Citation Nr: 21026185 Decision Date: 04/30/21 Archive Date: 04/30/21 DOCKET NO. 19-27 476 DATE: April 30, 2021 ORDER Entitlement to a rating of 100 percent for posttraumatic stress disorder (PTSD) is granted, subject to the laws and regulations governing the payment of monetary benefits. Service connection for human papillomavirus (HPV) is granted. Service connection for sleep apnea is denied. REMANDED Service connection for a neck disability is remanded. Service connection for a low back disability is remanded. Service connection for seizing of the left side of the body is remanded. Service connection for seizing of the right side of the body is remanded. Service connection for a right ankle disability is remanded. Service connection for migraine headaches is remanded. Service connection for tremors is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. On and after July 21, 2017, the Veteran’s PTSD has manifested as total occupational and social impairment. 2. The probative evidence of record is at least in equipoise as to whether the Veteran’s HPV is etiologically related to active service. 3. The preponderance of the evidence is against finding that the Veteran has sleep apnea. CONCLUSIONS OF LAW 1. With resolution of reasonable doubt in the Veteran’s favor, on and after July 21, 2017, the criteria for a disability rating of 100 percent for PTSD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.126, 4.130, Diagnostic Code 9411 (2020). 2. With resolution of reasonable doubt in the Veteran’s favor, the criteria for a grant of service connection for HPV have been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2020). 3. The criteria for establishing service connection for sleep apnea have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from September 1998 to February 1999, with additional service in the Army Reserve, Air Force Reserve, Navy Reserve, and Army National Guard.  These matters are on appeal from a January 2019 rating decision. The Veteran’s claim for service connection for a right ankle fracture has been recharacterized as a right ankle disability, to include a right ankle fracture. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009).    In her September 2019 substantive appeal (VA Form 9), the Veteran indicated that she did not want a hearing before a Veterans Law Judge.  In an additional statement later in September 2019, the Veteran requested a hearing. In a redundant VA Form 9 in November 2019, the Veteran indicated that she did not want a hearing. In a March 2021 letter, VA asked the Veteran to clarify her wishes with regard to a hearing; she responded that she did not want a hearing in this appeal. The Board therefore deems the hearing request withdrawn pursuant to 38 C.F.R. § 20.603(e) (2020).  In an August 2020 letter, the Veteran expressed her desire to revoke her former attorney’s authority to act. In a September 2020 letter, the former attorney consented to the withdrawal of representation. The Board notes the Veteran submitted her claim on May 11, 2018 as a fully developed claim (FDC) pursuant to VA’s program to expedite VA claims. Under this framework, a claim is submitted in a “fully developed” status, limiting the need for further development of the claim by VA. The notice that accompanies the FDC form informs the Veteran of what evidence is required to substantiate a claim and VA’s respective duties for obtaining evidence. See VA Form 21-526EZ. With regard to the duty to assist, the Veteran’s VA medical treatment records have been obtained. 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2020); Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). In her September 2019 substantive appeal and in a phone call later in September 2019, the Veteran requested that any future VA examinations be with specific private clinicians. The law contains no mechanism for VA to afford the Veteran VA examinations with specific private clinicians chosen by the Veteran. In a November 2019 statement, the Veteran’s former attorney argued that the July 2018 VA examinations were inadequate because they were conducted by a physician who is not a specialist. It is not required that medical examinations under section 5103A only be conducted by physicians, let alone by specialists. As provided by 38 C.F.R. § 3.159 (a)(1) (2020), “competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions.” In this case, the July 2018 VA examiner was a physician in emergency medicine, and thus is competent to provide diagnoses, statements, or opinions. The Veteran’s former attorney has not identified any specific incompetency of the examiner and has not demonstrated, by evidence, that the Board cannot rely on the examination. The former attorney has supplied a public profile indicating that, as of November 2019, the examiner was an actively registered physician who had been practicing medicine for 28 years. The former attorney’s unsupported assertions do not establish that a physician of nearly three decades’ experience is incompetent to provide medical opinions. Moreover, in this case, the Veteran’s former attorney is not shown to have the competency to establish that a specialist is required to provide an opinion in this case. See Kahana v. Shinseki, 24 Vet. App. 428, 433, 438 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Kern v. Brown, 4 Vet. App. 350, 353 (1993). In addition, in the same November 2019 statement, the Veteran’s former attorney contends that the July 2018 VA examinations are inadequate because the opinions contained therein are not supported by sufficient rationales. Because the Board is granting the Veteran’s claim for service connection for HPV, any challenge to the adequacy of that opinion is moot. Because the Board is denying the Veteran’s claim for service connection for sleep apnea based on the lack of a current disability, not the lack of a nexus to service, the adequacy of the opinion with regard to nexus is irrelevant. Because the Board is granting a 100 percent rating for the Veteran’s PTSD throughout the period on appeal, any discussion as to the adequacy of the VA examinations with regard to that issue is moot. In the same November 2019 statement and in the redundant November 2019 VA Form 9, the Veteran’s former attorney also sought to preserve for appeal any “failure to discharge the duty to assist.”  However, neither the Veteran nor her former attorney have raised any other specific issue with the duty to notify or duty to assist with regard to the claims being decided below.  See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). 1. PTSD The Veteran contends that her PTSD warrants a higher rating than that currently assigned. It is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411, for PTSD, with a 70 percent rating on and after July 21, 2017. The full period of service connection is on appeal. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate Diagnostic Codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4 (2020). Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. “Staged” ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). When entitlement to compensation has already been established and an increased rating is at issue, the relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed.  Hart, at 509; see also 38 U.S.C. § 5110(b)(3) (2012); 38 C.F.R. § 3.400(o)(2) (2020). Because VA received the Veteran’s TDIU claim, that included a claim for an increased rating for PTSD, on July 11, 2018, which is less than a year after the effective date for the grant of service connection, the full period of service connection is on appeal. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Under 38 C.F.R. § 4.130, psychiatric impairment is rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130 provides that a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A 70 percent evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful situations (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is in order when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, occupation, or own name. Id. When evaluating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant’s capacity for adjustment during periods of remission. See Vazquez–Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). VA shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126 (a). When evaluating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (b). During a September 2017 VA treatment appointment, the Veteran mentioned that she had an adult son. The record contains no information as to her relationship, if any, with her son. The treatment provider noted that the Veteran was “very agitated during the interview” and that it was difficult to obtain information from her. A December 2017 VA treatment record notes that the Veteran’s social judgment and insight into her illness were poor. The Veteran was afforded a VA examination by a psychologist in January 2018. She reported that she had been married to her spouse since 2013 but had marital difficulties because she had “detachment issues” and was “always trying to figure out what’s their angle.” The psychologist noted that the Veteran “appeared anxious and very tearful.” During a March 2018 VA treatment appointment, the Veteran reported feelings of worthlessness. During an April 2018 VA treatment appointment, the Veteran reported being unable to work and that she would rather commit suicide than remain in the Reserves. However, she added that she had no thoughts or plans to harm or kill herself or others but would defend herself. She also reported having “dates with [her] girlfriends,” which is the only mention in the record of having friends during the period on appeal, but she added that she could no longer interact with others. Later in April 2018, the Veteran reported to a treatment provider that she had suicidal ideation with intent and access to a firearm and that her psychotropic medications were recently “taken away” because she expressed intention to use them to end her life. As a result of this disclosure, she was hospitalized for more than a week in a military facility. Near the end of this hospitalization, in May 2018, a military psychiatrist found that, as a result of her psychiatric symptoms, the Veteran no longer met the retention standards for Reserve service. The psychiatrist found that “it can be reasonably determined that [the Veteran] is most likely not capable of performing the duties required of her MOS, grade, or rank,” that she “has had interpersonal conflict in occupational and social settings,” that she was “so disturbed in terms of hyperaroused and paranoid state that she carries a hand gun where she goes,” including on post, and that she “feels unsafe and threatened often and this causes distress.” The Veteran was afforded an additional VA examination in June 2018. The Veteran reported constant suicidal ideation. She also reported that she had frequent night terrors and that she had tried to strangle her spouse. She reported blacking out and difficulty with concentration, as well as problems with trust because others did not believe her accounts of repeated harassment and physical and sexual assault. She also reported that, as a result of these incidents, she did not trust anyone and felt that everyone was out to get her. In her July 2018 claim for a TDIU, the Veteran reported that she last worked full-time in November 2017. One day later, the Veteran reported to VA treatment providers that she was filing for divorce and wanted an order of protection against her spouse. She also reported that she had a history with multiple domestic violence shelters throughout the community. Four days later, a welfare check was initiated after the Veteran reported that she would defend herself against her husband and, when asked what this meant, stated that she would not be accused of premeditated murder. She also reported that she had barricaded her home and would defend herself with a knife, a sword, and a sawed-off shotgun. She stated that she was not leaving her home again and that her spouse would never touch her again. When asked if she was having thoughts of homicide, the Veteran responded by accusing the treatment provider of trying to protect the offender. During a VA treatment appointment later in July 2018, the Veteran reported that she had been suicidal in the past month due to her pending divorce, previous abuse, and inaction by authorities. She also reported that her spouse had been physically abusive and that she was going to court to obtain an order of protection that she hoped would be extended permanently. During an August 2018 VA treatment appointment, the Veteran reported that she had obtained a restraining order against her spouse but that he had come to her house anyway and grabbed her; she showed bruising on her upper left arm. She again reported her intention to obtain a permanent protective order. During a VA treatment appointment later in August 2018, the Veteran reported that she had been given a permanent protective order against her spouse and that she could not tolerate group treatment. The Veteran has submitted an October 2018 examination report by a private psychologist. During the examination, she reported that she was currently married and living with her spouse. She reported thoughts of suicide “all the time” with no plan or intent. She also reported severe emotional distress including anxiousness, depression, recurring nightmares, reliving the attacks, and hypervigilance. She also reported having a minimal support network and that she felt “very alone.” The psychologist diagnosed PTSD and major depressive disorder and characterized the latter as severe. In July 2019, the October 2018 private examiner opined that the Veteran’s psychiatric disabilities “impede her ability to maintain employment,” that they “cause difficulty for her with managing within groups of people, socialization, focusing/concentrating and managing her anger,” and that her mental health issues are “100% permanent/total.” The private examiner provided a similar opinion in February 2020. In a January 2019 decision, the Social Security Administration (SSA) found the Veteran disabled as of November 25, 2017 due to her psychiatric disabilities. SSA determinations, while relevant, are not binding upon the Board. Collier v. Derwinski, 1 Vet. App. 413, 417 (1991). During a February 2019 VA treatment appointment, the Veteran reported that she had been arrested for breaking and entering and burglary over a dispute with her neighbor about items stored in the neighbor’s garage. She reported that, during her arrest, she tried to wrap the seat belt in the police car around her head so that she would be placed on suicide watch instead of in the general inmate population. She also reported that she had made a suicide attempt by jumping off of a bench. In April 2019, the Veteran requested admission to inpatient treatment for PTSD. A May 2019 VA treatment record notes that the Veteran was scheduled for admission in July 2019. However, a June 2019 VA treatment record notes that the Veteran opted for outpatient treatment after being informed of how restrictive inpatient treatment would be. During a June 2019 VA treatment appointment, the Veteran reported that she had been living with her spouse in the same house since 2011. In a September 2019 statement, the Veteran reported having no friends and neglecting her family. The Veteran was afforded an additional VA examination by a psychologist in February 2020. The Veteran reported that she was filing for divorce; she also reported that she had a permanent restraining order against her former spouse and that he had a temporary restraining order against her, but it is not clear whether this refers to her first spouse or her then-current spouse. She reported thoughts of suicide, homicidal ideation, and constant panic attacks characterized by a racing heart, sweating, dizziness, and fear of losing control. She noted having delusions about other people’s intentions. The psychologist listed the Veteran’s symptoms for rating purposes as including gross impairment in thought processes or communication, persistent danger of hurting herself or others, intermittent inability to perform activities of daily living including maintenance of minimal personal hygiene, and disorientation to time or place. The psychologist characterized the Veteran’s overall level of functional impairment as total occupational and social impairment, which is consistent with a 100 percent rating. The psychologist found the Veteran to appear to be a reliable historian. The Veteran was granted a divorce in July 2020. Based on the evidence described above, the Board finds that, affording the Veteran the benefit of the doubt, her psychiatric symptoms and overall disability picture warrant an evaluation of 100 percent for PTSD throughout the period on appeal. During that period, the record contains evidence of gross impairment in thought processes or communication, grossly inappropriate behavior, persistent danger of hurting herself or others, intermittent inability to perform activities of daily living, and disorientation to time or place. In addition, the February 2020 VA examiner characterized the Veteran’s overall level of functional impairment as total occupational and social impairment and the October 2018 private examiner also characterized her impairment as permanent and total. For these reasons, the Board finds that Veteran’s symptoms most nearly approximate those that warrant a 100 percent rating throughout the period on appeal. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. With regard to occupational impairment, the Veteran has been unemployed for nearly the entire period on appeal and the SSA has found her to be disabled as a result of her psychiatric symptoms since her unemployment began. The Board therefore finds that it is at least as likely as not that she has been totally occupationally impaired throughout the period on appeal. With regard to social impairment, other than one reference to friends that was ambiguous in that she reported at the same time that she could no longer interact with others, the only social relationship she has reported during the period on appeal is to her now-former spouse. The Board has described in detail the volatility and violence of that relationship. Because it is unclear from the record at what point during the period on appeal that relationship became totally impaired, in order to afford the Veteran the benefit of the doubt, the Board finds that it is at least as likely as not that she has been totally socially impaired throughout the period on appeal. In sum, the Board finds that, resolving reasonable doubt in the Veteran’s favor, her impairment due to PTSD has been most consistent with a 100 percent disability rating throughout the period on appeal. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). As stated above, in addition to her active duty service, the Veteran served in the Army Reserve, Air Force Reserve, Navy Reserve, and Army National Guard. Periods of active duty for training (ACDUTRA) constitute active service for the purposes of service connection if the Veteran is disabled from a disease or injury incurred or aggravated in the line of duty during that period. 38 C.F.R. § 3.6. The benefit of the doubt rule provides that a veteran will prevail in a case where the positive evidence is in a relative balance with the negative evidence. Therefore, the Veteran prevails in a claim when (1) the weight of the evidence supports the claim or (2) when the evidence is in equipoise. It is only when the weight of the evidence is against the claim that the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. HPV The Veteran contends that she has HPV that is etiologically related to her active service. A March 2017 private treatment record notes that a recent test was positive for HPV. In her May 2018 claim, the Veteran ascribed her HPV to military sexual trauma. The Veteran is service-connected for PTSD and the underlying stressor for her PTSD is military sexual trauma; VA has therefore conceded that military sexual trauma took place. The Veteran was afforded a VA examination for gynecological conditions in July 2018. The clinician opined that it was less likely than not that her HPV was due to or the result of her service-connected PTSD and added that connecting the HPV to “any events surrounding related to the PTSD would be speculative.” As the VA clinician noted, there are inherent difficulties of proof in connecting the Veteran’s HPV to any specific incident. However, the Veteran has reported multiple instances of military sexual trauma and VA has conceded that military sexual trauma took place. In light of the totality of the circumstances, and after resolving all reasonable doubt in her favor, the evidence of record supports a finding that it is at least as likely as not that the Veteran’s HPV is etiologically related to her active service. Accordingly, the Board finds that granting service connection for HPV is the decision that is the most consistent with VA’s policy to administer the law under a broad and liberal interpretation consistent with the facts of the case. 38 C.F.R. § 3.303(a). 3. Sleep Apnea The Veteran contends that she has sleep apnea as a result of active service. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1110 (2012). Thus, the threshold question that must be addressed here (as with any claim seeking service connection) is whether the Veteran had the disability for which service connection is sought at any time during the period on appeal. In the absence of proof of a disability during that period, there is no valid claim of service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Degmetich v. Brown, 104 F.3d 1328 (1997). In March 2018, the Veteran reported a history of loud snoring and apnea spells to VA treatment providers, who scheduled a sleep study. A May 2018 VA treatment record notes that the sleep study took place in April 2018 and that the Veteran had a sleep efficiency of 90 percent and did not meet the criteria for a diagnosis of obstructive sleep apnea. The Veteran was afforded a VA examination in July 2018. She reported that interrupted sleep started after military sexual trauma and that she had persistent daytime hypersomnolence that was partially relieved by Continuous Positive Airway Pressure (CPAP) treatment. The clinician noted the negative sleep study and found that there was therefore insufficient evidence to support a diagnosis of obstructive sleep apnea. The record contains no competent, probative evidence of sleep apnea during the period on appeal. The Veteran is competent to report on matters observed or within her personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Board must determine on a case-by-case basis whether a particular medical issue is within the competence of a lay person. Kahana v. Shinseki, 24 Vet. App. 428 (2011). The Veteran in this case is not shown to possess any pertinent medical training or expertise that would make her competent to diagnose herself with sleep apnea. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Thus, to the extent that the Veteran’s lay statements express an opinion that her current interrupted sleep and hypersomnolence symptoms warrant a diagnosis of sleep apnea, they are not competent medical opinions and they cannot be assigned any probative weight. The July 2018 VA examiner’s opinion that the Veteran’s symptoms do not meet the diagnostic criteria for sleep apnea, which was supported by a sleep study sharing that conclusion, is of greater probative value than the Veteran’s lay contentions. The record does not contain any competent, probative evidence that the Veteran has been diagnosed with sleep apnea by any examiner or treatment provider during the period on appeal. As the evidence does not establish that the Veteran had sleep apnea during the period on appeal, the Board finds that service connection is not warranted. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that current disability requirement is satisfied when a claimant “has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim,”); see also Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013) (holding that the Board must address recent pre-claim evidence in assessing whether a current disability exists, for purposes of service connection, at the time the claim was filed or during its pendency). To the extent that the Veteran’s claim can be interpreted as including a disability other than sleep apnea that is manifested by interrupted sleep and hypersomnolence, after the increased rating granted above, the Veteran is service-connected for PTSD with a 100 percent rating throughout the period on appeal. The criteria for a 30 percent rating explicitly contemplate chronic sleep impairment. Those rating criteria do not explicitly reference daytime hypersomnolence, but they contemplate “such symptoms as” chronic sleep impairment. 38 C.F.R. § 4.130. Therefore, the fact that hypersomnolence is not explicitly listed in the rating criteria for PTSD does not necessarily mean that the rating criteria do not contemplate fatigue or tiredness. Moreover, the rating schedule represents, as far as can practicably be determined, the average impairment in earning capacity in civil occupations resulting from service-connected disabilities. 38 C.F.R. § 4.1. The functional impact of impaired sleep is fatigue. For these reasons, the presence of chronic sleep impairment in the rating schedule for the Veteran’s service-connected PTSD implicitly includes the hypersomnolence that is the functional impact of that symptom. REASONS FOR REMAND 1. Service connection for a neck disability is remanded. Once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide one that is adequate for purposes of the determination being made. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007).  The Veteran was afforded a VA examination for neck conditions in July 2018. The clinician opined that it was less likely than not that the Veteran’s neck disability was proximately due to or the result of her service-connected PTSD, but did not opine as to whether the neck disability had been aggravated by PTSD. To be adequate, a VA opinion must provide separate rationales for both causation and aggravation. Atencio v. O’Rourke, 30 Vet. App. 74 (2018). In addition, this opinion did not address the Veteran’s primary contention, which is that her neck disability is secondary to in-service physical and sexual assaults, not to the resulting PTSD itself.  For these reasons, a remand is warranted to obtain an additional medical opinion. 2. Service connection for a low back disability is remanded. The Veteran was afforded a VA examination for back conditions in July 2018. The clinician opined that it was less likely than not that the Veteran’s low back disability was proximately due to or the result of her service-connected PTSD, but did not opine as to whether the low back disability had been aggravated by PTSD. In addition, this opinion did not address the Veteran’s primary contention, which is that her low back disability is secondary to in-service physical and sexual assaults, not to the resulting PTSD itself.  For these reasons, a remand is warranted to obtain an additional medical opinion. 3. Service connection for seizing of the left side of the body is remanded. 4. Service connection for seizing of the right side of the body is remanded. The Veteran was afforded a VA examination for muscle injuries in July 2018. The clinician opined that it was less likely than not that the Veteran’s seizing of the left and right side of her body was proximately due to or the result of her service-connected PTSD, but did not opine as to whether the seizing had been aggravated by PTSD. In addition, this opinion did not address the Veteran’s primary contention, which is that her seizing is secondary to in-service physical and sexual assaults, not to the resulting PTSD itself.  In addition, despite noting the Veteran’s report of locking up in multiple areas of her body and that this locking can be painful, the clinician’s rationale for a negative opinion with regard to causation was that there was “no objective evidence to warrant a diagnosis.” This opinion does not reflect the decision in Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018), that “pain in the absence of a presently-diagnosed condition can cause functional impairment.” For these reasons, a remand is warranted to obtain an additional medical opinion. 5. Service connection for a right ankle disability is remanded. The Veteran was afforded a VA examination for ankle conditions in July 2018. The clinician opined that it was less likely than not that the Veteran’s right ankle disability was proximately due to or the result of her service-connected PTSD, but did not opine as to whether the right ankle disability had been aggravated by PTSD. In addition, this opinion did not address the Veteran’s primary contention, which is that her right ankle disability is secondary to in-service physical and sexual assaults, not to the resulting PTSD itself.  For these reasons, a remand is warranted to obtain an additional medical opinion. 6. Service connection for migraine headaches is remanded. The Veteran was afforded a VA examination for headaches in July 2018. The clinician opined that it was less likely than not that the Veteran’s migraine headaches were proximately due to or the result of her service-connected PTSD, but did not opine as to whether the migraine headaches had been aggravated by PTSD. In addition, this opinion did not address the Veteran’s primary contention, which is that her migraine headaches are secondary to in-service physical and sexual assaults, not to the resulting PTSD itself.  For these reasons, a remand is warranted to obtain an additional medical opinion. 7. Service connection for tremors is remanded. The Veteran was afforded a VA examination for central nervous system and neuromuscular diseases in July 2018. The clinician diagnosed tremors of undetermined etiology and opined that it was less likely than not that the Veteran’s tremors were proximately due to or the result of her service-connected PTSD, but did not opine as to whether the tremors had been aggravated by PTSD. In addition, this opinion did not address the Veteran’s primary contention, which is that her tremors are secondary to in-service physical and sexual assaults, not to the resulting PTSD itself.  For these reasons, a remand is warranted to obtain an additional medical opinion. 8. Entitlement to a TDIU is remanded. The Veteran submitted a claim for a TDIU at the same time as the other claims on appeal, including the increased rating claim granted above. Because the Veteran ascribed her unemployability to her PTSD in that claim, the Board finds that the issue of entitlement to a TDIU has been raised in connection with the claim on appeal for an increased rating. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board notes that the Veteran has expressed a preference for a schedular 100 percent rating for PTSD over a TDIU and has requested to withdraw her claim for a TDIU. As a result of the increased rating granted above, the Veteran’s PTSD is now rated 100 percent disabling throughout the period on appeal. However, consideration of entitlement to a TDIU is not rendered moot automatically by the assignment of a 100 percent schedular rating.  A veteran may be awarded special monthly compensation (SMC) under 38 U.S.C. § 1114 (s) (2012) based upon a finding that a single disability supports a TDIU rating and other service-connected disabilities are separately ratable at 60 percent or more.  See Bradley v. Peake, 22 Vet. App. 280 (2008).  Because SMC might be available if a TDIU is warranted based solely on the Veteran’s PTSD and service connection is granted for other disabilities that are separately ratable at 60 percent or more, in the interest of viewing the record in the light most favorable to the Veteran, the Board will continue to consider entitlement to a TDIU. Because the applicability of a TDIU will depend in part on whether service connection is granted for other disabilities, the TDIU claim is inextricably intertwined with this remand and the Board cannot fairly proceed in adjudicating the TDIU claim until the service connection claims have been resolved. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991); see also Tyrues v. Shinseki, 23 Vet. App. 166, 178 (2009). The matters are REMANDED for the following action: 1. Arrange for an opinion by an appropriate clinician for the purpose of determining the etiology of the Veteran’s neck disability. The entire claims file and a copy of this remand must be made available to the clinician for review. A new examination is only required if deemed necessary by the clinician. The clinician must provide opinions as to the following: a. Whether it is as likely as not (a probability of 50 percent or greater) that any current neck disability began in service, was caused by service, or is otherwise related to the Veteran’s active service (including periods of active or inactive duty for training), including as a result of physical or sexual assault. b. Whether it is as least as likely as not that any current neck disability was caused by the Veteran’s service-connected PTSD. c. Whether it is as least as likely as not that any current neck disability was aggravated beyond its natural progression by the Veteran’s service-connected PTSD. Although an independent review of the claims file is required, the Board calls the clinician’s attention to the Veteran’s statements regarding the circumstances of her in-service physical and sexual assaults, including her statements during the June 2018 VA PTSD examination. The rationale for any opinion expressed should be provided. Note that the fact that a disability is not mentioned in treatment records cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the clinician should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 2. Arrange for an opinion by an appropriate clinician for the purpose of determining the etiology of the Veteran’s low back disability. The entire claims file and a copy of this remand must be made available to the clinician for review. A new examination is only required if deemed necessary by the clinician. The clinician must provide opinions as to the following: a. Whether it is as likely as not (a probability of 50 percent or greater) that any current low back disability began in service, was caused by service, or is otherwise related to the Veteran’s active service (including periods of active or inactive duty for training), including as a result of physical or sexual assault. b. Whether it is as least as likely as not that any current low back disability was caused by the Veteran’s service-connected PTSD. c. Whether it is as least as likely as not that any current low back disability was aggravated beyond its natural progression by the Veteran’s service-connected PTSD. Although an independent review of the claims file is required, the Board calls the clinician’s attention to the following: a. The Veteran’s statements regarding the circumstances of her in-service physical and sexual assaults, including her statements during the June 2018 VA PTSD examination. b. A September 2018 private MRI noting a “vertically oriented bone bruise within the ventral cortex of the L5 vertebra indicating posttraumatic, inflammatory and reparative change.” The rationale for any opinion expressed should be provided. Note that the fact that a disability is not mentioned in treatment records cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the clinician should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 3. Arrange for an opinion by an appropriate clinician for the purpose of determining the etiology of the Veteran’s seizing of the left and right side of the body. The entire claims file and a copy of this remand must be made available to the clinician for review. A new examination is only required if deemed necessary by the clinician. The clinician is advised that, even if there is no diagnosable pathology causing the reported seizing, they must consider pain to constitute a disability if it causes functional impairment. The clinician must provide opinions as to the following: a. Whether it is as likely as not (a probability of 50 percent or greater) that any current seizing of the left or right side of the body began in service, was caused by service, or is otherwise related to the Veteran’s active service (including periods of active or inactive duty for training), including as a result of physical or sexual assault. b. Whether it is as least as likely as not that any current seizing of the left or right side of the body was caused by the Veteran’s service-connected PTSD. c. Whether it is as least as likely as not that any current seizing of the left or right side of the body was aggravated beyond its natural progression by the Veteran’s service-connected PTSD. Although an independent review of the claims file is required, the Board calls the clinician’s attention to the Veteran’s statements regarding the circumstances of her in-service physical and sexual assaults, including her statements during the June 2018 VA PTSD examination. The rationale for any opinion expressed should be provided. Note that the fact that a disability is not mentioned in treatment records cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the clinician should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 4. Arrange for an opinion by an appropriate clinician for the purpose of determining the etiology of the Veteran’s right ankle disability. The entire claims file and a copy of this remand must be made available to the clinician for review. A new examination is only required if deemed necessary by the clinician. The clinician must provide opinions as to the following: a. Whether it is as likely as not (a probability of 50 percent or greater) that any current right ankle disability began in service, was caused by service, or is otherwise related to the Veteran’s active service (including periods of active or inactive duty for training), including as a result of physical or sexual assault. b. Whether it is as least as likely as not that any current right ankle disability was caused by the Veteran’s service-connected PTSD. c. Whether it is as least as likely as not that any current right ankle disability was aggravated beyond its natural progression by the Veteran’s service-connected PTSD. Although an independent review of the claims file is required, the Board calls the clinician’s attention to the Veteran’s statements regarding the circumstances of her in-service physical and sexual assaults, including her statements during the June 2018 VA PTSD examination. The rationale for any opinion expressed should be provided. Note that the fact that a disability is not mentioned in treatment records cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the clinician should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 5. Arrange for an opinion by an appropriate clinician for the purpose of determining the etiology of the Veteran’s migraine headaches. The entire claims file and a copy of this remand must be made available to the clinician for review. A new examination is only required if deemed necessary by the clinician. The clinician must provide opinions as to the following: a. Whether it is as likely as not (a probability of 50 percent or greater) that any current migraine headaches began in service, were caused by service, or are otherwise related to the Veteran’s active service (including periods of active or inactive duty for training), including as a result of physical or sexual assault. b. Whether it is at least as likely as not that any current migraine headaches began within one year of separation from service. c. Whether it is as least as likely as not that any current migraine headaches were caused by the Veteran’s service-connected PTSD. d. Whether it is as least as likely as not that any current migraine headaches were aggravated beyond their natural progression by the Veteran’s service-connected PTSD. Although an independent review of the claims file is required, the Board calls the clinician’s attention to the following: a. A June 2010 service treatment record noting the Veteran’s report of headaches after drilling in hot weather. b. The Veteran’s statements regarding the circumstances of her in-service physical and sexual assaults, including her statements during the June 2018 VA PTSD examination. c. An article submitted by the Veteran’s former attorney in November 2019 regarding a link between PTSD and headaches. The rationale for any opinion expressed should be provided. Note that the fact that a disability is not mentioned in treatment records cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the clinician should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 6. Arrange for an opinion by an appropriate clinician for the purpose of determining the etiology of the Veteran’s tremors. The entire claims file and a copy of this remand must be made available to the clinician for review. A new examination is only required if deemed necessary by the clinician. The clinician must provide opinions as to the following: a. Whether it is as likely as not (a probability of 50 percent or greater) that any current tremors began in service, were caused by service, or are otherwise related to the Veteran’s active service (including periods of active or inactive duty for training), including as a result of physical or sexual assault. b. Whether it is as least as likely as not that any current tremors were caused by the Veteran’s service-connected PTSD. c. Whether it is as least as likely as not that any current tremors were aggravated beyond their natural progression by the Veteran’s service-connected PTSD. Although an independent review of the claims file is required, the Board calls the clinician’s attention to the following: a. The Veteran’s statements regarding the circumstances of her in-service physical and sexual assaults, including her statements during the June 2018 VA PTSD examination. b. An article submitted by the Veteran’s former attorney in November 2019 regarding a link between tremors and psychiatric disorders. The rationale for any opinion expressed should be provided. Note that the fact that a disability is not mentioned in treatment records cannot serve as the sole basis for a negative finding. If an opinion cannot be made without resort to speculation, the clinician should so state and provide reasoning as to why a conclusion would be so outside the norm that such an opinion is not possible. 7. Ensure that the directives specified in this remand have been implemented. If they have not, appropriate corrective action must be undertaken before readjudication. Stegall v. West, 11 Vet. App. 268 (1998) 8. Then, readjudicate the claims, including the TDIU claim. If any decision is unfavorable to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Ryan Frank, 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.