Citation Nr: 1808312 Decision Date: 02/08/18 Archive Date: 02/20/18 DOCKET NO. 11-11 731A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for chronic fatigue syndrome (CFS). 2. Entitlement to service connection for joint pain with fibromyalgia. 3. Entitlement to service connection for chronic headaches. 4. Entitlement to service connection for a disorder manifested by difficulty breathing, including as the result of undiagnosed illness. 5. Entitlement to service connection for acid reflux, claimed as gastroesophageal reflux disease (GERD), including as the result of undiagnosed illness. 6. Entitlement to an increased rating in excess of 30 percent for posttraumatic stress disorder (PTSD) with anxiety disorder. REPRESENTATION Appellant represented by: Christopher Loiacono, Agent WITNESSES AT HEARING ON APPEAL Appellant (the Veteran) and T. P. ATTORNEY FOR THE BOARD Joseph P. Gervasio, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty for training from November 1987 to May 1988 and on active duty from December 1990 to July 1991. This case comes to the Board of Veterans' Appeals (Board) on appeal of rating decisions of the Winston-Salem, North Carolina, Regional Office (RO) of the Department of Veterans Affairs (VA). In March 2016, a travel Board hearing was held before the undersigned in Winston-Salem, North Carolina. A transcript of the hearing is associated with the Veteran's claims file. In a May 2016 decision, the Board denied a rating in excess of 10 percent for residuals of a stress fracture of the left hip, dismissed the claim for a total disability rating by reason of individual unemployability due to service-connected disability (TDIU), granted a rating of 30 percent for IBS, and remanded the issues of service connection for chronic fatigue syndrome, joint pain with fibromyalgia, chronic headaches, a disorder manifested by difficulty breathing, acid reflux claimed as GERD, and an increased rating for PTSD with anxiety. Prior to the May 2016 decision, the Veteran's representative requested a 60 day extension in order to submit additional evidence. In July 2016, the Board vacated the May 2016 decision, leaving intact the dismissal of TDIU and the grant of the increased rating for IBS to 30 percent. In a December 2016 decision, the Board denied a rating in excess of 30 percent for IBS and a rating in excess of 10 percent for residuals of a stress fracture of the left hip. The remaining issues on appeal were again remanded for further development. The issues of service connection for GERD and headaches must again be returned for further development and are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if additional action is required on his part. FINDINGS OF FACT 1. The Veteran had honorable active service in the Southwest Asia Theater of operations during the Persian Gulf War. 2. While the Veteran was diagnosed as having CFS in 2005, the preponderance of the evidence does not support a confirmed diagnosis of CFS or a disability that is otherwise etiologically related to service. 3. The Veteran is diagnosed with fibromyalgia. 4. The Veteran has been diagnosed with asthma and history of bronchitis, but a chronic respiratory disorder is not shown during service and is not shown to have been caused by any undiagnosed illness. 5. Prior to June 4, 2013, the Veteran's PTSD was primarily manifested by symptoms of anxiety, with intolerance of crowds and worsening concentration. He also stated that he had difficulty with interrupted sleep every night, intrusive thoughts two to three times per week, startle response, and hypervigilance; and was productive of disability that causes no more than occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks. 6. As of June 4, 2013, the Veteran's PTSD is primarily manifested anxiety most of the time, nausea when he feels anxious, panic attacks occurring several times per week or more, feeling overwhelmed, distressing thoughts and memories of traumatic events, recurrent nightmares of traumatic events, flashback-like experiences, intense psychological and physiological reactions to trauma cues, avoidance of thoughts and feelings of traumatic events as well as avoidance of situational reminders. He also had loss of interest in pleasurable and other activities, concentration problems, feelings of emotional detachment, restricted range of affect, persistent sleep problems, irritability, hypervigilance and an exaggerated startle response; which are productive of occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. CFS was neither incurred in nor aggravated by service nor may it be presumed to have been. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 1117, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2017). 2. Service connection for fibromyalgia is warranted. 38 U.S.C. §§ 11091, 1112, 1110, 1112, 1113, 1116, 1117, 1137, 1154(a), 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2017). 3. A chronic respiratory disorder was neither incurred in nor aggravated by service nor may it be presumed to have been. 38 U.S.C. §§ 1101 , 1112, 1113, 1116, 1117, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2017). 4. The criteria for an increased rating in excess of 30 percent for PTSD were not met prior to June 4, 2013. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.130, Diagnostic Code (Code) 9411 (2017). 5. As of June 4, 2013, the criteria for a rating of 50 percent for PTSD have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.130, Diagnostic Code (Code) 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA's duty to notify was satisfied by letters dated in February 2005, June 2005, March 2007, August 2009, September 2011, May 2015, and July 2015. See 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). With regard to the duty to assist, the Veteran's service treatment records (STRs) and pertinent post-service treatment records, including records utilized in a disability determination by the Social Security Administration (SSA), have been secured. The Veteran was afforded VA medical examinations, most recently in August 2017. The Board finds that the opinions obtained are adequate. The opinions were provided by qualified medical professionals and were predicated on a full reading of all available records. The examiners also provided a detailed rationale for the opinions rendered. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Neither the Veteran nor the representative has challenged the adequacy of the examinations obtained. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist, including with respect to obtaining a VA examination or opinion, has been met. 38 C.F.R. § 3.159(c)(4) (2017). Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition, as identified in 38 C.F.R. § 3.309(a), noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The Veteran's service personnel records reflect Persian Gulf War service. Service connection may be granted to a Persian Gulf War Veteran who exhibits objective indications of a "qualifying chronic disability." 38 U.S.C. § 1117(a)(1); 38 C.F.R. § 3.17(a)(1). A qualifying chronic disability is currently defined as either an undiagnosed illness or a medically unexplained chronic multisymptom illness defined by a cluster of signs or symptoms. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2). CFS, fibromyalgia, and functional gastrointestinal disorders are listed as medically unexplained chronic multisymptom illnesses. 38 U.S.C. § 1117(a)(2)(B); 38 C.F.R. § 3.317(a)(2)(B)(1). The symptoms must be manifest to a degree of 10 percent or more during the presumptive periods prescribed by the Secretary or by December 31, 2021. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. By history, physical examination and laboratory tests, the disability cannot be attributed to any known clinical diagnosis. 38 C.F.R. § 3.317(a)(1)(ii). Objective indications of chronic disability include both "signs" in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(2)(ii)(3). Disabilities that have existed for 6 months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. 38 C.F.R. § 3.317(a)(2)(ii)(4). The signs and symptoms which may be manifestations of undiagnosed illness or a chronic multisymptom illness include, but are not limited to, fatigue and muscle and joint pain. 38 U.S.C. §§ 1117(g)(1),(4),(5); 38 C.F.R. § 3.317 (b)(1),(4),(5). Entitlement to service connection is possible for both (1) chronic fatigue syndrome as a medically unexplained chronic multisymptom illness defined by a cluster of signs or symptoms and (2) fatigue as a signs or symptom which may be a manifestation of undiagnosed illness or a chronic multisymptom illness. Functional gastrointestinal disorders are a group of conditions characterized by chronic or recurrent symptoms that are unexplained by any structural, endoscopic, laboratory, or other objective signs of injury or disease and may be related to any part of the gastrointestinal tract. Specific functional gastrointestinal disorders include, but are not limited to, irritable bowel syndrome, functional dyspepsia, functional vomiting, functional constipation, functional bloating, functional abdominal pain syndrome, and functional dysphagia. These disorders are commonly characterized by symptoms including abdominal pain, substernal burning or pain, nausea, vomiting, altered bowel habits (including diarrhea, constipation), indigestion, bloating, postprandial fullness, and painful or difficulty swallowing. Diagnosis of specific functional gastrointestinal disorders is made in accordance with established medical principles, which generally require symptom onset at least 6 months prior to diagnosis and the presence of symptoms sufficient to diagnose the specific disorder at least 3 months prior to diagnosis. Note to 38 C.F.R. 3.317(a)(2)(i)(B)(3). In order to prevail on the issue of service connection, there must be medical evidence of current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1990). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1990); 38 C.F.R. § 3.303(a). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence where appropriate and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017). When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Lay statements may support a claim for service connection by establishing the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), they are not competent to provide opinions on medical issues that fall outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d 1372. Competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). CFS The Veteran seeks service connection for CFS, which he asserts results from his service in the Persian Gulf. During the Board hearing in March 2016, the Veteran testified that, while he had not been formally diagnosed as having CFS, he has been treated for fatigue in the years following his discharge from service. Review of the Veteran's STRs shows no complaint or manifestation of CFS. Post-service medical records include a report of a VA general medical examination in September 2005. At that time, the Veteran claimed chronic fatigue that he stated had started in 1991 when he returned from Southwestern Asia. He stated that he was " exhausted pretty much all of the time." He related that he would sometimes sleep 16 hours and took naps on weekends and days when he was not working. The pertinent diagnosis was CFS with no evidence of fibromyalgia on examination. Review of private treatment records dated from 2006 to 2012 show assessments of various disorders, including insomnia, but do not note the presence of CFS. VA records of outpatient treatment dated from 2015 to 2017 show no complaints or manifestations of CFS. An examination was conducted by VA in June 2013. At that time, the Veteran was evaluated for possible CFS. After examination and review of the claims folder, the examiner stated that the Veteran did not and had not been diagnosed with CFS. After reviewing the specific criteria required for a diagnosis of CFS, the examiner noted some of the criteria, but not a sufficient number for a diagnosis. The examiner further indicated that many of the symptoms that the Veteran described were actually attributable to his service-connected PTSD and were not manifestations of CFS. An examination was conducted by VA in August 2017. After evaluation and review of the record, the examiner opined that it was less likely than not that the Veteran had CFS that was incurred in or caused by a claimed in-service injury, event or illness. The rationale was that the Veteran's medical records and STRs were silent for diagnosis or management of CFS during military service or proximate thereto. To date, there was no mention of CFS diagnosis or management by his primary care provider. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). The weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Sklar v. Brown, 5 Vet. App. 140, 146 (1993); Guerrieri, 4 Vet. App. at 470-71. While the record shows that the Veteran did have a diagnosis of CFS in 2005, the subsequent review of the record by two evaluators fails to show a basis for this diagnosis. In 2013, the examiner thoroughly reviewed the criteria necessary for a diagnosis, but found that the Veteran did not meet a sufficient number for such a diagnosis. Moreover, the examiner stated that the symptoms that the Veteran did exhibit were more likely attributed to his service-connected PTSD. This opinion is reinforced by the examiner in 2017 who indicated that it was less likely than not that the Veteran had CFS as a result of service. The Board may not ignore a medical opinion, but it is certainly free to discount the relevance of a physician's statement, as it has done in this case. See Sanden v. Derwinski, 2 Vet. App. 97 (1992). In this case, the Board finds that the 2013 and 2017 VA medical opinions are more probative than the diagnosis made in 2005. The latter did not provide a basis for the diagnosis while the 2013 opinion gave specific reasons why the Veteran did not meet the criteria for a diagnosis of CFS and the 2017 opinion relied on the private and VA medical treatment records that do not show a diagnosis or management of CFS. Given the lack of supporting evidence for the diagnosis, the Board finds that CFS has not been clinically confirmed in the record and service connection must be denied. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for CFS, 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. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Fibromyalgia and Joint Pain The Veteran contends that service connection should be established for fibromyalgia and going pain that he states had their onset during service. During the hearing before the undersigned, the Veteran testified that he had not been treated for fibromyalgia or joint pain during service. (The Board notes that service connection is in effect for residuals of a left hip injury, which is not at issue at the present time.) He stated that he was first treated for fibromyalgia in 2002, but that he had never been formally diagnosed with fibromyalgia. The Board has reviewed the evidence of record and finds that there is a basis for a grant of service connection for fibromyalgia. It is initially noted that the Veteran's STRs are completely silent for fibromyalgia symptoms or complaints of joint pain. Post service medical evidence includes VA examinations in 2005, 2013, and 2017 that evaluated the Veteran for possible fibromyalgia. In addition, private treatment records show that the Veteran was assessed as having fibromyalgia or possible fibromyalgia. In 2005, the examiner noted that, while the Veteran had generalized aches and pain, he had no specific muscle tenderness areas such as would be found in fibromyalgia. The pertinent diagnosis was that there was no evidence of fibromyalgia on examination. On examination in 2013, however, the examiner rendered a diagnosis of fibromyalgia based upon symptoms of widespread musculoskeletal pain, stiffness, fatigue, sleep disturbances, headache, depression, anxiety, and irritable bowel symptoms. These were constant or nearly constant and often precipitated by environmental or emotional stress or overexertion. The Veteran appeared to be depressed and his fibromyalgia symptoms impacted his ability to work. While the evaluation in 2017 did not find a basis for a diagnosis of fibromyalgia, the rationale included the fact that this diagnosis was not found in the record. As such, the basis for this opinion is not consistent with evidence of record. The Board finds that service connection is warranted for fibromyalgia. The Veteran's service records clearly show that he served in the Persian Gulf. The Veteran has a diagnosis of fibromyalgia that is manifested to a rate of 10 percent or more (obviously diagnosed before December 2021). Under Code 5025, 38 C.F.R. § 4.71(a), the criteria for a 10 percent disability rating for fibromyalgia consists of widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud's like symptoms that require continuous medication for control. The 2013 VA examination shows these symptoms. The Board acknowledges the negative nexus opinion provided by the VA examiner in 2017, but notes that presumptive service connection eliminates the need for the nexus element typically necessary for standard service connection cases. In light of the foregoing, and resolving all reasonable doubt in the Veteran's favor, the Board finds that service connection is warranted. Respiratory Disorder The Veteran contends that service connection is warranted for a chronic respiratory disorder that he asserts is an undiagnosed illness that is the result of his service in the Persian Gulf. During the Board hearing in March 2016 the Veteran testified that he had been exposed to burning oil fields during service and now had a hacking cough like one would hear from a smoker, although he stated that he had never smoked. Review of the Veteran's STRs shows no complaint or manifestation of a respiratory disability. On examination by VA in September 2005, the Veteran had no complaints of a respiratory disorder, with respiration and the chest normal on examination. An examination was conducted by VA in June 2013. At that time, the pertinent diagnosis was shortness of breath due to nervousness and anxiety. A chest X-ray study showed no active disease. Pulmonary function testing (PFT) showed mild to moderate restrictive defect and a mild obstructive defect, although effort was sub-optimal. The assessment was mild reduction in diffusion. The examiner commented that "a lot of" the Veteran's symptoms were due to nervousness and anxiety. Private treatment records show that the Veteran was diagnosed with obstructive sleep apnea (OSA) in 2014. An examination was conducted by VA in August 2017. At that time, the diagnoses were asthma and history of bronchitis. The examiner's review of the Veteran's medical records showed that the Veteran was noted to have asthma in September 2013 and that bronchitis was noted in September 2016. In addition, the Veteran's OSA was also noted. The examiner remarked that the Veteran had intermittent dyspnea with associated anxiety and unspecified asthma that was mentioned in 2013, but was not on his active list of problems. Of note was that a recent PFT was normal. The examiner noted that the Veteran's STRs were silent for chronic respiratory pathology and that the medical records were also silent to chronic respiratory pathology proximate to military service. The medical records show that the Veteran did not manifest a respiratory disorder in service or in the years soon thereafter. While he testified that he has had respiratory complaints since service, on examination by VA in 2005 he made no mention of breathing difficulties. On examination in September 2013, he was noted to have a respiratory disorder that could be related to anxiety, which could include his service-connected PTSD, but PFT at that time showed mild obstructive and restrictive defects. The 2017 examination report noted diagnoses of known respiratory disorders, including OSA, asthma and a history of bronchitis. As the Veteran has diagnosed respiratory disorders to account for his complaints of shortness of breath, the regulations applicable to undiagnosed illness are not applicable for this matter. As asthma, bronchitis or OSA were not manifested during service or until many years after service, service connection is not warranted for a chronic respiratory disorder. Increased Rating Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2017). 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3 (2017). The United States Court of Appeals for Veterans Claims has held that "staged" ratings are appropriate for an increased rating claim where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to these appeals. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. PTSD Service connection for PTSD was granted by the RO in a May 2007 rating decision. The 30 percent disability rating was awarded under the provisions of Code 9411. The appeal arises from a 2010 rating decision that continued the 30 percent rating. In a lay statement dated in October 2009, the Veteran's sister-in-law related that she had witnessed the Veteran have difficulty handling normal household business and work related stressors. She had noted abnormal sleep patterns and stated that, while she was not a doctor, she had worked with PTSD clients as a behavioral technician and she recognized many PTSD symptoms in the Veteran's behavior. In a subsequently received statement, the Veteran's wife indicated since she met him in 1992, the Veteran had had trouble expressing his thoughts and could become easily angered. He was nervous and anxious the majority of the time, had problems sleeping with nightmares, and stayed fatigued all the time. She stated that the Veteran only spoke of his experiences during the war on one occasion and was very uncomfortable when talking about it. A PTSD examination was conducted by VA in December 2009. At that time, the Veteran stated that he had increased symptoms of anxiety, was less tolerant of crowds and that his concentration had worsened. He also stated that he had difficulty with interrupted sleep every night. He denied nightmares, but stated that he had intrusive thoughts two to three times per week. He was easily startled, hypervigilant, and intolerant of crowds. On examination, the Veteran was alert, cooperative, and appropriately dressed. There were no lucid dissociations or flight of ideas. There were no bizarre motor movements or ticks. Mood was tense, but cooperative and friendly. Affect was appropriate. There was no homicidal or suicidal ideation or intent. No impairment of thought processes or communication. No delusions, hallucinations, ideas of reference or suspiciousness. He was oriented in three spheres. Memory of both remote and recent events was adequate. Insight and judgment appeared to be adequate. The diagnoses were PTSD and anxiety disorder. His Global Assessment of Functioning (GAF) score was 56, representing moderate and persistent symptoms of PTSD with no remissions. The anxiety disorder was believed to be related to the PTSD. He took no medication. He worked full time and his psychiatric symptoms resulted in some impairment of social function. Private treatment records, dated from 2010 to 2012 show that the Veteran was treated for complaints of PTSD with insomnia. Medical records utilized in a disability determination by SSA dated in December 2013 include a mental status evaluation that showed that no psychomotor abnormalities were noted. Eye contact was good. Speech was normal. Mood was "okay." Affect was constricted and thought processes were linear. Associations were intact. The Veteran denied audio or visual hallucinations as well as suicidal or homicidal ideations. Insight and judgment were fair. In February 2014, the Veteran was noted to be oriented times four, but with a euthymic mood and congruent affect. Compression was good. There was no thought distortion. Memory, attention, and concentration were coherent. Speech was euthymic. There were no psychomotor impairments, but insight was poor to average. The Veteran denied suicidal or homicidal ideation. An examination was conducted by VA on June 4, 2013. At that time, the diagnoses were PTSD, anxiety disorder and depressive disorder. The GAF score was reported to be 50. The examiner noted that it was not possible to differentiate the symptoms of the three diagnoses. The Veteran's occupational and social impairment was noted to be consistent with occupational and social impairment with reduced reliability and productivity. Regarding the Veteran's social adjustment, it was reported that he had been married twice, but was not in a relationship now as his second wife had died of cancer. He reported that he avoided people and had lost interest in forming new relationships. He stated that since he had lost his job in "2011" he had few regular activities. He reported that he mainly stayed at home watching television. He reported no regular leisure activities and attributed this loss of interest to avoidance and fatigue. Regarding employment history, he stated that he had been laid off from his job in November "2012" when the plant shut down. He stated that work had been stressful for him, which he attributed to his having to interact with people. While not currently working, the Veteran stated that he was trying to find work. On examination, when asked about his current symptoms, the Veteran stated that he had persistent sleep problems, avoided crowds, felt "paranoid" of people and avoided going out because he felt that people were watching him. He had irritability and felt anger much of the time. He had frequent panic attacks, shortness of breath, a depressed mood, low self-esteem, feelings of hopelessness, muscle tensions, fatigues, and physical symptoms related to anxiety such as joint pain, vomiting and muscle aches. He had difficulty relaxing and had lost interest in most leisure activities. He reported having anxiety most of the time and nausea when he felt anxious. His panic attacks occurred several times per week, or more often. These were triggered when he had to leave the house and interact socially. He often felt overwhelmed, moody and "down." PTSD symptoms included: distressing thoughts and memories of traumatic events, recurrent nightmares of traumatic events, flashback-like experience; intense psychological and physiological reactions to trauma cues, avoidance of thoughts and feelings of traumatic events as well as avoidance of situational reminders and loss of interest in pleasurable and other activities, concentration problems, feelings of emotional detachment, restricted range of affect, persistent sleep problems, irritability, hypervigilance and exaggerated startle response. The sleep problems occurred nightly and he had periods of up to 10 days when he essentially did not sleep. He was currently taking psychotropic medications, but was not sure that these were working for him. He reported having thoughts that he would be better off dead and had occasional thoughts of suicide. He reported that within the last year, he had a time when he took a lot of medication for sleep, but was not entirely sure whether there might have been some intent to self-harm. This occurred during a time when he was having trouble sleeping for an extended period of time. He denied having any current plan or intent for self-harm. The Veteran met many of the diagnostic criteria for a PTSD diagnosis. PTSD symptoms included depressed mood; anxiety; suspiciousness; panic attacks more than once per week; chronic sleep impairment; mild memory loss; a flattened affect; circumstantial, circumlocutory, or stereotyped speech; disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a worklike setting; and suicidal ideation. In a report of a private psychological evaluation, the Veteran was noted to be experiencing symptoms of insomnia, anhedonia, inattention, lethargy, difficulty with memory, tearfulness, nervousness, irritability, suicidal ideation, withdrawal from daily activities and social isolation. The examiner commented that the Veteran currently exhibited severe symptoms of PTSD. He could not concentrate, exhibited extreme fluctuations in mood, irritability, poor memory, and poor attention. He had deficits that impaired cognitive, occupational, and social functioning and was unable to perform competitive work duties due to his service related psychiatric impairments. VA outpatient treatment records show that the Veteran has been receiving regular therapy for his PTSD symptoms. When last examined, in January 2017, mental status evaluation showed him to be oriented in four spheres. Mood and affect were euthymic and congruent to content. Eye contact was appropriate. Comprehension was good. There were no thought distortions. Memory, attention, and concentration were coherent. Speech was euthymic. There were no psychomotor abnormalities. Judgment and insight were poor to average. There were no suicidal or homicidal ideations. An examination was conducted by VA in August 2017. At that time, the diagnosis was PTSD. The examiner summarized the Veteran's level of occupational and social impairment with regard to his mental diagnosis as occupational and social impairment with reduced reliability and productivity. Regarding his employment, the Veteran was currently working full time as a "shift lead." He stated that his job was to insure people were at their work stations. He stated that he did not like interacting with people or sitting in meetings. He continued to get stressed at work and stated that he vomited every day at work. The Veteran reported having been psychiatrically hospitalized in 2013 when he began "really getting treatment" for his PTSD. He reported that he contemplated suicide " about every day." He said that he was always stressed and depressed. He was always looking out the window, although he felt safe at home. The examiner noted that the Veteran's collateral medical records showed that the Veteran's PTSD was stable and that during weekly visits he was calm, attentive, and displayed a euthymic mood. He reported continued struggles with nightmares and struggled to maintain sleep. He endorsed continued avoidance of trauma reminders, and feelings of chronic anxiety. He also endorsed fleeting periods of hopelessness as a result of suffering constant anxiety. He met the majority of the diagnostic criteria for a diagnosis of PTSD. Symptoms included anxiety, suspiciousness, chronic sleep impairment, disturbances of mood and motivation, and difficulty in adapting to stressful circumstances. He was oriented in four spheres, adequately groomed, and fully engaged. Mood appeared subdued, with a flat affect. Speech was clear and of normal rate and tone. Thought processes were congruent and goal directed. There was no evidence of psychosis, delusions, or perceptual disturbance. There was no active suicidal or homicidal ideation, plan or intent. Judgment and insight appeared intact. The General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130 provides the following ratings for psychiatric disabilities: 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), a 30 percent rating. Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships, a 50 percent rating. Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships, a 70 percent rating. Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name, a 100 percent rating. 38 C.F.R. § 4.130. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). On the other hand, if the evidence shows that the veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. The United States Court of Appeals for the Federal Circuit has embraced the Mauerhan court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Prior to June 4, 2013, the Veteran's psychiatric disability was primarily manifested by symptoms of anxiety, with intolerance of crowds and worsening concentration. He also stated that he had difficulty with interrupted sleep every night, intrusive thoughts two to three times per week, startle response, and hypervigilance. He was alert, cooperative, and appropriately dressed, with no lucid dissociations or flight of ideas and no bizarre motor movements or ticks. His mood was tense, but cooperative and friendly. Affect was appropriate. There was no homicidal or suicidal ideation or intent, impairment of thought processes or communication, and no delusions, hallucinations, ideas of reference or suspiciousness. He was oriented in three spheres. Memory of both remote and recent events was adequate. Insight and judgment appeared to be adequate. This symptomatology is not shown to be productive of disability that causes more than occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks. His symptoms are not of the frequency, severity or duration so as to approximate the criteria for an increased rating. As such a rating in excess of 30 percent is not shown to have been warranted. On examination on June 4, 2013, The Veteran's occupational and social impairment was found to be consistent with occupational and social impairment with reduced reliability and productivity. His symptoms were primarily anxiety most of the time, nausea when he felt anxious, panic attacks occurring several times per week or more, feeling overwhelmed, distressing thoughts and memories of traumatic events, recurrent nightmares of traumatic events, flashback-like experiences, intense psychological and physiological reactions to trauma cues, avoidance of thoughts and feelings of traumatic events as well as avoidance of situational reminders. He also had loss of interest in pleasurable and other activities, concentration problems, feelings of emotional detachment, restricted range of affect, persistent sleep problems, irritability, hypervigilance and an exaggerated startle response. The sleep problems occurred nightly and he had periods of up to 10 days when he essentially did not sleep. Overall, these symptoms are consistent with or approximate the criteria for the 50 percent rating for PTSD. They are not consistent with occupational and social impairment with deficiencies in most areas. For example, the Veteran is able to work full time and has not been noted to have current suicidal ideations, obsessional rituals that interfered with routine activities, illogical or obscure speech, near-continuous panic attacks or an inability to function independently. As such, a rating in excess of 50 percent is not shown to be warranted. ORDER Service connection for CFS is denied. Service connection for fibromyalgia is granted. Service connection for a chronic respiratory disorder is denied. A rating in excess of 30 percent for PTSD prior to June 4, 2013, is denied; a rating of 50 percent, but no higher, for PTSD is warranted as of June 4, 2013. The appeal is granted to this extent, subject to controlling regulations governing the payment of monetary benefits. REMAND Regarding the Veteran's claim of service connection for GERD, the Board notes that, while a negative nexus opinion was rendered by a VA examiner in August 2017, the rationale included the fact that the Veteran did not have manifestations of gastrointestinal disturbance during service. As pointed out in the Board's prior remand, the Veteran did have such complaints at the time of his examination for separation from service. As such, the opinion relies on inaccurate information and the matter must be returned for a supplemental medical opinion. In addition, the Board notes that the Veteran has contended that his GERD is related to a service-connected disability, or one of the medications utilized to treat them. Regarding the claim of service connection for headaches, the Board notes that, while the Veteran was evaluated to ascertain whether he had a current headache disorder that could be the result of service in the Persian Gulf, the negative nexus opinion that was rendered by a VA examiner in August 2017 is based in part upon faulty rationale. Specifically, the examiner states that the Veteran's headache diagnosis is not an undiagnosed illness and is not a diagnosable, but medically unexplained chronic multisymptom illness of unknown etiology and is not a diagnosable chronic multisymptom illness with a partially explained etiology. The Board notes that headaches are specifically mentioned as a symptom of undiagnosed illness in the regulations pertinent to Persian Gulf veterans. 38 C.F.R. § 3.317. Most importantly, the VA examiner did not provide an explanation for the diagnosis of headaches that has been rendered on several occasions in the record, including in 2005, 2013, and by this examiner, in 2017. As an explanation for the diagnosis has not been provided, the Board cannot determine whether the symptom could be due to an unexplained illness. Additionally, it is noted that during testimony before the undersigned, the Veteran stated that he believed that his headaches may be related to service-connected psychiatric and bowel disease or medications utilized to treat these disorders. As such, an additional medical opinion is warranted. Accordingly, the case is REMANDED for the following action: 1. The AOJ should contact the examiner who rendered the August 2017 opinion relating to the Veteran's GERD and request a supplemental opinion that takes the Veteran's complaints of gastrointestinal disturbance at separation from service into account regarding whether it is at least as likely as not (50 percent or greater probability) that the GERD is related to service or is proximately due to or aggravated by his service-connected disabilities or medications utilized for treatment thereof. If the examiner who rendered the August 2017 examination is not available, another examination should be scheduled so that the above opinion may be rendered. The claims folder should be made available for review in connection with this examination. The examiner should provide complete rationale for all conclusions reached. 2. The AOJ should contact the examiner who rendered the August 2017 opinion relating to the Veteran's headaches and request a supplemental opinion that considers that headaches may be a symptom of undiagnosed illness and that the record contains a diagnosis of headaches, to include in 2005, 2013 and 2017. The examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that his headaches are related to service or is an undiagnosed illness that may be presumed to be due to service. If the examiner who rendered the August 2017 examination is not available, another examination should be scheduled so that the above opinion may be rendered. The claims folder should be made available for review in connection with this examination. The examiner should provide complete rationale for all conclusions reached. 3. Thereafter, the AOJ should readjudicate the remaining issues on appeal. If the determination remains unfavorable to the Veteran, he and his representative should be provided with a supplemental statement of the case (SSOC) that addresses all relevant actions taken on the claims for benefits, to include a summary of the evidence and applicable law and regulations considered. They should be given an opportunity to respond to the SSOC prior to returning the case to the Board for further review, if in order. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of the claim. See 38 C.F.R. § 3.655 (2017). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs