Citation Nr: 21072329 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 13-25 515A DATE: December 2, 2021 ORDER Entitlement to a 70 percent rating, but no higher, for service-connected posttraumatic stress disorder (PTSD) is granted effective February 28, 2011 to August 29, 2021, subject to the law and regulations governing the payment of monetary benefits. Entitlement to a rating in excess of 70 percent for service-connected PTSD, effective August 30, 2021, is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted throughout the period on appeal, subject to the law and regulations governing the payment of monetary benefits. REMANDED Entitlement to service connection for chronic pain syndrome is remanded. Entitlement to service connection for gastroesophageal reflex disease (GERD) is remanded. FINDINGS OF FACT 1. The severity, frequency, and duration of the Veteran's PTSD symptoms most nearly approximated occupational and social impairment with deficiencies in most areas throughout the period on appeal; however, his symptoms did not more closely approximate total occupational and social impairment. 2. The most probative evidence of record establishes that the Veteran was no longer employed as of July 31, 2006, prior to the period on appeal. 3. The most probative evidence of record establishes that it is at least as likely as not "factually ascertainable" that, throughout the period on appeal, the Veteran's service-connected PTSD was productive of functional impairment which precluded substantially gainful employment consistent with his high school education and occupational experience in truck driving, construction, and facilities maintenance. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 70 percent, but no higher, for PTSD have been met from February 28, 2011 to August 29, 2021. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for a rating in excess of 70 percent for PTSD effective August 30, 2021 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 3. The criteria for a TDIU solely due to service-connected PTSD have been met for the entire period on appeal. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from August 1972 to August 1976. This matter is before the Board of Veterans' Appeals (Board) on appeal from July 2012 and April2 017 rating decisions. This matter has a lengthy appeal history, including multiple prior remands by the Board. Most recently, the above issues were previously before the Board in April 2021, at which time it was remanded to the Department of Veterans Affairs (VA) Regional Office (RO) for further development. Prior to the most recent remand, a September 2019 Board remand directed the RO to give the Veteran the opportunity to submit a new 21-4142 for his mental health records at the Vet Center because the prior authorization received in May 2014 had expired. The directives also required the RO to attempt to obtain outstanding VA treatment records, including any outstanding records from 1976 onward. Although the RO sent a subsequent development letter in November 2019 asking the Veteran to complete a new form, there has been no form 21-4142 received from the Veteran since May 2014. Additionally, the RO obtained updated VA treatment records through January 2020 and a response from the Release of Information Department indicating that, "[a]fter a thorough search of the archived records, as well as the Vista electronic health record, no responsive records could be located." The Board finds that there was substantial compliance with the remand directives because the Veteran was given an opportunity to submit a new 21-4142 but did not, and because the RO attempted to obtain outstanding VA records until they received a negative response. The April 2021 remand directives only required the RO to obtain new medical opinions and examinations there was not a directive requiring additional record development. The adequacy of each of the obtained opinions and examinations is further discussed as to each issue below. Following the April 2021 remand, the RO granted a partial increased rating for the Veteran's service-connected PTSD, assigning a 70 percent evaluation effective August 30, 2021. Rating Decision dated September 2021. Because the decision did not grant the full benefits sought on appeal and did not apply throughout the entire appellate period, the issue of entitlement to an increased initial rating for PTSD remains before the Board. The Board acknowledges that, in his March 2019 Form 9, the Veteran began to assert that he is entitled to an earlier effective date of December 2004 for service-connected PTSD. However, the Veteran's June 2017 Notice of Disagreement (NOD) appealing the initially assigned rating for PTSD did not appeal the effective date. Specifically, on the Form 21-0958 the Veteran only checked the box for "Evaluation of Disability;" the words written in column C only indicated that he was requesting a 100% rating; and the correspondence he submitted with the NOD did not show disagreement with the effective date or even cite to the August 2004 medical record emphasized in his later assertions. Since the Veteran did not file a NOD as to the effective date for the grant of service connection for PTSD, that issue is not before the Board at this time. 38 C.F.R. §§ 19.20, 19.21. As a final matter, the Board notes that some of the Veteran's correspondence discussing his rating for PTSD also discuss physical symptoms or diagnoses, such as hypertension or headaches. E.g., Correspondence received March 2019. If the Veteran believes that he has diagnoses or functional impairment for physical conditions that are caused by his PTSD and are not already being adjudicated by the RO or the Board, he is encouraged to file a claim for service connection for those conditions so that they can be adjudicated by the RO in the first instance. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.902(c). Additional reference to the Veteran's disabilities is presented in the evidence of record beyond the most detailed pertinent evidence discussed by the Board in this decision. The additional evidence of record does not present findings that significantly expand upon, revise, or contradict the findings in the most detailed evidence discussed by the Board in this decision. Increased Ratings Disability ratings are assigned in accordance with VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from a disability. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. When a question arises as to which of two ratings shall be applied under a particular diagnostic code, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Where, as here, the rating appealed is the initial rating assigned with a grant of service connection, the entire appeal period is for consideration, and separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Moreover, adjudication of a claim for a higher initial disability rating should include specific consideration of whether staged ratings are appropriate. See Fenderson v. West, 12 Vet. App. 119 (1999). In McGrath v. Gober, 14 Vet. App. 28 (2000), the Court held that when the Veteran was actually experiencing symptoms is what is relevant for assigning rating effective dates, not when evidence was created. Thus, the Board will consider whether the evidence of record suggests that the severity of pertinent symptoms increased sometime prior to the date of the examination reports noting pertinent findings. The Board has also considered the history of the Veteran's disability prior to the rating period on appeal to see if it supports a higher rating during the rating period on appeal. The Board has reviewed all of the evidence in the Veteran's record. Although the Board is required to provide reasons and bases supporting its decision, there is no need to discuss each item of evidence in the record. The Board will summarize the pertinent evidence as deemed appropriate, and the Board's analysis will focus specifically on what the evidence of record shows, or does not show, with respect to the claim. See Gonzalez v. West, 218 F.3d 1278, 1380-81 (Fed. Cir. 2000). 1. Entitlement to an increased rating for service-connected PTSD The Veteran contends the record supports assigning a 100 percent evaluation because the RO proposed a finding of incompetency in an April 2017 rating decision and because he requires the help of a VA case worker to help him in following his treatment plan. Correspondence received June 2017, August 2020. The issue in this appeal is whether the Veteran's associated symptoms caused the level of impairment required for a disability rating in excess of 50 percent from February 28, 2011 to August 29, 2021; and in excess of 70 percent from August 30, 2021 to present. The Board concludes that the Veteran's symptoms more closely approximated the symptoms associated with a 70 percent rating, and resulted in a level of impairment that most closely approximated the level of impairment associated with a 70 percent rating, throughout the entire period on appeal. However, the Veteran's symptoms did not cause the level of impairment required for a disability rating of 100 percent. The Veteran's service-connected PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411, which is rated using the General Rating Formula for Mental Disorders (General Formula). Under the General Formula, the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The Veteran's symptoms as demonstrated in the record are associated with the General Formula's 30 percent rating criteria and higher. Those criteria are: A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause 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 normal conversation). A 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned 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; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. The period on appeal covers more than a decade, and the severity and frequency of the Veteran's symptoms have changed over time. A number of the Veteran's symptoms are associated with a lower level of impairment, such as anxiety, depressed mood, suspiciousness, panic attacks, mild memory impairment, and chronic sleep impairment. See, e.g., VA examinations dated August 2013, February 2017, August 2018, January 2020, August 2021; CAPRI records dated October 2013; Form 9 received March 2019; Correspondence received August 2020. As the Board is granting a partial increased rating of 70 percent, it will primarily focus its analysis on the symptoms demonstrating occupational and social impairment associated with the 70 percent criteria and above. The most recent VA examination for the Veteran's PTSD was conducted in August 2021 and was obtained in response to the Board's April 2021 remand directives. The remand directives required a new examination to be obtained that assessed the current severity of the Veteran's PTSD, resolved the issue of whether the Veteran properly has a traumatic brain injury (TBI) diagnosis and whether the Veteran's reported memory deficiencies are attributable to PTSD or a TBI. Disability Benefits Questionnaires (DBQs) were completed for both PTSD and TBI. The examiner who completed the TBI DBQ was a physiatrist and concluded that the record does not support a TBI diagnosis based on the symptoms reported at the time of the Veteran's in-service motor vehicle accident(s). The examiner also noted "some unremarkable CT Heads done in 1992 that were done secondary to an unrelated incident[.]" The examiner then opined that the Veteran's emotional and behavioral signs and symptoms are solely due to his PTSD, but acknowledged that a potential stroke nine years prior "may be part of the memory loss picture." The Board finds that the examiner's findings are adequately supported by the record. Further, as the findings are beneficial to the Veteran, remand for further clarification would constitute an inappropriate attempt to obtain negative evidence. The August 2021 PTSD DBQ was completed by a psychologist. Although the psychologist initially marked "Yes" to question 3C "Does the Veteran have a diagnosed traumatic brain injury (TBI)?" it is clear from the remainder of the DBQ that the response was a mistake. The examiner marked "Not Applicable" to a question of whether it was possible to differentiate symptoms, and specifically stated that "The Veteran was not diagnosed with a TBI" in response to "Additional Question 3." In relation to the Veteran's memory, the examiner found that "His memory for recent and remote events was poor; he was able to describe his daily activities." She also found that, based on description by the Veteran and his caseworker, he met the criteria for the DBQ's "mild memory loss" and "impairment of short and long term memory" symptoms throughout the appeal, consistent with the Veteran's first two PTSD DBQs. In considering the evidence from the TBI and PTSD DBQs together, the Board finds that the Veteran's memory loss is attributable to his service-connected PTSD. Further, because the TBI examiner indicated that he "may" have had a stroke nine years ago that "may contribute" to his memory loss, the Board finds that it is not possible to differentiate the cause of his memory loss symptoms if they are attributable to a stroke at all. Where it is not possible to distinguish the symptoms of a service-connected disability from non-service connected manifestations, all the manifestations will be considered part of the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998). Over time, the Veteran's PTSD VA examinations have reported several symptoms listed in the 70 percent and 100 percent rating criteria, to include suicidal ideation (VA Examination dated January 2020); intermittently illogical, obscure, or irrelevant speech (VA Examination dated August 2018); difficulty in adapting to stressful circumstances (VA Examination dated August 2021); inability to establish effective relationships (VA Examination dated August 2018); and intermittent inability to perform activities of daily living (VA Examination dated August 2021). The first four of those symptoms (which are all associated with the 70 percent rating criteria) find additional support in the record. The record shows that the Veteran reported experiencing suicidal ideation in September 2013, October 2013, and January 2020. These instances were all associated with loss of a family member, and the medical professionals all found that the Veteran did not express any intent and was not in danger of harming himself. For most of the rest of the period on appeal, the evidence shows the Veteran actively denied suicidal ideation. E.g., CAPRI records dated November 2017, May 2015, March 2014, January 2011. The Board finds that the record supports a finding that the Veteran's PTSD produced intermittently illogical, obscure, or irrelevant speech. In March 2011, a VA Report of General Information reported that the "Veteran was not really focused and his thoughts are all over the place." February 2017 and August 2018 PTSD examiners observed that the Veteran had disorganized thoughts and speech. Along these lines, a December 2013 social worker note indicated that the Veteran's bank account was overdrawn, and he didn't understand how it happened, and that he tended to become easily agitated and overwhelmed by financial issues or written correspondence. In the Veteran's correspondence, he has reported that he has an inability to focus on a topic and tends to The Board observes that the Veteran's correspondence to VA regarding his appeal was likewise disorganized and sometimes irrelevant to the matters at issue. As to an inability to adapt to stressful situations, A November 2015 CAPRI record reports difficulty adjusting to stressful life events such as family deaths or illness. Many other records also suggest difficulty with stressful family events, such as death or illness. Finally, the Veteran has reported mistrust of people outside of his family and difficulty maintaining romantic relationships, as evidenced by the fact that he fathered 11 children with four different women. See Correspondence received October 2020. It is clear that the Veteran's symptoms waxed and waned throughout the appeal period. Nonetheless, as argued by the Veteran, his consistent need for help from a VA caseworker and family members in order maintain his financial and medical affairs tends to support a finding that the Veteran has experienced persistent occupational and social impairment in most areas. When the evidence is read together, and in giving the benefit of the doubt to the Veteran, the Board finds that the record supports a finding that the Veteran's PTSD symptoms have produced occupational and social impairment with difficulty in most areas, to include ability to work, thinking, and mood. Although the August 2021 examiner indicated that the Veteran experiences intermittent inability to perform activities of daily living (which is associated with a 100 percent disability rating), the record does not support that any such difficulty is of the frequency or severity contemplated by 100 percent rating criteria. The record consistently shows that the Veteran was observed to have normal grooming and hygiene, and that he kept his apartment clean and orderly. See CAPRI Records dated July 2011, May 2012, January 2013, December 2013, May 2015, April 2017, August 2017. Indeed, even the August 2021 examiner observed that The Veteran was neatly dressed and had good grooming. The Veteran has not otherwise reported an inability to perform the activities of daily living, such as maintenance of minimum personal hygiene. Thus, as described above, the Board finds that the checkbox on the August 2021 examination supports a 100 percent rating. The Board notes that the Veteran expressed suicidal ideation, which can be similar to persistent danger of self-harm, as contemplated by the 100 percent criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). However, the severity, frequency, and duration of the Veteran's suicidal ideation has not risen to the level contemplated by the 100 percent disability rating. The Veteran regularly denied thoughts, intent, or a plan involving self-harm in existing treatment records, and during all of his VA examinations other than the one conducted in January 2020. Further, medical professionals have consistently assessed that the Veteran was not at imminent risk of harming himself or others. See CAPRI Records dated January 2011, March 2014, May 2015, August 2017, April 2018, December 2019. Finally, the evidence simply cannot support a finding of total social impairment for this Veteran. Although the Veteran has reported some suspicion of people outside of his family, the record consistently shows that the Veteran maintained strong relationships with a large number of his family members throughout the appeal period (e.g., his uncle, siblings, children) and that he has reported friendships in the community. See CAPRI Records dated July 2011, August 2012, October 2013, November 2015, April 2019; VA Examinations dated August 2013, January 2020, August 2021. While the Veteran experiences some social impairment, for instance with romantic relationships, the evidence does not support a finding of total social impairment. In sum, while the Veteran did experience symptoms contemplated by a 100 percent rating, the evidence overall does not demonstrate the level of impairment associated with a 100 percent rating. As noted above, the Veteran's other remaining symptoms were either contemplated by or more consistent with a 70 percent rating To the extent that the Veteran's reference to his PTSD medication in correspondence to VA indicates that he believes that the Board should not consider its ameliorative effects, the Board notes that the plain language of the criteria for a 10 percent rating under the General Formula specifically contemplates the effects of medication. Consequently, Jones v. Shinseki, 26 Vet. App. 56 (2012) does not apply, and the Board's evaluation of the Veteran's PTSD may include the ameliorative effects of medication. See McCarroll v. McDonald, 28 Vet. App. 267, 271-73 (2016). Additionally, although the Veteran has referenced Global Assessment of Functioning (GAF) scores in his correspondence advocating for a higher rating, "[a]n adjudicator is not permitted to rely on evidence that the American Psychiatric Association itself finds lacking in clarity and usefulness." Golden v. Shulkin, 29 Vet. App. 221, 225 (2018). Thus, the Board's analysis focuses on the severity, frequency, and duration of the Veteran's symptoms, rather than GAF scores. In short, the Board finds that it is at least as likely as not that the severity, frequency, and duration of the Veteran's symptoms throughout the period on appeal have been productive of occupational and social impairment with deficiencies in most areas. However, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran's symptoms resulted in total occupational and social impairment. The criteria for a 100 percent or higher rating are not met and the appeal must be denied. 2. Entitlement to a TDIU The Veteran contends that his service-connected PTSD produces unemployability and seeks a TDIU. A TDIU may be assigned, where the schedular rating is less than total, where a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). To qualify for schedular consideration of a TDIU, if there is only one such disability, this disability shall be ratable at 60 percent or more, and, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. Id. For the purposes of one 60 percent disability, or one 40 percent disability in combination, the following will be considered as one disability: (1) Disabilities of one or both upper extremities, one or both lower extremities, including the bilateral factor, if applicable; (2) disabilities resulting from common etiology or a single accident; (3)disabilities affecting a single body system, e.g., orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric; (4) multiple injuries incurred in action; or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16(a); see Moody v. Wilkie, 30 Vet. App. 329, 339 (2018) (combining disabilities as "one disability" to meet the rating threshold of § 4.16(a) requires the use of the combined rating table). The phrase "unable to secure and follow a substantially gainful occupation" contains both economic and noneconomic components. See Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The economic component refers to an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. Id. The noneconomic component requires a determination as to a veteran's ability to secure and follow such employment. Id. Attention should be given to the veteran's history, education, skills, and training; whether the veteran has the physical ability (both exertional and nonexertional) to perform the types of activities required by the occupation at issue (e.g., lifting, bending, sitting, standing, walking, climbing, as well as auditory and visual limitations); and whether the veteran has the mental ability to perform the activities required by the occupation at issue (e.g., memory, concentration, ability to adapt to change, handle work place stress, get along with coworkers, and demonstrate reliability and productivity). Id. An award of TDIU is an individualized determination, specific to a veteran's particular circumstances, e.g., their history, education, skills, and training. See Todd v. McDonald, 27 Vet. App. 79, 85 (2014). It does not require a showing of 100 percent unemployability. Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). The ultimate question is whether they are capable of performing the physical and mental acts required by employment, not whether they can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Veteran has the following disabilities that are service connected: PTSD (rated 70 percent, now effective February 28, 2011); degenerative disease of the cervical spine (rated 10 percent from August 20, 2008 to February 27, 2011, and 20 percent from February 28, 2011 onward); left upper extremity radiculopathy (rated 20 percent, effective February 28, 2011); and right upper extremity radiculopathy (rated 20 percent, effective February 28, 2011). Based on the forgoing, the Veteran has at least one disability rated at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. Accordingly, the Board may consider the claim for a TDIU on a schedular basis. 38 C.F.R. § 4.16(a). For the reasons that follow, the Board finds that a TDIU is warranted based on his service-connected PTSD symptoms. The Veteran has a high school diploma and has not completed any other education. His work history includes driving heavy machinery in the military, and work in construction and facilities maintenance after the military. He was most recently employed in July 2006, prior to the period on appeal. See Form 21-8940 received June 2011; Form 21-4192 received August 2011; CAPRI Records dated October 2013, April 2017. Although the Veteran receives social security benefits, he reports they are due to age rather than disability, and SSA has reported it has no medical records for the Veteran. See Correspondence received February 2017, May 2018. The Veteran's ability to secure and follow a substantially gainful occupation is impacted by the mental effects of his service-connected PTSD. Although the Veteran's employment history was primarily based on physical duties, construction and maintenance require follow safety protocols, and to show up on time and in the right place. The record shows that the Veteran has difficulty remembering appointments and tasks, difficulty with concentrating or maintaining a consistent train of thought, difficulty adapting to stressful circumstances, and intermittent difficulty conveying his thoughts. These symptoms could be dangerous in the kinds of employment with which the Veteran is familiar because it is necessary to follow safety protocols and effectively communicate information. Further, forgetting when or where to show up to work on a regular basis would reasonably result in termination by most employers. Finally, training in a new field is not reasonably feasible based on the Veteran's inability to retain new information, difficulty adapting to stressful circumstances, and difficulty communicating. Given the forgoing, the Veteran's service-connected PTSD precludes him from the ability to secure and follow a substantially gainful occupation consistent with his education, skills, training, and work history. Accordingly, a TDIU is warranted. REASONS FOR REMAND The Board must once again remand the Veteran's claims for entitlement to service connection. Although nexus opinions were obtained, as directed by the Board's last remand, the opinions provided raised additional issues that have not been addressed. 1. Entitlement to service connection for chronic pain syndrome In August 2021, the Veteran was provided with a VA examination for his peripheral nerves condition that referenced the claim for service connection for chronic pain syndrome. It provided a diagnosis for bilateral upper extremity radiculopathy, for which the Veteran has already received service connection. However, it did not address whether a diagnosis of chronic pain syndrome was supported by the record. Despite this, an August 2021 etiology opinion provided a positive nexus for "any currently diagnosed condition(s) related to the Veteran's chronic pain syndrome of the bilateral upper extremities" to the Veteran's service-connected cervical spine disability. It then went on to discuss symptoms associated with the Veteran's service-connected radiculopathy. Although the record contains a diagnosis of chronic pain syndrome on two occasions, both occurred years prior to the Veteran's 2011 claim. Specifically, an August 1997 VA examination diagnosed the Veteran with "chronic pain syndrome, probably secondary to mild degenerative disease of the cervical and lumbar spine." A May 2009 CAPRI record indicated it was a followup on chronic pain syndrome, but only discussed symptoms related to the Veteran's non-service connected low back and knees. Thus, the Board finds it is necessary to obtain a new VA examination to determine whether the Veteran is properly diagnosed with chronic pain syndrome at any time since 2011. 2. Entitlement to service connection for GERD An August 2021 VA opinion found that it was less likely than not that the Veteran's GERD is related to service, or secondary to or aggravated by pain medication taking for service-connected disabilities. However, the examiner also observed that the Veteran had a history of alcohol abuse, which is a known risk factor in developing GERD. Although alcohol or drug abuse cannot serve as a primary disability, it can serve as an intermediate link between a primary disability such as a psychiatric disorder, and a secondary disability such as GERD. In order to do so, a there must be clear medical evidence that his alcohol abuse disorder is secondary to or caused by their primary service-connected disability, and that it is not due to willful wrongdoing. See 38 U.S.C. §§ 101 (16), 105, 1110; OGCPRECOP 02-97; Allen v. Principi, 237 F.3d 1368, 1376 (Fed.Cir.2001). The record contains numerous reports that the Veteran has abused alcohol in response to family stressors, such as the death of a loved one. For instance, he reports that his initial alcohol abuse disorder in the 1990's developed following his sister's death. E.g., CAPRI record dated September 2013, December 2019. However, there is not "clear medical evidence" that the Veteran's alcohol abuse was caused by his service-connected PTSD and that it was not due to willful wrongdoing. A remand is required to obtain a medical opinion. Additionally, in the Veteran's August 2020 correspondence to the Board, the Veteran contended "medical studies have supported and proven Veterans suffering from PTSD are at high risk to develop, permanently aggravate and/or contract frequent and recurrent GERD." The Veteran did not cite to any supporting studies. Nonetheless, as the Veteran is not represented and the issue requires a remand on alternate grounds, that a medical opinion should also be obtained as to whether the Veteran's GERD at least as likely as not developed secondary to his PTSD. The matters are REMANDED for the following action: 1. Attempt to associate with the record all outstanding VA treatment records. 2. Schedule the Veteran for a VA examination for his claimed chronic pain syndrome. The examiner must review the claims file. The examiner is asked to provide a response to the following: (a.) At any point since 2011, does the record support a distinct diagnosis of chronic pain syndrome? (b.) If a diagnosis can be provided, is it possible to differentiate the symptoms of chronic pain syndrome from the Veteran's other service-connected disabilities? (c.) If the answer to (a) and (b) are yes, is the chronic pain syndrome at least as likely as not related to his in-service motor vehicle accidents? (d.) If the answer to (a) and (b) are yes, is the chronic pain syndrome at least as likely as not proximately due to or aggravated (any increase in disability) by his service-connected cervical spine disability? Provide a rationale to support the opinions. 3. Obtain an addendum opinion from an appropriate clinician regarding the Veteran's GERD. The examiner must review the claims file. The examiner is asked to provide a response to the following: (a.) Is it at least as likely as not that the Veteran's GERD is proximately due to or aggravated (any increase in disability) by his service-connected PTSD? The examiner should address the Veteran's contention that there are medical studies that establish a link. (b.) Is it at least as likely as not history of alcohol abuse disorder is secondary to or caused by his PTSD, and that it is not due to willful wrongdoing? (c.) If the answer to (b) is yes, is it at least as likely as not that the Veteran's GERD was caused by his alcohol abuse disorder? Provide a rationale to support the opinions. Z. SAHRAIE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Beeler, C. 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.