Citation Nr: 22016192 Decision Date: 03/21/22 Archive Date: 03/21/22 DOCKET NO. 18-15 536 DATE: March 21, 2022 ORDER The appeal of the issue of entitlement to service connection for diabetes mellitus with peripheral neuropathy of the bilateral lower extremities is dismissed. The appeal of the issue of entitlement to service connection for chronic cholecystitis is dismissed. The appeal of the issue of entitlement to service connection for a bilateral foot disability is dismissed. The appeal of the issue of entitlement to service connection for latus degeneration of both retinas is dismissed. The appeal of the issue of entitlement to service connection for a heart disability is dismissed. The appeal of the issue of entitlement to service connection for acute costochondritis is dismissed. The appeal of the issue of entitlement to service connection for vasovagal syncope is dismissed. The appeal of the issue of entitlement to service connection for fibroid cysts is dismissed. The appeal of the issue of entitlement to service connection for anemia is dismissed. The appeal of the issue of entitlement to service connection for chronic fatigue syndrome is dismissed. The appeal of the issue of entitlement to service connection for cognitive dysfunction is dismissed. The appeal of the issue of entitlement to service connection for hair loss is dismissed. The appeal of the issue of entitlement to service connection for upper and lower respiratory infections is dismissed. The appeal of the issue of entitlement to service connection for a disability manifested by neurological symptoms is dismissed. The appeal of the issue of entitlement to service connection for Gulf War syndrome is dismissed. The appeal of the issue of entitlement to service connection for thalassemia is dismissed. The appeal of the issue of entitlement to service connection for a gastrointestinal disability is dismissed. Entitlement to a rating of 30 percent, and no higher, for irritable bowel syndrome (IBS) is granted. Entitlement to service connection for migraine headaches is granted. REMANDED Entitlement to service connection for a psychiatric disability to include anxiety, posttraumatic stress disorder (PTSD), and depression, is remanded. Entitlement to service connection for residuals of a traumatic brain injury (TBI) is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. FINDINGS OF FACT 1. In October 2021 written correspondence, the appellant withdrew the pending appeal of the claim of entitlement to service connection for diabetes mellitus with peripheral neuropathy of the bilateral lower extremities. 2. In October 2021 written correspondence, the appellant withdrew the pending appeal of the claim of entitlement to service connection for chronic cholecystitis. 3. In October 2021 written correspondence, the appellant withdrew the pending appeal of the claim of entitlement to service connection for a bilateral foot disability. 4. In October 2021 written correspondence, the appellant withdrew the pending appeal of the claim of entitlement to service connection for latus degeneration of both retinas. 5. In October 2021 written correspondence, the appellant withdrew the pending appeal of the claim of entitlement to service connection for a heart disability. 6. In October 2021 written correspondence, the appellant withdrew the pending appeal of the claim of entitlement to service connection for acute costochondritis. 7. In October 2021 written correspondence, the appellant withdrew the pending appeal of the claim of entitlement to service connection for vasovagal syncope. 8. In October 2021 written correspondence, the appellant withdrew the pending appeal of the claim of entitlement to service connection for fibroid cysts. 9. In October 2021 written correspondence, the appellant withdrew the pending appeal of the claim of entitlement to service connection for anemia. 10. In October 2021 written correspondence, the appellant withdrew the pending appeal of the claim of entitlement to service connection for chronic fatigue syndrome. 11. In October 2021 written correspondence, the appellant withdrew the pending appeal of the claim of entitlement to service connection for cognitive dysfunction. 12. In October 2021 written correspondence, the appellant withdrew the pending appeal of the claim of entitlement to service connection for hair loss. 13. In October 2021 written correspondence, the appellant withdrew the pending appeal of the claim of entitlement to service connection for upper and lower respiratory infections. 14. In October 2021 written correspondence, the appellant withdrew the pending appeal of the claim of entitlement to service connection for a disability manifested by neurological symptoms. 15. In October 2021 written correspondence, the appellant withdrew the pending appeal of the claim of entitlement to service connection for Gulf War syndrome. 16. In October 2021 written correspondence, the appellant withdrew the pending appeal of the claim of entitlement to service connection for thalassemia. 17. In October 2021 written correspondence, the appellant withdrew the pending appeal of the claim of entitlement to service connection for a gastrointestinal disability. 18. Throughout the appeal period, the appellant's service-connected IBS has been manifested by severe diarrhea with recurrent abdominal distress. 19. Resolving any reasonable doubt in the appellant's favor, the appellant's migraine headache disability developed during active duty with continuing symptomatology since service. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the pending appeal of the claim of entitlement to service connection for diabetes mellitus with peripheral neuropathy of the bilateral lower extremities have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The criteria for withdrawal of the pending appeal of the claim of entitlement to service connection for chronic cholecystitis have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 3. The criteria for withdrawal of the pending appeal of the claim of entitlement to service connection for a bilateral foot disability have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 4. The criteria for withdrawal of the pending appeal of the claim of entitlement to service connection for latus degeneration of both retinas have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 5. The criteria for withdrawal of the pending appeal of the claim of entitlement to service connection for a heart disability have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 6. The criteria for withdrawal of the pending appeal of the claim of entitlement to service connection for acute costochondritis have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 7. The criteria for withdrawal of the pending appeal of the claim of entitlement to service connection for vasovagal syncope have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 8. The criteria for withdrawal of the pending appeal of the claim of entitlement to service connection for fibroid cysts have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 9. The criteria for withdrawal of the pending appeal of the claim of entitlement to service connection for anemia have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 10. The criteria for withdrawal of the pending appeal of the claim of entitlement to service connection for chronic fatigue syndrome have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 11. The criteria for withdrawal of the pending appeal of the claim of entitlement to service connection for cognitive dysfunction have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 12. The criteria for withdrawal of the pending appeal of the claim of entitlement to service connection for hair loss have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 13. The criteria for withdrawal of the pending appeal of the claim of entitlement to service connection for upper and lower respiratory infections have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 14. The criteria for withdrawal of the pending appeal of the claim of entitlement to service connection for a disability manifested by neurological symptoms have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 15. The criteria for withdrawal of the pending appeal of the claim of entitlement to service connection for Gulf War syndrome have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 16. The criteria for withdrawal of the pending appeal of the claim of entitlement to service connection for thalassemia have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 17. The criteria for withdrawal of the pending appeal of the claim of entitlement to service connection for a gastrointestinal disability have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 18. The criteria for entitlement to a rating of 30 percent, and no higher, for IBS have been met. 38 U.S.C. §§ 1151, 5107; 38 C.F.R. § 4.114, DC 7319. 19. The criteria for entitlement to service connection for migraine headaches have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant served on active duty in the U.S. Navy from January 1994 to August 1998, including service in the Southwest Asia theater of operations. See e.g. February 2018 rating decision. This matter comes before the Board of Veterans' Appeals (Board) from a June 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), which, in pertinent part, denied entitlement to a rating in excess of 10 percent for IBS, denied entitlement to a TDIU, and denied entitlement to service connection for (1) a psychiatric disability to include anxiety, PTSD, and depression; (2) a TBI; (3) headaches; (4) diabetes mellitus with peripheral neuropathy of the bilateral lower extremities; (5) chronic cholecystitis; (6) a bilateral foot disability; (7) latus degeneration of both retinas; (8) a heart disability; (9) acute costochondritis; (10) vasovagal syncope; (11) fibroid cysts; (12) anemia; (13) chronic fatigue syndrome; (14) cognitive dysfunction; (15) hair loss; (16) upper and lower respiratory infections; (17) a disability manifested by neurological symptoms; (18) Gulf War syndrome; (19) thalassemia; and (20) a gastrointestinal disability. The appellant filed a timely Notice of Disagreement (NOD), received in September 2013. A February 2018 rating decision, in pertinent part, increased the rating for irritable bowel syndrome to 30 percent, effective June 4, 2013. Although a higher rating was granted, the issue remains in appellate status, as the maximum schedular rating was not assigned for the entire period on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). A Statement of the Case (SOC) was issued in February 2018. A timely substantive appeal was received in March 2018. The appellant was afforded a virtual hearing before the undersigned Veterans Law Judge (VLJ) in September 2021. A transcript is of record. While the RO previously denied a claim of entitlement to service connection for PTSD in an unappealed June 2003 rating decision, as additional service treatment records have been associated with the claims file since such decision, reconsideration of the claim is required, as opposed to requiring new and material evidence. 38 C.F.R. § 3.156(c). The Board has recharacterized the issues of entitlement to service connection for anxiety, depression, and PTSD as entitlement to service connection for an acquired psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6, 8 (2009) (holding that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by a claimant's description of the claim, reported symptoms, and the other information of record). Withdrawal of Claims The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 19.55(a). Received in October 2021 was a statement from the appellant and her attorney which stated that the appellant wished to withdraw the issues of service connection for diabetes mellitus with peripheral neuropathy of the bilateral lower extremities, chronic cholecystitis, a bilateral foot disability, latus degeneration of both retinas, a heart disability, acute costochondritis, vasovagal syncope, fibroid cysts, anemia, chronic fatigue syndrome, cognitive dysfunction, hair loss, upper and lower respiratory infections, a disability manifested by neurological symptoms, Gulf War syndrome, thalassemia, and a gastrointestinal disability. The withdrawal was in writing, included the name of the appellant, the file number, and a clear statement that the appeal of the aforementioned issues was withdrawn. See Hembree v. Wilkie, 33 Vet. App. 1 (2020). Thus, the criteria for a withdrawal of these issues have been met and there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review these issues and such are dismissed. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if that disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where a claimant appeals the denial of a claim of an increased disability rating for a disability for which service connection was in effect before she filed the claim for increase, the present level of disability is the primary concern, and past medical reports should not be given precedence over current medical findings. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). Where VA's adjudication of the claim for increase is lengthy, and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different, or "staged," ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). The appellant's IBS has been rated analogously to irritable colon syndrome, pursuant to 38 C.F.R. § 4.114, Diagnostic Code (DC) 7319. Under DC 7319, a noncompensable rating is warranted for mild irritable bowel syndrome, with disturbances of bowel function with occasional episodes of abdominal distress. A 10 percent disability rating is warranted for moderate irritable bowel syndrome with frequent episodes of bowel disturbance and abdominal distress. A maximum schedular 30 percent disability rating is warranted for severe irritable bowel syndrome with diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress. 38 C.F.R. § 4.114, DC 7319. The words "mild," "moderate," and "severe" are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6. For purposes of this decision, the term "severe" is understood to mean extremely intense. WEBSTER'S II NEW COLLEGE DICTIONARY at 1012 (1995). 1. Entitlement to a rating in excess of 10 percent for IBS prior to June 4, 2013, and in excess of 30 percent thereafter. For the reasons that follow, the Board finds that the evidence is in relative equipoise as to whether a rating of 30 percent, and no higher, is warranted for the appellant's IBS for the entire period on appeal. Since June 4, 2013, the appellant has been in receipt of a 30 percent rating for IBS, which is the maximum schedular rating available under DC 7319. During a January 2011 VA examination, the appellant reported that her current IBS symptoms included alternating constipation and diarrhea, but mostly constipation, up to three weeks in duration each month, with one week of persistent diarrhea. Nausea without vomiting occurred several times per week. There was no history of ulcerative colitis, fistula, or ostomy. There was epigastric intestinal pain to both lower quadrants. This pain was stabbing in nature, occurred a few times per week, and lasted up to an hour, until pain medication kicked in. She described the pain as severe. The appellant also endorsed bloating, flatulence, fatigue, malaise, and intermittent perceived edema of the lower extremities. There was no history of a small-bowel obstruction. Activities of daily living were affected with toileting. There were no significant symptoms of weight loss or malnutrition; and there were no signs of anemia or fistula. A March 2011 colonoscopy report from Valley View Medical Center states that there were no pathologic findings except for hemorrhoids. Such had been ordered due to rectal bleeding. In February 2013, F.K., M.D., reported that the appellant experienced chronic diarrhea, nausea, abdominal pain and cramping, malaise, loss of appetite, fatigue, ineffective straining at stool (rectal tenesmus), and abdominal distension. The appellant's generalized abdominal pain occurred three to four times a week for five to six hours at a time. She also experienced constipation and pain 7/10. Prior to June 4, 2013, the Board finds that the appellant's IBS was also manifested by symptoms most nearly approximating severe irritable bowel syndrome with diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress. As such, a 30 percent rating is also warranted during that period. Again, 30 percent is the maximum schedular rating available under DC 7319. For these reasons, the record is sufficient to award a 30 percent rating, and no higher, for IBS for the entire period on appeal. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. "To establish a right to compensation for a present disability, a Veteran must show: '(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service'the so-called 'nexus' requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including organic diseases of the nervous system, such as migraine headaches, may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a) (3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 2. Entitlement to service connection for migraine headaches. For the reasons that follow, the Board finds that entitlement to service connection for migraine headaches is warranted. The appellant contends that her migraine headaches are related to an in-service head injury with loss of consciousness. Service treatment records reveal that the appellant was hospitalized from December 6, 1994, to December 9, 1994, following head trauma. She was found unconscious and unresponsive, lying on the deck. However, contemporaneous clinical records indicate that there was no persistent or prolonged loss of consciousness. During a January 1998 optometric examination, the appellant complained of headaches. On her July 1998 separation Report of Medical History, the appellant endorsed having frequent or severe headaches. The examiner elaborated that the appellant's reported headaches were status post 1994 head injury, with hospital admission, but that records were lost. Neurology evaluation was negative. Although the appellant was positive for experiencing occasional headaches, such were not considered disabling. On the July 1998 Report of Medical Assessment, it was noted that the appellant reported that she had been hospitalized in November 1994 for a head injury due to a hatch on a ship hitting her, and that she has had migraines ever since. The July 1998 separation examination was essentially normal regarding the head and neurology. In pertinent part, the post-service record on appeal includes a December 2010 private clinical note from Southwest Neurology which records the appellant's reports that she had fallen in her house and struck the back of her head the day prior. She stated that she had lost consciousness for a few seconds. She provided a history of vasovagal syncope which began in 1994 when she was struck on the head while on active duty, but not of headaches. The January 2011 VA examiner for fibromyalgia noted that the appellant had complained of headache, lightheadedness, and fatigue in November 2009, and that she later experienced a loss of consciousness in December 2010. The appellant was afforded a VA examination in March 2011. The claims file was reviewed. The appellant reported that she has experienced intermittent headaches since being hit by a hatch in 1994. Her headaches occur two to three times weekly, and last one to two hours. She must lie flat during headaches, cannot perform regular activities, and has light sensitivity. A negative medical opinion was offered, primarily on the basis that "there is no good evidence of a chronic condition." It was noted that the appellant had been diagnosed with fibromyalgia with associated headaches in January 2011, there was no evidence of headache chronicity in service treatment records or VA medical records. As such, it was less likely than not that the appellant had a chronic headache disability which was related to severe headaches in 1998. However, the Board finds the March 2011 medical opinion is inadequate to the extent that it does not consider the appellant's competent reports of continuity of symptomatology. Indeed, the Federal Circuit has held that a medical opinion which relies on the absence of contemporaneous medical evidence, and fails to consider whether lay statements present sufficient support of the etiology of the claimed disability, is inadequate. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). An MRI of the brain was performed in December 2012 due to headache and a family history of brain aneurysm. The impression was a normal study. An August 2020 medical opinion from L.R., M.D., is of record. Based upon patient-provided history and review of medical records, Dr. L.R. opined that the appellant's migraine headaches were as likely as not related to her in-service fall. References were made to medical studies regarding the relationships between head injuries and the development of headaches, but no other rationale was offered. The Board finds that, resolving any reasonable doubt in the appellant's favor, service connection for migraine headaches is warranted. The Board finds that the evidence, lay and medical, demonstrates that the appellant developed headaches in service, has a current diagnosis of migraine headaches and claims to have had chronic headaches since service. The Board has considered the medical opinion evidence of record but concludes that the appellant's statements and hearing testimony are of equal probative weight regarding the onset of her current headache disability. Since filing her claim, the appellant has consistently asserted that her headaches had their onset during service. The Board recognizes the appellant is competent to report the occurrence of lay-observable symptoms, such as headaches. 38 U.S.C. § 1153(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In addition, her statements of onset are corroborated by the contemporaneous clinical record. Indeed, as delineated above, the appellant's service treatment records note that she began to experience headaches in December 1994 following her head injury and that such continued thereafter. Additionally, she reported such at separation on her July 1998 Report of Medical History. The Board notes that the evidence of post-service continuity is not unequivocal. Nonetheless, after weighing the positive and negative evidence of record, and resolving reasonable doubt in favor of the appellant, the Board finds that entitlement to service connection for migraine headaches is warranted based on a showing of continuity of symptomatology since service. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, service connection for migraine headaches is granted. REASONS FOR REMAND 1. Entitlement to service connection for a psychiatric disability to include anxiety, PTSD, and depression. The Board finds that a new examination is necessary to clarify the nature and etiology of the appellant's current psychiatric disability. The appellant has reported multiple stressful events while on active duty, including being robbed at gunpoint in 1995 and being sexually assaulted on three occasions. She contends that she developed a psychiatric disability as a result of these experiences. She also contends that she developed a psychiatric disability as secondary to her service-connected IBS and fibromyalgia. Service treatment and personnel records reveal that the appellant was treated for a personality disorder and administratively separated for such in 1998. An August 1995 police report regarding an armed robbery is also of record. The June 2011 VA examiner opined that the appellant's reported stressor of being sexually assaulted on three occasions during active service met the stressor criterion for PTSD under DSM-IV, but that the appellant did not meet the criteria for a diagnosis of PTSD. Rather, undifferentiated somatoform disorder, bipolar disorder, and paranoid personality disorder were diagnosed. However, the claims file was not made available to the examiner at that time. In February 2013, Dr. F.K. opined that the appellant's anxiety and depression were related to her IBS. No rationale was offered, however. The March 2013 award of entitlement to Social Security Administration (SSA) disability benefits was based, in part, upon the following seven psychiatric disorders, described as "severe impairments": intermittent explosive disorder, personality disorder, bipolar disorder, depressive disorder, conversion disorder, PTSD, and obsessive-compulsive disorder. The June 2011 VA examiner provided an addendum in June 2013, following review of the claims file in which she confirmed that the appellant's psychiatric diagnoses were undifferentiated somatoform disorder, bipolar disorder, and paranoid personality disorder. The VA examiner also opined that it was less likely than not that any current psychiatric disorder was in any way related to the appellant's in-service personality disorder with borderline features, either by causation or aggravation. The VA examiner explained that the symptoms documented in service are not consistent with any of the appellant's current diagnoses and that there is no evidence to connect them. Further, the current disorders had progressed normally, with no indication of aggravation, which indicated that there had been no impact by the appellant's in-service experiences or diagnoses. The May 2017 VA examiner diagnosed schizoid personality disorder. A June 2020 VA clinical note states that the appellant had been diagnosed with PTSD and depression. The November 2020 contracted examiner, K.P., Ph.D., diagnosed PTSD and major depressive disorder, and opined that claimed anxiety was subsumed by PTSD. However, Dr. K.P. did not offer a nexus opinion regarding major depressive disorder. She indicated that the appellant's reported stressors of being robbed and being sexually assaulted were both sufficient to support a PTSD diagnosis. Both stressors were related to in-service personal assault; and Dr. K.P. noted the police report as a marker which may substantiate the robbery stressor. The only marker noted regarding the reported sexual assaults was a VA Form 21-0781a, upon which the appellant provided a lay statement. The Board notes that a personality disorder is not a disease or injury for VA compensation purposes, as it is well-established that personality disorders are not diseases or injuries within the meaning of applicable statutes and regulations. 38 C.F.R. §§ 3.303(c), 4.9; see also Morris v. Shinseki, 676 F.3d 1346, 1354-56 (Fed. Cir. 2012) (noting that "according to the express language of 38 C.F.R. § 3.303(c), personality disorders are not diseases or injuries within the meaning of § 1110 and thus are not compensable"); Conley v. Peake, 543 F.3d 1301, 1305 (Fed. Cir. 2008) ("personality disorders are considered congenital or developmental defects for which service connection cannot be granted because they are not diseases or injuries within the meaning of applicable legislation"). However, where it is not possible to distinguish the symptoms of a service-connected disability from non-service-connected manifestations, all the manifestations will be considered part of the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998). Additionally, after the June 2011 and June 2013 VA medical opinions were provided, VA amended 38 C.F.R. § 4.125(a) to indicate that a diagnosis of a mental disorder, to include PTSD, must conform to the standards set in the DSM-5. The amendments are applicable to the appellant's claim. See 38 C.F.R. § 4.125; 79 Fed. Reg. 45,093, 45,094-096 (Aug. 4, 2014); 80 Fed. Reg. 14,308 (Mar. 19, 2015) (final) (providing that for claims that were initially certified for appeal to the Board, the Court of Appeals for Veterans Claims (CAVC), or the U.S. Court of Appeals for the Federal Circuit prior to August 4, 2014, DSM-IV will apply. For all applications for benefits received by VA or pending before the AOJ on or after August 4, 2014, DSM-5 will apply). As the appellant's claim was certified on appeal in March 2018, DSM-5 applies to her claim. While the VA clinician who offered the June 2011 and June 2013 opinions explained that only diagnoses of undifferentiated somatoform disorder, bipolar disorder, and paranoid personality disorder were warranted under DSM-IV, since such time, the appellant has been diagnosed with other psychiatric disorders under DSM-5, including schizoid personality disorder, PTSD, and major depressive disorder. Medical opinions have not been obtained regarding such, nor have the reported stressors been verified, although a police report from August 1995 is of record. While there is the February 2013 positive opinion regarding service connection on a secondary basis, such is insufficient to grant the benefit sought because it is conclusory in nature and wholly lacking in rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). As such, after the appellant's psychiatric disability or disabilities during the period on appeal have been identified, adequate etiological opinions are necessary. Barr, supra. The Board makes no credibility findings at this juncture. 2. Entitlement to service connection for residuals of a TBI. The Board finds that remand is necessary to afford the appellant additional examination(s) to determine if her in-service head injury resulted in a TBI and, if so, what the residuals of that injury are. The appellant contends that she has residuals in the form of seizures, cognitive impairment, and memory impairment. The appellant has reported seizures since her in-service head injury on multiple occasions, including during her July 2016 Decision Review Officer (DRO) hearing. In the attorney's September 2021 brief, it is contended that the appellant experienced a TBI while on active duty when she fell, hit her head, was found unconscious, and then taken to the hospital. It was also contended that residuals of this TBI included impaired memory. The evidence of record is conflicting as to whether the appellant indeed experienced a TBI, and also as to whether she exhibits any current residuals of her in-service head injury, TBI or not. The May 2013 VA examiner opined that it was less likely than not that the appellant had residuals of a TBI which were causally related to her active service because objective evidence failed to reveal data consistent with residual facets attributable to a TBI. The examiner also noted that formal neuropsychological testing was performed in July 2011, which revealed no evidence of any significant cognitive deficit. However, a March 2017 clinical note of X.M., M.D., suggests that the appellant may experience seizures as a residual of the 1994 head injury. However, this clinical note appears to based primarily upon lay history provided to Dr. X.M. by the appellant, including report of a 13-day coma following an in-service head injury. The Board notes that this report is wholly inconsistent with the contemporaneous service treatment records, which reveal a three-day hospitalization following a brief loss of consciousness. The November 2020 contracted psychiatric examiner stated that the appellant has a diagnosed TBI and that she has residual symptoms from such. The examiner also concluded that such symptoms could not be differentiated from the appellant's psychiatric disabilities, diagnosed at that time as PTSD and major depressive disorder. The examiner, however, did not provide a rationale for the diagnosis. As such, the Board finds that a new examination is warranted. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr, supra. 3. Entitlement to a TDIU. As resolution of the claims of entitlement to service connection for residuals of a TBI and an acquired psychiatric disorder may have an impact on the appellant's claim of entitlement to a TDIU, the issues are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any appellate review meaningless and a waste of judicial resources, the two claims are inextricably intertwined). The matters are REMANDED for the following action: 1. Schedule the appellant for an examination to determine the etiology of her claimed psychiatric disorder(s). All indicated tests and studies should be conducted. The contents of the electronic claims file must be made available to the examiner for review in connection with the examination. Following examination of the appellant and review of the relevant evidence of record, the examiner is requested to provide an opinion as to whether the appellant meets the criteria for any psychiatric disorder(s) under the DSM-5 criteria at any point during the period on appeal. If not, the examiner should so specify and provide a rationale. If a current psychiatric disability is identified, then the examiner must provide an opinion addressing the following: (a). Whether any current psychiatric disorder clearly and unmistakably (i.e., obviously or undebatably) pre-existed the appellant's active service. (b). If the examiner determines that such psychiatric disorder clearly and unmistakably pre-existed service, the examiner must state whether it is clear and unmistakable (obvious, manifest, and undebatable) that the pre-existing disease or injury WAS NOT aggravated (i.e., permanently worsened) during service. (c). The examiner must also opine whether the appellant had a personality disorder in service and, if so, whether any current psychiatric disability is due to the aggravation of the appellant's personality disorder by superimposed disease or injury. (d). Regardless of the answers to the above questions, the examiner should opine whether it is at least as likely as not (i.e., probability of 50 percent or greater) that any currently diagnosed acquired psychiatric disorder had its onset during service or was otherwise causally or etiologically related to service. If not, is it at least as likely as that any currently diagnosed acquired psychiatric disorder was proximately due to or the result of service-connected IBS and/or fibromyalgia? If neither, is it at least as likely as not that any currently diagnosed acquired psychiatric disorder was aggravated (made worse) by service-connected IBS and/or fibromyalgia? If aggravation is found, the examiner must attempt to establish a baseline level of severity prior to aggravation. (e). If PTSD is diagnosed, the examiner should specify the stressor(s) upon which the diagnosis is based and opine as to whether a personal assault(s) occurred while on active duty (38 C.F.R. § 3.304 (f)(5)). If the examiner finds that evidence indicates that a personal assault occurred during the appellant's active service, the examiner must opine whether any PTSD is at least as likely as not related to the in-service personal assault. For reference: if a PTSD claim is based on in-service personal assault, evidence from sources other than the veteran's service records may corroborate the veteran's account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. 38 C.F.R. § 3.304(f)(5). In providing the requested opinions, the clinician should consider the appellant's reported symptoms in service and thereafter, including the nature, onset, progression and severity of the appellant's reported symptoms. If there is any medical reason to accept or reject the proposition that the reported symptoms in service and thereafter represented the onset of any currently diagnosed psychiatric disability this should be noted. Stated another way, do the appellant's reports about her symptoms align with how the currently-diagnosed psychiatric disorder is known to develop or are the appellant's reports generally inconsistent with medical knowledge or implausible? The examiner's attention is directed to: (a) service treatment and personnel records which reveal that the appellant was treated for a personality disorder and administratively separated for such; (b) the August 1995 police report; (c) the June 2011 VA examination report and opinion; (d) the February 2013 medical opinion of Dr. F.K.; (e) the March 2013 award of entitlement to SSA disability benefits which lists seven psychiatric disorders, described as "severe impairments": intermittent explosive disorder, personality disorder, bipolar disorder, depressive disorder, conversion disorder, PTSD, and obsessive-compulsive disorder; (f) the June 2013 addendum opinion of the June 2011 VA examiner; (g) the May 2017 VA examination report; (h) the June 2020 VA clinical note which includes diagnoses of PTSD and depression; (i) the November 2020 contracted examination report and opinion; and (j) the appellant's reports of in-service robbery and multiple rapes. The Board makes no credibility findings at this juncture. 2. Provide the appellant an examination by an appropriate clinician(s) regarding the nature and etiology of any TBI or residuals thereof. The claims file must be made available to, and reviewed by, the clinician(s) rendering the requested opinions. After examining the appellant and reviewing the claims file, the clinician(s) should opine as to whether it is at least as likely as not (50 percent or greater probability) that the appellant currently exhibits a TBI, or residuals thereof, which was incurred in or is otherwise causally related to her active service. If the appellant did not incur a TBI while on active duty, the clinician(s) should opine as to whether it is at least as likely as not that the appellant currently exhibits residuals of the December 1994 head injury which resulted in a three-day hospitalization. Service connection is already in effect for migraine headaches. Attention is directed to (a) the appellant's lay contentions of continuity of symptomatology including her July 2016 DRO testimony; (b) the attorney's September 2021 brief; (c) the May 2013 VA examination report and opinion; (d) the results of July 2011 formal neuropsychological testing; (e) the March 2017 clinical note of X.M., M.D.; and (f) the November 2020 contracted psychiatric examination report. In providing the requested opinions, the clinician should consider the appellant's reported symptoms in service and thereafter, including the nature, onset, progression and severity of the appellant's reported symptoms. If there is any medical reason to accept or reject the proposition that the appellant's in-service head injury and reported symptoms in service and thereafter represented the onset or cause of any current disability, this should be noted. Stated another way, do the appellant's reports about her injury and symptoms align with how the currently diagnosed disability is known to develop or are the appellant's reports generally inconsistent with medical knowledge or implausible? The Board makes no credibility findings at this juncture. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Behlen, 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.