Citation Nr: 21008646 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 10-13 627 DATE: February 17, 2021 ORDER Entitlement to service connection for a cervical strain, arthritis, intervertebral disc syndrome (IVDS) with radiculopathy of bilateral upper extremities, to include as secondary to hyperparathyroidism, and as due to an undiagnosed illness or medically unexplained chronic multi-symptoms illness (MUCMI) under 38 C.F.R. § 3.317, is denied. Entitlement to service connection for degenerative arthritis of the thoracolumbar spine, IVDS with radiculopathy of the right lower extremity, status post (SP) discectomy, to include as secondary to hyperparathyroidism, and as due to an undiagnosed illness or MUCMI under 38 C.F.R. § 3.317, is denied. Entitlement to service connection for an acquired psychiatric disorder, claimed as posttraumatic stress disorder (PTSD), to include as secondary to hyperparathyroidism and fibromyalgia, is denied. REMANDED Entitlement to restoration of a 60 percent rating for hyperparathyroidism, status post (SP) parathyroidectomy, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran served aboard a naval vessel in the Persian Gulf during the Persian Gulf Conflict. 2. A cervical strain, arthritis, and IVDS with radiculopathy are first shown years after service and are unrelated to military service; are not undiagnosed illnesses and are not a MUCMI; and are not due to or aggravated by service-connected disability. 3. Degenerative arthritis of the thoracolumbar spine, IVDS with radiculopathy, and SP discectomy are first shown years after service and unrelated to service; are not undiagnosed illnesses and are not a MUCMI; and are not due to or aggravated by service-connected disability. 4. PTSD is not shown and an acquired psychiatric disorder other than PTSD is first shown years after service and unrelated to any inservice event; and is not due to or aggravated by service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a cervical strain, arthritis, intervertebral disc syndrome (IVDS) with radiculopathy of bilateral upper extremities, to include as secondary to hyperparathyroidism, and as due to an undiagnosed illness or medically unexplained chronic multi-symptoms illness (MUCMI) under 38 C.F.R. § 3.317, have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 1137, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310, 3.317. 2. The criteria for service connection for degenerative arthritis of the thoracolumbar spine, IVDS with radiculopathy of the right lower extremity, status post (SP) discectomy, to include as secondary to hyperparathyroidism, and as due to an undiagnosed illness or MUCMI under 38 C.F.R. § 3.317 have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 1137, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310, 3.317. 3. The criteria for service connection for an acquired psychiatric disorder, claimed as posttraumatic stress disorder (PTSD), to include as secondary to hyperparathyroidism and fibromyalgia, have not been met. 38 U.S.C. §§ 1110, 1131, 1137, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from December 1987 to August 1991 in the U.S. Marine Corps. His DD 214 shows that he participated in Operation Desert Shield/Storm from August 18, 1990 to March 23, 1991. In pertinent part, in February 2013, the Board of Veterans’ Appeals (Board) denied service connection for a back disorder; and remanded a claim for service connection for a psychiatric disorder. On appeal, the U. S. Court of Appeals for Veterans Claims (Court), in April 2014, vacated the Board’s decision. However, a September 2020 rating decision granted service connection for osteoporosis of the spine, as due to service-connected hyperparathyroidism, SP parathyroidectomy, and assigned an initial noncompensable disability rating effective August 1, 2011. This was considered a partial grant. A November 2020 rating decision separated the grants service connection for spinal disability and assigned a 20% disability rating for osteoporosis of the cervical spine and a 10% disability rating for osteoporosis of the thoracolumbar spine. Both grants were made effective August 1, 2011, i.e., the date of reduction of the 60% rating for hyperparathyroidism, SP parathyroidectomy, to a noncompensable rating. A November 2020 Supplemental Statement of the Case (SSOC) addressed the claims for service connection for disabilities of the cervical and the thoracolumbar spinal segments other than osteoporosis; service connection for a psychiatric disorder; and a TDIU rating. Service Connection Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d per curium, 78 F.3d 604 (Fed. Cir. 1996) (table); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a), (d). Service connection may be granted for any disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). However, not every manifestation of joint pain during service will permit service connection for arthritis first shown as a clear-cut clinical entity at some later date. 38 C.F.R. § 3.303(b). Certain chronic diseases, such as arthritis, will be presumed related to service, absent an intercurrent cause, if shown as chronic in service; or, if manifested to a compensable degree within a presumptive period following separation from service; or, if noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection will be granted on a secondary basis for disability that is proximately due to or the result of, or permanently aggravated by, an already service-connected condition. 38 C.F.R. § 3.310(a) and (b). This requires (1) evidence of a current disability; (2) a service-connected disability; and (3) evidence establishing a nexus between the service-connected disability and the claimed disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). A veteran of the Persian Gulf War can establish entitlement to service connection on a presumptive basis if the veteran "exhibits objective indication of a qualifying chronic disability" that manifests during active duty or to a compensable degree during the specific presumptive period. 38 U.S.C. § 1117(g); 38 C.F.R. § 3.317. To qualify for presumptive service connection under § 3.317, a claimant must have a "qualifying chronic disability" that results from either an "undiagnosed illness" or a medically unexplained chronic multi-symptom illness (MUCMI) "defined by a cluster of signs or symptoms." 38 C.F.R. § 3.317(a)(2)(i); see Atencio v. O'Rourke, 30 Vet. App. 74, 80-82 (2018). A "MUCMI" is a "diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities." 38 C.F.R. § 3.317(a)(2)(ii). "[A]n illness is a MUCMI where either the etiology or pathophysiology of the illness is inconclusive." Stewart v. Wilkie, 30 Vet. App. 383, 390 (2018). "Conversely, a multisymptom illness is not a MUCMI where both the etiology and the pathophysiology of the illness are partially understood." Id. 38 U.S.C. § 1154(b) and 38 C.F.R. § 3.304(d) provide that if a veteran engaged in combat during active service, lay or other evidence will be considered sufficient proof of the service events in combat, if consistent with the circumstances, of service, even if there is no official record of such incurrence during service; however, this does not create a presumption of service connection and competent evidence of a current disability and of a link between the current disability and service is still required. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 507-13 (1995); see also Collette v. Brown, 82 F.3d 389, 392 (Fed. Cir. 1996). Reasonable doubt will be favorably resolved but if the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1365-66 (Fed. Cir. 2001). Initial Considerations The Veteran’s DD 214 shows that he participated in Operation Desert Shield/Storm from August 1990 to March 1991. He had no foreign service but had 8 months and 6 days of sea service, and service personnel records show that during Operations Desert Shield/Storm he served on the U.S.S. Nassau in the North Arabian Sea and the Persian Gulf. His military decorations include the Sea Service Deployment Ribbon, and Southwest Asia Service Medal with star. His military occupational specialty (MOS) was Aircraft Maintenance Ground Support. Evidence throughout the record shows that the Veteran has repeatedly alleged that he is service-connected for Gulf War Syndrome (GSW). However, this is not correct. Rather, he is service-connected for fibromyalgia as stemming from his service in the Persian Gulf, and rated 40 percent which encompasses widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headaches, irritable bowel symptoms, depression, anxiety, or Raynaud’s-like symptoms, which are constant or nearly so, and refractory to therapy. See 38 C.F.R. § 4.71a, Diagnostic Code 5025. He is also service-connected for hyperparathyroidism, SP parathyroidectomy, (and he has not had kidney stones since the parathyroidectomy), as well as osteoporosis of the cervical spine, rated 20% and thoracolumbar spine, rated 10%, with each being due to the hyperparathyroidism, SP parathyroidectomy. The Veteran contends that an Anthrax inoculation during service caused his fibromyalgia and hyperparathyroidism; is related to his claimed disabilities of the spine; and his physical reaction to that vaccination caused a psychiatric disability, including PTSD, which may also be due to witnessing planes crash. See January 2005 Psychiatric/Psychological Assessment by a private psychologist, in conjunction with a claim for Social Security Administration (SSA) benefits (noting that the Veteran believed he was awarded VA benefits due to disability from an in-service anthrax vaccination). However, the Veteran is not competent to attest that any such inoculation caused fibromyalgia or hyperparathyroidism, and service connection for these disorders has not been granted on this basis. Likewise, he is not competent to attest that such an inoculation caused any spinal or psychiatric disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). To the contrary, at a Gulf War Evaluation in July 2010 the Veteran’s extensive medical history was reviewed and it was noted that a June 2008 VA clinical record reflected his belief that his prolonged history of symptoms of multiple bodily systems was connected to an Anthrax vaccination during service but that “anthrax [sic] vaccine has an excellent safety record and we don’t see any cause and effect relationship with his chronic symptoms.” Additionally, a December 21, 2017, RO letter informed the Veteran that his complete service treatment records (STRs) could not be located and therefore were unavailable for review. All efforts to obtain the needed information had been exhausted, and based on these facts, it was determined that further attempts to obtain the records would be futile. His claim file contained documentation of the written and telephonic efforts made to attempt to obtain these records. However, the presence of incomplete service records does not lower the threshold for allowing a claim but creates a heightened duty to evaluate the evidence and consider the benefit of the doubt doctrine. Russo v. Brown, 9 Vet. App. 46, 51 (1996). 1. Service connection for cervical strain, IVDS with radiculopathy of the bilateral upper extremities, to include as secondary to service-connected hyperparathyroidism Although the Veteran had a mild thoracic strain during service, the service treatment records (STRs) reflect no complaints or findings for pathology of the cervical spine, and it is not contended or shown that he sustained injury or otherwise sought or received treatment during service for any cervical spine pathology, including any strain. As to any contention that the Veteran had continuous symptoms of cervical spine pathology during and continuing after service, he is already service-connected for fibromyalgia which, as noted, encompasses widespread musculoskeletal pain and tender points, as well as cervical osteoporosis. He is not competent to diagnose himself with any other cervical spine pathology or provide an opinion of the etiology of any symptoms relative to his cervical spine as being due to the currently claimed pathologies, as distinguished from symptoms due to service-connected fibromyalgia, as this is not susceptible to lay observation. The etiology of his current cervical spine pathology is a complex medical matter that requires medical knowledge of the musculoskeletal system and its disease processes. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Veteran has been diagnosed as having a cervical strain, spondylosis and degenerative disc disease (DDD) with IVDS and radiculopathy. Thus, he does not have an undiagnosed illness and these disease processes are of at least partially understood etiology and pathophysiology and, so, are not a MUCMI for the purpose of service connection based on service in the Persian Gulf. Specifically, an August 2010 VA Nurse’s opinion and an opinion at an August 2016 VA spinal examination both noted that his cervical spinal condition was consistent with the aging process. Contemporaneous postservice evidence shows no complaints of the cervical spine prior to May 2001, when records of Dr. H. show that in May 2001 the Veteran had the onset of numbness of both arms, and some fingers only 2 weeks earlier, and without known trauma. The Veteran was evaluated by VA on multiple occasions as to the etiology of his cervical spine disorders. In August 2010 a Nurse opined, after a review of the records, that his cervical spondylosis was not caused by or a result of military service. The rationale was that there was no documentation of an ongoing neck condition during military service and that spondylosis was part of the natural aging process and seen as soon as the 3rd decade of life. On VA examination in August 2016 the Veteran reported having had neck pain for the last 17 to 18 years. The diagnoses were degenerative arthritis, DDD, and IVDS of the cervical spine. It was opined that these conditions were less likely as not related to military service and the rationale was that he was not treated for such conditions during service and was only found to have degenerative changes in 2010, 19 years after service, which was part of the aging process. Essentially the same diagnoses were rendered at a later VA examination in June 2020, with the addition of a cervical strain and radiculopathy, when again his records were reviewed, at which time he related the onset of cervical spine disability to 2004 or 2005. X-rays in July 2010 revealed cervical spondylosis. The examiner opined that the relevant cervical spine conditions were less likely than not incurred in or caused by an inservice injury, event or illness because, based on medical records and physical objective examination, there was no documentation of spinal disability that was incurred in or caused by an inservice injury, event or illness. Standing against these VA medical opinions is no more than the Veteran’s contention that his current cervical pathologies are of service origin. The Board assigns greater probative value to the Veteran’s STRs, which show no abnormal cervical pathology. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than a self-reported history). Particularly, when it is not alleged that he had injury or in-service treatment of the cervical spine. Also, the Board assigns greater probative value to the many years intervening service and the first documented findings for abnormal cervical pathology. Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006); see also Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom., Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (holding that the Board may take into consideration the passage of a lengthy period of time in which the Veteran did not complain of the disorder at issue); Forshey v. West, 12 Vet. App. 71, 74 (1998), aff’d sub nom., Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002). As to secondary service connection, the August 2016 VA examiner opined that it was less likely as not that the cervical spine conditions were caused or aggravated by his service-connected residuals of hyperparathyroidism, and the rationale was that he was not treated for such a condition during service and was only found to have degenerative changes in 2010, 19 years after service, which was part of the aging process. Similarly, the VA examiner that conducted the June 2020 evaluation, opined in October 2020 that because hyperparathyroidism leads to osteoporosis, the claimed osteopenia was related to the service-connected hyperparathyroidism. However, the diagnosed cervical strain, radiculopathy, DDD/IVDS, and spondylosis were unrelated to the service-connected hyperparathyroidism. These medical opinions are unrebutted by any other clinical evidence on file and are of greater probative value, being premised on medical knowledge, training, and expertise, than the Veteran’s lay assertions to the contrary. Thus, the evidence shows that the Veteran’s current pathologies of the cervical spine, other than his service connected osteopenia (osteoporosis), first manifested many years after service, are not of service origin, are unrelated to any service in the Persian Gulf, and are not due to or aggravated by his service-connected hyperparathyroidism, SP parathyroidectomy. Thus, the preponderance of the evidence is unfavorable and there is no doubt to be favorably resolved. 2. Service connection for degenerative arthritis of the thoracolumbar spine, IVDS with radiculopathy of the right lower extremity, and SP discectomy, to include as secondary to service-connected hyperparathyroidism The STRs show that in May 1990 the Veteran complained of pain of the left side of his back at approximately the “T-8” level, left-sided tenderness from T-6 to T-10, but without any known strain or trauma, and on examination he was neurologically intact. The assessment was a mild thoracic strain, for which he was to remain in his quarters for 48 hours and was given Motrin and Flexeril. On examination for service discharge in August 1991 no pertinent abnormality was found. In an adjunct medical history questionnaire, he reported having or having had kidney stones but denied all other relevant complaints. Although the Veteran now asserts that he had had continuous thoracolumbar symptoms since service, the Board again notes that he is service-connected for fibromyalgia which, as noted, encompasses widespread musculoskeletal pain and tender points. He is not competent to diagnose himself with thoracolumbar spine pathology or provide an opinion of the etiology of any symptoms relative to his thoracolumbar spine as being due to the currently claimed pathologies, as distinguished from symptoms due to service-connected fibromyalgia, as this is not susceptible to lay observation. The etiology of his current thoracolumbar spine pathology is a complex medical matter that requires medical knowledge of the musculoskeletal system and its disease processes. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Veteran has been diagnosed as having thoracolumbar arthritis and DDD with IVDS. Thus, he does not have an undiagnosed illness and these disease processes are of at least partially understood etiology and pathophysiology and, so, are not a MUCMI for the purpose of service connection based on service in the Persian Gulf. Specifically, an August 2010 VA Nurse’s opinion, noting a 1999 postservice back injury, and an opinion at an August 2016 VA spinal examination both noted that his thoracolumbar spinal condition was consistent with the aging process. Moreover, the latter opinion specifically indicated that after the 1990 thoracic strain there was no medical evidence of ongoing treatment for a thoracic strain which implied the acute condition resolved and after service performed vigorous work and was not found to have degenerative changes of the lumbar spine until 19 years after service, and in the thoracic spine 25 years after service. Similarly, a 2020 VA examiner specifically noted the Veteran’s report of continued low back problems since his inservice injury. That examiner reported that while it was known that hyperparathyroidism could cause osteoporosis, as demonstrated by a January 2003 Bone Densitometry demonstrating osteopenia of the lumbar spine, as to degenerative arthritis, IVDS, radiculopathy of the right lower extremity, and SP discectomy, these conditions were not related to service. Rather, the likely cause of IVDS was from trauma or injury not related to military service. The right lower extremity radiculopathy and SP discectomy were caused by IVDS. The likely cause of degenerative arthritis, diagnosed 19 years after service, was simple wear-and-tear over time, and there was no evidence shown that there was an injury incident causing degenerative arthritis. The 2020 VA examiner also stated that the Veteran’s degenerative arthritis, IVDS, radiculopathy of the right lower extremity, and SP discectomy, were less likely as not due to or the result of a service-connected condition. Standing against these VA medical opinions is no more than the Veteran’s contention that his current thoracolumbar pathologies are of service origin. The Board assigns greater probative value to these medical opinions which were rendered after a review of the records, examination of the Veteran, and the application of medical knowledge, training, and expertise. Thus, the evidence shows that the Veteran’s current pathologies of the thoracolumbar spine, other than his service connected osteopenia (osteoporosis), first manifested many years after service, are not of service origin, are unrelated to any service in the Persian Gulf, and are not due to or aggravated by his service-connected hyperparathyroidism, SP parathyroidectomy. Thus, the preponderance of the evidence is unfavorable and there is no doubt to be favorably resolved. 3. Service connection for an acquired psychiatric disorder, claimed as PTSD, to include as secondary to service-connected hyperparathyroidism and fibromyalgia A report of a January 2005 Psychiatric/Psychological Assessment by a private psychologist, in conjunction with a claim for SSA benefits rendered a diagnosis that the Veteran had a personality disorder. Likewise, a psychologist that conducted a VA psychiatric examination in May 2014, and rendered additional reports in February 2018 and May 2020, also diagnosed a personality disorder. The rationale expressed by the 2014 VA examiner for a diagnosis of a paranoid personality disorder was a pervasive distrust and suspiciousness of others; a reluctance to confide in others because of the fear others will use the information maliciously against him; reading hidden meaning or threatening meanings into benign remarks; persistently bearing grudges, unforgiving of insults, and being quick to react angrily to perceived counterattacks that are not apparent to others. However, personality disorders, as such, are not diseases or injuries within the meaning of applicable legislation. 38 C.F.R. § 3.303(c); see also VAOPGCPREC 82-90. The Veteran did not participate in combat, having been continually stationed aboard a naval vessel in the Persian Gulf during the Persian Gulf Conflict. In part, as stressors putatively causing PTSD, he has reported having seen planes crash. A June 23, 2010, Administrative Decision made a formal finding that there was a lack of information required to corroborate stressors associated with a claim for service connection for PTSD. To the extent that the Veteran asserts that he has PTSD due to events in service, the Board finds that while he believes he has PTSD and has asserted such to medical providers, he is not competent to diagnose himself with PTSD, as this is a complex medical determination that requires medical knowledge and training to assess whether the criteria for PTSD as shown in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, of the American Psychiatric Association (DSM-V) are met. See 38 C.F.R. § 4.130. It is noted that a diagnosis of a mental disorder should conform to DSM-V. See 38 C.F.R. § 4.125(a). Although PTSD has been noted, or transcribed, into the medical record based on the Veteran's report of having PTSD, the mere transcription of medical history does not transform the information into competent medical evidence merely because the transcriber happens to be a medical professional. See LeShore v. Brown, 8 Vet. App. 406 (1995). For example, VA clinical records include an August 25, 2004, negative PTSD screening reflecting that the Veteran denied having had an experience that was so frightening, horrible or upsetting that in the past month he had had nightmares, intrusive thoughts, startle reaction, guarding or numbness. This contrasts with a later, July 13, 2005 VAOPT record of PTSD screening, which was positive because he responded in the positive as to such an event that in the past month he had been guarded, easily startled and felt numb. Also, an August 21, 2006, report of VA PTSD Advanced Assessment Screening reflects that the Veteran responded in the affirmative to virtually every question posed relative to PTSD, including experiencing an event in which his life was endangered. The assessment was PTSD, noting that he related that after having been given an Anthrax inoculation he was hospitalized for the side effects and he had thought he was going to die. However, the record shows that the Veteran was hospitalized for a painful occurrence of kidney stones. He has, at times, attempted to relate having had an Anthrax inoculation which, 90 days later, led to his having kidney stones. But he has also, at times, simply reported that an Anthrax inoculation led to a life-threatening episode or episodes for which he was hospitalized. In other words, he has seemingly comingled his clinical history into a confusing array which at times has misled evaluating clinicians. For example, VA and SSA records show that in 2003 the Veteran related having been seen by many specialists for unusual symptoms or a mysterious illness, which he thought to be due to either Gulf War Syndrome or an Anthrax inoculation during service. Similarly, the Veteran’s April 2004 letter attributed kidney stones, hypercalcemia, and hyperparathyroidism, as well as overall deteriorating health, to an inservice Anthrax inoculation. Therefore, the Veteran's statements have little probative value in these matters. The Board assigns greater probative value to the Veteran's STRs because they are contemporaneous with the time during which the Veteran suggests that his psychiatric symptoms started. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the claimant). The STRs are negative for psychiatric disability. In February 2018, the VA psychologist that conducted the May 2014 VA psychiatric examination opined that the Veteran’s unauthorized absence during service was not a result of or a manifestation of the onset of psychiatric disability at that time because his absence was for a logical and rational purpose, i.e., to go home to cope with family problems and, as such, was not reflective of mental health problems. The Veteran’s overall clinical picture has been evaluated several times. A December 30, 2003 VA Consultation reflects that “[i]n brief, this patient relates his misery to an Anthrax vaccine ten years ago, after which he started falling downhill. Today, for example, he reports maybe 25 different complaints to me, and I tried to put those down in writing, but I couldn’t follow up with his diffuse aches and pains.” He related having a problem with virtually every bodily system. The assessment was that hypochondriasis was evident. It was felt that his complaints were more psychogenic than physical due to the absence of (a) findings on physical examination, (b) relevant and meaningful history, and (c) findings on thorough lab workups. It was believed that he had either Munchausen syndrome, or he had a somatization disorder. A report of a January 2005 Psychiatric/Psychological Assessment by a private psychologist, in conjunction with a claim for SSA benefits, shows that the Veteran (incorrectly) believed that he had been awarded VA disability benefits due to an inservice anthrax vaccination. He had numerous physical complaints and had considerable persecutory ideation as to his relationships with medical providers. The current diagnoses were a somatoform disorder; pain disorder with significant psychological factors; depressive disorder, not otherwise specified (NOS); intermittent explosive disorder. On VA psychiatric examination in August 2007, the Veteran’s records were reviewed. The examiner noted that the Veteran attributed his many problems to an inservice Anthrax inoculation and while he had subsequently complained of a great many physical and, more recently, psychological maladies and it had been speculated that his problems were of hysterical and/or hypochondriacal origin. Specifically, he related having had tremendous physical pain from inservice kidney stones. At the 2007 examination he reported not having experienced intense fear or feelings of hopelessness during service, but the record shows that he subsequently did report having had such subjective feelings. Further, at that examination he related having had more than 50 postservice episodes of nausea, vomiting, and seizures due to dehydration and hypokalemia at which times he thought he would die. While the 2007 examiner stated that the Veteran met the DSM-IV stressor criterion, the formal diagnoses were hypochondriasis with poor insight, and a conversion disorder with mixed presentation. Although based on the Veteran’s description of his symptoms and the detailing of the stressors the Veteran provided, the 2007 examiner indicated that it would seem reasonable to diagnosis PTSD, but the examiner did not render such a diagnosis because to do so would, the examiner believed, cloud the extant clinical picture. The examiner found no evidence in the record of symptoms of PTSD prior to August of 2006 and there was evidence that his physical maladies could well be psychogenic, or significantly psychogenic, in character. The examiner was compelled to infer that the psychological symptoms were, analogously, the result of hypochondriacal and hysterical phenomena, as opposed to his experiences with kidney stones during service. While from the Veteran’s self-description, it would appear reasonable to append a diagnosis of PTSD, the examiner was highly skeptical and believed it considerably more likely than not that the symptoms were either being greatly exaggerated or had been determined to be hysterical and hypochondriacal, or both. Thus, the examiner suspected that the Veteran was either greatly exaggerating his symptoms or that they were caused by hysterical and hypochondriacal mechanisms. In conclusion, the 2007 examiner opined that PTSD was less likely as not caused by or a result of the Veteran’s inservice experiences and ultimate health problems and disability status. It was stated that: The examiner has diagnosed [the Veteran] with both a hysterical disorder and hypochondriasis, and would view the [V]eteran as having developed symptoms of PTSD as a result of these manifestations, as opposed to the occurrence, as he argues, of extreme stress. The examiner draws heavily [on] his experience with similar individuals in similar circumstances, but also on his familiarity with currently accepted theoretical treatments of PTSD, in arriving at this opinion. On the other hand, on VA PTSD evaluation in January 2012, the Veteran’s records were reviewed, and an examiner rendered diagnoses of (1) PTSD, (2) anxiety, (3) an impulse control disorder, and (4) a mood disorder. However, given the varying diagnoses of record, including a mood disorder and an impulse control disorder in 2008, the 2012 examiner reported that he could not reconcile an accurate differential diagnosis without resorting to mere speculation. The Board has considered the foregoing evidence, including the medical opinions advanced but finds that subsequent medical opinions by a 2014 VA examiner, with addendums in 2018 and 2020 are of greater probative value. The 2014 examiner conducted an in-depth formal examination and thoroughly reviewed the evidence, while expressing opinions with detailed rationales. In particular, the 2014 examiner noted that the Veteran related having observed or heard of plane crashes while onboard ship, but the Veteran did not consider these events to be his main, more proximate PTSD stressors. Thus, the examiner reported that the stressors did not relate to a fear of hostile military or terrorist activity, and the stressors did not meet the criteria to adequately support a diagnosis of PTSD. Rather, the Veteran seemed anxious to attribute his symptoms to PTSD and the 2014 VA examiner noted that the Veteran “culled” all symptoms under the umbrella of PTSD. Also, his “too quick symptom endorsement” lacking substantiation undermined verisimilitude. Further, his recurring distressing dreams were normal anxiety dreams and not PTSD nightmares and he did not have flashbacks or dissociative episodes. Significantly, at the 2014 examination, the Veteran presented a 16 page list of his symptoms and treatment since military service and the examiner noted that this was evidence of a somatic conversion disorder and not PTSD, but the Veteran was culling all symptoms under the umbrella of PTSD. The diagnoses were a paranoid personality disorder; and a somatic symptoms disorder, previously diagnosed in DSM-IV as hypochondriasis and conversion disorder. Due to an interdependence of symptoms it was not possible to differentiate which symptoms were attributable to each disorder. Each disorder was less likely at not caused by or a result of or incurred during service. The rationale was (1) the absence of evidence of a vaccine being administered which could cause subsequent chronic illness; (2) the evidence of a recorded diagnostic assessments of kidney stones; (3) the chronic and untreatable nature of the somatic symptom which yielded, (4) secondary gains accruing to the Veteran due to maintaining the untreatable somatic symptom disorder (e.g., financial, occupational); (5) the subsequent angry and paranoid behavior displayed in public that were inappropriate and out of proportion to the situations; and (6) the interaction between the paranoid personality and the somatic symptom such that the personality disorder was the primary diagnosis. The 2014 examiner noted that the prior psychiatric examiner in 2007 rendered a correct diagnosis of a somatic symptom disorder, previously diagnosed under DSM-IV as hypochondriasis and conversion disorder, and properly did not diagnosis PTSD. The rationale for a diagnosis of a somatic symptom disorder was the presence of somatic symptoms that were distressing and result in disruption of daily life; excessive thoughts, feelings, and behaviors related to the somatic symptom as evidenced by disproportionate and persistent thoughts about the seriousness of the symptoms; persistently high levels of anxiety about the symptoms; excessive time and energy devoted to the symptom; the predominant feature of the somatic symptom being pain; persistence of symptoms for greater than six months. As to the rationale for not diagnosing PTSD, the Veteran’s symptoms were not related to service or to any confirmed stressor was based upon (1) the stressor the Veteran reported was inadequate to support a diagnosis of PTSD; (2) his symptoms, behaviors, perceptions, were due to another diagnosis; (3) the other diagnoses of a paranoid personality disorder and somatic symptom disorder more proximately account for his present symptoms. In February 2017 the Veteran’s attorney submitted an article entitled “Medical Disorders as a Cause of Psychological Trauma and Posttraumatic Stress Disorder.” It was stated therein that research had increasingly targeted sources of serious or life-threatening illnesses as traumatic events and there was a growing literature about PTSD among such medical patients. However, that article does not address the matter of the impact of any comitant psychiatric disorder(s), such as a somatoform disorder. Nevertheless, the 2014 examiner was requested to address this, and did so in 2018 stating that hysterical and hypochondriasis, and conversion disorder, were inadequate to be valid stressors under Criteria A, i.e., injury to self, witness injury to others, or loss of close friend to injury. The perception of trauma that could have occurred, but did not, was insufficient to constitute actual trauma. Hysterical hypochondriasis and conversion disorders were not Criteria A PTSD stressors; what was lacking was objective behavioral evidence of the fear of life due to illness. A subjective pronouncement of the same was insufficient to sustain a diagnosis of PTSD. It was opined that the Veteran’s diagnosed paranoid personality disorder and somatic symptom disorder were not related, connected to, or aggravated by, or caused by, or anything else, and, in fact, were independent from his service-connected fibromyalgia and hyperparathyroidism. In 2020, the 2014 examiner further explained that the Veteran’s diagnosed psychiatric disorders were not caused or aggravated by his service-connected fibromyalgia or hyperparathyroidism, stating as the rationale that the separate medical diagnoses of fibromyalgia and hyperparathyroidism did not equate with nor were they etiologic of either a personality disorder or a somatic disorder, and were separate, independent conditions. Although the Veteran has at times presented what would seem to be a confusing clinical picture, the Board finds that the opinions expressed by the 2014 VA examiner are, by far, of greater probative value because of the review of records, personal examination, and thoroughly explained and detailed rationales. Unfortunately, the opinions do not support the service connection claim. Thus, the preponderance of the evidence is unfavorable and there is no doubt to be favorably resolved. REASONS FOR REMAND Entitlement to restoration of a 60 percent rating for hyperparathyroidism, SP parathyroidectomy, is remanded. Entitlement to a TDIU rating is remanded. A February 2013 Board decision upheld an August 2010 rating reduction for hyperparathyroidism, SP parathyroidectomy, from 60% to a noncompensable rating, because of curative surgery, following which the Veteran had no more kidney stones. The Court vacated the Board’s decision holding that the rating reduction was proper, nothing that the Veteran did not dispute the Board finding that the hyperparathyroidism had been cured by surgery, but alleged that a rating should be assigned for residuals, under the note following 38 C.F.R. § 4.119, Diagnostic Code 7904, including residuals of the digestive system. The Court further noted that the Board had referred for initial RO adjudication a claim for service connection for a gastrointestinal (GI) disorder, but the Court stated that it was not clear why the Board did not have jurisdiction of this matter. Then, in April 2015 the Board found that it had jurisdiction of the claim for service connection for a gastrointestinal (GI) disorder but only as part of the matter of the appropriate rating for the service-connected hyperparathyroidism issue on appeal. In August 2017 the Board further clarified that it “currently has jurisdiction to consider GI symptoms to the extent that they are associated with the Veteran's service-connected hyperparathyroidism” [sic] but as to “an additional GI disability, separate from his hypothyroidism” [sic] as due to Gulf War service on a direct basis or secondary to psychiatric disability, this was “inextricably intertwined with the rating for hyperparathyroidism symptoms [and it lacked] the medical expertise to distinguish one from the other, [thus] the Board does not have jurisdiction over the [claim for service connection for a] GI disability (claimed as distinct and separate from any GI symptoms as residuals of hyperparathyroidism surgery), because it has not been adjudicated” by the RO. Thus, the August 2017 Board decision again referred the claim for service connection for a GI disorder, to include as due to Gulf War illness or as secondary to psychiatric disability, to the RO for initial adjudication. Nevertheless, the RO has still not adjudicated the claim for service connection for a GI disorder, to include as due to Gulf War illness or as secondary to psychiatric disability. Because this matter is, as stated by the Board in August 2017, “inextricably intertwined” with the rating, following reduction, for service-connected hyperparathyroidism, SP parathyroidectomy, and would impact the TDIU claim, the RO must first adjudicate the claim for service connection for a GI disorder, to include as due to Gulf War illness or as secondary to psychiatric disability, before the Board may adjudicate the claim for (a) restoration of a 60% rating for service-connected hyperparathyroidism, SP parathyroidectomy, and (b) a TDIU rating. Thus, the claims for service connection for a GI disability, distinct and separate from any GI symptoms as residuals of hyperparathyroidism, and a TDIU rating must again be referred to the RO for initial consideration. The matters are REMANDED for the following action: 1. The RO should take the appropriate steps, including an appropriate examination if necessary, to determine which, if any, GI symptoms the Veteran has are due to his service-connected hyperparathyroidism, SP parathyroidectomy, and which, if any, are due to a GI disability, distinct and separate from any GI symptoms as residuals of hyperparathyroidism. 2. Thereafter, the RO should again adjudicate the claim for a TDIU rating with consideration given to any determination(s) as to GI symptoms due to his service-connected hyperparathyroidism, SP parathyroidectomy, and any due to a GI disability, distinct and separate from any GI symptoms as residuals of hyperparathyroidism. L. ANDERSEN Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Fussell, 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.