Citation Nr: 21076872 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 17-49 617 DATE: December 28, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for fibromyalgia, including as due to an undiagnosed illness, is remanded. Entitlement to service connection for chronic fatigue syndrome (CFS), including as due to an undiagnosed illness, is remanded. Entitlement to service connection for irritable bowel syndrome (IBS), including as due to an undiagnosed illness, is remanded. Entitlement to service connection for headaches, including as due to an undiagnosed illness, is remanded. REASONS FOR REMAND The Veteran served in the United States Army from September 2008 to February 2009 and from March 2011 to November 2011, to include service in the Southwest Asia Theater of operations during the Persian Gulf War. The matters come to the Board of Veterans' Appeals (Board) on appeal from a December 2013 rating decision. 1. Acquired Psychiatric Disorder The Veteran claims entitlement to service connection for an acquired psychiatric disorder, to include PTSD, as a result of his military service. Specifically, the Veteran attributes his current problems to his experiences while service in Iraq, including hearing sirens go off due to mortar attacks. The Board notes that the Veteran's DD Form 214 reflects that he served in a designated imminent danger pay area. In the August 2017 statement of the case, the agency of original jurisdiction (AOJ) conceded that the Veteran was assigned to an area where hostile military or terrorist activities occurred. The Veteran's service treatment records indicate that the Veteran reported sleep problems and little interest or pleasure in doing things during a post-deployment health assessment in September 2011. See September 2011 Service Treatment Record. In June 2016, the Veteran underwent a VA examination, and the examiner determined that the Veteran did not meet the diagnostic criteria for PTSD or any other mental disorder that conformed with the DSM-5. Subsequent VA treatment records, however, reflect acquired psychiatric disorder diagnoses that were not identified by the June 2016 VA examiner. For example, an October 2016 VA treatment record noted that the Veteran's active problems included anxiety disorder, depression, insomnia, and PTSD. A March 2018 VA treatment record notes a diagnosis of adjustment disorder with mixed anxiety and depressed mood. Thus, because the medical evidence of record is insufficient to resolve the Veteran's claim for service connection for an acquired psychiatric disorder, a new examination is necessary that adequately addresses any current diagnoses, as well as whether any currently-diagnosed acquired psychiatric disorder is related to his military service, to include the fact that he was assigned to an area where hostile military or terrorist activities occurred. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 2. Fibromyalgia, CFS, IBS, and Headaches The Veteran generally contends that he has fibromyalgia, CFS, IBS, and headaches that are related to service in Southwest Asia. See January 2012 VA Form 21-526. He further contends that each issue is related to service in Southwest Asia, and that he experienced symptoms while in service and upon exit. See June 2020 Appellate Brief. With respect to fibromyalgia, the Veteran contends that he hurts/aches between his back and his knees, and it is a struggle every morning to get himself out of bed to start the day. With respect to CFS, he contends that he is lucky to sleep three to four hours a night due to not being able to relax or feeling like somebody is outside or trying to get into his house. Regarding IBS, the Veteran contends that he has not had a solid bowel movement since he came home from Iraq and sometimes has problems controlling his bowel movements. See September 2017 VA Form 9. The Veteran contends that headaches started occurring during the last six months of his deployment; his headaches come out of nowhere and last for hours on end, if not for a day or so; and ibuprofen doesn't seem to touch it half of the time. See January 2012 VA Form 21-526; see also September 2017 VA Form 9. A September 2011 post-deployment health assessment noted the Veteran's report of problems sleeping or still feeling tired after sleeping. A March 2012 post-deployment health assessment noted the Veteran's report of bad headaches; feeling weak; muscle aches; and diarrhea, vomiting, or frequent indigestion/heartburn. It was also noted that the Veteran received treatment for his digestive problems, muscle and joint pain, and headaches. November 2015 and January 2016 VA treatment records indicate that the Veteran experienced diarrhea, constipation, and upset stomach. The record indicates that the Veteran has reported a history of migraines. See September 2016 VA treatment records. In connection with his claim, the Veteran was afforded multiple VA examinations in June 2016, including a Gulf War General Medical Examination, a headaches examination, a fibromyalgia examination, an intestinal examination, and a chronic fatigue examination. In the Gulf War examination, the examiner noted that the Veteran had no diagnosed illnesses for which no etiology was established, but that if the Veteran was diagnosed with IBS, CFS, and fibromyalgia, then these diagnoses would be considered "in the #2 category and possibly related to the Gulf War syndrome." See June 2016 VA Examination Report. In the headaches examination report, the Veteran was diagnosed with tension headaches, and the examiner indicated that the diagnosis dated back to 2011 after the Veteran served in Iraq. In the chronic fatigue examination report, the examiner concluded that the Veteran had never been diagnosed with chronic fatigue, despite his reported of feeling fatigue dating back to September 2011 when he was still in Iraq. In the intestinal examination report, the examiner concluded that the Veteran had never been diagnosed with an intestinal condition, despite his reported symptoms of diarrhea, sharp pains, and constipation, after returning home from Iraq. In the fibromyalgia examination report, the examiner concluded that the Veteran had never been diagnosed with fibromyalgia, despite his report of muscle aches and pains starting in August 2011 during his active duty service. The examiner noted that the Veteran reported that he has musculoskeletal pain all over and wakes up with stiffness all over in the mornings; he takes aspirin for the symptoms, which include widespread musculoskeletal pain, stiffness, muscle weakness, fatigue, sleep disturbances, headache, depression, anxiety, and IBS. The VA examiner noted that symptoms are present more than 1/3 of the time and that the Veteran has tender points including both trapezius muscles, supraspinatus muscles, right lateral epicondyle, both gluteal, right greater trochanter, and right knee. In a December 2016 opinion, the June 2016 VA examiner provided an addendum opinion in which she noted that the Veteran had not had a medical work up for fibromyalgia or CFS and, therefore, the symptoms listed for both cannot be attributed to Gulf War Syndrome until other possible causes for the symptoms are ruled out. She also noted that the Veteran had not had a neurology work addressing his headaches, which was necessary to rule out other causes prior to any indication that his headaches were related to his service in Southwest Asia. She also noted that it is not possible to separate out the symptoms for CFS, fibromyalgia, and headaches as the symptoms overlap. The VA examiner provided another addendum opinion in May 2017 in which she noted that the Veteran has been followed by primary care and had not been diagnosed with fibromyalgia or CFS. She noted that the Veteran works construction, which accounts for some muscle and joint aches and pains, and that he has several diagnoses which can account for several of his symptoms of fibromyalgia and CFS including chronic low back pain, ankle pain from a fracture, depression, anxiety, sleep apnea, PTSD and insomnia, which also causes muscle aches and pains. The VA examiner noted that as the Veteran is being followed by primary care it is within their prerogative to work the Veteran up for fibromyalgia and CFS if they believe these conditions to be applicable to the Veteran, but they have not done so. The VA examiner reiterated that the symptoms of fibromyalgia and CFS at this point in time can all be attributed to other diagnoses and therefore not attributed to Gulf War syndrome. The Board finds that further medical clarification is needed before an informed decision can be made as to whether the Veteran's disabilities are MUCMIs warranting an award of service connection on a presumptive basis. Indeed, no examiner as fully addressed both the etiology and pathophysiology of the conditions in the context of the Veteran's circumstances. Moreover, notwithstanding the applicability of the presumption, an additional medical opinion addressing whether a direct relationship may exist between the Veteran's disabilities and his exposures to environmental hazards is necessary, as the opinions currently of record do not include adequate explanation or rationale. Thus, to have sufficient information upon which to decide these claims, the Board finds a remand is necessary to obtain new VA examinations and opinions. The matters are REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. 2. The Veteran should be afforded a new VA examination by a qualified mental health professional to determine whether any acquired psychiatric disorder is related to his military service. The record must be made available to, and reviewed by, the examiner. Any indicated evaluations, studies, and tests should be conducted, and the examiner should take a history from the Veteran as to the onset and progression of his claimed disability. Upon review of the file, as well as interview and examination of the Veteran, the examiner should respond to each of the following: (a) Identify all current psychiatric disabilities, i.e., any disorder that has been present at any time since the Veteran's discharge from active duty in November 2011, even if not shown on the current examination. In this regard, an October 2016 VA treatment record noted that the Veteran's active problems included anxiety disorder, depression, insomnia, and PTSD, and a March 2018 VA treatment record notes a diagnosis of adjustment disorder with mixed anxiety and depressed mood. If PTSD is diagnosed, the stressor(s) to support such diagnosis must be identified. (b) With regard to any identified acquired psychiatric disorder, is it at least as likely as not (50 percent or greater probability) that such had its onset in, or is otherwise related to, his active service, to include his conceded assignment to an area where hostile military or terrorist activities occurred? In offering any opinion, the examiner must consider the full record, to include the Veteran's lay statements regarding in-service and continuity of symptomatology. A clearly-stated rationale for any opinion offered should be provided. 3. The Veteran should be afforded a new VA examination by a qualified medical professional to determine whether any current intestinal disorder, to include IBS; headaches disorder; any disorder manifested by joint and muscle pains, to include fibromyalgia; and/or any chronic fatigue disorder had its onset during, or is otherwise related to, his military service, to include his service in Southwest Asia. The record must be made available to, and reviewed by, the examiner. Any indicated evaluations, studies, and tests should be conducted, and the examiner should take a history from the Veteran as to the onset and progression of his claimed disabilities. Following a review of the entire record, to include the Veteran's lay statements concerning onset and continuity of symptomatology, the examiner(s) should address the following questions: a) Identify any current intestinal disorder, to include IBS; headaches disorder, to include tension headaches; any disorder manifested by joint and muscle pains, to include fibromyalgia; and/or any chronic fatigue disorder. With regard to the Veteran's headaches, please note that the Veteran was diagnosed with tension headaches during the June 2016 VA examination. b) If the Veteran's intestinal symptoms, headache symptoms, joint and muscle pain symptoms, and chronic fatigue symptoms cannot be attributed to a known diagnosis, the examiner must provide an opinion as to whether any such symptoms represent an objective indication of chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multisymptom illness related to his service in Southwest Asia. c) For any intestinal disorder, headache disorder, joint and muscle pain disorder, and/or chronic fatigue disorder attributable to a known diagnosis, is it at least as likely as not (i.e., a 50 percent or greater probability) that such had its onset in, or is otherwise related to his period of active duty service, to include directly due to any environmental exposures while serving in Southwest Asia? In offering any opinion, the examiner must consider the full record, to include the Veteran's lay statements regarding in-service incurrence and continuity of symptomatology. A complete rationale must be provided for all opinions, and must be based on consideration of all pertinent lay and medical evidence. 4. Thereafter, readjudicate the issues on appeal. James Springer Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Fulmer, 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.