Citation Nr: 21032349 Decision Date: 05/26/21 Archive Date: 05/26/21 DOCKET NO. 16-25 676 DATE: May 26, 2021 ORDER Entitlement to a higher initial rating for an anxiety disorder with alcohol use disorder, rated as 30 percent for prior to January 1, 2021 and 70 percent thereafter, is denied. REMANDED Entitlement to service connection for chronic fatigue syndrome, to include as due to service in Southwest Asia or as an undiagnosed illness, is remanded. Entitlement to service connection for a skin disorder, to include as due to service in Southwest Asia or as an undiagnosed illness, is remanded. Entitlement to service connection for chronic joint pain, to include as due to service in Southwest Asia or as an undiagnosed illness, is remanded. Entitlement to service connection for headaches, to include as due to service in Southwest Asia or as an undiagnosed illness, is remanded. FINDINGS OF FACT 1. For the appeal period prior to January 1, 2021, the impairment associated with the Veteran's anxiety disorder with alcohol use disorder was productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks without occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas or total occupational and social impairment. 2. For the appeal period beginning January 1, 2021, the impairment associated with the Veteran's anxiety disorder with alcohol use disorder has been productive of occupational and social impairment with deficiencies in most areas without total occupational and social impairment. CONCLUSION OF LAW The criteria for a higher initial rating for an anxiety disorder with alcohol use disorder, rated as 30 percent disabling prior to January 1, 2021 and 70 percent thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.14.14, 4.126, 4.130, Diagnostic Code 9400. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran had active military service from August 1989 to August 1992, to include service in Southwest Asia (Iraq) during the Persian Gulf War. These matters come to the Board of Veterans' Appeals (Board) on appeal from a December 2015 rating decision issued by the Department of Veterans Affairs (VA). In March 2020, the Veteran testified at a video conference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is included in the claims file. This case was before the Board in September 2020, at which time the issues currently on appeal was remanded for additional development. The case has now been returned to the Board for further appellate action. In a January 2021 rating decision, the Veteran was assigned a higher rating for his service-connected anxiety disorder with alcohol use disorder from 30 percent to 70 percent, effective January 1, 2021. As the Veteran is presumed to seek the maximum available benefits, this issue remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Increased Rating Claims Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Board must also consider staged ratings. Hart v. Mansfield, 21 Vet. App. 505, 50910 (2007). The Veteran's entire history is considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A review of the recorded history of a disability is necessary to make an accurate rating. 38 C.F.R. §§ 4.2, 4.41. The regulations do not give past medical reports precedence over current findings where such current findings are adequate and relevant to the rating issue. Francisco v. Brown, 7 Vet. App. 55 (1994); Powell v. West, 13 Vet. App. 31 (1999). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 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; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Anxiety Disorder with Alcohol Use Disorder The Veteran generally asserts that he should have higher ratings for his anxiety disorder with alcohol use disorder as it is worse than contemplated by the currently assigned ratings. This appeal stems from a claim dated in August 2015. During the period on appeal, the Veteran's anxiety disorder with alcohol use disorder is rated 30 percent prior to January 1, 2021 and 70 percent thereafter under Diagnostic Code 9400, which assigns ratings based upon the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. A 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal, due to such symptoms as: depressed mood, anxiety, suspiciousness, weekly or less often panic attacks, chronic sleep impairment, and mild memory loss, such as forgetting names, directions, recent events. Id. A 50 percent rating is warranted when there is 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 such as, retention of only highly learned material, forgetting to complete tasks; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to 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, or 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 circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. Id. A maximum 100 percent rating is warranted 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; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; disorientation to time and place; memory loss for names of close relatives, own occupation, or own name. Id. The symptoms listed in the General Rating Formula for Mental Disorders are not intended to constitute an exhaustive list. Rather, the symptoms serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In addition, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the lengths of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all 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. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. The Board notes that with regard to the use of the phrase "such as" in 38 C.F.R. § 4.130 (General Rating Formula for Mental Disorders), ratings are assigned according to the manifestations of particular symptoms. However, the use of the phrase "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve only as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment. The Board acknowledges that psychiatric examinations frequently include assignment of a global assessment of functioning (GAF) score. The American Psychiatric Association has released the Diagnostic and Statistical Manual of Mental Disorders (5th Ed.) (DSM-5), and 38 C.F.R. § 4.130 has been revised to refer to the DSM-5. The DSM-5 does not contain information regarding GAF scores. Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders to remove outdated references to the DSM-IV and replace them with references to the DSM-5. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). VA adopted as final, without change, the interim final rule and clarified that the provisions of the final rule did not apply to claims that were pending before the Board, this Court, or the U.S. Court of Appeals for the Federal Circuit on August 4, 2014, even if such claims were subsequently remanded to the agency of original jurisdiction. See 80 Fed. Reg. 14,308 (Mar. 19, 2015). In Golden v. Shulkin, 29 Vet. App. 221 (2018), the Court held that given that the DSM-5 abandoned the GAF scale and that VA has formally adopted the DSM-5, the Board errs when it uses GAF scores to assign a psychiatric rating in cases where the DSM-5 applies. This appeal was initially certified to the Board in June 2016. As such, the DSM-5 applies, and the GAF scores will not be considered. A review of the record reveals that the Veteran sought mental health treatment from VA facilities, as well as treatment for his other health needs. To the extent that the Veteran's treatment records contain information relevant to the severity of his mental health, to include mental health screenings, the Board will summarize this evidence. In October 2015, the Veteran was afforded a VA examination. At that time, the examiner diagnosed generalized anxiety disorder and alcohol use disorder, in early remission. The Veteran reported that he had two children and that he lived with his son. He indicated that he enjoyed social time with his family and that he and his son enjoyed hunting, camping and fishing. The Veteran reported that he had limited interactions with friends because most of them were frequently consumed alcohol. The Veteran indicated that he worked as a communications circuit designer and that he had worked for the same company for approximately 16 years. The Veteran indicated that he experienced difficulty with concentration on the job, but he denied experiencing any additional occupational difficulties. On examination, the Veteran presented as neatly groomed, clean and appropriately dressed. Psychomotor activity, thought process, thought content, and speech were found to be unremarkable. The Veteran was found to be cooperative, friendly, relaxed and attentive. His affect was found to be normal with mildly anxious mood. The Veteran was found to be well oriented to person, place and time. The Veteran denied experiencing delusions, ritualistic behavior, and hallucinations, as well as suicidal or homicidal ideation or intent. The Veteran reported that he did not have difficulty maintaining hygiene or performing activities of daily living. The examiner reported that the Veteran's anxiety disorder with alcohol use disorder was productive of anxiety, mild memory loss, suspiciousness, hypervigilance, problems with concentration, and sleep disturbances. The examiner opined that the Veteran's anxiety disorder with alcohol use disorder was most productive of occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. At a September 2017 VA mental health appointment, the Veteran indicated that he worked full-time and that he had recently purchased a house for him and his children to live. At that time, the Veteran appeared appropriately groomed and casually dressed. He was found to be well-oriented to person, place and time. His mood was found to be euthymic with normal affect. Speech, thought process, insight and judgment were found to be within normal limits. The Veteran denied experiencing delusions or hallucinations, as well as suicidal or homicidal ideation or intent. An October 2018 VA mental health notes shows that the Veteran worked full-time and lived with his son. At that time, the Veteran appeared casually dressed with good hygiene. Motor skills, speech and thought content were found to be within normal limits. His mood was up and down with full range of affect. The Veteran denied experiencing delusions or hallucinations, as well as suicidal or homicidal ideation or intent. Memory, insight and judgment were found to be intact and the Veteran was found to be well oriented to person, place and time. At an October 2019 VA mental health appointment, the Veteran indicated that he was on short-term disability due to his back and neck conditions and that he lived with his son. At that time, the Veteran presented as tired and fidgety. He appeared alert and cooperative. Attention, judgment, insight, concentration and memory were found to be within normal limits. The Veteran was found to be well-oriented to person, place and time, and thought process and content were normal. The Veteran denied homicidal and suicidal ideations and intent, as well as hallucinations and delusions. At a March 2020 hearing before the Board, the Veteran reported that he experienced anxiety attacks when triggered and that it sometimes resulted in a small amount of hyper-aggression. The Veteran indicated that panic attacks occurred sporadically, sometimes three per month and sometimes a couple of months between attacks. The Veteran indicated that he was on short-term disability leave from work due to his back pain. The Veteran reported that he did not bathe every day. He attributed going days without bathing to depression and physical pain. The Veteran indicated that he had tried dating but that none had been successful in the long term. At a December 2020 mental health consultation, the Veteran denied homicidal ideations or attempts as well as hallucinations and delusions. The provider indicated that the Veteran's concentration, speech, thought process and memory, were all within normal limits. The examiner reported that the Veteran appeared alert and cooperative, with euthymic mood and broad affect. The Veteran was found to be well oriented to person, place and time and judgment, insight and memory were found to be intact. At a January 2021 VA examination, the Veteran reported that he used prescription medication to treat his mental health disorder. He indicated that he received intensive out-patient substance abuse treatment for alcohol abuse from September 2020 to November 2020. The Veteran reported that he was single and lived with one of his children. He indicated that he had two children with who he had good relationships. The Veteran reported that his parents lived close by and that he had a good relationship with them as well as his siblings. He indicated that he was employed as a designer for a communications company and that he had been employed at this job for 21 years. The Veteran reported that he enjoyed his job but that he had experienced several health problems in the past few years that had added stress and lead to decreased work productivity. On examination, the Veteran presented as pleasant and cooperative. He made appropriate eye contact and interacted appropriately. He was appropriately dressed. His mood was found to be depressed with anxious affect. He indicated that he experienced increased difficulty with maintaining minimal personal hygiene and other basic activities of daily living. Thought process and communication were found to be normal. The Veteran denied experiencing delusions or hallucinations, as well as suicidal or homicidal ideation or intent. The examiner reported that the Veteran's anxiety disorder with alcohol use disorder was productive of depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including a work or a work like setting, and neglect of personal appearance and hygiene. The examiner opined that the Veteran's anxiety disorder with alcohol use disorder was most productive of occupational and social impairment with reduced reliability and productivity. A review of the record shows that the Veteran receives treatment at the VA Medical Center for various disabilities. However, there is no indication from the record that his alcohol disorder with alcohol use disorder symptoms are manifestly different than those reported at above-mentioned examinations and treatment notes. Of note, throughout the appeal period, the Veteran has denied experiencing suicidal ideations. Indeed, as much was noted in the VA treatment records as well as the private and VA examination reports of record. After reviewing the foregoing evidence, the Board first finds that entitlement to a rating in excess of 30 percent is not warranted for the period on appeal prior to January 21, 2021. To that end, the evidence does not show that the Veteran has had occupational and social impairment with reduced reliability and productivity or occupational and social impairment with deficiencies in most areas for the appeal period prior to January 21, 2021. In this regard, the October 2015 VA examiner reported that the Veteran's anxiety disorder with alcohol use disorder was productive of occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. The Board considered the lay statements of record describing symptoms, and considers them to be probative, but finds that they are representative of symptomatology that most closely approximates a rating of 30 percent. To that end, the evidence does not reflect that the Veteran had trouble with speech, panic attacks more than once a week, difficulty understanding complex commands, impaired memory, judgment, or abstract thinking, difficulty in establishing and maintaining effective work and social relationships, or disturbances of motivation or mood not already considered in the 30 percent rating during this period. In fact, the examiner's responses suggest these symptoms were not present. The Veteran was able to appropriately engage with the examiner and was described as cooperative and well-oriented to all spheres during the examination. Occupational and social impairment with deficiencies in most areas was ot shown for the appeal period prior to January 21, 2021. Impairment to mood was demonstrated as the Veteran consistently reported anxiety. Impairment to work was not demonstrated as the Veteran reported that he maintained full-time employment during the appeal period. At the October 2015 VA examination, the Veteran reported that he worked full-time as a designer for a communications company. The October 2019 mental health note shows that the Veteran was on short-term disability; however, it was related to his back and neck disabilities and not his anxiety disorder with alcohol use disorder. Impairment to family relations was not demonstrated as he reported maintaining good relationships with his children, parents and siblings throughout the appeal. Impairment to judgment and thinking was not shown by the record as thought processes, insight and judgment were consistently found to be within normal limits. School was not attempted during the appeal period. Further, there is no evidence that the Veteran experienced suicidal ideations or intent. When taking into account all of the symptomatology of record, social, and occupational impairment was to a lesser degree than reduced reliability and productivity. See Bankhead v. Shulkin, No. 15-2404 (Vet. App. May 9, 2017) (noting that the presence or lack of evidence of a specific sign or symptom listed in the evaluation criteria is not necessarily dispositive of any particular disability level); Vazquez-Claudio, 713 F.3d at 117 -18. In that regard, as noted above, although the Veteran's symptoms are the "primary consideration" in assigning an evaluation under § 4.130, the determination of a particular evaluation requires a factual conclusion as to the level of occupational and social impairment. The Board acknowledges that the symptoms reported at the January 2021 VA examination meet the criteria for a higher rating. However, the date of the VA examination is the earliest date from which it is factually ascertainable that the Veteran experienced symptoms associated with a higher rating, such as neglect of personal appearance and hygiene, and difficulty in adapting to stressful circumstances. Prior to the date of that examination, the record does not contain evidence that the Veteran's anxiety disorder with alcohol use disorder was productive of such symptomatology. Therefore, a higher rating is not warranted prior to January 21, 2021. See 38 C.F.R. § 4.130, Diagnostic Code 9400. In addition, the record reflects that the Veteran's symptoms have not been consistent with total occupational and social impairment such that a 100 percent disability rating is warranted at any point during the pendency of the appeal. In that regard, the Veteran has not displayed gross impairment in thought processes or communication, nor has the record shown that he is a persistent danger of hurting himself or others or grossly inappropriate behavior. Moreover, there is no evidence that the Veteran has experienced hallucinations or delusions, or obsessive rituals. Further, the Veteran has not displayed disorientation to time or place, or memory loss for names of close relatives, his prior occupations, or his own name. Although the Veteran indicated that he experienced greater difficulty bathing, he appeared well dressed at both examination and his decision to shower less frequently appears to be substantially related to physical pain. Here, while the Veteran reports not bathing for periods of a few days since he has been on short-term disability, there is no evidence or allegation that he was unable to maintain minimal personal hygiene such as brushing his teeth and washing his hands. The Veteran did not display an intermittent inability to perform activities of daily living and had reported that he maintained full-time employment throughout the appeal period, other than for a period he was on short-term disability related to his back and neck disabilities. In terms of social impairment, the Veteran reported that he had a good relationship with his children, parents and siblings. This is not a disability picture indicating total occupational and social impairment. In assessing the severity of the anxiety disorder with alcohol use disorder, the Board has considered the competent lay assertions regarding symptoms experienced and observed. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994) and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, the criteria needed to support higher ratings as the required medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of any higher rating pursuant to any applicable criteria at any point pertinent to this appeal. The Board notes the contentions of the Veteran that his anxiety disorder with alcohol use disorder is more severe than currently shown on examination; and the Board observes that the Veteran, while competent to report his observable symptoms, he is not competent to report that his mental health symptoms are of sufficient severity to warrant a higher rating under VA's tables for rating such disabilities because such an opinion requires medical expertise which he has not been shown to have. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002). Despite the foregoing, the Board acknowledges the Veteran and his representative's reports of the Veteran's symptoms. However, even after considering such contentions as to the effects of the disability on his daily life, the Board finds that the criteria for a higher 50, 70 or 100 percent ratings are not met, respectively. The Rating Schedule contemplates such impairment under the ordinary conditions of daily life. 38 C.F.R. § 4.10; see also Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). This argument is therefore without merit. The Board has considered whether additional staged ratings under Hart, supra is appropriate; however, the Board finds that his symptomatology has been stable throughout each period on appeal. Therefore, assigning additional staged ratings is not warranted. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). The Board is cognizant of the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a TDIU rating, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim. However, Rice is not applicable in this case. The Veteran's reported that aside from a period of short-term disability related to back and neck disabilities, he has been employed full-time throughout the period on appeal. Moreover, he has not asserted at any point in time that he is unable to secure and maintain employment due to his service-connected anxiety disorder with alcohol use disorder. In this case, the preponderance of the evidence is against a rating in excess of 30 percent for alcohol disorder with alcohol use disorder prior to January 1, 2021 and a rating in excess of 70 percent beginning January 1, 2021; and the claims must, accordingly, be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND The Board finds that additional development is required before the remaining claims on appeal may be decided. Service Connection Chronic Fatigue Syndrome In December 2020, the Veteran was afforded a VA examination. At that time, the Veteran indicated that he had difficulty staying awake and that he occasionally slept for long periods of time. The Veteran reported that he often lacked energy and that he had trouble sleeping. The examiner reported that the Veteran did not have a diagnosis of chronic fatigue syndrome; however, the examiner noted that in order to establish whether the Veteran had a diagnosis of chronic fatigue syndrome, a more complete workup was required. Additionally, the examiner indicated that no sleep study was conducted. The Board finds that it is unable to decide the claim based on the findings contained in the December 2020 VA examination report. In this regard, the examiner reported that the Veteran experienced symptoms of sleep impairment; however, no sleep study had been performed and the examiner indicated that additional testing was required to either diagnose or rule out a diagnosis of chronic fatigue syndrome. Therefore, the Board finds that the Veteran should be afforded a new VA examination to determine the nature and etiology of his claimed chronic fatigue syndrome. Stegall v. West, 11 Vet. App. 268 (1998). Skin Disorder At a December 2020 VA examination, the examiner reported that the Veteran did not have a diagnosed skin condition. At that time, the Veteran reported that he first experienced a rash on the back on his neck during service in approximately 1991 and that the rash has continuously come and gone since that time. The Veteran also indicated that he experienced a skin lesion on his right jaw joint that began in approximately 1990 that also comes and goes and is aggravated by shaving. The Veteran indicated that these skin conditions are productive of burning and itching when present. Additionally, the Veteran provided pictures of these two skin conditions that appeared recent. Ultimately, as there was no evidence of a skin condition on examination, the examiner opined that the Veteran did not have a skin condition that was related to his period of active service. The Board finds that it is unable to decide the claim based on the findings contained within the December 2020 VA medical opinion report. In this regard, the examiner indicated that the Veteran did not have a skin disorder; however, the Veteran indicated that his skin disorder was not present at that time, but that it was present at times during the period on appeal. Moreover, the Veteran submitted photographs of his skin disorders that appeared to be recent. As such, there is evidence that the Veteran has a current diagnosis of a skin disorder during the period on appeal. Therefore, the Board finds that a new VA medical opinion is warranted to address the nature and etiology of the Veteran's claimed skin disorder. Stegall v. West, supra. Chronic Joint Pain The Veteran asserts that he has a disability manifested by chronic joint pain that is related to his period of active service, to include exposure to environmental toxins in Southwest Asia. In his June 1992 separation examination Report of Medical History, the Veteran indicated that he experienced painful joints and recurrent back pain. At his March 2020 hearing before the Board, the Veteran reported that the Veteran indicated that the onset of joint pain began shortly after his separation from service and has become progressively worse since that time. In a June 2020 VA primary care note, the Veteran complained of joint and muscle pain. At that time, the physician commented that the Veteran's symptoms were consistent with fibromyalgia but indicated that other etiologies such as inflammatory, neuropathy and infectious needed to be ruled out. In a December 2020 VA medical opinion report, the examiner reported that the Veteran did not have a diagnosis of chronic joint pain "outside of subjective reporting on separation examination in 1992 with normal exam and not evaluated until August 20, 2015." The Board finds that it is unable to decide the claim based on the findings contained in the December 2020 VA examination report. In this regard, the examiner reported that the Veteran complained on chronic joint pain and indicated that recent medical records showed complaints of joint pain, to include a June 2020 report from his primary physician indicating that the Veteran may have fibromyalgia. However, the examiner did not explain the Veteran's reports of chronic joint pain were not indicative of a disability manifested by chronic joint pain, to include the possibility that the Veteran may have fibromyalgia. Therefore, the Board finds that the Veteran should be afforded a new VA examination to determine the nature and etiology of his claimed chronic joint pain. Stegall v. West, supra. Headaches In December 2020, the Veteran was afforded a VA examination. At that time, the examiner commented that the Veteran reported a history of frequent headaches on his enlistment examination. The examiner indicated that the Veteran's record reflected that he experienced headaches prior to service and that because the Veteran's headaches did not appear to have changed until 2008, 16 years after service, it is unlikely that military service caused or resulted in any abnormal progression of the condition. The Board finds that it is unable to decide the claim based on the findings contained in the December 2020 VA examination report. In this regard, the examiner did not provide a rationale as to why the Veteran's headaches did not appear to have been aggravated by service. Moreover, although the Veteran's May 1989 Report of Medical History reflects that the Veteran had, in pertinent part, indicated that he experienced frequent headaches; clinical evaluation did not reveal any head or sinus conditions. As such, the Veteran is entitled to the presumption of soundness. Additionally, the record reflects that the Veteran's headaches may be related to his claimed chronic fatigue syndrome. Therefore, the Board finds that the Veteran should be afforded a new VA examination to determine the nature and etiology of his claimed headaches. Stegall v. West, supra. The matters are REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records from January 2021 to present. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and her representative and afford him an opportunity to submit any copies in their possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, schedule the Veteran for a Gulf War VA examination by an examiner with sufficient expertise to address the nature and etiology of the Veteran's chronic fatigue syndrome. The claims file must be made available to the examiner in conjunction with the examination. Any indicated studies should be conducted, to include a sleep study. The need for further in-person examination is left to the discretion of the examiner. Based on the examination of the Veteran and review of the record, the examiner should provide a current diagnosis for all disabilities related to the Veteran's claimed chronic fatigue. If the Veteran is found to experience chronic fatigue that is not supported by underlying pathology sufficient to make a clinical diagnosis of a disability, then that information should be specifically noted in the examination report. Then, the examiner should provide an opinion for all diagnosed disabilities as to whether it is at least as likely as not (50 percent or better probability) that any currently present disability manifested by chronic fatigue had its onset during the Veteran's active service, or is otherwise etiologically related to such service, to specifically include environmental exposures sustained while serving in Southwest Asia. If the Veteran's symptoms of chronic fatigue cannot be ascribed to any known clinical diagnosis, specify whether the Veteran has objective indications of a chronic disability resulting from an undiagnosed illness, as established by history, physical examination, and laboratory tests, that have either (1) existed for six months or more, or (2) exhibited intermittent episodes of improvement and worsening over a six-month period. If the Veteran's symptoms of chronic fatigue cannot be ascribed to any known clinical diagnosis, then is it at least as likely as not that the Veteran's symptoms represent a "medically unexplained chronic multisymptom illness" (MUCMI)? Such is defined as a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. A complete rationale should be given for each opinion expressed. In this regard, a discussion of the facts and medical principles involved would be considerable assistance to the Board. 3. Following the receipt of outstanding records, schedule the Veteran for a Gulf War VA examination by an examiner with sufficient expertise to address the nature and etiology of the Veteran's claimed skin disorder to include a neck rash. The need for a physical examination is left to the discretion of the medical professional offering the medical opinion. The record must be made available to the examiner for review, and the examiner should indicate that the record was reviewed in connection with the examination. All indicated tests and studies should be accomplished and the findings then reported in detail. If the Veteran is found to experience a skin disorder or neck rash that is not supported by underlying pathology sufficient to make a clinical diagnosis of a disability, then that information should be specifically noted in the examination report. Then, the examiner should provide an opinion for all diagnosed disabilities as to whether it is at least as likely as not (50 percent or better probability) that any currently present skin disability manifested by a neck/jaw rash had its onset during the Veteran's active service, or is otherwise etiologically related to such service, to specifically include environmental exposures sustained while serving in Southwest Asia. The examiner must consider the Veteran's lay statements regarding the onset and continuity of his symptoms, to include his reports that he experienced a neck rash and right jaw lesions that come and go, as well as the photographs provided by the Veteran in January 2021 showing evidence of such. If the Veteran's symptoms of neck/jaw rash or skin disorder cannot be ascribed to any known clinical diagnosis, specify whether the Veteran has objective indications of a chronic disability resulting from an undiagnosed illness, as established by history, physical examination, and laboratory tests, that have either (1) existed for six months or more, or (2) exhibited intermittent episodes of improvement and worsening over a six-month period. If the Veteran's symptoms of neck/jaw rash or skin disorder cannot be ascribed to any known clinical diagnosis, then is it at least as likely as not that the Veteran's symptoms represent a "medically unexplained chronic multisymptom illness" (MUCMI)? Such is defined as a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. A complete rationale should be given for each opinion expressed. In this regard, a discussion of the facts and medical principles involved would be considerable assistance to the Board. 4. Following the receipt of outstanding records, schedule the Veteran for a Gulf War VA examination by an examiner with sufficient expertise to address the nature and etiology of the Veteran's chronic joint pain. The claims file must be made available to the examiner in conjunction with the examination. Any indicated studies should be conducted. The need for further in-person examination is left to the discretion of the examiner. Based on the examination of the Veteran and review of the record, the examiner should provide a current diagnosis for all disabilities related to the Veteran's chronic joint pain. If the Veteran is found to experience chronic joint pain that is not supported by underlying pathology sufficient to make a clinical diagnosis of a disability, then that information should be specifically noted in the examination report. Then, the examiner should provide an opinion for all diagnosed disabilities as to whether it is at least as likely as not (50 percent or better probability) that any currently present disability manifested by chronic joint pain, to specifically include consideration of a diagnosis of fibromyalgia and/or arthralgia, had its onset during his active service, or is otherwise etiologically related to such service, to specifically include environmental exposures sustained while serving in Southwest Asia. If the Veteran's symptoms of joint pain cannot be ascribed to any known clinical diagnosis, specify whether the Veteran has objective indications of a chronic disability resulting from an undiagnosed illness, as established by history, physical examination, and laboratory tests, that have either (1) existed for six months or more, or (2) exhibited intermittent episodes of improvement and worsening over a six-month period. If the Veteran's symptoms of joint pain cannot be ascribed to any known clinical diagnosis, then is it at least as likely as not that the Veteran's symptoms represent a "medically unexplained chronic multisymptom illness" (MUCMI)? Such is defined as a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. A complete rationale should be given for each opinion expressed. In this regard, a discussion of the facts and medical principles involved would be considerable assistance to the Board. 5. Following the receipt of outstanding records and development for entitlement to service connection for chronic fatigue syndrome, schedule the Veteran for a Gulf War VA examination by an examiner with sufficient expertise to address the nature and etiology of the Veteran's claimed headaches. The claims file must be made available to the examiner in conjunction with the examination. Any indicated studies should be conducted. The need for an in-person examination is left to the discretion of the examiner. Based on the examination of the Veteran and review of the record, the examiner should provide a current diagnosis for all disabilities related to the Veteran's headaches. If the Veteran is found to experience headaches that are not supported by underlying pathology sufficient to make a clinical diagnosis of a disability, then that information should be specifically noted in the examination report. Then, the examiner should provide an opinion for the following: (A) Did the Veteran have headaches that clearly and unmistakably existed at the time of his entry into either period of active service? If so, was any such pre-existing headaches were clearly and unmistakably NOT aggravated by that service? If the answer to either part of the above question is yes, the examiner should specifically note what evidence compels that finding. The Veteran's statements alone do not constitute clear and unmistakable evidence of a headache disability preexisting service. (B) If headaches did not preexist service, or preexisted service but is not shown to have clearly and unmistakably NOT been aggravated by service, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's headache disability had its onset during the Veteran's active service, or is otherwise etiologically related to such service, to include environmental exposures sustained while serving in Southwest Asia, as well as the Veteran's assertion that his headaches may be related to medicine the Veteran was given to treat the affects of neurological conditions related to exposure to gas and other environmental toxins. The examiner should consider the Veteran's statements regarding the onset and continuity of his symptoms. (C) If the answer to the above is no, the examiner should provide an opinion t is at least as likely as not (50 percent or better probability) that the any currently present headache disability was caused OR aggravated by his chronic fatigue syndrome? If the Veteran's symptoms of headaches cannot be ascribed to any known clinical diagnosis, specify whether the Veteran has objective indications of a chronic disability resulting from an undiagnosed illness, as established by history, physical examination, and laboratory tests, that have either (1) existed for six months or more, or (2) exhibited intermittent episodes of improvement and worsening over a six-month period. If the Veteran's symptoms of headaches cannot be ascribed to any known clinical diagnosis, then is it at least as likely as not that the Veteran's symptoms represent a "medically unexplained chronic multisymptom illness" (MUCMI)? Such is defined as a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. A complete rationale should be given for each opinion expressed. In this regard, a discussion of the facts and medical principles involved would be considerable assistance to the Board. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Christopher O'Donnell, 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.