Citation Nr: 21071123 Decision Date: 11/29/21 Archive Date: 11/29/21 DOCKET NO. 17-40 311 DATE: November 29, 2021 REMANDED Entitlement to service connection for joint pain, to include as due to an undiagnosed Gulf War illness, is remanded. Entitlement to service connection for a neurological condition, to include as due to an undiagnosed Gulf War illness, is remanded. Entitlement to service connection for a psychiatric disorder claimed as a sleep disorder, to include as due to an undiagnosed Gulf War illness, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1989 to November 1993. This matter is before the Board of Veterans' Appeals (Board) on appeal from an August 2013 rating decision by a Department of Veterans Affairs Regional Office (RO). In March 2021, the Veteran testified at a hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. The Board held the record open for 60 days for the Veteran to submit additional relevant evidence. Entitlement to service connection for joint pain, a neurological condition and a sleep disorder, to include as due to an undiagnosed Gulf War illness, is remanded. The Veteran seeks entitlement to service connection for joint pains, a neurological condition and a sleep disorder, all claimed as due to Gulf War illness. See December 2011 Claim. Additionally, he asserts that his joint pains (affecting his back, neck and hands) are etiologically related to wear and tear during service due to his military occupational specialty (MOS) working on a mechanized canon crew, running and long marches while carrying heavy equipment. Neurological symptoms reportedly also affect his back and neck. See May 2017 VA Form 27-0820, Report of General Information and March 2021 Board Hearing Transcript. With regard to his sleep disorder, during his Board hearing, he testified that the condition was related to nightmares caused by depression and anxiety, psychiatric conditions he asserts are related in-service trauma. Initially, the Board notes the Veteran receives medical treatment through his VA medical center. However, the most recent VA medical record associated with the claims file is dated in May 2012. Additionally, a May 2014 Social Security Administration (SSA) profile shows he filed a claim for benefits that was denied. However, no efforts have been made to obtain any SSA records. Accordingly, the Board finds that efforts should be made to obtain updated VA medical records and any SSA records. A Remand is also warranted to obtain VA examinations. A review of the Veteran's DD 214 shows his MOS was Cannon Fire Direction Specialist. VA medical records also show he was assessed with chronic neck and back pain, and he reported pain in his hands in March 2012. In Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), the Federal Circuit held that "'disability' pursuant to 38 U.S.C. § 1110 refers to the functional impairment of earning capacity" and "pain in the absence of a presently-diagnosed condition can cause functional impairment," en route to its conclusion that "pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability." See also, Wait v. Wilkie, 33 Vet. App. 8 (2020). With regard to his claim for a sleep disorder, as noted above, the Veteran has asserted his sleep disorder is symptomatic of a psychiatric disorder. In this regard, in January 2005, a VA medical record shows he reported having anxiety and depression. The physician also noted symptoms of reoccurring nightmares and flashbacks. Another VA medical record of the same date noted symptoms of depressed mood, diminished interest or pleasure, insomnia, fatigue, loss of energy, diminished ability to think or concentrate, indecisiveness, and recurrent thoughts of death. The physician noted questionable suicidal ideation. He was admitted for inpatient care. A January 2005 in-patient VA mental health record shows a diagnosis for possible major depressive disorder with psychotic features. In April 2012, he reported feeling depressed and that his sleep was up and down. He also reported having been depressed since service, and that he was discharged for depression. He also reported that during service, he saw "guys get shot" at Fort Sill, Oklahoma, and that he had intrusive thoughts of that event and was awakened by nightmares. See VA Medical Records Received May 2012. A review of his DD 214 shows he was stationed at Fort Sill. The Board notes that when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Accordingly, the Board has broadened the Veteran's claim for a sleep disorder to include a claim for a psychiatric disorder. Additionally, efforts should be made to verify his reported in-service stressors and to obtain a VA examination to determine the nature and etiology of any diagnosed psychiatric disorder. Lastly, with regard to the Veteran's assertion that his claims on appeal are related to Gulf War illness, an August 2013 VA memorandum determined that the there was a lack of information required to corroborate service in Southwest Asia. The memorandum notes that "[t]he Veteran submitted no information to attempt to corroborate Southwest Asia service." However, a review of the claims file show that VA never asked the Veteran to submit any such information. The claims file does include a January 2005 VA mental health record showing the Veteran reported being a Gulf War non-combat veteran. See VA Medical Records Received May 2012. Additionally, his DD 214 shows that he was awarded an overseas service ribbon. Accordingly, the Veteran should be requested to provide any information as to any service in the Southwest Asia theater of operations. TDIU The Veteran filed his TDU claim in December 2012. In an accompanying VA Form 21-4192, he stated that he last worked in February 2005. At that time, he reported working in a warehouse and that he stopped working due to pain and cramps. However, in August 2019, he submitted a resume which reflects continuous employment from September 2001 through January 2017. The resume also includes the names of his former employers. As such, further development is necessary to adequately adjudicate this issue on appeal. The Veteran should be afforded an opportunity to furnish information about his employment history during the period on appeal. The matters are REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from his VA treatment facilities, including records dating from 1993 (to include any archived records), and all private treatment records not already associated with the file. 2. Obtain any outstanding SSA records. 3. Ask the Veteran to provide any information related to his asserted service in the Southwest theater of operations, and verify such service if necessary. 4. Provide the Veteran with VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, with instructions to complete and return the form as to the period of time to the present the Veteran has been working. 5. After the development in 1-3 is completed, schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of any diagnosed lumbar spine, cervical spine and/or hand condition, to include any secondary neurological conditions (or telehealth interview, review of the record, etc., if an in-person examination is not feasible). The examiner should provide the following opinions: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran has a diagnosed lumbar spine, cervical spine and/or hand condition, including any secondary neurological conditions, that is etiologically related to his period of service? The examiner is asked to consider the Veteran's lay statements that his conditions are due to in-service wear and tear caused by his MOS as a mobile cannon crew member, running and long marches with heavy equipment. The examiner should review pertinent documents in the Veteran's claims file in connection with the examination. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. 6. After the development in 1-3 is completed, schedule the Veteran for a VA examination to evaluate his claim for an acquired psychiatric disorder, to include sleep disorder. All necessary special studies or tests should be accomplished. The examiner should provide the following information: (a) Provide a full multiaxial diagnosis for any acquired psychiatric disorder and identify each stressor event upon which the diagnosis is based. (b) With respect to any psychiatric disorder found upon examination or identified during a review of the claims folder, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that each such psychiatric disability was caused by active duty service. The examiner should review pertinent documents in the Veteran's claims file in connection with the examination. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. 7. Thereafter, the RO should readjudicate the claims on appeal, to include the claim for a TDIU. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Lamb, 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.