Citation Nr: 21022602 Decision Date: 04/16/21 Archive Date: 04/16/21 DOCKET NO. 16-21 118 DATE: April 16, 2021 ORDER Entitlement to a disability rating in excess of 20 percent prior to July 22, 2014, and in excess of 40 percent thereafter, for a left ankle disability is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. Prior to July 22, 2014; the Veteran’s left ankle disability manifested with painful motion. 2. From July 22, 2014, forward, the Veteran’s left ankle disability manifested with ankylosis. CONCLUSION OF LAW The criteria for a disability rating in excess of 20 percent for a left ankle disability, prior to July 22, 2014 and in excess of 40 percent, thereafter, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, Diagnostic Codes (DCs) 5271 and 5270. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty from October 1980 to December 1980. This matter comes before the Board of Veteran’s Appeals (Board) from an August 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in April 2020 when the claims were remanded for development. The Board finds the April 2020 remand directives have been substantially complied with, and the matter is again before the Board. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to a disability rating in excess of 20 percent prior to July 22, 2014 and in excess of 40 percent thereafter for a left ankle disability The Veteran seeks a disability rating in excess of 20 percent prior to July 22, 2014, and in excess of 40 percent thereafter for his left ankle disability. By way of history, the Veteran was initially awarded service connection for his left ankle disability in a June 1981 rating decision, with an initial disability rating of 10 percent, effective December 25, 1980. The Veteran presented claims for increased rating multiple times and his 10 percent disability rating was continued multiple times in various rating decisions. Then, in May 2012, the Veteran presented a new claim for increased rating pertaining to his left ankle disability. A December 2012 rating decision increased the Veteran’s left ankle disability rating from 10 percent to 20 percent, effective May 24, 2012. In June 2013, the Veteran presented an informal claim requesting an increased rating for his left ankle disability. See Correspondence of June 2013. An August 2014 rating decision increased the Veteran’s left ankle disability rating from 20 percent to 40 percent effective July 22, 2014. See rating decision of August 2014. In February 2015, the Veteran presented a notice of disagreement (NOD) regarding the rating assigned to his left ankle disability in the August 2014 rating decision. In May 2016, a Statement of the Case (SOC) was issued. That same month, the Veteran perfected the present appeal by submitting a completed Form 9 (Appeal to the Board). See Form 9 dated May 2016. As the present appeal stems from the informal claim received by VA in June 19, 2013; the appeal period is from that date forward, to include the one-year look back period. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. A Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board acknowledges that with respect to a claim for an increased rating for an already service-connected disability, a Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The rating schedule is intended to recognize actually painful, unstable, or mal-aligned joints due to healed injury as entitled to at least the minimum compensable rating for the joint. See 38 C.F.R. § 4.59. Application of 38 C.F.R. § 4.59 is not limited to cases of painful motion in which there is a finding of arthritis. See Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. Furthermore, the selection of diagnostic codes or applicable rating criteria is not protected and may be appropriately revised if the action does not result in the reduction of compensation. See 38 C.F.R. §§ 3.951, 3.957. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1991). Furthermore, evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.40 state that disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence of part, or all, of the necessary bones, joints and muscles, or associated structures. It may also be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. See 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. See 38 C.F.R. § 4.45. Additionally, pertinent to the present case, in Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. The final sentence provides that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint." The Court found that, "to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59." Correia, 28 Vet. App. at 169-170. An examination must also determine whether a disability is manifested by weakened movement, excess fatigability, incoordination, or pain, and, where feasible, express these determinations in terms of the degree of additional range of motion lost due to any weakened movement, excess fatigability, incoordination, or pain. DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Court has also held that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to the following factors: decreased or abnormal excursion, strength, speed, coordination, or endurance (38C.F.R. §4.40 ), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38C.F.R. §4.45). The Veteran’s left ankle disability is currently evaluated under diagnostic code 5270. Under diagnostic code 5270, a 40 percent rating is warranted when there is ankle ankylosis in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion or eversion deformity. A 30 percent rating is warranted when there is ankle ankylosis in plantar flexion, between 30 and 40 degrees, or in dorsiflexion between 0 and 10 degrees. A 20 percent rating is warranted for ankle ankylosis in plantar flexion less than 30 degrees. Ankylosis is stiffening or fixation of the joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996) see also Coyalong v. West, 12 Vet. App. 524, 528 (1999); Lewis v. Derwinski, 3 Vet. App. 259 (1992). The Board notes that normal range of motion for the ankle on dorsiflexion is to 20 degrees and to 45 degrees on plantar flexion. See 38 C.F.R. § 4.71a, Plate II. The Veteran’s medical records have been associated with the claims file. In July 2012, the Veteran was administered an Ankle Conditions Disability Benefits Questionnaire (Ankle DBQ). In this examination, the Veteran reported complaints of constant left ankle pain, decreased range of motion and weakness. No flareups were reported. The Veteran’s left ankle plantar flexion range of motion was noted from zero degrees to 10 degrees, and plantar dorsiflexion was noted from zero degrees to 5 degrees. No joint instability nor ankylosis was noted. See Ankle DBQ of July 2012. In July 2014, the Veteran was again administered an Ankle DBQ. In this examination, the Veteran reported that his left ankle hurt and gave out on him. He was noted to use a knee-high brace. The Veteran reported that any movement caused his ankle to hurt more. In terms of mitigating factors, the examiner noted elevation and pain medication. The Veteran reported flareups, described as pain out of nowhere, but that he did not consider these instances as flareups because he had constant pain rated at a 9 out of a 10-point scale. The Veteran’s initial range of motion for his left ankle was noted as zero degrees in all movements. The examiner also noted that the Veteran was unable to perform repetitive use testing because he reported constant pain and being unable to move the left ankle. No joint instability was noted. The examiner determined the Veteran had ankylosis in plantar flexion to less than 30 degrees, in dorsiflexion between zero degrees and 10 degrees, with abduction, adduction, inversion or eversion deformity in both good and poor weight-bearing positions. The examiner also noted that the Veteran’s left ankle is permanently fixed in an inverted position with the toes turned medially as an additional pertinent finding related to the service-connected condition. See Ankle DBQ of July 2014. The Board finds this examination adequate, in light of the limitations expressed by the examiner, and assigns it high probative value. In September 2014, the Veteran reported ankle pain. See medical records for September 2014. In October 2014, a physician noted that the Veteran either could not move or would not move his left ankle, as well as the Veteran’s report of his left ankle being paralyzed. See medical records for October 2014. In March 2015, the Veteran was noted to be able to activate his left ankle in both plantar flexion and dorsiflexion, but no range of motion measurements were noted. See medical records for March 2015. In January 2017, the Veteran was noted to have decreased muscle strength to his left dorsiflexors to the foot or ankle. See medical records for January 2017. In August 2020, the Veteran was readministered an Ankle DBQ. The Veteran reported as current symptoms: spasms, pain and soreness all the time. The Veteran also reported flareups, occurring all the time, lasting all the time or all day and severe in nature. The Veteran reported that everything precipitates a flareup and nothing alleviates them. He also reported wearing a plastic boot to keep the ankle stable. No range of motion results were noted because the Veteran was not able to perform the movement due to a lot of pain and because of a spasm of the left upper leg. See Ankle DBQ of August 2020. The Board finds this examination adequate, given the noted limitations by the examiner, and assigns it high probative value. Thus, based on the above, the Board finds that a disability rating in excess of 20 percent prior to July 22, 2014 and in excess of 40 percent thereafter is not warranted at any time during the appeal period for the Veteran’s left ankle disability. The Board notes that prior to July 22, 2014; the Veteran’s left ankle disability was evaluated as 20 percent disabling, under diagnostic code 5271 for limitation of motion of the ankle. Under diagnostic code 5271, a 10 percent rating is warranted for moderate limitation of motion of the ankle, and a 20 percent rating is warranted for marked limitation of motion. 38 C.F.R. § 4.71a, diagnostic code 5271. Thus, 20 percent is the maximum disability rating under this diagnostic code. Accordingly, the Board finds that prior to July 22, 2014, the Veteran was in receipt of the maximum schedular rating for his limitation of motion of the left ankle under diagnostic code 5271. Thus, a disability rating in excess of 20 percent is not warranted, prior to July 22, 2014, under diagnostic code 5271. Additionally, the Board has considered whether the Veteran’s disability could warrant a higher disability rating, prior to July 22, 2014 under any other applicable diagnostic code. However, the evidence of record does not support the finding that prior to July 22, 2014 the Veteran’s ankle was ankylosed in plantar flexion between 30 degrees and 40 degrees or in dorsiflexion between zero degrees and 10 degrees; which would warrant a disability rating of 30 percent under diagnostic code 5270. Diagnostic code 5270 is the only applicable diagnostic code that specifies a disability rating above 20 percent. The Board is cognizant that in the Ankle DBQ of July 2012, the Veteran’s left ankle range of motion was noted to be severely limited. However, the examiner that completed the Ankle DBQ of July 2012 determined that there was no ankylosis. Further, the available medical records dated prior to July 22, 2014 do not note any complaints pertaining to the Veteran’s left ankle, to include being unable to move it at all. As a matter of law, when a disability is specifically listed in the rating schedule, it may not be rated by analogy under a different diagnostic code. See Copeland v. McDonald, 27 Vet. App. 333, 337 (2015). Further, marked limited range of motion is not tantamount to ankylosis since ankylosis requires no ankle motion at all. Thus, as there is no evidence of ankylosis prior to July 22, 2014; the Board is unable to apply diagnostic code 5270 to the appeal period prior to July 22, 2014 and finds that the Veteran’s disability symptomatology was contemplated in the disability rating assigned of 20 percent under diagnostic code 5271, for the appeal period prior to July 22, 2014. The Board has also considered the application of diagnostic codes 5272, 5273, and 5274 which pertain to disabilities of the ankle. However, these diagnostic codes are not for application in the present case for the appeal period prior to July 22, 2014 because they do not provide a disability rating in excess of 20 percent nor apply to the Veteran’s symptomatology. The Board also finds that a disability rating in excess of 40 percent for the Veteran’s left ankle disability is not warranted from July 22, 2014; forward. In July 22, 2014 the Veteran was administered an Ankle DBQ. The examiner that completed this examination diagnosed the Veteran with ankylosis of his left ankle. Thus, it is from the date of this examination, where the Veteran was diagnosed with ankylosis of the left ankle, that there is evidence supporting a higher disability rating under diagnostic code 5270. As previously noted, 40 percent is the maximum rating under diagnostic code 5270 and is also the highest disability rating available for ankle disabilities in the rating schedule. Thus, the Board must deny the claim of a disability rating in excess of 40 percent from July 22, 2014, forward, as a matter of law because the Veteran is already in receipt of the highest available rating for his condition under the schedular criteria. The Board has also considered the application of diagnostic codes 5272, 5273, and 5274 which pertain to disabilities of the ankle for the appeal period beginning in July 22, 2014. However, these diagnostic codes are not for application in the present case because they do not provide a disability rating in excess of 20 percent. Finally, the record does not show that the Veteran's left ankle disability manifests with symptomatology not considered in the diagnostic codes assigned to his disability throughout the entire appeal period. Thus, referral for extraschedular consideration pursuant to 38 C.F.R. § 3.321 (b)(1) is not warranted because this case does not present such an exceptional or unusual disability picture that it would be impracticable to apply the schedular standards. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). Rather, the evidence shows that his disability manifested prior to July 2014 as joint pain and limited mobility, and from July 2014 with ankylosis. The applicable diagnostic codes contemplate such symptomatology. Additionally, the evidence of record does not support the finding that the functioning of the Veteran’s left lower extremity is so diminished that amputation with prosthesis would equally serve him. Therefore, the provisions under diagnostic code 5165 are not for application. In conclusion and based on all of the above, the Board finds that the preponderance of the evidence is against the finding that that the Veteran’s disability has manifested with symptomatology that would warrant a disability rating in excess of 20 percent prior to July 22, 2014 and in excess of 40 percent thereafter. Accordingly, as the preponderance of the evidence is against the finding entitlement to higher disability ratings than the already assigned throughout the appeal period, the claim must be denied, and the benefit of the doubt rule does not apply. REASONS FOR REMAND 1. Entitlement to service connection for an acquired psychiatric disorder is remanded. The Veteran seeks service connection for an acquired psychiatric disorder. In favor of his claim, the Veteran has asserted that his psychiatric disorder is related to his service. He also asserted that while he did suffer in his childhood, he coped with it. He further asserted that he did not have mental health issues prior to service. Additionally, the Veteran also asserted that his left ankle disability aggravates his psychiatric disorder. See most recently, statement from the Veteran associated with the claims file in February 2021. As threshold matter the Board notes the Veteran’s medical records show multiple diagnoses of psychiatric disorders, throughout the years. For example, in November 2002, the Veteran was given a provisional diagnosis of bipolar disorder, type I. Medical records suggest this diagnosis was ruled out in 2014. See medical records for November 2002 and for August 2016. In January 2004, the Veteran’s records note that the Veteran’s anger, impulsivity and intensity could be explained by a borderline personality structure in addition to a history of antisocial acts. See medical records for January 2004. Social Security Administration (SSA) records note a diagnosis of severe schizophrenia and other psychotic disorder. See SSA records dated April 2012, associated with the claims file in March 2019. In April 2016, diagnoses of adjustment disorder or mood disorder, as well as an antisocial personality disorder were noted. See medical records for April 2016. In December 2019, a Mental Disorder (other than PTSD and Eating Disorders) Disability Benefits Questionnaire (Mental Disorders DBQ), completed by a private psychologist, Dr. H-C, was associated with the claims file. This Mental Disorders DBQ was signed in January 2017 and notes a diagnosis of major depressive disorder, recurrent with psychotic features in accordance with the DSM-5. In this examination, the Veteran denied a mental health history prior to his service. The Board notes that this same Mental Disorders DBQ was re-submitted in February 2021. Further, it seems the resubmission of the Mental Disorders DBQ included a medical opinion dated January 2017, that is not signed nor contains any indication of who is the expert that prepared it. This opinion, dated January 2017, cites relevant medical literature and pertinent medical documentation contained in the Veteran’s C-file and opines that the Veteran’s major depressive disorder more likely than not began in military service, continues uninterrupted to the present, and is aggravated by his left ankle disability. This medical opinion also notes that the Veteran’s major depressive disorder prevents the Veteran from maintaining substantially gainful employment. See private medical opinion dated January 2017, associated with the claims file in February 2021. The Board is unable to afford probative value to this medical opinion because it lacks a complete rationale for the opinion expressed. While the physician seems to suggest that there is a body of literature detailing the emergence of mental health symptoms within active duty servicemen, and that active duty military personnel have more mental health events than civilians, the physician fails to explain how the Veteran’s psychiatric disorder originated in service or is otherwise related to it. Further, the Board is unable to afford probative value to this opinion because it is based on an erroneous factual premise, as the Veteran denied any mental health history prior to service, contradictory to other medical records of file that note reports of possible mental health symptomatology prior to service. Additionally, this physician did not address the Veteran’s diagnosis of a personality disorder, and it is unclear if the physician was aware of it when rendering her opinion. For these reasons and as the actual medical opinion does not have a signature or any other indication of the name of the expert that prepared it, the Board finds it inadequate for adjudication purposes and assigns it no probative value. In April 2020, the Board remanded the claim of service connection for an acquired psychiatric disorder for a VA examination and medical opinion. Pursuant to the Board’s remand directives, in August 2020, the Veteran was administered an Initial Posttraumatic Stress Disorder Disability Benefits Questionnaire (PTSD DBQ). In this examination, diagnoses of PTSD with psychotic features and antisocial personality disorder were noted. See PTSD DBQ dated August 2020. Following the examination, the examiner subscribed three medical opinions. In one, the examiner opined that the claimed condition which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by the Veteran’s service. In favor of this opinion, the examiner noted the Veteran’s report of childhood abuse, a history of ADHD and use of medication for the condition during childhood, and an early drug history beginning at age 13. Thus, the examiner reasoned, that the Veteran was not psychiatrically stable due to severe psychological disturbances that existed since childhood and were present prior to his enlistment. See medical opinion for aggravation of a condition that existed prior to service, dated August 2020. In a medical opinion for direct service connection the examiner opined that the claimed condition was less likely than not incurred in or caused by the Veteran’s service. In favor of this opinion, the examiner noted how the Veteran was referred for a mental health evaluation during service. He also noted how the Veteran’s report of abuse by his father could indicate a pre-existing undiagnosed condition prior to military service. Further, the examiner noted that the Veteran was diagnosed with PTSD with psychotic features based on his reports of an incident involving an explosion, recurring images, thoughts and nightmares as well as sounds of the explosion, mood instability, delusional thinking, and significant anxiety/panic symptoms. The examiner reasoned that the Veteran had an undiagnosed condition during childhood secondary to his childhood trauma at the hands of his father and that although it was undiagnosed, it would have met the criteria for PTSD. The examiner further asserted that this condition was further aggravated during military service and subsequently diagnosed as PTSD. See medical opinion for direct service connection, dated August 2020. Thus, the examiner seems to suggest in his opinion that the Veteran had an undiagnosed condition of PTSD prior to service and that since this condition pre-existed service it was not caused by or incurred in service. However, the examiner also seems to suggest this condition was aggravated by the Veteran’s service. Finally, in an opinion regarding conflicting medical evidence the examiner noted the Veteran’s report of childhood physical, emotional, and sexual abuse and opined that such severe childhood traumas caused characterological disturbances in the Veteran that manifested in the form of a personality disorder. Thus, the examiner opined that the Veteran was not psychiatrically stable due to severe psychological disturbance that existed since childhood and given his unstable state, the Veteran’s characterological disturbance (personality disorder) was further aggravated by the stressors associated with the military service. Thus, the examiner seems to reason that although the Veteran was not diagnosed with a personality disorder during service, that he indeed suffers from a personality disorder that pre-existed service and was aggravated by service. See medical opinion regarding conflicting medical evidence, dated August 2020. When VA provides an examination or obtains an opinion, the examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Moreover, a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). The Board finds the medical opinion for aggravation of a condition that existed prior to service, dated August 2020, inadequate for adjudication purposes as it only provides conclusory statements, does not offer a complete rationale for the opinion expressed, and does not address whether there is clearly and unmistakable evidence that the Veteran’s disability was not aggravated by his service. Furthermore, the Board notes that the examiner did not address the Veteran’s various diagnoses of different mental disorders and only provided a statement about how the condition, presumably PTSD, clearly and unmistakably preexisted service in this opinion. Further, the Board notes that the medical opinion for direct service connection suggests that the Veteran’s PTSD pre-existed service and was aggravated by the Veteran’s military service, to include the explosion. Thus, as these two opinions are in clear conflict regarding whether there is clear and unmistakable evidence that the Veteran’s condition was not aggravated by his military service beyond its natural progression, the Board finds them inadequate for adjudication purposes. Thus, a remand is necessary to obtain a new medical opinion addressing whether the Veteran’s acquired psychiatric disorder clearly and unmistakably pre-existed service, and whether it was clearly and unmistakably not aggravated by service beyond its natural progression. Additionally, the Board notes the opinion for direct service connection is also inadequate as the examiner focused on explaining that the Veteran’s PTSD pre-existed service and did not address whether the Veteran’s PTSD was caused by or related to his military service. While the Board understands the examiner’s opinion that the condition pre-existed service; the Veteran might still be entitled to the presumption of soundness if VA does not rebut the presumption with clear and unmistakable evidence. If the presumption of soundness is not rebutted in the present claim, the claim must be analyzed under the direct service connection theory of entitlement for which a medical opinion addressing the etiology of the condition and its possible relation or nexus to service is required. Additionally, the Board notes that in the opinion regarding conflicting medical evidence the examiner seems to opine that the Veteran also has a personality disorder that was aggravated by the stressors associated with his military service. However, the examiner does not provide a rationale for this opinion. While the examiner cited evidence pertinent to his conclusion, he offered no supporting data or a reasoned medical explanation for the opinion expressed. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Thus, the Board finds this opinion inadequate for adjudication purposes. In February 2021, another Mental Disorders DBQ signed by private psychologist Dr. G, and dated February 2021, was associated with the claims file. This Mental Disorders DBQ notes diagnoses of major depressive disorder and delusional disorder. See Mental Disorders DBQ of February 2021. The Board notes it is unclear if the diagnoses were made according to the DSM-5 as the Mental Disorders DBQ -VA Form 21-0960P-2, submitted instructs the examiner to note all mental disorders that conform to the DSM-IV criteria. Further the Board notes that the physician noted that the Veteran had no mental health issues prior to military, in this Mental Disorders DBQ. The Mental Disorders DBQ, dated February 2021, was also accompanied by a private medical opinion, signed by Dr. G. where she opined that the Veteran’s major depression and delusional disorders more likely than not began in service and have continued uninterrupted to the present. In favor of this opinion, the physician noted pertinent medical evidence in the Veteran’s records and medical journal articles that note higher than expected levels of depression among entry level military members. While she noted how the Veteran spent the bulk of the interview discussing his distress over an explosion that occurred in the military and how he reported that he was later awarded a Purple Heart for saving men from getting hit during the explosion, as well as his conclusion that his injury ended his military career; the physician did not note or explain how are the Veteran’s diagnoses related to his military service. Additionally, she noted that the Veteran was given the presumption of soundness upon entry and that there is no medical evidence of pre-service mental health problems. However, she did not discuss the Veteran’s reports of mental health symptomatology existing prior to service, noted in his medical records. Further, the physician also noted that the Veteran has been diagnosed with various psychiatric disorders over the years, to include a diagnosis of antisocial personality disorder. She noted that there is no other record, aside from the medical record dated June 2013- where a medical professional noted a diagnosis of antisocial personality disorder, to substantiate such diagnosis. She reasoned that the Veteran’s symptoms are in contrast with a typical antisocial presentation as his mental health history seems to suggest that the Veteran’s problems appear motivated not out of a desire for personal gain but by poorly managed mental health symptoms. Thus, this medical opinion seems to suggest that the Veteran does not have a personality disorder. However, it is unclear from the wording of the opinion if this is the desired conclusion. This opinion does not address the Veteran’s diagnosis of PTSD. The Board notes the Veteran’s military records do not contain any mention of a Purple Heart award. Further, in the present case, the presumption of soundness is part of the controversy, as the record suggests that the Veteran suffered from mental health symptomatology prior to service. Thus, the Board will defer any findings on the adequacy of this medical opinion pending further development. Notwithstanding, the Board invites the Veteran and his representative to seek and submit any clarification from the physician that signed the February 2021 medical opinion, consistent with the observations herein noted. Accordingly, based on the above, the Board finds that the claim of service connection for an acquired psychiatric disorder must be remanded for further development, as the evidence of record is inadequate for adjudication purposes. As noted above, the VA medical opinions are inadequate for adjudication purposes as they do not properly address the questions of whether there is clear and unmistakable evidence that the Veteran’s acquired psychiatric disorder existed prior to service, and whether there is clear and unmistakable evidence that the condition was not aggravated by the Veteran’s service. The Board notes that “clear and unmistakable” is an “onerous” and “very demanding” evidentiary standard, requiring that the evidence be “undebatable.” See Cotant v. West, 17 Vet. App. 116, 131 (2003). Furthermore, there is conflicting medical evidence as to whether the Veteran’s symptomatology is consistent with a diagnosis of an antisocial personality disorder. Thus, clarification as to whether the Veteran symptomatology is consistent with an antisocial personality disorder is also warranted. The Board notes that personality disorders are considered congenital or developmental defects and not diseases or injuries within the meaning of applicable legislation and, therefore do not constitute disabilities for VA compensation purposes. See 38 C.F.R. §§ 3.303(c), 4.9. However, service connection may be granted for additional disability resulting from a mental disorder that is superimposed upon the personality disorder during service. 38 C.F.R. §§ 3.303(c), 4.9, 4.127; see also VAOPGCPREC 82-90, 55 Fed[.] Reg. 45,711 (July 18, 1990); Carpenter v. Brown, 8 Vet. App. 240, 245 (1995); Monroe v. Brown, 4 Vet. App. 513, 514-15 (1993). Accordingly, it is important for adjudication purposes to clarify whether the Veteran has a personality disorder and if so, whether any of the Veteran’s diagnosed psychiatric disorders are superimposed upon the Veteran’s personality disorder or whether otherwise any of the Veteran’s diagnosed psychiatric disorders arise from the Veteran’s personality disorder. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. The Veteran has asserted that his service-connected left ankle disability renders him unemployable. Further, the evidence of record seems to suggest that the Veteran’s acquired psychiatric disorder may also influence his ability to work. See generally private medical opinions and Veteran’s statements. The Board notes that currently, the Veteran’s disability rating for his service-connected disability does not meet the schedular requirements for consideration of a TDIU. 38 C.F.R. § 4.16 (a). Nonetheless, it is established VA policy that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated as totally disabled, the Board will submit to the Director of Compensation (Director) for extraschedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities but who fail to meet the above percentage standards. 38 C.F.R. § 4.16 (b). The Board cannot assign an extraschedular rating in the first instance, but must specifically adjudicate whether to refer a case to the Director for consideration of an extraschedular rating under section 4.16(b) when the issue is either raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008) (citing Thun v. Peake, 22 Vet. App. 111, 115 (2008)). The central inquiry is “whether the Veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). The sole fact that the Veteran was or is unemployed or has difficulty obtaining employment is not enough. A disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the Board must evaluate whether there are circumstances in the Veteran’s case, apart from any non-service-connected conditions and advancing age, which would justify a total rating based on individual unemployability due solely to the service-connected conditions. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993); see also Blackburn v. Brown, 5 Vet. App. 375 (1993). Presently, the Veteran is only service connected for his left ankle disability, which is currently evaluated as 40 percent disabling. The Veteran’s left ankle was found to be ankylosed in the July 2014 Ankle DBQ. Further, the Veteran presented a lay statement where he noted his physical limitations due to his ankle disability. In this statement, he noted that his ankle condition impacted his ability to work over the years because he is unable to stand or walk for a full workday requiring any physical or labor work. He also noted that he takes morphine for his ankle pain which makes him feel drugged out. See lay statement, of February 2021. Additionally, the TDIU claim is inextricably intertwined with the claim of service connection for an acquired psychiatric disorder and must be remanded, as the grant or denial of service connection for the Veteran’s psychiatric disorder may reasonably affect the adjudication of his claim for TDIU on either a schedular or extraschedular basis. Harris v. Derwinski, 1 Vet. App. 180 (1991). Thus, the Board finds that after the readjudication of the Veteran’s claim of service connection for an acquired psychiatric disorder, if the Veteran’s combined evaluation remains under the schedular criteria for schedular consideration of a TDIU, the claim of entitlement to a TDIU must be referred to the Director of Compensation for extraschedular consideration. The matters are REMANDED for the following actions: 1. Update existing medical records. 2. Regarding the claim of service connection for an acquired psychiatric disorder: a. Obtain clarification as to the Veteran’s current psychiatric disorder(s) in accordance with the DSM-5. i. The examiner is asked to opine whether the Veteran has a current diagnosis of PTSD, a personality disorder, a major depression disorder, or another not specified psychiatric disorder. The examiner must explain his/her findings. ii. The examiner is asked to address the Mental Disorders DBQs of January 2017 and February 2021 and the diagnoses rendered therein. b. After the Veteran’s diagnoses have been clarified, the examiner must opine whether the diagnosed disorder(s) (addressed separately): i. clearly and unmistakably pre-existed service, ii. clearly and unmistakably was NOT aggravated by service beyond their natural progression. The examiner is reminded that a finding of “insufficient evidence” of aggravation does not meet VA’s burden under the clear and unmistakable evidence standard to show that the condition was not aggravated by service. Horn v. Shinseki, 25 Vet. App. 231 (2012). c. For any diagnosed psychiatric disorder, the examiner must also opine whether it is at least as likely as not that such disorder originated in service or is otherwise related to service. d. For any diagnosed disorder, the examiner must also opine whether such disorder is caused by or aggravated beyond its normal progression by the Veteran’s service-connected left ankle disability. e. If the Veteran is diagnosed with a personality disorder: i. the examiner is asked to opine how does the Veteran meet the DSM-5 criteria for such disorder, ii. the examiner is asked to address the February 2021 medical opinion suggesting that the Veteran’s symptomatology in not indicative of a personality disorder, iii. the examiner must also opine whether any other diagnosed psychiatric disorder (beside the personality disorder) is superimposed on the personality disorder or whether it is otherwise a progression of the personality disorder. The examiner is asked to provide a complete rationale for all opinions expressed. If the examiner cannot provide the requested opinion(s) without resorting to speculation, the report should expressly indicate this, and the examiner should explain why an opinion cannot be provided without resorting to speculation. If the inability to provide an opinion is the result of a need for additional information, the physician must identify the additional information needed. It is left to the examiner’s discretion whether re-examination of the Veteran is necessary to provide the above requested opinions. 3. After the requested medical opinions are obtained, re-adjudicate the claim on appeal. If the benefit sought is not granted, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate opportunity to respond thereto before returning the case to the Board, if in order. 4. After the claim of service connection for an acquired psychiatric disorder has been readjudicated, if the Veteran’s combined evaluation remains under the schedular threshold for TDIU consideration, refer the claim for a TDIU to the Director of Compensation Services for extraschedular consideration. 5. Then, readjudicate the claims on appeal. If the benefits sought are not granted, provide the Veteran and his attorney with a supplemental statement of the case and allow an appropriate opportunity to respond thereto before returning the case to the Board, if in order. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Gonzalez-Maldonado 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.