July 2013, the Veteran reported having back pain continuing since the military. He currently has a diagnosis of degenerative joint disease of the lumbosacral spine and spinal lysis. 2. Service connection for a right and left knee disorder, including as due to Gulf War service, is remanded. The Board cannot make a fully-informed decision on the issue of service connection for a right and left knee disorder, because no VA examiner has opined whether the Veteran’s current left and right knee strain is related to service, other than as due to Gulf War service. The Veteran asserts that his left and right knee pain was incurred in service. See September 2015 Statement in Support of Claim. He asserts that he did not go to sick call for complaints of the pain, but self-treated it. See id. Service treatment records show the Veteran was treated for muscle strains of the right and left leg in March 1990. 3. Service connection for tinea versicolor, including as due to Gulf War service, is remanded. The Board cannot make a fully-informed decision on the issue of service connection for tinea versicolor because no VA examiner has opined whether the current disorder is related to the instances of skin rash in service. Instead, the examiner opined only on whether it was related to exposures in the Gulf War. 4. Service connection for sleep apnea, including as due to Gulf War service, is remanded. The Veteran claims service connection for OSA including as due to his Gulf War service. See April 2017 notice of disagreement. An illness is a MUCMI where either the etiology or the pathophysiology of the illness is inconclusive. A multisymptom illness is not a MUCMI where both the etiology and the pathophysiolocy are partially understood. Stewart v. Wilkie, No. 15-4458, 2018 U. S. App. Vet. Claims LEXIS 1685. “Pathophysiology” is defined as “the physiology of abnormal states; spec[ifically]: the functional changes that accompany a particular syndrome or disease.” Webster’s Third New International Dictionary of the English Language Unabridged 1655 (1966). Id. at Note 5. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease, including due to his Gulf War service. The January 2017 VA examiner indicated that sleep apnea is a condition with a clear and specific etiology and diagnosis. With regard to whether sleep apnea is a MUCMI, the opinion is inadequate because it does not address pathophysiology. Id. A remand is needed so that an addendum opinion can be provided. 4. A TDIU is remanded. The implementation of the grant of service connection for irritable bowel syndrome and the determinations of the issues being remanded may have a substantial impact on the outcome of the TDIU claim. Therefore, it is inextricably intertwined with the issues being remanded and the implementation of the grant of service connection for irritable bowel syndrome. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination with an appropriate clinician for his spine disability. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s disability began during active service, or is related to an incident of service, including the May 1994 motor vehicle accident and complaints of back pain. 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. 2. Schedule the Veteran for an examination with an appropriate clinician for his knee disabilities. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s disabilities began during active service, or are related to an incident of service, including the March 1990 reports of leg muscle strains. 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 March 2015 VA skin examination 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. A new examination is only required if deemed necessary by the examiner. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s tinea versicolor began during active service, or is related to an incident of service, to include August 1992 and May 1993 treatment for a rash on the back. 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. 4. Return the Veteran’s claims file to the examiner who provided the January 2017 sleep apnea opinion so that a supplemental opinion may be provided. The examiner must provide an opinion as to whether sleep apnea or its symptoms is a medically unexplained chronic multi-symptom illness related to the Veteran’s Persian Gulf War service. The examiner must address both of the following: a. Determine whether the etiology of the Veteran’s sleep apnea is inconclusive. b. Determine whether the pathophysiology of the Veteran’s sleep apnea is inconclusive. 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. 5. Then, readjudicate the claims, including the TDIU claim. If any decision is unfavorable to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Rocktashel, Counsel