Citation Nr: 21026388 Decision Date: 04/30/21 Archive Date: 04/30/21 DOCKET NO. 17-14 771 DATE: April 30, 2021 ORDER New and material evidence has been received, and the claim of entitlement to service connection for an acquired psychiatric disorder is reopened. Service connection for an acquired psychiatric disorder, to include major depressive disorder (MDD), somatic symptom disorder (SSD), and agoraphobia with panic attacks, is granted. Service connection for psoriatic arthritis is denied. Service connection for fibromyalgia is denied. Service connection for a cervical spine condition is denied. Service connection for a low back condition is denied. Service connection for a sleep disorder is denied. REMANDED Entitlement to an initial compensable rating for hypothyroidism is remanded. Entitlement to an effective date prior to June 28, 2013 for the award of service connection for hypothyroidism is remanded. Entitlement to service connection for sexual dysfunction, claimed as loss of consortium, is remanded. Entitlement to service connection for loss of balance is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. An unappealed June 2009 Board decision denied the claim of entitlement to service connection for an acquired psychiatric disorder. This Board decision subsumed the June 2004 rating decision on this issue. 2. Evidence received since the final June 2009 Board decision is both new and material to the claim of service connection for an acquired psychiatric disorder. 3. The Veteran served on active duty for less than 90 days. 4. The Veteran’s current acquired psychiatric disorders, to include MDD, SSD, and agoraphobia with panic attacks, are etiologically related to her service-connected migraine headache disability. 5. The Veteran’s current psoriatic arthritis is not related to or caused by service, and was not caused or aggravated by her service-connected disabilities. 6. The Veteran’s current fibromyalgia is not related to or caused by service, and was not caused or aggravated by her service-connected disabilities. 7. The Veteran’s current cervical spine condition is not related to or caused by service, and was not caused or aggravated by her service-connected disabilities. 8. The Veteran’s current low back condition is not related to or caused by service, and was not caused or aggravated by her service-connected disabilities. 9. The Veteran does not have a currently diagnosed sleep disorder that is distinct from the chronic sleep impairment that is a symptom of her now service-connected acquired psychiatric disorders, to include MDD, SSD, and agoraphobia with panic attacks. CONCLUSIONS OF LAW 1. The June 2009 Board decision that denied the claim of entitlement to service connection for an acquired psychiatric disorder is final. 38 U.S.C. § 7104(b); 38 C.F.R. § 20.1104. 2. Evidence received since the June 2009 Board decision is new and material and the petition to reopen a claim for entitlement to service connection for an acquired psychiatric disorder is granted. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. The criteria for service connection for an acquired psychiatric disorder, to include MDD, SSD, and agoraphobia with panic attacks, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for service connection for psoriatic arthritis have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for service connection for fibromyalgia have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. The criteria for service connection for a cervical spine condition have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 7. The criteria for service connection for a low back condition have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 8. The criteria for service connection for a sleep disorder are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 2001 to May 2001, for a total of less than 90 days. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from July 2013 and January 2017 decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In July 2017, the Veteran requested a Board hearing. However, in October 2019, the Veteran withdrew her request for a Board hearing. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the appellant and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). New and Material Evidence In June 2009, the Board denied the claim of entitlement to service connection for a psychiatric disorder and subsumed the prior decision on this issue. This decision was not appealed and it thus became final. See 38 C.F.R. §§ 20.1100, 20.1104. It was the last final decision on this matter. On review, the Board reopens the service connection claim for an acquired psychiatric disorder based on subsequent medical evidence indicating that the Veteran’s current MDD, SDD, and agoraphobia with panic attacks are related to her service-connected migraine headache disability. See November 2019 private psychological evaluation report. This new and material evidence, coupled with the evidence already in the file, raises a reasonable possibility of substantiating the claims. 38 C.F.R. § 3.156(a). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection is also warranted for disability proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease. 38 C.F.R. § 3.310(b). While arthritis is a "chronic disease" listed under 38 C.F.R. § 3.309(a), a veteran must have had at least 90 days of active service in order for the presumptive provisions to apply. See 38 U.S.C. §§ 1101, 1131, 1137; see also 38 C.F.R. §§ 3.303(b), 3.307, 3.309. As noted above, the Veteran had less than 90 days of active service. Therefore, the presumptive provisions relating to chronic diseases do not apply. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether a veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465, 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d 1372, 1377. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 1. Entitlement to service connection for an acquired psychiatric disability, to include MDD, SSD, and agoraphobia with panic attacks. The Veteran contends that her current acquired psychiatric disabilities are related to or caused by her service-connected disabilities. As an initial matter, the Veteran has current diagnoses of MDD, SSD, agoraphobia with panic attacks, and bipolar disorder. See November 2019 private psychological evaluation report. Next, the Board notes that the Veteran has been in receipt of service connection for migraine headaches with vision disturbances and near syncope since May 2001 and hypothyroidism since June 2013. Turning to the issue of etiology, a December 2002 VA psychiatric evaluation report indicated that the Veteran was first diagnosed with anxiety attacks in March 2001, and had been diagnosed with bipolar disorder in December 2002. The Veteran was afforded a VA examination in April 2003. The Veteran reported that her panic attacks began in April 2001. Diagnoses of panic disorder with agoraphobia and bipolar disorder, severe with psychotic features, were noted. The VA examiner opined that he did not find any evidence that the Veteran’s anxiety disorder or bipolar disorder were secondary to her migraine headaches. The Board finds this opinion to have minimal probative value, as it is not supported by an adequate rationale. A March 2006 VA examination report indicated that the Veteran had been diagnosed with depressive disorder not otherwise specified (NOS), posttraumatic stress disorder (PTSD), and panic disorder with agoraphobia. The VA examiner opined that the Veteran’s psychiatric problems began following her time in the military, except for the PTSD which was related to her history of childhood sexual abuse. The examiner further opined that the Veteran “will probably meet criteria for diagnosis of a personality disorder.” However, no opinion was given as to whether the Veteran’s psychiatric diagnoses are related to or aggravated by her service-connected disabilities. An April 2008 VA examination report indicated that the Veteran had been diagnosed with depressive disorder NOS, of unknown etiology. The VA examiner stated that there was no specific link between the depression and the Veteran’s migraine headaches. The Board finds this opinion to have minimal probative value, as it does not include any rationale. In a January 2009 letter, the Veteran’s treating VA social worker indicated that she was being treated for panic disorder and depressive disorder NOS, and that there was not sufficient evidence to warrant the diagnosis of bipolar disorder. In December 2019, the Veteran’s representative submitted a November 2019 private psychological evaluation report. After extensive testing, review of the record, and an interview with the Veteran, the private psychologist opined that the Veteran’s MDD and SSD developed secondary to her service-connected migraine headaches with vision loss. Furthermore, the psychologist opined that it is more likely than not that the Veteran’s agoraphobia with panic attacks is secondary to her MDD, SSD, migraine headaches, and subsequent inability to maintain social interactions outside her home. The psychologist gave a detailed explanation for why his diagnoses differed from those of the March 2006 and April 2008 VA examiners, as well as why the prior diagnosis of bipolar disorder was incorrect. The Board finds this opinion to be adequate and highly probative, as it is based on a thorough review of the record and interview of the Veteran, explains the differences in diagnoses of record, and includes an adequate rationale. On review, and resolving all reasonable doubt in the Veteran’s favor, the Board finds that the weight of the evidence, particularly the November 2019 private psychological evaluation report, supports the claim for service connection for an acquired psychiatric disorder, to include MDD, SSD, and agoraphobia with panic attacks. As explained above, the November 2019 private medical opinion is the only adequate opinion of record and is highly probative, and there is no sufficient basis for the Board to reject this supportive opinion and to further develop the claim. Cf. Mariano v. Principi, 17 Vet. App. 305, 312 (2003). Thus, the weight of the evidence supports a finding that the Veteran's current acquired psychiatric disorder, to include MDD, SSD, and agoraphobia with panic attacks, are etiologically related to her service-connected disabilities. To the extent that the record reflects that the Veteran has been diagnosed with numerous other acquired psychiatric disorders, to include PTSD and bipolar disorder, the Board finds that the November 2019 private psychological evaluation report clearly illustrates that these diagnoses were either inaccurate or indicate that it is not possible to differentiate what symptoms were attributable to these diagnoses versus the service-connected MDD, SSD, and agoraphobia with panic attacks. See generally Mittleider v. West, 11 Vet. App. 181, 182 (1998). Therefore, no further discussion of these diagnoses is warranted. Finally, to the extent that the record reflects that the Veteran has been diagnosed with a personality disorder, personality disorders are not a disease or injury under VA regulations and therefore not a disability for which service connection can be granted. 38 C.F.R. § 3.303(c). Nevertheless, service connection may be awarded based upon probative evidence showing that another psychiatric disorder was incurred or aggravated in service or superimposed upon the preexisting personality disorder. 38 C.F.R. §§ 4.9; 4.125(a), 4.127; Carpenter v. Brown, 8 Vet. App, 240 (1995); Beno v. Principi, 3 Vet. App. 439 (1992). Here, however, the November 2019 private psychological evaluation report indicates that any diagnoses of a personality disorder were erroneous. The Board finds this opinion to be highly probative, as it is based on a thorough review of the record and interview of the Veteran, explains the differences in diagnoses of record, and includes a lengthy and detailed rationale. Therefore, further discussion of a personality disorder is not warranted. For this reason, and resolving all reasonable doubt in the Veteran's favor, the Board finds that the criteria for service connection for an acquired psychiatric disorder, to include MDD, SSD, and agoraphobia with panic attacks, as secondary to the service-connected migraine headache disability, have been met. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for psoriatic arthritis. The Veteran contends that her psoriatic arthritis is related to or caused by either service or her service-connected disabilities. As an initial matter, the Veteran has a current diagnosis of psoriatic arthritis. See December 2016 VA examination report. Next, the Board notes that the Veteran has been in receipt of service connection for migraine headaches with vision disturbances and near syncope since May 2001. and hypothyroidism since June 2013. The Board also awards herein service connection for an acquired psychiatric disorder. Turning to the issue of etiology, in December 2016, the Veteran was afforded a VA examination. The VA examiner opined that the Veteran’s complaints of muscle/joint pain during service are most likely related to her thyroid disease that was diagnosed during service, as the inflammatory arthritis was not diagnosed until after she left service. Furthermore, the VA examiner opined that it is less likely than not that the Veteran’s psoriatic arthritis is proximately due or the result of, or aggravated beyond its natural progression by, her service-connected migraine headaches. The VA examiner explained psoriatic arthritis is an inflammatory arthritis related to over activation of components of the immune system. Migraine headache is not a primary inflammatory condition and is not related to inflammatory conditions such as psoriatic arthritis. Finally, the VA examiner opined that it is less likely than not that the Veteran’s psoriatic arthritis is proximately due to or the result of, or aggravated by, her thyroid condition. The VA examiner explained that while psoriatic arthritis and Graves’ disease are both associated with the over activation of components of the immune system, they do not typically occur together, and there is no evidence of causation of one condition by the other. The Board finds the December 2016 VA examiner’s opinions to be adequate and highly probative, as they are based on a thorough review of the record and examination of the Veteran, and include an adequate rationale. The Board notes that this is the only adequate nexus opinion of record. Therefore, that the weight of the evidence supports a finding that the Veteran’s current psoriatic arthritis is not related to, or caused by, either service or the Veteran’s service-connected disabilities. The benefit-of-the-doubt doctrine is therefore not for application, and the appeal is denied. 3. Entitlement to service connection for fibromyalgia. The Veteran contends that her fibromyalgia is related to or caused by either service or her service-connected disabilities. As an initial matter, the Veteran has a current diagnosis of fibromyalgia. See December 2016 VA examination report. Next, the Board notes that the Veteran has been in receipt of service connection for migraine headaches with vision disturbances and near syncope since May 2001. and hypothyroidism since June 2013. The Board also awards herein service connection for an acquired psychiatric disorder. In addition, her service treatment records indicate she had joint pains during service. See April 2001 service treatment records. Turning to the issue of etiology, in December 2016, the Veteran was afforded a VA examination. The VA examiner noted that the Veteran was not diagnosed with fibromyalgia during service, and opined that she developed muscle and joint pain during service on the basis of her already service-connected thyroid disease. The VA examiner explained that the symptoms of untreated thyroid disease and fibromyalgia are frequently similar, but in this case the diagnosis of thyroid disease was established during service and explains the Veteran’s symptoms of myalgias and arthralgias. Therefore, it is less likely than not that the Veteran’s fibromyalgia was incurred in or caused by the in-service complaints of muscle/joint pain. Furthermore, the VA examiner opined that the Veteran’s fibromyalgia is less likely than not proximately due to or the result of her service-connected migraine headaches. The VA examiner explained that while fibromyalgia and migraine headaches often occur together in patients, there is no established causative relationship between the two conditions. The VA examiner also opined that it is less likely than not that the Veteran’s fibromyalgia was aggravated beyond its natural progression by migraine headaches, as the natural course of fibromyalgia is variable. While the Veteran continues to have symptoms despite treatment, that is not unusual for this diagnosis. Finally, the VA examiner opined that it is less likely than not that the Veteran’s fibromyalgia was proximately due to or the result of, or aggravated by, her thyroid condition, as they are separate conditions and there is no evidence in the medical literature that thyroid disease causes or aggravates fibromyalgia. The Board finds the December 2016 VA examiner’s opinions to be adequate and highly probative, as they are based on a thorough review of the record and examination of the Veteran, and include adequate rationales. The Board notes that these are the only adequate nexus opinions of record. Therefore, that the weight of the evidence supports a finding that the Veteran’s current fibromyalgia is not related to or caused by either service or the Veteran’s service-connected disabilities. The benefit-of-the-doubt doctrine is therefore not for application, and the appeal is denied. 4. Entitlement to service connection for a cervical spine condition. The Veteran contends that her current cervical spine condition is related to or caused by either service or her service-connected disabilities. Specifically, she stated that she has had chronic neck pain ever since her in-service migraine headaches began in 2001. As an initial matter, the Veteran has current diagnoses of cervical strain, cervical degenerative disc disease (DDD), and cervical degenerative joint disease (DJD). See December 2016 VA examination report. As explained above, the presumptive provisions relating to chronic diseases, including arthritis, do not apply as the Veteran had less than 90 days of active service. Next, the Board notes that the Veteran has been in receipt of service connection for migraine headaches with vision disturbances and near syncope since May 2001. and hypothyroidism since June 2013. The Board also awards herein service connection for an acquired psychiatric disorder. Turning to the issue of etiology, in December 2016, the Veteran was afforded a VA examination. The VA examiner opined that it is less likely as not that the Veteran’s current cervical spine DDD/DJD is proximately due to or caused by military service, including complaints of muscle and joint pain during service. The VA examiner noted that the Veteran’s in-service complaints of muscle and joint pain did not include reports of neck pain. Furthermore, the VA examiner noted that a 2011 private chiropractic treatment record described the onset of the Veteran’s neck pain as being in 2005. The VA examiner also opined that it is less likely as not that the Veteran’s current cervical spine condition is proximately due to or aggravated by her service-connected migraine headaches. The current peer reviewed medical literature does not support a causal relationship between migraine headaches and cervical spine disease. Additionally, while it is generally accepted that cervical DDD can lead to chronic occipital headaches, migraine headaches do not usually exacerbate neck problems. Migraine headaches generally are frontal in location and can lead to local muscle soreness, but that would resolve after the acute headache is over, and would not cause permanent worsening of the cervical spine DDD/DJD. Finally, the VA examiner opined that it is less likely as not that the Veteran’s cervical spine condition is due to or aggravated by her thyroid condition. The VA examiner explained that while hypothyroidism can cause arthralgia, it is not going to cause cervical spine DDD/DJD. Review of the medical literature does describe a constellation of symptoms from both hyperthyroidism and hypothyroidism, but neck pain/DDD/DJD and its exacerbation are not part of the symptom list. Additionally, the VA examiner noted that the Veteran’s current TSH level is very stable. The Board finds the December 2016 VA examiner’s opinions to be adequate and highly probative, as they are based on a thorough review of the record and examination of the Veteran, and include adequate rationales. The Board notes that these are the only adequate nexus opinions of record. Therefore, that the weight of the evidence supports a finding that the Veteran’s current cervical spine conditions are not related to or caused by either service or the Veteran’s service-connected disabilities. The benefit-of-the-doubt doctrine is therefore not for application, and the appeal is denied. 5. Entitlement to service connection for a low back condition. The Veteran contends that her current low back condition is related to or caused by either service or her service-connected disabilities. Specifically, the Veteran reported that she has had chronic lower back pain since the onset of her severe headaches during service in 2001. See December 2016 VA examination report. As an initial matter, the Veteran has current diagnoses of lumbar strain and lumbar spine DDD/DJD. See December 2016 VA examination report. As explained above, the presumptive provisions relating to chronic diseases, including arthritis, do not apply as the Veteran had less than 90 days of active service. Next, the Board notes that the Veteran has been in receipt of service connection for migraine headaches with vision disturbances and near syncope since May 2001. and hypothyroidism since June 2013. The Board also awards herein service connection for an acquired psychiatric disorder. Turning to the issue of etiology, in December 2016, the Veteran was afforded a VA examination. The VA examiner opined that it is less likely as not that the Veteran’s current low back condition is proximately due to or caused by military service, including complaints of muscle and joint pain during service. The VA examiner noted that the Veteran’s in-service complaints of muscle and joint pain did not include reports of low back pain. Furthermore, the VA examiner noted that a 2001 private chiropractic treatment record described the onset of the Veteran’s low back pain as being in 2009. The VA examiner also opined that it is less likely as not that the Veteran’s current cervical spine condition is proximately due to or aggravated by her service-connected migraine headaches. The current peer reviewed medical literature does not support a causal relationship between migraine headaches and lumbar DJD. Additionally, while migraine headaches can be quite debilitating, they are not known to aggravate lower back conditions, mostly due to lack of proximity of the affected body parts. Finally, the VA examiner opined that it is less likely as not that the Veteran’s low back condition is due to or aggravated by her thyroid condition. Review of the medical literature describes multiple constitutional symptoms from both hyperthyroidism and hypothyroidism, but lower back issues and exacerbation of the same are not part of the constellation of symptoms. Hypothyroidism can cause arthralgias, but not usually lower back pain, and currently the Veteran’s TSH level is very normal. The Board finds the December 2016 VA examiner’s opinions to be adequate and highly probative, as they are based on a thorough review of the record and examination of the Veteran, and include adequate rationales. The Board notes that these are the only adequate nexus opinions of record. Therefore, that the weight of the evidence supports a finding that the Veteran’s current low back conditions are not related to or caused by either service or the Veteran’s service-connected disabilities. The benefit-of-the-doubt doctrine is therefore not for application, and the appeal is denied. 6. Entitlement to service connection for a sleep disorder. The Veteran is seeking service connection for a sleep disorder, claimed as loss of sleep, as a separate and distinct condition. Herein, the Board awards service connection for an acquired psychiatric disorder, to include MDD, SSD, and agoraphobia with panic attacks. All psychiatric disabilities are evaluated under the General Rating Formula for Mental Disorders, which contemplates chronic sleep impairment. The November 2019 private psychological evaluation report indicated that the Veteran’s MDD and other psychiatric diagnoses were characterized by symptoms of sleep impairment and feeling tired easily. Review of the medical evidence of record does not indicate that the Veteran has a current diagnosis of a sleep disorder that is separate and distinct from her psychiatric diagnoses. Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disability. 38 C.F.R. § 4.14. Thus, the Board finds that separate service connection for a sleep disorder is not warranted, as it would violate the rule against pyramiding. See 38 C.F.R. § 4.14. As the Veteran's symptoms of sleep impairment have been attributed to her now service-connected MDD and are contemplated by the rating criteria for psychiatric disabilities, no further discussion of service connection for a sleep disorder is warranted. REASONS FOR REMAND 1. Entitlement to an initial compensable rating for hypothyroidism is remanded. 2. Entitlement to an effective date prior to June 28, 2013 for the award of service connection for hypothyroidism is remanded. In a January 2017 rating decision, the RO granted service connection for hypothyroidism and assigned an initial rating of 0 percent, effective June 28, 2013. In November 2017, the Veteran submitted a notice of disagreement (NOD) as to the initial rating and effective date assigned in that decision. To date, a statement of the case (SOC) has not been issued as it relates to these issues. The Board is required to remand the claims for issuance of a SOC. Manlicon v. West, 12 Vet. App. 238 (1999). These issues are not before the Board at this time, and will only be before the Board if the Veteran timely files a substantive appeal of the issues after the SOC is issued. 3. Entitlement to service connection for sexual dysfunction, claimed as loss of consortium, is remanded. The Veteran appears to contend that she experiences sexual dysfunction secondary to her service-connected acquired psychiatric disorders. While the November 2019 private psychological evaluation report indicates that the Veteran has difficulty starting a romantic/sexual relationship with someone due to her agoraphobia, it is not clear from the record that such symptoms constitute a separate diagnosis of sexual dysfunction. To date, VA has not obtained a competent medical examination and opinion addressing this claim. Accordingly, a VA examination is necessary prior to further adjudication. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 4. Entitlement to service connection for loss of balance is remanded. The Veteran contends that she experiences loss of balance secondary to her service-connected disabilities. An April 2003 VA examination report indicated that the Veteran felt dizzy during panic attacks. A March 2006 VA examination report also indicated that the Veteran experienced panic attacks characterized by symptoms of “shortness of breath, dizziness, lightheadedness, and the feeling as if she is going to black out.” The Board notes that these symptoms may cause or aggravate balance difficulties. To date, VA has not obtained a competent medical examination and opinion addressing this claim. Accordingly, a VA examination is necessary prior to further adjudication. See McLendon, supra. 5. Entitlement to a TDIU is remanded The Board in this decision has granted service connection for an acquired psychiatric disorder, to include MDD, SDD, and agoraphobia with panic attacks. The RO’s implementation of this new award of service-connection may impact the issue of entitlement to a TDIU. Therefore, remand is necessary. In addition, the Veteran is not entitled to a TDIU based on her current schedular rating. See 38 C.F.R. § 4.16 (indicating that a TDIU is warranted where the Veteran meets certain schedular requirements but that it is VA's policy that a TDIU is warranted whenever a Veteran is unemployable due to service connected disability). However, as the Board cannot consider entitlement to extraschedular TDIU under 38 C.F.R. § 4.16(b) in the first instance, this issue must be remanded for referral to the Director, Compensation Service. Bowling v. Principi, 15 Vet. App. 1, 10 (2001). The matters are REMANDED for the following action: 1. Issue a SOC on the issues of entitlement to an initial compensable rating for hypothyroidism and an effective date prior to June 28, 2013 for the award of service connection for hypothyroidism. The Veteran should be advised of the time limit for perfecting an appeal, and afforded such period of time to do so. If he timely perfects an appeal of these matters, it should be returned to the Board. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of any current sexual dysfunction and balance impairments. The entire claims file, including a copy of the Remand, should be made available to, and be reviewed by, the VA examiner. All appropriate tests, studies, and consultation should be accomplished, and all clinical findings should be reported in detail. **IF an in-person examination is not feasible given the circumstances surrounding the recent pandemic, attempt to obtain the necessary medical information and opinions through other means, such as scheduling the Veteran for a virtual interview with a VA examiner or referring the case to the appropriate VA medical professional for a thorough review of the record and medical opinion. After examination of the Veteran and review of the claims file, the examiner(s) should: a. Indicate whether the Veteran has a current diagnosis or symptoms of sexual dysfunction or balance impairments. b. If so, provide an opinion as to whether such diagnosis or symptoms are at least as likely as not (i.e., 50 percent or greater probability) proximately due to, or aggravated by, the Veteran's service-connected disabilities, to include MDD, SSD, agoraphobia with panic attacks, hypothyroidism, and migraine headaches with vision disturbances and near syncope. A detailed rationale should be provided for the opinion(s) rendered. 3. Implement the Board’s award of service connection for an acquired psychiatric disorder, to include MDD, SDD, and agoraphobia with panic attacks. 4. Then, if the Veteran is not entitled to a TDIU based on her schedular rating for any part of the period on appeal, refer the issue of entitlement to a TDIU to the Director, Compensation Service, for consideration of entitlement to an extraschedular TDIU. 5. Then, readjudicate the remaining issues on appeal. T. Berry Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Thomas, 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.