Citation Nr: 21076587 Decision Date: 12/27/21 Archive Date: 12/27/21 DOCKET NO. 16-09 491 DATE: December 27, 2021 REMANDED Entitlement to service connection for a headache condition, to include as secondary to service-connected tinnitus is remanded. Entitlement to service connection for peripheral vestibular disorder (claimed as vertigo and dizziness), to include as secondary to service-connected tinnitus is remanded. Entitlement to service connection for an acquired psychiatric condition, to include adjustment disorder with mixed anxiety and depressed mood, is remanded. REASONS FOR REMAND The Veteran had active service from October 1970 to October 1977; and October 1980 to September 1993. These matters are before the Board of Veterans' Appeals (Board) on appeal from a February 2013 rating decision (denying service connection for adjustment disorder with mixed anxiety and depressed mood); and an August 2015 rating decision (denying service connection for vertigo, dizziness, and headaches) issued by a Department of Veterans Affairs (VA) Regional Office (RO). In a January 2018 written statement, the Veteran requested a Board hearing. A May 2021 Board hearing note reflects that the Veteran's representative withdrew the request for a hearing and elected to submit a written brief. An October 2021 letter was sent to the Veteran's representative noting that the hearing was withdrawn and to afford an opportunity to submit a written brief. In December 2021, a written brief was received and associated with the claims file. 1. Entitlement to service connection for a headache condition, to include as secondary to service-connected tinnitus is remanded. 2. Entitlement to service connection for peripheral vestibular disorder (claimed as vertigo and dizziness), to include as secondary to service-connected tinnitus is remanded. The Veteran asserts that his vertigo and dizziness are due to his service-connected tinnitus. The Veteran also asserts that he has headaches due to his exposure to loud noise during his military service and/or caused or aggravated by his service-connected tinnitus. The Board notes that the Veteran's representative references current treatment for headaches in the December 2021 written brief. As the record only contains VA treatment records through February 2019, a remand is needed to obtain updated treatment records. During an August 2015 VA ear conditions examination, the Veteran was diagnosed with peripheral vestibular disorder. After reviewing the evidence of record, and in light of Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the Board has recharacterized the Veteran's claims of service connection for vertigo and dizziness, to entitlement to service connection for peripheral vestibular disorder (claimed as dizziness and vertigo), to include as secondary to service-connected tinnitus, as reflected on the title page. The August 2015 examiner noted that the Veteran experienced tinnitus and vertigo attributed to his peripheral vestibular condition. However, the examiner opined that the Veteran's vertigo was less likely than not caused by the tinnitus or due to an associated etiology. The rationale offered was that the symptoms of vertigo, fluctuating hearing loss, tinnitus, and aural pressure are excluded because the Veteran does not exhibit hearing loss. The Board finds the August 2015 opinion inadequate for rating purposes. The examiner failed to address whether the Veteran's peripheral vestibular disorder, to include vertigo, dizziness, aural pressure, and popping, was caused by or proximately due to his military noise exposure. Additionally, while the examiner noted that vertigo was not caused by his tinnitus, she did not address if the tinnitus aggravates his vertigo. As such, the Board finds that remand is required in order to obtain an addendum opinion to determine the etiology of his peripheral vestibular disorder, and any such diagnosis, to include as secondary to his service-connected tinnitus. 3. Entitlement to service connection for an acquired psychiatric condition, to include adjustment disorder with mixed anxiety and depressed mood is remanded. The Veteran asserts that his acquired psychiatric condition is attributed to his military service. In November 2012, the Veteran was afforded a VA PTSD examination. The examiner diagnosed the Veteran with adjustment disorder with mixed anxiety and depressed mood. The examiner noted that the Veteran experienced stressor events while serving in Vietnam, and although the Veteran reported anxiety symptoms, he did not meet the criteria for PTSD secondary to military stressor. The examiner concluded that the Veteran's depression symptoms appeared to be primarily related to financial difficulties and resulting problems with housing. No further discussion was provided regarding whether the Veteran's currently diagnosed psychiatric condition had its onset in or is otherwise related to his military service. Additionally, the examiner did not address the October 1986 service record, which revealed a mental health care contact at his last base for reported paranoid ideation. The veteran attributed his previous problems to a new squadron commander. In December 2018, the Veteran was afforded another VA PTSD examination. In this instance, the examiner found no diagnosable mental health condition. Specifically, the examiner noted that while he has experienced a criterion A stressor, he does not meet DSM5 criteria for either PTSD or Other Specified Trauma Related Disorder. However, the examiner did not address or acknowledge the November 2012 psychiatric diagnosis. Further, in the December 2021 written brief, the Veteran's representative noted that current outpatient treatment records from VAMC New Orleans, LA, shows a current diagnosis of PTSD, with conceded stressor of the appellant fearing for his life while in combat theater. The Board finds that remand is required to obtain an opinion as to whether the Veteran has a current acquired psychiatric diagnosis, and if so, it is etiologically related to service. The matters are REMANDED for the following action: 1. Obtain any outstanding VA or private treatment records and associate them with the claims file. All attempts to obtain these records should be documented in the claims folder. 2. After completing the foregoing development, schedule the Veteran for a VA examination to determine the etiology of any currently diagnosed headache and/or peripheral vestibular disorder, to include vertigo and dizziness. The entire claims file, including a copy of the REMAND, should be made available to, and be reviewed by, the VA examiner. All appropriate tests, studies, and consultation should be accomplished, and all clinical findings should be reported in detail. Based on examination and review of the record, the examiner is asked to provide an opinion whether it is at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran's headaches and/or peripheral vestibular disorder, and any such diagnosis, is related to an in-service injury, event, or disease, to include military hazardous noise exposure. Based on the review of the record, the examiner is asked to provide an opinion whether it is at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran's headaches and/or peripheral vestibular disorder, and any such diagnosis, is (1) caused, or (2) aggravated beyond its natural progression by any service-connected disability, to include tinnitus. The examiner is advised that the term "aggravation" is defined for legal purposes as a chronic worsening of the underlying condition beyond its natural progression. If aggravation is present, the clinician should indicate, to the extent possible, the approximate level of disability (i.e., a baseline) before the onset of the aggravation. The examiner should review and discuss the opinion from https://houseofhearing.ca/blog/relationship-tinnitus-vertigo/, cited to by the Veteran's representative in the December 2021 brief, addressing tinnitus and vertigo. The examiner must be advised that the Veteran is competent to report symptoms and treatment and that his reports, including his reports as to the onset and chronic nature of his symptoms, must be considered, along with the other evidence of record, in formulating the requested opinions. The Veteran's statements may not be discounted solely on the basis of the lack of confirmation in the medical records. A complete rationale must be provided for all opinions. If the examiner is unable to provide an opinion without resorting to speculation, an explanation as to why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered should be provided. 3. Schedule the Veteran for a VA examination to determine the etiology of any currently diagnosed acquired psychiatric disorder. The entire claims file, including a copy of the REMAND, should be made available to, and be reviewed by, the VA examiner. All appropriate tests, studies, and consultation should be accomplished, and all clinical findings should be reported in detail. For each diagnosed acquired psychiatric disorder, to include adjustment disorder with anxiety and depression, the examiner should provide an opinion as to whether such acquired psychiatric disorder is at least as likely as not (i.e., 50 percent or greater probability) related to or caused by service. The examiner should note the Veteran's reported traumatic experiences during service. Additionally, the examiner should review and discuss the October 1986 service record, which revealed a mental health care contact at the Veteran's last base for reported paranoid ideation. The Veteran attributed his previous problems to a new squadron commander (Continued on the next page) A complete rationale must be provided for all opinions. If the examiner is unable to provide an opinion without resorting to speculation, an explanation as to why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered should be provided. A. J. Spector Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Camille NeSmith, Associate 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.