Citation Nr: 21022838 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 19-36 091 DATE: April 19, 2021 ORDER New and material evidence having been received, the claim of entitlement to service connection for a psychiatric disorder is reopened is granted. Entitlement to an effective date prior to May 4, 2017 for the grant of entitlement to service connection for tinnitus is denied. Entitlement to an effective date prior to May 4, 2017 for the grant of entitlement to service connection for bilateral hearing loss is denied. Entitlement to an effective date prior to May 4, 2017 for the grant of entitlement to service connection for dry eye syndrome is denied. Entitlement to service connection for headaches is denied. Entitlement to service connection for gout is denied. Entitlement to service connection for a respiratory disorder is denied. Entitlement to a rating in excess of 10 percent for hiatal hernia and peptic ulcer disease (PUD) is denied. Entitlement to an initial 10 percent rating for bilateral dry eye syndrome is granted. Entitlement to an extraschedular rating in excess of 10 percent for tinnitus is denied. REMANDED Entitlement to service connection for a skin condition is remanded. Entitlement to service connection for hypertension, to include as due to service-connected disabilities, is remanded. Entitlement to service connection for a lumbar spine disorder, to include as due to service-connected disabilities, is remanded. Entitlement to service connection for a psychiatric condition, to include as due to service-connected disabilities, is remanded. Entitlement to service connection for a sleep disorder, to include as due to service-connected disabilities, is remanded. Entitlement to an initial compensable rating for bilateral hearing loss is remanded. Entitlement to a rating in excess of 10 percent for Reiter's syndrome with degenerative arthritis, left knee, is remanded. Entitlement to a rating in excess of 10 percent for Reiter's syndrome with degenerative arthritis, right knee, is remanded. Entitlement to a rating in excess of 10 percent for Reiter's syndrome with degenerative arthritis, left ankle, is remanded. Entitlement to a rating in excess of 10 percent for Reiter's syndrome with degenerative arthritis, right ankle, is remanded. Entitlement to total disability based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. In a December 1984 rating decision, a RO denied service connection for depression and anxiety, finding that the Veteran did not have symptoms or diagnoses in service. An October 2007 rating decision denied entitlement to service connection for depression secondary to his service-connected disabilities, finding that the Veteran had bipolar disorder, and that his symptom of depression was not due ot his disabilities or service. A January 2010 rating decision denied entitlement to service connection for a mental disorder, finding that there was no evidence showing a mental condition incurred in service or caused by his service-connected disabilities. An October 2014 rating decision found that new and material evidence had not been received to reopen a claim of entitlement to service connection for depression. The Veteran did not appeal the decision and new and material evidence was not received within the one-year appeal period. 2. Evidence associated with the record since the October 2014 decision relates to unestablished facts and raises a reasonable possibility of substantiating the claim of entitlement to service connection for an acquired psychiatric disorder. 3. The Veteran submitted formal claims of entitlement to service connection for tinnitus, bilateral hearing loss, and “bilateral eye condition” on May 4, 2017. 4. A review of the record does not show a formal or informal (prior to March 2015) of entitlement to service connection for tinnitus, bilateral hearing loss, or an eye condition prior to May 4, 2017. 5. The preponderance of the evidence is against finding that headaches began during active service, or are otherwise related to an in-service injury or disease. 6. The preponderance of the evidence is against finding that gout began during active service, or is otherwise related to an in-service injury or disease. 7. The preponderance of the evidence is against finding a respiratory disorder began during active service, or is otherwise related to an in-service injury or disease. 8. The Veteran’s hiatal hernia/PUD resulted in recurrent epigastric distress, dysphagia, pyrosis, reflux, regurgitation, substernal pain, sleep disturbance, and nausea/vomiting. However, the evidence does not show that his symptoms are productive of considerable impairment of health. 9. Resolving reasonable doubt in the Veteran’s favor, his service-connected dry eye syndrome resulted in eye crusting, discharge, and symptoms of active conjunctivitis. He did not have decreased visual acuity or incapacitating episodes due to his service-connected disability. 10. The 10 percent rating currently in effect for the Veteran’s service-connected tinnitus disability is the maximum schedular rating. He has made no argument as to the exceptional nature of his tinnitus. The evidence of record does not show that the Veteran’s tinnitus disability is so exceptional or unusual that referral for extraschedular consideration by designated authority is required. CONCLUSIONS OF LAW 1. New and material evidence has been received and the claim seeking service connection for an acquired psychiatric disorder is reopened. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156(a) (2019). 2. The criteria for an effective date prior to May 4, 2017 for the grant of entitlement to service connection for tinnitus have not been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. §§ 3.102, 3.155, 3.156, 3.400 (2019). 3. The criteria for an effective date prior to May 4, 2017 for the grant of entitlement to service connection for bilateral hearing loss is have not been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. §§ 3.102, 3.155, 3.156, 3.400 (2019). 4. The criteria for an effective date prior to May 4, 2017 for the grant of entitlement to service connection for dry eye syndrome have not been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. §§ 3.102, 3.155, 3.156, 3.400 (2019). 5. The criteria for service connection for headaches have not been met. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 6. The criteria for service connection for gout have not been met. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 7. The criteria for service connection for a respiratory disorder have not been met. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 8. The criteria for a rating in excess of 10 percent for hiatal hernia and peptic ulcer disease (PUD) have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 U.S.C. §§ 4.1, 4.2, 4.3, 4.7, 4.114, DC 7346 (2019). 9. The criteria for an initial 10 percent rating for bilateral dry eye syndrome have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 U.S.C. §§ 4.1, 4.2, 4.3, 4.7, 4.79, DC 6016 (2019). 10. The claim for a rating in excess of 10 percent for tinnitus is without legal merit. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.87, Diagnostic Code 6260 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from February 1982 to May 1984. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a January 2018 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In March 2018, the Veteran, through his attorney, submitted a notice of disagreement with the January 2018 rating decision. This included disagreeing with the effective dates assigned for his hiatal hernia/PUD, and knee and ankle disabilities. As no effective dates were assigned for these issues in the January 2018 rating decision, these are free-standing earlier effective date claims. The Veteran’s attorney has been informed in numerous prior decisions written by this Board attorney (and likely a number of other Board attorneys) that free-standing earlier effective dates claims are not permitted, yet continues to attempt to file these claims. Again, the United States Court of Appeals for Veterans Claims (CAVC) has emphasized that an effective date cannot be challenged with a freestanding earlier effective date claim. Rudd v. Nicholson, 20 Vet. App. 296 (2006). The free-standing earlier effective date claims are improper. CREDIBILITY In adjudicating a claim, the Board must assess the competence and credibility of the Veteran. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board also has a duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). The Board acknowledges that the Veteran is competent to give evidence about what he experiences. See Layno v. Brown, 6 Vet. App. 465 (1994). Competency of evidence, however, must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). See also Buchanan, supra (The Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. If the Board concludes that the lay evidence presented by a veteran is credible and ultimately competent, the lack of contemporaneous medical evidence should not be an absolute bar to the veteran's ability to prove his claim of entitlement to disability benefits based on that competent lay evidence.) Although the Veteran is competent to report his psychiatric and physical symptoms (e.g. pain, anxiety, etc.), the Board finds that the Veteran has been less than credible in reporting his symptoms onset and severity. There are a large number of examples in the record to support the finding that the Veteran’s statements on his symptom severity and onset are less than credibility, the Board will provide some examples below. A June 3, 2013 Emergency Room record included the Veteran was withdrawing from Xanax, Percocet, and Adderall and seeking additional prescriptions to ease his symptoms. The ER physician, Dr. M.R., sought to treat the Veteran in the hospital with IV medications. However, the Veteran “just wanted prescriptions” and that he did not want to “get off pain medications because he can’t ‘live in pain forever’ and needs to work.” The physician noted that the Veteran’s “very dramatic withdrawal symptoms of shaking, weakness, and shaky voice noticeably stopped at this point.” He was asked for a urine toxicology screen to see if he was on the medications, he stated he was withdrawing form, but he refused and admitted it would test positive for other drugs and he did not want pain management to find out. A December 10, 2013 psychological evaluation from Dr. T.M.E., referred by the Ohio Disability Determination, included the Veteran’s report of using cocaine in high school and that this use became problematic after he was discharged from service in 1983 to 1984. He stated he used it for two years. He then stated that he used cocaine three times in the past two years and last used it in September 2013. He stated he used marijuana in the past, and last used it one month prior at a party. He was last employed in May 2012 when he worked sweeping for a friend’s construction company. When asked how he got along with his coworkers at his longest place of employment (Energy Systems) was that he always worked by himself. He then stated that he had no friends and was a loner. “He reported that he did not have any psychiatric symptoms that affected him in the workplace.” The examiner diagnosed depressive disorder, with stressors of unemployment and interpersonal problems. The examiner also noted it was quite likely he had a personality disorder, particularly borderline, but as personality disorder testing was not completed, he did could not diagnose this. A July 10, 2014 VA psychiatry record included the Veteran’s reported that he had an IEP and was in full-time special education classes from kindergarten through high school graduation. He reported he had dyslexia and was unable to read or write. However, later in the interview the Veteran stated he read things on the internet. He reported that his two older brothers would regularly physically assault him, his brother’s friends would physically assault him, and his brothers also sexually abused him. He also stated that a man in his neighborhood tried to rape him as a teenager. He stated his mother had anxiety and his father had depression. (He has reported in other records that there was no family history of mental health problems). The Veteran reported having last used cocaine in September 2013. He reported having tried most drugs (e.g. acid, ecstasy, Quaaludes), except for crystal meth. He was diagnosed with bipolar disorder, likely hypomanic given his behavior at the interview. He was also diagnosed with PTSD from childhood trauma and borderline personality disorder with probably learning disorder (unspecified) and possible ADD (as reported by the Veteran). During an August 6, 2014 VA mental health examination, the examiner diagnosed a borderline personality disorder and bipolar disorder under the DSM-V. Numerous clinical records documented BPD, antisocial personality disorder, and cluster B. traits. His personality disorder characteristics more likely than not stem from his childhood abuse issues and dysfunctional family dynamics. The Veteran “himself admits his depression has nothing to do with his service-connected hiatal hernia/ulcer condition.” In February 2015, the Veteran reported that his prescribed Tramadol took “the edge off but wasn’t as good as narcotics.” Dr. P.G. noted that the Veteran stated that “nobody will prescribe what he needs, that his history of drug abuse and ‘only 2 relapses’ is not relevant...[Dr. P.G.] pointed out that this problem exists because of his other doctors (such as his pain management doctor or his VA PCP) is willing to prescribe his pain medications.” A March 25, 2015 Cleveland Clinic record noted that the Veteran was a “challenging patient” with a history suggestive of reactive arthritis, with no current findings on his joint examination that would indicate the validity of such a diagnosis. A January 25, 2016 SSA record included Dr. C.N.’s opinion that the Veteran was not an “outright malingerer, but tends to exaggerate problems to get [prescriptions] he wants.” A July 31, 2017 Dr. D.S-C. record noted that the Veteran was seen for low back, left arm, left foot pain, and Reiter’s syndrome. The Veteran “turned his back” on the doctor and was “no longer interested in the appointment” once she informed him that she would not be prescribing Percocet, or any narcotics. She reminded him his toxicology screen was positive for cocaine. He stated he had a relapse a few days ago. She reminded him that he had denied use since 2013. The Veteran was denied Social Security Administration disability benefits in September 2017. The SSA administrative judge’s opinion included that the Veteran’s “statements about the intensity, persistence, and limiting effects of his symptoms were inconsistent as the record showed that his main interest was in securing certain prescription medication.” The decision included citations to a number of records to support this statement. This included the June 2013 Lakewood Hospital treatment for withdrawal and refusal of IV treatment when seeking prescriptions, his dismissal from Dr. J.N. (Cleveland Back and Pain management) due to violation of the pain agreement, attempts to obtain narcotics from Dr. P.G. The Board notes that the Veteran was also dismissed from Dr. K.E. and Dr. D. S-C. for violating pain medication agreements (testing positive for illicit and non-prescription medications). In December 2020, a private psychologist submitted an evaluation of the Veteran. The psychological symptom statement included that the Veteran had symptoms of major depressive disorder (listed in the statement) with ongoing “negative beliefs and emotions about traumatic experiences while in the Army.” He denied mental health related symptoms prior to service, and reported the onset of symptoms while he was in service. “Over the course of the progression of his depression, the Veteran reported using alcohol and cocaine to cope with symptoms.” He stated he was sober from cocaine and alcohol since 2011. (The report cited records wherein the Veteran reported cocaine use in 2016). In a February 8, 2021 statement, the Veteran reported that VA did not treat him for his Reiter’s syndrome for 30 years after he was “thrown out” of service. He argued that his condition being untreated caused him stress, anger and depression. He stated that his pain and depression were constant, and he could not work. Given the above, the Board finds that the Veteran’s statements related to pain, anxiety, or other symptoms necessary to obtain the prescription medications are not considered credible. 1. New and material evidence having been received, the claim of entitlement to service connection for a psychiatric disorder is reopened. A decision of the RO becomes final and is not subject to revision on the same factual basis unless a notice of disagreement is filed within one year of the notice of the decision. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. If a claim of entitlement to service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108; see Manio v. Derwinski, 1 Vet. App. 140, 145 (1991). New evidence means existing evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The credibility of the evidence is presumed for purposes of reopening the claim. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). The threshold for reopening is low. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has indicated that evidence may be considered new and material if it contributes “to a more complete picture of the circumstances surrounding the origin of a Veteran’s injury or disability, even where it will not eventually convince the Board to alter its ratings decision.” Hodge v. West, 115 F.3d 1356, 1363 (Fed. Cir. 1998). In December 1984, the Veteran’s claims of entitlement to service connection for depression and anxiety (“nerves”) were denied. The RO noted that there was no evidence of treatment, complaints or findings of any nervous disorder in service treatment records. An October 2007 rating decision denied entitlement to service connection for depression secondary to his service connected disabilities, finding that the Veteran had bipolar disorder, and that his symptom of depression was not due ot his disabilities or service. A January 2010 rating decision denied entitlement to service connection for a mental disorder, finding that there was no evidence showing a mental condition incurred in service or caused by his service-connected disabilities. An October 2014 rating decision found that new and material evidence had not been received to reopen a claim of entitlement to service connection for depression. The Veteran did not appeal the decision and new and material evidence was not received within the one-year appeal; the October 2014 rating decision became final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1100. Therefore, new and material evidence is needed to reopen the claim. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156; Barnett v. Brown, 83 F. 3d 1380 (Fed. Cir. 1996). Evidence of record at the time of the October 2014 rating decision included that Veterans’ service treatment records, an August 1984 VA examination, VA treatment records from 2000 to 2014, and some private treatment records. Evidence added to the claims file since the October 2014 rating decision includes additional ongoing VA and private treatment records, SSA disability records, an August 2014 VA mental condition examination which provided negative nexus opinions, and a 2020 private psychological examination. The evidence is new in that it was not before decision makers at the time of the October 2014 decision, and it is not cumulative of prior evidence as the Veteran’s psychiatric diagnoses have changed/evolved, his substance use has changed, and the 2020 private psychologist provided a positive nexus opinion linking a psychiatric disorder to service and the pain associated with service-connected disability. As such, the new evidence is also material and relates to an unestablished fact necessary to substantiate the claim (nexus). As new and material evidence has been received, the claim of entitlement to service connection for a psychiatric condition is reopened. Effective Date 2. Entitlement to an effective date prior to May 4, 2017 for the grant of entitlement to service connection for tinnitus is denied. 3. Entitlement to an effective date prior to May 4, 2017 for the grant of entitlement to service connection for bilateral hearing loss is denied. 4. Entitlement to an effective date prior to May 4, 2017 for the grant of entitlement to service connection for dry eye syndrome is denied. The Veteran and his representative have not provided any arguments related to his earlier effective date claims. The 2021 attorney brief did not mention the effective dates assigned, although the Veteran and his attorney continued the appeal process to the Board. Effective March 24, 2015, VA amended its regulations to require that all claims governed by VA’s adjudication regulations be filed on a standard form. The amendments also, inter alia, eliminate the constructive receipt of VA reports of hospitalization or examination and other medical records as informal claims to reopen. See 38 C.F.R. §§ 3.151, 3.155, 3.160. The amended regulations apply only to claims filed on or after March 24, 2015, such as here. Unless specifically provided otherwise, the effective date of an award based on an original claim, a claim reopened after final adjudication, or a claim for increase, of compensation, dependency and indemnity compensation, or pension, shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. On May 4, 2017, the Veteran submitted a formal claim of entitlement to service connection for tinnitus, bilateral hearing loss, and a bilateral eye condition (unspecified). The last prior record was a 2014 Award Print. This Board member was unable to locate any records of an intent to file a claim within one year prior to the May 4, 2017 claim date. Again, the Veteran and his representative have provided no argument as to why the claims for earlier effective dates were made and continued through the appellate process. Entitlement to effective dates prior to May 4, 2017 for entitlement to service connection for tinnitus, bilateral hearing loss, and bilateral dry eye syndrome are not warranted. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). The Board must determine the value of all evidence submitted, including lay and medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 5. Entitlement to service connection for headaches is denied. The Veteran and his representative have not provided any statements or arguments in support of the Veteran’s claim of entitlement to service connection for headaches. The 2021 attorney brief did not include a mention of the Veteran’s headache claim. A review of the Veteran’s service treatment records did not reveal complaints of ongoing headaches. On his March 12, 1984 separation medical history, the Veteran denied frequent or severe headaches. A review of VA and private treatment records revealed the occasional complaint of headache. On March 24, 2000, the Veteran reported frequent headaches on one side of his head, photosensitivity, and seizure activity. On May 9, 2000, the Veteran reported a history of migraines. During in-patient substance treatment from May 28 to June 11, 2002 the Veteran reported a closed-head injury with headaches. On June 4, 2002, the Veteran reported occasional headache for the past month since a head injury the month prior in prison when he hit his head on a shelf. He stated that Tylenol was ineffective for pain management; he was seeking better pain medication. On September 30, 2002, the Veteran denied having had a headache since his last visit and he had failed to keep an appointment with a neurologist. He was diagnosed with resolved headaches. The Board notes that the Veteran’s VA and private treatment records include providers determining that the Veteran was seeking to obtain prescription drugs, including that he was no longer interested in interacting with physicians who refused to prescribe his requested medications. On October 18, 2013, the Veteran was seen in the Emergency Room due to hypertension. He complained of headache and eye pain following eye surgery the week prior due to a traumatic left eye injury following assault. During a December 6, 2013 Ohio Disability Determination Services evaluation with Dr. K.S., the Veteran reported acute headaches status-post traumat to the head and left eye blindness/injury. He reported being kicked unconscious in September 2013, with “acute headaches since the beating.” During a December 10, 2013 psychological evaluation by Dr. T.M.E. (as part of his Social Security Administration (SSA) disability claim), the Veteran reported frequent migraines since September 2013. Additionally, VA treatment records showed the Veteran’s complaint of on and off headaches during treatment for hepatitis C. The Hepatitis C clinic warned that a side effect of the medication used was headaches. He had headaches on and off from August to October 2016 during this treatment. VA did not afford the Veteran an examination for his headache claim. Under McLendon v. Nicholson, 20 Vet. App. 79 (2006), in disability compensation (service connection) claims, the VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. With respect to the third factor, the types of evidence that “indicate” that a current disorder “may be associated” with service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. Id. Here, the Veteran did not complain of headaches in service, and denied frequent or severe headaches at separation. He has reported headaches on and off over the years, twice in connection with post-service head injuries. The first post-service record the Board was able to locate wherein the Veteran complained of headaches was in 2000, almost 20 years after separation. The Veteran and his representative have provided no arguments or statements which would indicate a link between his headaches reported in 2000, 2002, 2013, and 2016 and his service. As such, the Veteran’s claim for headaches does not meet the low threshold requirements of McLendon, and VA was not required to afford him an examination on this claim. As the Veteran did not develop a headache condition in service, denied severe or frequent headaches at separation, reported his headaches were related to post-service head injuries, an SSA disability physician related his headaches to his 2013 assault, and the record does not contain argument or nexus linking his headaches to service, the Board finds that entitlement to service connection for headaches is not warranted. 6. Entitlement to service connection for gout is denied. The Veteran and his representative have not provided any statements or arguments in support of the Veteran’s claim of entitlement to service connection for gout. The 2021 attorney brief did not include a mention of the Veteran’s gout claim. The Veteran’s service treatment records do not include a diagnosis or treatment for gout. The Veteran was diagnosed with Reiter’s syndrome in service with soreness in some of his joints; however, he is service-connected for Reiter’s syndrome and there is no evidence of high uric acid or symptoms later diagnosed as gout in service. A review of the extensive VA, private, and SSA treatment records reveals limited records related to gout. November 28, 2016 and January 3, 2017 private treatment records from Dr. K.E. showed elevated uric acid in the Veteran’s blood. Prior records from October 2016 did not show elevated uric acid. A January 31, 2017 Dr. K.E. record noted that the Veteran again had elevated uric acid in his blood with no evidence of an acute gout flare. He was placed on low-dose Allopurinol. A February 10, 2017 record included Dr. K.E.’s diagnoses of gout and Reiter’s syndrome, and the Veteran was referred to a rheumatologist. In April 2017, the Veteran was dismissed from Dr. K.E.’s practice after a positive urine toxicology screen. A July 20, 2017 private record from Dr. D. S-C. included a list of “active” medical conditions, including gout. He was noted to be on Allopurinol for gout. However, after examination of the Veteran, Dr. D.S-C. did not include gout as a diagnosed disorder. VA did not afford the Veteran an examination for his gout claim. Under McLendon v. Nicholson, 20 Vet. App. 79 (2006), in disability compensation (service connection) claims, the VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. With respect to the third factor, the types of evidence that “indicate” that a current disorder “may be associated” with service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. Id. Here, the Veteran did not have in-service complaints, treatment, or diagnosis related to gout. The Veteran was diagnosed with gout in 2017, based on high uric acid in the blood. The high uric acid was not noted in prior VA or private treatment records from 1984 to 2016. The record does not contain any arguments or explanation from the Veteran and his representative regarding why his gout should be service-connected. As such, the Veteran’s claim for gout does not meet the low threshold requirements of McLendon, and VA was not required to afford him an examination on this claim. As there was no in-service diagnosis of or treatment for gout, his gout was not diagnosed until more than 30 years after service, there is no medical or lay evidence which would suggest that his gout is related to service, and the Veteran and his attorney have provided no argument in support of this claim, the Board finds that entitlement to service connection for gout is not warranted. 7. Entitlement to service connection for a respiratory disorder is denied. On his May 4, 2017 claim form, the Veteran requested entitlement to service connection for a “respiratory condition.” The Veteran and his representative have not presented any argument in support of this claim, to include specifying the respiratory condition (or symptoms) for which service connection is sought. The Veteran’s service treatment records included a normal examination of lungs and chest at separation. On his March 1984 separation medical history, the Veteran denied a history of asthma or shortness of breath. His remaining service treatment records did not include a diagnosis of a respiratory disorder. An August 1984 VA general medical examination a normal evaluation of his respiratory system/lungs and did not include a diagnosis of or complaints related to a respiratory disorder. In December 2006, the Veteran requested an inhaler to be used as needed due to a history of asthma, although presenting having no respiratory difficulty. The inhaler was ordered based on the Veteran’s request as the Veteran was “in a hurry to leave.” A January 3, 2007, the Veteran sought a refill of Levalbuterol. He stated he had not been able to refill his prescriptions while incarcerated. His medical history contained in this record did not include any respiratory diagnoses, but the notation for Levalbuterol was for “shortness of breath.” Other treatment records included a diagnosis of an upper respiratory infection in November 2012, and a report of shortness of breath related to an anxiety attack (May 2010), and with hepatitis C treatment (August 2016). VA did not afford the Veteran an examination for his gout claim. Under McLendon v. Nicholson, 20 Vet. App. 79 (2006), in disability compensation (service connection) claims, the VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. With respect to the third factor, the types of evidence that “indicate” that a current disorder “may be associated” with service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. Id. Here, the Veteran did not have in-service complaints, treatment, or diagnosis related to a respiratory disorder. He was not diagnosed with a respiratory disorder during his VA examination in 1984. It is unclear what respiratory disorder the Veteran is seeking service connection for, but he has received prescription inhalers for shortness of breath, and he has reported a history of asthma. The available VA and private treatment records did not include work up for or diagnosis of asthma. The record does not contain any arguments or explanation from the Veteran and his representative regarding why a respiratory disorder should be service-connected. As such, the Veteran’s claim for a respiratory disorder does not meet the low threshold requirements of McLendon, and VA was not required to afford him an examination on this claim. As service treatment records did not include diagnosis of or complaints related to a respiratory disorder, the Veteran was not diagnosed with a respiratory disorder during his 1984 VA examination, there is no medical or lay evidence of a nexus between a respiratory disorder and service, entitlement to service connection for a respiratory disorder is not warranted. Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be “staged.” Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service- connected disability exhibits symptoms that would warrant different ratings.); see also Fenderson v. West, 12 Vet. App. 119, 126 (2001). 8. Entitlement to a rating in excess of 10 percent for hiatal hernia and peptic ulcer disease (PUD) is denied. The Veteran is seeking an increased rating for his hiatal hernia and PUD, which he described as “throat condition” and “stomach condition.” The Veteran and his representative have not presented argument related to his claim for an increased rating and his hiatal hernia/PUD were not addressed in the attorney’s 2021 brief. The Veteran is currently assigned a 10 percent rating for hiatal hernia/PUD under 38 C.F.R. § 4.114, DC 7346, pertaining to hiatal hernia. DC 7346, a 10 percent rating is warranted where the evidence shows two or more of the symptoms for the 30 percent rating of less severity. A 30 percent rating is warranted where there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent rating contemplates a level of impairment which includes symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. The Veteran participated in an August 6, 2014 VA esophageal disorders examination. He was diagnosed with a hiatal hernia and PUD in 1983. He used continuous medication (over-the-counter antacids). His symptoms included pyrosis and reflux. He had a normal upper GI study in 2001. His most recent laboratory testing was in January 2014, without significant diagnostic test findings. A March 1, 2016 VA GI outpatient note included the Veteran’s denial of GI upset or heartburn. He made sure to eat a lot of greens and yogurt. He denied abdominal discomfort, increased abdominal girth or lower extremity swelling. He was seeking hepatitis C treatment. A May 2, 2017 the Veteran underwent a VA upper endoscopy and partial colonoscopy (aborted due to poor preparation). The upper endoscopy showed evidence of irritation of the lining of his stomach. It was recommended he avoid Ibuprofen, smoking, and drinking alcohol. He was to continue taking acid suppressing medication such as omeprazole. On September 11, 2017, the Veteran participated in another VA esophageal examination. He reported episodes of mid-epigastric pain into his chest, with acid reflux daily. He underwent an EGD in May 2017 which showed erythematous mucosa and localized esophagitis, but otherwise normal esophagus. The impression was of no evidence of esophageal varices. Esophagitis was seen in the gastroesophageal junction. Also, possible hypertensive portal gastropathy found in the stomach, and erythema in the duodenal bulb. It was an otherwise normal study. The examiner selected that the Veteran was on continuous medication (omeprazole). His hiatal hernia and PUD had symptoms of persistently recurrent epigastric distress, dysphagia, pyrosis, reflux, regurgitation, substernal pain, sleep disturbance caused by reflux 4 or more times per year lasting less than one day, and nausea/vomiting both occurring 4 or more times per year lasting less than one day. He did not have stricture, spasm, or diverticular findings. The Veteran’s VA and private treatment records included ongoing prescription of omeprazole. However, there are limited treatment records related to the Veteran’s hiatal hernia and PUD. The symptoms the Veteran reported in the 2017 examination are not noted in his ongoing treatment records. He has reported difficulty sleeping, which he has related to epigastric pain, joint pain, and as a psychiatric symptom (staying awake at night, sleeping during the day, staying awake for days at a time, etc.). The Board notes that the records show that the Veteran’s symptoms fall between the criteria for a 10 percent and 30 percent ratings under DC 7346. The 2017 examination included that the Veteran had recurrent epigastric distress, dysphagia, pyrosis, reflux, regurgitation, substernal pain, sleep disturbance, and nausea/vomiting. However, the evidence does not show that his symptoms are productive of considerable impairment of health. VA primary care physician records and private pain management treatment records did not include the Veteran’s report of hiatal hernia/PUD symptoms. The record does not indicate weight loss, anemia, melena, or other signs that may be productive of considerable impairment of health. As such, the Board finds that the Veteran’s symptoms more nearly approximate the criteria for a 10 percent rating. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 9. Entitlement to an initial 10 percent rating for bilateral dry eye syndrome is granted. The Veteran is seeking an initial compensable rating for his bilateral dry eye syndrome. The Veteran and his representative have not provided argument in support of this claim, and the issue was not addressed in the 2021 Brief. The Veteran’s bilateral dry eye syndrome is currently noncompensably rated under 38 C.F.R. § 4.79, DC 6018, for chronic conjunctivitis (nontrachomatous). During the pendency of the appeal, VA issued a final rule revising the portion of the VA Schedule for Rating Disabilities that addresses the organs of special sense and schedule of ratings-eye. 89 Fed. Reg. 15316 (Apr. 10, 2018). The final rule went into effect May 13, 2018. Where there is a change in the rating criteria during the appeal period, the Board will consider the claim in light of both the former and revised schedular rating criteria, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments. Both the former and revised criteria distinguish active and inactive disease processes. Under the former criteria, an active disease process (with objective findings, such as red, thick conjunctivitae, mucous secretion, etc.) is assigned a 10 percent rating. Under the revised criteria, an active disease process is rated pursuant to the General Rating Formula for Diseases of the Eye, with a minimum rating of 10 percent. The General Rating Formal for Diseases of the Eye instructs to evaluate on the basis of either visual impairment due to a particular condition or on incapacitating episodes, whichever results in a higher evaluation. For an inactive disease process, both the former and revised criteria instruct to evaluate based on residuals, such as visual impairment and disfigurement (DC 7800). With regard to visual impairment, the May 2018 amendments made no substantive changes to how visual acuity is rated. With regard to visual field and muscle function examinations, the use of a Goldmann chart is no longer required. There are otherwise no substantive changes to how those types of visual impairment are rated. A January 27, 2012 optometry consultation included the Veteran’s report of trouble wearing his glasses/not getting used to them. He used artificial tears for dryness, and felt they were helpful. He denied ocular/visual complaints. He reported a remote history of multiple corneal abrasions of both eyes. His uncorrected vision was 20/50+2 right and 20/30-2 left. His corrected distance vision was 20/20 bilaterally. On slit lamp evaluation, he had meibomian gland dysfunction of both eyes, clear conjunctivae of both eyes, trace superficial punctate keratitis/low tear break up time both eyes. On fundus examination, he had clear bilateral lenses. He was diagnosed with bilateral presbyopia, bilateral dry eye, and unremarkable dilated ocular health. “Normal vision: 20/25 or better: unspecified disorder of refraction or accommodation.” Unfortunately, the Veteran was assaulted in September 2013, which resulted in significant injury to the left eye. A December 6, 2013 Ohio Disability Determination evaluation included that the Veteran’s corrected visual acuity was 20/70 right and “20/00” left. He denied blurred vision and diplopia. He had left eye conjunctivitis and hemorrhage status-post his third surgery. A March 6, 2014 VA ophthalmology record noted a history of a ruptured globe surgery left eye September 2013, choroidal and retinal detachment repair, recurrent retinal detachment, and vitrectomy for proliferative vitreoretinopathy left eye. During a January 31, 2014 examination, his corrected vision was 20/100 right eye. A June 27, 2014 VA ophthalmology visit included that his visual acuity was 20/80 right eye, with full visual fields on the right. A January 9, 2015 record included uncorrected visual acuity findings of 20/200+ left and 20/70 right. A March 25, 2015 Cleveland Clinic record included the Veteran’s report of having his “eye glued shut every day” in service. He stated he was using “five eye drops.” An October 1, 2015 record diagnosed nuclear sclerotic cataract of the right eye with a medical opinion that the cataract was the primary cause, or significantly contributory cause of his visual dysfunction. He had left aphakia, history of ruptured globe, history of detached retina, history of vitrectomy, left corneal scar, and left proliferative vitreoretinopathy. The Veteran underwent right cataract surgery with lens implantation in December 2015. Prior to surgery his uncorrected distance vision was 20/200+1 right. He had 3+ nuclear sclerotic cataract, trace posterior subcapsular cataract. His right conjunctivae were normal. An October 12, 2016 VA primary care physician record included the Veteran’s report of visual problems after his right eye cataract surgery. A March 28, 2017 University Hospital record included a finding of mild conjunctival erythema with some discharge from his left eye. A November 13, 2017 VA eye examination included diagnoses of dry eye syndrome, right eye pseudophakia, left eye aphakia. He also previously had left eye retinal detachment. The Veteran had a complicated ocular history regarding his left eye. He was assaulted in September 2013 resulting in complex combined tractional and rhegmatogenous retinal detachment with proliferative vitreal-retinopathy status-post open globe injury. He underwent numerous eye surgeries in 2013, resulting in aphakia (left). He also had cataract surgery on his right eye in 2015 for nuclear sclerotic cataract per the treatment records. The Veteran reported dry eyes with mucous discharge. He was using polyvinyl alcohol artificial tears to treat his dry eyes. His corrected distance vision was 20/40 or better right and 5/200 or worse left. His left pupil was dilated. The Veteran’s left vision was limited such that he was unable to recognize test letters at 1 foot or closer. On external examination, the Veteran had left ptosis, left trace central band keratopathy/endothelial pigment dusting, and aphakia. He had right eye posterior chamber intraocular lens implant, and an otherwise normal external examination. His fundus (internal) examination showed left distorted, pigment mottling macula, left sheathing vessels, left vitrectomy, and left choroidal fold central, chorioretinal scarring/atrophy 360 degrees. His right fundus examination was normal throughout. He did not have a visual field defect. Regarding his dry eye syndrome, the examiner noted that this involved both eyes and did not result in decreased visual acuity or other visual impairment. Regarding his cataracts, the Veteran had right replacement lens, and left aphakia. His visual impairment was due to his left aphakia. He also had a detached left retina resulting in his visual impairment. The Veteran did not have scarring or disfigurement, and had not had any incapacitating episodes (former definition) in the prior 12 months. His ability to work was impacted by his decreased vision in his left eye which resulted in loss of depth perception. In the remarks section, the examiner noted “dry eye syndrome/chronic conjunctivitis” included the Veteran’s complaint of dryness and mucous discharge, “more likely than not related to Veteran’s Reiter’s syndrome,” and with no effect on his vision or function. The examiner noted that the Veteran’s right eye cataracts and resultant pseudophakia were “secondary to aging changes, less likely than not related to [his] Reiter’s syndrome.” Additionally, his pseudophakia did not have an impact on his vision. His left eye aphakia and retinal detachment were status post traumatic globe rupture, not related to Reiter’s syndrome. He had “hand motion vision secondary” to these conditions Although the record does not contain objective findings of active conjunctivitis prior to the September 2013 assault and injury to the left eye. Thereafter, there were notations of discharge from the Veteran’s left eye. However, the Veteran has reported ongoing mucous discharge, waking with crusted eyes, and evaluations have shown low tear break up time. Resolving reasonable doubt in the Veteran’s favor, the Board finds that the Veteran has active conjunctivitis, warranting a 10 percent rating. The evidence does not support a rating in excess of 10 percent. The Veteran’s left eye vision loss is a result of the September 2013 assault. The 2017 examiner noted that the Veteran’s right eye cataracts was due to aging and not related to his Reiter’s syndrome. DC 6066 provides a noncompensable rating for corrected distance vision of 20/40 or better bilaterally. Treatment records do not indicate incapacitating episodes of service-connected dry eye syndrome/conjunctivitis (“severe enough to require a clinic visit to a provider specifically for treatment purposes”). As such, a rating in excess of 10 percent is not warranted based on visual acuity or incapacitating episodes. 10. Entitlement to an extraschedular rating in excess of 10 percent for tinnitus is denied. The Veteran is seeking an extraschedular rating for tinnitus, which is currently rated at the schedular maximum (10 percent). The Veteran and his representative have not provided any statements or arguments in support of this claim, to include any indication of extraschedular symptoms. The 2021 attorney’s Brief did not address the issue. During a September 2017 VA audio examination, the Veteran reported bilateral tinnitus that began “years ago.” The tinnitus was constant. He did not report functional impact caused by his tinnitus. The remaining treatment records did not mention complaints or treatment related to tinnitus. The 10 percent rating assigned for the Veteran’s service-connected tinnitus is the maximum (and only) rating provided under DC 6260 for tinnitus. As such, the Veteran’s claim for an increased rating for tinnitus is a claim for an extraschedular rating. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran’s level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran’s disability picture exhibits other related factors such as those provided by the regulation as “governing norms.” Third, if the rating schedule is inadequate to evaluate a veteran’s disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran’s disability picture requires the assignment of an extraschedular rating. Here, the evidence does not present an exceptional disability picture. Tinnitus is a subjective ringing in the ears, and the Veteran has described his tinnitus as a such. He has provided no additional statements that would indicate his tinnitus is exceptional or results in symptoms not contemplated by the 10 percent rating. His disability picture, constant ringing in his ears, is exactly the disability picture contemplated by the 10 percent rating for tinnitus. As noted above, the Veteran and his attorney have not provided any statements or arguments in support of this claim. In short, the rating criteria reasonably describe the Veteran’s disability level and symptomatology. The Board, therefore, has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. § 3.321 (b)(1) is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for a skin condition is remanded. The Veteran has filed a claim of entitlement to service connection for a skin condition, and has not specified the skin condition on appeal. His service treatment records include a March 1984 complaint of a pruritic rash around the genitalia. The handwriting on the note is difficult to read, but appears to include an assessment of contact dermatitis. Ongoing treatment records from as early as 2000 (some of the earliest post-service treatment records available) include a diagnosis of condyloma accuminata/genital warts. He reported in June 2000 that his genital warts had been present for 10 years (1990), and in September 2001 that they had been present for 16 years (1985). The Veteran was scheduled for a VA skin examination in March 2018. The record includes a printout that the Veteran “failed to report” to the examination. The record does not contain evidence of how the Veteran was informed of the scheduled examination. He reported to a number of examinations in 2017. The Veteran also has a history of difficulty maintaining housing. On remand, the Veteran should be afforded an additional opportunity to participate in a VA skin examination. 2. Entitlement to service connection for hypertension, to include as due to service-connected disabilities, is remanded. The Veteran has alleged that he either developed hypertension as a result of the pain from his service-connected Reiter’s syndrome, or that the pain from his Reiter’s syndrome aggravated his hypertension. A December 4, 2006 record from in-patient mental health treatment included that the Veteran had a new diagnosis of hypertension. A January 31, 2014 treatment record wherein the Veteran was seen for eye pain following eye injury and surgery, included the physician’s opinion that his hypertension was “most likely due to pain.” On remand, the Veteran must be afforded a VA examination which addresses his secondary service-connection claim for hypertension. 3. Entitlement to service connection for a lumbar spine disorder, to include as due to service-connected disabilities is remanded. The Veteran claims that his lumbar spine disorder is due to his Reiter’s syndrome. He has not been afforded a VA examination with nexus opinion related to his lumbar spine claim. On remand, an examination must be provided. 4. Entitlement to service connection for a psychiatric condition, to include as due to service-connected disabilities, is remanded. 5. Entitlement to service connection for a sleep disorder, to include as due to service-connected disabilities, is remanded. The record contains a December 1972 Psychological report he was referred for due to extreme difficulty he was experiencing in his 4th grade classroom. Testing showed he was of average ability but below average in terms of achievement which could be defined as a learning disability with much medical developmental history indicating a minimal brain dysfunction, so the learning disability is due to a neurological disorganization. He was recommended a tutorial program for neurologically handicapped students through the Department of Special Education. The record did not indicate a diagnosis of ADD or ADHD. Notably, this evaluation was prior to the age in which the Veteran reported his abuse by his brothers and neighbor. The Veteran’s January 1982 enlistment examination was negative for psychiatric conditions, he denied any medical history of psychiatric symptoms. He also denied a history of drug use and alcohol abuse. On his March 12, 1984 discharge medical history, the Veteran denied depression or excessive worry, nervous trouble of any sort, and frequent trouble sleeping. On August 6, 1984, the Veteran participated in a special psychiatric evaluation after reporting “nerves” on his service connection claim form. He reported a learning disability and dyslexia as a kid, but that he played sports and had friends. He was “feeling tired and tense and anxious with increased sweating, palpitations, biting his nails.” He felt that he was out of shape. His affect was depressed, feeling hopeless and helpless at times. His “reality testing is sometimes impaired.” He was diagnosed with adjustment disorder of anxiety and depression. An April 25, 2000 VA record included the Veteran’s report that he remained depressed after his discharge from service in 1984. He reported alcohol and cocaine use/abuse on and off since shortly after discharge from service in 1984. He used alcohol, cannabis, and LSD in high school, but none since then. He noted that his brothers and father were alcoholics. Here, he denied a history of auditory of visual hallucinations except when taking substances such as LSD and mushrooms. He reported smoking marijuana starting at age 11, alcohol use starting at age 13 and cocaine use starting in 1985. An April 26, 2000 record diagnosed alcohol dependence and cocaine dependence with substance-induced mood disorder depressed type. A May 23, 2000 record noted that the Veteran had “manic-like symptoms” in sessions. After in-patient treatment from May 5th to 23rd, the Veteran was discharged with diagnoses of cocaine dependency, alcohol abuse, depressive disorder NOS, and borderline personality disorder. A December 4, 2006 psychiatric inpatient discharge record showed diagnoses of bipolar disorder NOS, exacerbation secondary to medication non-adherence, rule out SIMD secondary to cocaine use, borderline personality disorder. The discharge note included that his mood disorder may be due to SIMD v. bi-polar disorder mixed episode as the Veteran had cocaine intoxication and ADHD by history with non-adherence to bi-polar medication and probably some aspect of his borderline personality disorder contributing to his clinical picture. A March 25, 2010 record diagnosed bipolar disorder with a history of cocaine dependence, alcohol abuse, depressive disorder NOS, and cluster B traits (axis II). An August 6, 2014 VA psychiatric examination included diagnoses of borderline personality disorder and bipolar disorder under the DSM-V. The examiner noted that the Veteran’s personality disorder was not caused by his service-connected conditions. Numerous clinical records documented BPD, antisocial personality disorder, and cluster B. traits. His personality disorder characteristics more likely than not stem from his childhood abuse issues and dysfunctional family dynamics. The Veteran “himself admits his depression has nothing to do with his service-connected hiatal hernia/ulcer condition.” The examiner noted that “it cannot be concluded that it is as likely as not that the Veteran’s depression is proximately due to or a result of his service-connected rheumatoid arthritis.” At the time he was first treated for depression (1999), he endorsed some depression related to financial problems and underemployment (which he attributed to his knee problems), but records also document difficulty getting along with coworkers, marital difficulties, legal problems, and substance abuse. This makes it difficult to attribute his first symptoms of depression to one specific cause such as his arthritis. The examiner also noted that the Veteran’s depression was part of his bipolar type and not a “unipolar depression.” “While unipolar depression can be brought on by an individual’s response to situational factors such as complications of medical illness, this is not the case with bipolar disorder, which has an organic basis. While the veteran’s response/stress to his service-connected conditions undoubtedly adds to the severity of the depression (depressed phase of his [bipolar disorder]), such stress does not cause bipolar disorder.” The examiner noted that there are numerous records that documented periods when the Veteran was free of depression even while his pain and service-connected medical conditions remained chronic in nature. Numerous records also documented depression related to relationship problems and substance abuse. “It is more likely than not that his depression is a part of his bipolar disorder which is not caused by his service-connected conditions.” “It is as likely as not that his depression is secondary to his non-service-connected conditions of borderline personality disorder, ADHD, and polysubstance abuse.” The examiner noted that the Veteran contradicted himself regarding the cause of his depression and whether it was present when his pain was under control/he had access to the prescription narcotics. He was noted to have increased difficulty with PTSD symptoms since his September 2013 assault. The examiner included a confusing conclusion that “although [the Veteran’s] chronic pain undoubtedly adds to his depressed mood, his depression is felt to be part of a bipolar disorder, not caused by his service-connected conditions. He also appears to have high levels of depressed mood stemming from chronic relationship problems, interpersonal difficulties, underemployment and psychosocial functioning difficulties stemming from his other mental health diagnoses including ADHD, polysubstance abuse, PTSD and borderline personality disorder that it is NOT possible to conclude that it is as likely as not that his depression is due to his service-connected arthritis.” The examiner noted his substance misuse predated his military service and knee symptoms, and were not due to his service-connected disabilities. “Concerns regarding and symptoms relating to these conditions can contribute to fluctuations in mood and periodic depression, but are less likely than not the cause of his depression, given the magnitude of his other stressors and multiple psychiatric conditions which are also frequently associated with depression.” A December 2, 2020 private psychologist opinion included the diagnosis of diagnosed major depressive disorder, moderate, recurrent, and borderline personality disorder. She noted that his mental health conditions mutually exacerbated each other, and the symptoms could not be separated. The opinion cited “traumatic experiences while in the Army,” although the traumatic experiences were not specifically cited. “Over the course of the progression of his depression, the Veteran reported using alcohol and cocaine to cope with symptoms.” He stated he had been sober from cocaine and alcohol since 2011. The private psychologist noted that the Veteran presented with major depressive disorder and that “bi-polar features were absent.” The Veteran was interviewed via videoconference. “Notably, whether a genetic inheritance exists within a disorder (i.e., bi-polar disorder as referenced by the previous examiner), it remains the case that mood disorders can and are exacerbated by stressful conditions.” She also noted that the Veteran’s personality disorder was not noted on entrance, “indicating that existing symptomology was not present at the time of enlistment.” She found that his physical pain contributed to his mental health symptoms. The record currently contains conflicting medical opinions, and none of the opinions fully addresses the information of record. On remand, the Veteran should be afforded a VA examination that addresses whether the Veteran clearly and unmistakably had a psychiatric condition prior to service, and whether it clearly and unmistakably was not aggravated by service. The examiner should also address whether the Veteran developed a psychiatric condition during service, or within one year of discharge. Lastly, an opinion on whether the Veteran has a separate psychiatric disorder of depression (as diagnosed by the private psychologist) or if his depression symptoms are a part of his bipolar diagnosis (as most predominantly diagnosed in the record). 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, 4.9, 4.127. Service connection can only be granted for additional disability resulting from a mental disorder that is superimposed upon the personality disorder. 38 C.F.R. §§ 3.303 (c), 4.9, 4.127; see also Carpenter v. Brown, 8 Vet. App. 240, 245 (1995); Monroe v. Brown, 4 Vet. App. 513, 514-15 (1993). The nexus opinions provided will need to address whether the Veteran’s psychiatric disorders include personality disorder with or without superimposed mental disorders, and whether any of his diagnosed disorders began during or were aggravated by service. 6. Entitlement to an initial compensable rating for bilateral hearing loss is remanded. The September 11, 2017 VA audio examination did not include information on the functional impact caused by the Veteran’s hearing loss. On remand, the Veteran should be afforded an updated examination. 7. Entitlement to a rating in excess of 10 percent for Reiter's syndrome with degenerative arthritis, left knee, is remanded. 8. Entitlement to a rating in excess of 10 percent for Reiter's syndrome with degenerative arthritis, right knee, is remanded. 9. Entitlement to a rating in excess of 10 percent for Reiter's syndrome with degenerative arthritis, left ankle, is remanded. 10. Entitlement to a rating in excess of 10 percent for Reiter's syndrome with degenerative arthritis, right ankle, is remanded. The Veteran was afforded VA knee, ankle, and arthritis examinations in 2014 and 2017. The 2017 examiner did not answer the questions related to passive and active motion or pain in the joint with weightbearing. Additionally, effective February 7, 2021, portions of the rating schedule addressing musculoskeletal system were revised. Given that the 2017 examination was inadequate, and recent changes to the ratings schedule, the Veteran must be afforded updated examinations on remand. An April 6, 2010 VA rheumatologist noted that the Veteran’s chronic pain was consistent with somatization related to underlying psychiatric disorders and osteoarthritis of the right knee. He had been diagnosed with Reiter’s syndrome in service, and the rheumatologist noted that he had in 50 percent of cases patients with reactive arthritis the joint inflammation was self-limited and eventually resolves. The VA rheumatologist noted that there was no record of joint inflammation from 1999 to the present. The VA examiner should address whether the Veteran continues to have symptoms related to his Reiter’s syndrome. The Board notes that the Veteran’s ongoing VA and private treatment records include a number of records wherein the Veteran was noted to be seeking specific prescription drugs. He was additionally dismissed from pain management practices due to failing urine toxicology screens. As noted above, the Veteran is less than credible in reporting the severity and onset of his symptoms, including the severity of his pain related to seeking prescription medication. 11. Entitlement to total disability based on individual unemployability (TDIU) is remanded. The Veteran’s claim of entitlement to TDIU is intertwined with his increased rating claims and service connection psychiatric claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). If the Veteran does not meet the schedular rating requirements for TDIU under 38 C.F.R. § 4.16 (a) after his increased rating and service connection claim are readjudicated, then his claim for TDIU should be forwarded to the Director of Compensation for an extraschedular TDIU opinion. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA skin examination. After a review of the record and interview and examination of the Veteran, the examiner should provide the following: Is it at least as likely as not (50/50 probability or greater) that the Veteran has a skin condition that began during or is otherwise related to service? The examiner should note the March 1984 service treatment record of a rash around his genitals and the ongoing treatment records from at least 2000 with a diagnosis of genital warts. A complete rationale must accompany each opinion expressed. 2. Schedule the Veteran for a VA hypertension examination. After a review of the record and interview and examination of the Veteran, the examiner should provide the following: (a.) Is it at least as likely as not (50/50) probability or greater that the Veteran’s hypertension began during or is otherwise related to his service? (b.) Is it at least as likely as not (50/50) probability or greater that the Veteran’s hypertension is due to or caused by his service-connected Reiter’s syndrome, to include pain? (c.) Is it at least as likely as not (50/50) probability or greater that the Veteran’s hypertension has been aggravated beyond its natural progression by his service-connected Reiter’s syndrome, to include pain? A complete rationale must accompany each opinion expressed. 3. Schedule the Veteran for a VA lumbar spine examination. After a review of the record and interview and examination of the Veteran, the examiner should provide the following: (a.) Is it at least as likely as not (50/50) probability or greater that the Veteran’s lumbar spine disorder began during or is otherwise related to his service? To include whether his lumbar spine symptoms are caused by the Reiter’s syndrome diagnosed in service. (b.) Is it at least as likely as not (50/50) probability or greater that the Veteran’s lumbar spine disorder is caused by his service-connected Reiter’s syndrome of the knees and ankles? (c.) Is it at least as likely as not (50/50) probability or greater that the Veteran’s lumbar spine disorder was aggravated by his service-connected Reiter’s syndrome of the knees and ankles? A complete rationale must accompany each opinion expressed. 4. Schedule the Veteran for a VA psychiatric examination. After a review of the electronic file, this REMAND, and an interview of the Veteran, the examiner should provide the following: (a.) List the Veteran’s current (from 2013 to the present) psychiatric diagnoses? Does the Veteran have a diagnosis of depression or is his depression part of his diagnosis for bipolar disorder? The examiner should provide a full explanation addressing why or why not certain diagnoses are more likely present. (b.) Did the Veteran’s psychiatric disorder(s) (depression, adjustment disorder, bipolar disorder, etc.) clearly and unmistakably (undebatable) exist prior to his service? (c.) If yes, then was his psychiatric disorder(s) (depression, adjustment disorder, bipolar disorder, etc.) clearly and unmistakably (undebatable) NOT aggravated by service? (d.) If no, is it at least as likely as not (50/50 probability or greater) that the Veteran has a psychiatric disorder that was caused by or began in service? The examiner should address the August 1984 examination which diagnosed adjustment disorder of anxiety and depression. (e.) Is it at least as likely as not (50/50 probability or greater) that the Veteran’s psychiatric disorder was caused or aggravated by his service-connected disabilities (Reiter’s syndrome)? The examiner must address the 2020 private psychological opinion. (f.) If the examiner determines that the Veteran’s psychiatric disorder was aggravated beyond its natural progression by his service-connected disabilities, then the examiner should cite a record of the severity of his psychiatric disorder prior to aggravation. The examiner should note that the Board has found the Veteran’s reports regarding the severity of his pain from his Reiter’s syndrome to be less than credible. (g.) Does the Veteran have a separate disorder related to his complaints of unusual sleep patterns and insomnia? Are his complaints of disordered sleeping a symptom of a psychiatric disorder? If he has a separate sleep disorder, is it at least as likely as not (50/50 probability or greater) that his sleep disorder is due to service or a service-connected disability? A full explanation/rationale must accompany each opinion expressed. 5. Schedule the Veteran for an updated audiologist examination to determine the current severity of the Veteran’s bilateral hearing loss. 6. Schedule the Veteran for an updated VA knee examination to determine the current severity of his service-connected Reiter’s syndrome. The examiner should note that the Veteran is less than credible in reporting the severity of his pain. The examiner should pay attention to whether the Veteran’s subjective reports align with the severity seen objectively. 7. Schedule the Veteran for an updated VA ankle examination to determine the current severity of his service-connected Reiter’s syndrome. The examiner should note that the Veteran is less than credible in reporting the severity of his pain. The examiner should pay attention to whether the Veteran’s subjective reports align with the severity seen objectively. 8. Schedule the Veteran for an updated VA rheumatoid arthritis examination to determine the current severity of his service-connected Reiter’s syndrome. After a review of the record from 2013 to the present, does the Veteran continue to have symptoms of Reiter’s syndrome? The examiner should address the April 2010 rheumatologist’s indication that the Veteran’s Reiter’s syndrome resolved and the March 25, 2015 Cleveland clinic that there were no current findings that would indicate the validity of reactive arthritis. 9. If the Veteran does not meet the schedular requirements for TDIU after his increased rating and service connection claims have been addressed, then refer his TDIU claim to the Director, Compensation Service for extraschedular consideration of TDIU. 10. After completing the development requested above, readjudicate the Veteran’s claims. If any of the benefits sought are not granted in full, the Veteran and his representative should be furnished a Supplemental Statement of the Case and given the opportunity to respond thereto. The case should then be returned to the Board, if otherwise in order. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. H. Stubbs, 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.