Citation Nr: 21069633 Decision Date: 11/19/21 Archive Date: 11/19/21 DOCKET NO. 19-24 153 DATE: November 19, 2021 ORDER Service connection for an acquired psychiatric condition claimed as posttraumatic stress disorder (PTSD) is granted. REMANDED The issue of entitlement to service connection for an acquired psychiatric condition other than PTSD is remanded. The issue of entitlement to service connection for hypertension is remanded. The issue of entitlement to service connection for a right knee condition is remanded. The issue of entitlement to service connection for a disability manifested by chronic fatigue, including as a result of an undiagnosed condition, is remanded. The issue of entitlement to service connection for a disability manifested by primary anemia is remanded. VETERAN'S CONTENTIONS The Veteran contends that he has PTSD related to in-service stressors he experienced during his combat duty in the Southwest Asia Theater of Operations. FINDINGS OF FACT 1. The Veteran had active service in the Southwest Asia Theater of Operations, including combat service. 2. The Veteran's diagnosed PTSD is etiologically related to combat stressors associated with his active service. CONCLUSION OF LAW The criteria for service connection for PTSD are met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from August 1984 to July 1985 and from December 1990 to June 1991. These matters come to the Board of Veterans' Appeals (Board) on appeal from an October 2017 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). Jurisdiction is currently with the RO in Buffalo, New York. The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) in May 2021 and a transcript of the hearing has been associated with the claims file. The Board has expanded the claim of service connection for PTSD, to one for service connection for an acquired psychiatric condition. The Board has also expanded the claims of service connection for chronic fatigue syndrome and service connection for anemia, to claims for service connection for a disability manifested by chronic fatigue syndrome, including an undiagnosed condition, and service connection for a disability manifested by anemia. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled). Entitlement to service connection for an acquired psychiatric condition claimed as PTSD After a review of the evidence of record, the Board finds that the preponderance of the evidence supports a finding that the Veteran has PTSD related to service. Generally, service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. This means that the facts establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). Service connection for PTSD in particular requires medical evidence diagnosing the condition under the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), or by findings supported in an examination report; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. §§ 3.304(f), 4.125(a). If the evidence establishes that a Veteran engaged in combat and the claimed stressor is related to that combat, the stressor may be established by the Veteran's lay testimony alone, provided that the stressor is consistent with the circumstances, conditions, or hardships of the Veteran's service, and in the absence of clear and convincing evidence to the contrary. 38 C.F.R. § 3.304(f). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical evidence. VA must also consider all favorable lay evidence of record. See 38 U.S.C. § 5107(b); see also Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (a Veteran is competent to report on that of which he or she has actually observed and is within the realm of his or her personal knowledge). In addressing the criteria of a current diagnosis, TG (Licensed Clinical Social Worker) confirmed ongoing treatment for PTSD in March 2016 correspondence. See March 2016 Correspondence. The Veteran's post-service VA treatment records also confirm a current diagnosis of PTSD. See November 2015 PASCO OPC Records. In addressing in-service incurrence, the Veteran's military personnel records confirm that the Veteran engaged in combat during his active duty service. Specifically, the Veteran received a Meritorious Mast for exceptional performance while serving as an ammunition resupply driver assigned to Detachment 3, Truck Company, 6th Motor Transport Battalion in the Kingdom of Saudi Arabia from February 11, 1991 to February 28, 1991 during Operation Desert Storm, for working long, arduous hours under difficult desert conditions before and during ground combat operations against Iraq. Supplementing his military personnel records are the Veteran's lay statements which describe SCUD missile attacks, the processing and transporting of enemy prisoners of war and deceased soldiers, recovery of damaged combat vehicles and the transport of captured enemy combat vehicles and traveling through mine fields. In addressing the element of nexus, in March 2016 correspondence TG opined that the Veteran's PTSD was caused by his military trauma. TG noted that she had been meeting with the Veteran since November 2015 on an ongoing and consistent basis to address his PTSD symptoms. In determining that his PTSD was related to service, TG reasoned that the Veteran experienced symptoms including anxiety and mood dysfunction during his service and his residual mental health symptoms continued to the present time as barriers to his ability to socialize and meet his daily needs. The Board finds TG's opinion to be highly probative. The opinion was based on the relevant facts, and an ongoing relationship with the Veteran, and TG provided a detailed rationale. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board notes that VA treatment records document the Veteran's ongoing treatment with TG for PTSD related to combat military trauma. Thus, the Board interprets TG's opinion finding PTSD to have been caused by military trauma to specifically include the Veteran's combat service. The Board acknowledges that the evidence of record includes an August 2017 Initial Posttraumatic Stress Disorder Disability Benefits Questionnaire in which the examiner indicated that the diagnostic criteria for an acquired psychiatric condition, including PTSD, were not met due to invalid testing results. However, the August 2017 VA examiner did not consider the evidence submitted from TG, and in light of the evidence of record, to specifically include TG's opinion, the Board finds that the evidence is at least in equipoise regarding whether the Veteran's current PTSD is etiologically related to his active service. Hence, affording him the benefit of the doubt, service connection for PTSD is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). REASONS FOR REMAND 1. Entitlement to service connection for an acquired psychiatric condition other than PTSD is remanded. The Veteran contends that he has an acquired psychiatric condition related to in-service stressors during his combat experience in the Southwest Asia Theater of Operations. As discussed in detail above, the Board concludes that service connection for PTSD is warranted. However, the Board is unable to ascertain whether service connection is warranted for any psychiatric condition other than PTSD, based on the record as it currently stands. In this regard, the evidence of record includes a December 2016 Initial PTSD Disability Benefits Questionnaire in which the examiner indicated that the Veteran did not have a mental disorder diagnosis. The examiner indicated that the criteria for an acquired psychiatric condition were not met due to invalid testing results. The Board, however, finds the December 2016 Initial PTSD Disability Benefits Questionnaire inadequate to decide the Veteran's claim for service connection for an acquired psychiatric condition other than PTSD. The examiner indicated that the criteria for an acquired psychiatric condition were not met due to invalid testing results. However, VA treatment records document current diagnoses of unspecified anxiety disorder and alcohol dependence. See October 2015 PASCO OPC Records and December 2015 PASCO OPC Records. As indicated above, the Board has expanded the Veteran's claim for service connection for PTSD to a claim for an acquired psychiatric condition to include PTSD. Therefore, an addendum opinion addressing these psychiatric diagnoses is necessary. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). 2. Entitlement to service connection for hypertension is remanded. The Veteran contends that he has hypertension secondary to PTSD. Specifically, the Veteran contends that he has hypertension as a result of anxiety related to PTSD. In this regard, the evidence of record includes an August 2017 Hypertension Disability Benefits Questionnaire in which the examiner diagnosed the Veteran with essential (primary) hypertension and indicated that essential hypertension was: not related to a specific exposure event experienced by the Veteran during service in Southwest Asia; is not one of certain presumptive diseases that are related to the Gulf War per VA guidelines; and is a clear diagnosis with known specific risk factors for its development, including advanced age, obesity and weight gain, family history, race, high-sodium diet, recued nephron number, excessive alcohol consumption, physical inactivity, diabetes and dyslipidemia, and personality trains and depression. The Board finds the August 2017 Hypertension Disability Benefits Questionnaire inadequate to decide the Veteran's claim for service connection for hypertension. The examiner only addressed the etiology of hypertension with regard to exposure events in service in the Gulf War. As indicated above, the Veteran also contends that he has hypertension secondary to PTSD and service connection for PTSD was granted in the above decision. Therefore, the Board finds that an addendum opinion addressing this additional theory of entitlement should be obtained on remand. See Id. 3. Entitlement to service connection for a right knee condition is remanded. The Veteran contends that he has a right knee condition as a result of physical strain during service including jumping in and out of trucks, long runs, and marching with heavy packs. In this regard, the evidence of record includes an August 2017 Knee and Lower Leg Condition Disability Benefits Questionnaire in which the examiner diagnosed the Veteran with degenerative arthritis and indicated that degenerative joint disease is: a disease with a clear and specific etiology and diagnosis; is not related to a specific exposure event experienced by the Veteran during service in Southwest Asia; is not one of certain presumptive disease that relate to service in the Gulf War per VA guidelines; and is more likely secondary to expected aging process as commonly seen in the Veteran's age group. The Board finds the August 2017 Knee and Lower Leg Condition Disability Benefits Questionnaire inadequate to decide the Veteran's claim for service connection for hypertension. The examiner indicated that the Veteran's degenerative arthritis is more likely secondary to the expected aging process. However, the examiner did not provide a rationale for this opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning, and neither an examination report nor a medical opinion is entitled to any weight if it contains only data and conclusions). The Board notes that the Veteran testified during the May 2021 Board hearing that he experienced knee problems prior to age 40, suggesting that his knee condition may be traumatic in nature as opposed to age related. Therefore, the Board finds that an addendum opinion should be obtained on remand. See Barr, 21 Vet. App. at 312 (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). 4. Entitlement to service connection for a disability manifested by chronic fatigue, including as a result of an undiagnosed condition, is remanded. 5. Entitlement to service connection for a disability manifested by primary anemia is remanded. The Veteran contends that he has chronic fatigue syndrome and primary anemia as a result of in-service exposures related to service in the Southwest Asia Theater of Operations. In this regard, the evidence of record includes an August 2017 Gulf War Disability Benefits Questionnaire in which the examiner indicated that the Veteran did not have diagnosed illnesses for which no etiology was established, or additional signs and/or symptoms that may represent an undiagnosed illness or diagnosed medically unexplained chronic multi symptom illness. The Board finds the August 2017 Gulf War Disability Benefits Questionnaire, however, inadequate to decide the Veteran's claims for service connection for chronic fatigue syndrome and primary anemia. The examiner did not address whether chronic fatigue syndrome and/or anemia were directly related to service. As indicated above, the Veteran contends that he has chronic fatigue syndrome and primary anemia as a result of in-service exposures. The Veteran's post-service treatment records document current diagnoses of fatigue and anemia. See July 2015 Land O'Lakes Primary Care. See also April 2021 Tampa Florida VAMC Records. The Veteran testified during the May 2021 Board Hearing that he was exposed to chemical warfare agents and biological warfare agents during service. Although the Veteran may not meet the criteria for a diagnosis of chronic fatigue syndrome, it remains unclear to the Board whether he experiences fatigue and primary anemia related to his service. Therefore, the Board finds that an addendum opinion should be obtained on remand. Id. The matters are REMANDED for the following action: 1. Request that the Veteran provide or authorize VA to obtain records of his relevant treatment that have not yet been associated with the claims file, and associate with the claims file any outstanding VA treatment records. 2. Ensure that the Veteran's complete military personnel records are associated with the claims file; including military personnel records associated with any Reserve service. 3. Return the claims file to the VA examiner who conducted the Veteran's December 2016 Initial PTSD Disability Benefits Questionnaire, if available. If that examiner is not available, send the claims file to another qualified examiner. The claims file and this remand should be made available to the examiner and review of the file should be noted in the requested report. After reviewing the claims file the examiner should respond to the following: (a.) Please identify all current psychiatric disorders other than PTSD. (b.) For each diagnosed psychiatric disorder other than PTSD, is it at least as likely as not (50 percent probability or more) that it had its onset in service or within one year of his separation from service, or is otherwise related to service? (c.) In formulating the requested opinions, please specifically acknowledge and discuss the psychiatric diagnoses of record, including unspecified anxiety disorder and alcohol dependence. (d.) In determining whether the Veteran meets the criteria for a current psychiatric diagnosis, please consider medical and lay evidence dated both prior to and since the filing of the June 2016 claim for service connection. Please note that although the Veteran may not meet the criteria for a psychiatric diagnosis at the present time, diagnoses made prior to and since the date of claim filing meet the criteria for a "current" diagnosis. Please also note that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinions. (e.) All findings and conclusions should be supported with a complete rationale and set forth in a legible report, which should reflect the examiner's consideration and analysis of both the medical and lay evidence of record. If it is not possible to provide an opinion without resort to speculation, the reason that is so should be explained, indicating whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide an opinion is based on the limits of medical knowledge. 4. Return the claims file to the VA examiner who conducted the Veteran's August 2017 Hypertension Disability Benefits Questionnaire, if available. If that examiner is not available, send the claims file to another qualified examiner. The claims file and this remand should be made available to the examiner and review of the file should be noted in the requested report. After reviewing the claims file the examiner should respond to the following: (a.) Is it at least as likely as not that the Veteran's hypertension was caused or aggravated by service-connected PTSD? Please address both causation and aggravation separately and explain why or why not. Please address the Veteran's testimony that trigger events (being around crowds, nightmares, etc.) bring on vasovagal episodes. (b.) If the examiner finds the Veteran's hypertension was aggravated by his service-connected PTSD, he/she should attempt to quantify the degree of aggravation beyond the baseline level. (c.) All findings and conclusions should be supported with a complete rationale and set forth in a legible report, which should reflect the examiner's consideration and analysis of both the medical and lay evidence of record. If it is not possible to provide an opinion without resort to speculation, the reason that is so should explained, indicating whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide an opinion is based on the limits of medical knowledge. 5. Return the claims file to the VA examiner who conducted the Veteran's August 2017 Knee and Lower Leg Conditions Disability Benefits Questionnaire, if available. If that examiner is not available, send the claims file to another qualified examiner. The claims file and this remand should be made available to the examiner and review of the file should be noted in the requested report. After reviewing the claims file the examiner should respond to the following: (a.) Is it at least as likely as not (50 percent probability or more) that the Veteran's right knee disability had its onset in service, or within one year of his separation from service, or is otherwise related to service? The examiner is asked to address the Veteran's contention that he has a right knee condition as a result of physical strain during service including jumping in and out of trucks, long runs, and marching with heavy packs. The examiner is also asked to address the Veteran's testimony regarding experiencing knee problems prior to age 40, suggesting that his knee condition may be traumatic in nature as opposed to age related. (b.) All findings and conclusions should be supported with a complete rationale and set forth in a legible report, which should reflect the examiner's consideration and analysis of both the medical and lay evidence of record. If it is not possible to provide an opinion without resort to speculation, the reason that is so should explained, indicating whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide an opinion is based on the limits of medical knowledge. 6. Schedule the Veteran for a VA examination to determine the nature and etiology of his disability manifested by chronic fatigue. The claims file and this Remand should be made available to the examiner and review of the file should be noted in the requested report. The examiner should record the full history of the identified disability, including the Veteran's competent account of his symptoms. After review of the claims file and examination of the Veteran the examiner should respond to the following: (a.) Is it at least as likely as not (50 percent probability or more) that the condition causing chronic fatigue had its onset in service, or within one year of his separation from service, or is otherwise related to service? The examiner is asked to address the Veteran's contention that he has chronic fatigue as a result of in-service exposures related to service in the Southwest Asia Theater of Operations (inoculations (anthrax, smallpox), medications (ciprofloxacin hydrochloride, pyridostigmine bromide), diesel fuel, burning oil wells, contaminated soil, burn pits, decaying bodies, depleted uranium, sarin, mustard gas, and pesticides etc.) The Veteran testified during the May 2021 Board Hearing that he was exposed to chemical warfare agents and biological warfare agents during service. The examiner is also asked to address the chronic fatigue syndrome diagnosis documented in the Veteran's post-service treatment records and hospitalization in August 2020. (b.) All findings and conclusions should be supported with a complete rationale and set forth in a legible report, which should reflect the examiner's consideration and analysis of both the medical and lay evidence of record. If it is not possible to provide an opinion without resort to speculation, the reason that is so should explained, indicating whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide an opinion is based on the limits of medical knowledge. 7. Schedule the Veteran for a VA examination to determine the nature and etiology of any disability manifested by anemia. The claims file and this Remand should be made available to the examiner and review of the file should be noted in the requested report. The examiner should record the full history of the identified disability, including the Veteran's competent account of his symptoms. After review of the claims file and examination of the Veteran the examiner should respond to the following: (a.) Is it at least as likely as not (50 percent probability or more) that it had its onset in service, or within one year of his separation from service, or is otherwise related to service? The examiner is asked to address the Veteran's contention that he has anemia as a result of in-service exposures related to service in the Southwest Asia Theater of Operations (inoculations (anthrax, smallpox), medications (ciprofloxacin hydrochloride, pyridostigmine bromide), diesel fuel, burning oil wells, contaminated soil, burn pits, decaying bodies, depleted uranium, sarin, mustard gas, and pesticides etc.) The Veteran testified during the May 2021 Board Hearing that he was exposed to chemical warfare agents and biological warfare agents during service. The examiner is also asked to address the anemia diagnosis documented in the Veteran's post-service treatment records and hospitalization in August 2020. (b.) All findings and conclusions should be supported with a complete rationale and set forth in a legible report, which should reflect the examiner's consideration and analysis of both the medical and lay evidence of record. If it is not possible to provide an opinion without resort to speculation, the reason that is so should explained, indicating whether there is additional evidence that could enable an opinion to be provided or whether the inability to provide an opinion is based on the limits of medical knowledge. S.C. Krembs Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Smith-Jennings, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.