Citation Nr: 1042597 Decision Date: 11/12/10 Archive Date: 11/24/10 DOCKET NO. 06-16 372 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to an initial disability rating in excess of 10 percent for service-connected nightmare disorder. 2. Entitlement to service connection for psychiatric disabilities other than a nightmare disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. Mecone, Associate Counsel INTRODUCTION The Veteran had active military service from August 1988 to August 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal of rating decisions issued in January 2003 and April 2004 by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. This case was remanded by the Board in May 2009. The requested development has been completed and the case is once again before the Board. The Board notes that the United States Court of Appeals for Veterans Claims (Court) has held that an appeal from an original award does not raise the question of entitlement to an increased rating, but instead is an appeal of an original rating. Fenderson v. West, 12 Vet. App. 119 (1999). Consequently, the Board has characterized the rating issue on appeal as a claim for a higher evaluation of an original award. Analysis of this issue requires consideration of the rating to be assigned effective from the date of award of service connection-in this case, March 15, 2002. FINDINGS OF FACT 1. The Veteran's nightmare disorder is not productive of more than mild occupational and social impairment. 2. The Veteran is not currently diagnosed with PTSD. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 10 percent for service-connected nightmare disorder are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, and 4.130, Diagnostic Code 9413 (2010). 2. PTSD was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance Requirements 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 and 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010) describe VA's duties to notify and assist claimants in substantiating a claim for VA benefits. Upon receipt of a complete or substantially complete application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and notify the claimant and his or her representative, if any, of what information and evidence not already provided, if any, is necessary to substantiate, or will assist in substantiating, each of the five elements of the claim including notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Dingess v. Nicholson, 19 Vet. App. 473 (2006). In the present case, with regard to the Veteran's claim for a higher initial disability rating, the Board notes that the Veteran's claim was originally for service connection, which was granted in the January 2003 rating decision and was evaluated as 10 percent disabling effective March 15, 2002 (the date the Veteran's claim for service connection was filed). The Veteran disagreed with the 10 percent evaluation of this now service- connected disability in January 2003. The Board finds that VA's obligation to notify the Veteran was met as the claim for service connection was obviously substantiated. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). Therefore, any deficiency in notice relating to the Veteran's appeal for an increased rating is not prejudicial to him As for the Veteran's claim for service connection for PTSD, notice was provided to the Veteran in June 2003, prior to the initial AOJ decision on his claim. The Board finds that the notice provided fully complies with VA's duty to notify as to the content stated above, but the RO failed to provide notice that a disability rating or an effective date for the award of benefits will be assigned if service connection is awarded, as required by Dingess v. Nicholson, 19 Vet. App. 473 (2006). However, given the denial hereafter of the Veteran's claim for service connection for PTSD, any questions as to a disability rating or an effective date are moot. Thus the Board finds that the Veteran has not been prejudiced by VA's failure to provide notice on these elements of his claim. Likewise, the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claim. He was told it was his responsibility to support the claim with appropriate evidence and has been given the regulations applicable to VA's duty to notify and assist. Indeed, the Veteran submitted evidence in connection with his claim, which indicates he knew of the need to provide VA with information and evidence to support his claim. Thus the Board finds that the purposes behind VA's notice requirement have been satisfied, and VA has satisfied its "duty to notify" the Veteran, and any error in this regard is harmless. Regarding VA's duty to assist, the RO obtained the Veteran's service treatment records (STRs), VA medical records, and provided examinations in furtherance of his claim. VA examination with respect to the issues on appeal were obtained in May 2002, November 2002, July 2003, January 2004, and July 2009. 38 C.F.R. § 3.159(c)(4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA opinions obtained in this case are adequate, as the examiners considered the STRs, and the Veteran's lay statements regarding the severity of his nightmares and his in-service stressful incidents which the Veteran believed resulted in PTSD, and his allegations regarding continuity of PTSD symptomatology ever since service. The examiners also provided information necessary to apply the relevant diagnostic code pertaining to the Veteran's nightmare disorder. Accordingly, the Board finds that VA's duty to assist in obtaining a VA examination or opinion with respect to the issues of service connection for PTSD, and entitlement to an initial rating in excess of 10 percent for a nightmare disorder have been met. 38 C.F.R. § 3.159(c)(4). II. Factual Background The Veteran was afforded a mental disorder examination in May 2002. The Veteran's main psychological complaint was regular nightmares about his experiences in the Gulf War. He reported having nightmares about 4 to 5 times per week, and noted that the frequency fluctuated from once or twice a month to near daily. The Veteran reported that he had these since March 1991, and noted that he awakens feeling scared and gets up and checks the doors to his home, then returns to bed. The Veteran reported that he generally falls back to sleep within an hour, and gets about five hours of sleep per night. He denied excessive daytime sleepiness, and denied taking naps. He reported adequate energy to perform work and household chores but complained of some fatigue that limited his participation in sports. The Veteran also denied any work interference due to mental health problems. In terms of his social functioning, the Veteran noted that he played sports, and was engaged in a variety of household and yard duties. He visited with his mother regularly, attended church with his family, but reported that he did not have any friends and never really did. On examination, the examiner rendered an Axis I diagnosis of a nightmare disorder-subsyndromal, and assigned the Veteran a global assessment of functioning (GAF) score of 85. The examiner noted that the Veteran's affect was calm, mood was reported as "no problem," his speech was within normal limits in rate, tone, volume and content, and there was no sign of a thought disorder. The Veteran denied suicidal or homicidal ideation. The Veteran reported good functioning in all areas and denied significant current psychosocial stressors. He denied anxiety related symptoms, worries and mood problems. The Veteran also denied irritability or temper problems. He reported good attention and concentration, and denied hallucinations, rituals, obsession or compulsions. The examiner reported that the Veteran's complaint centered around recurrent nightmares about his Gulf War experience (one battle), but noted that the Veteran did not meet the full criteria for a nightmare disorder because there did not appear to be any impairment in functioning caused by the symptoms. The examiner also noted that there were no other psychological disorders suggested by the interview. In November 2002, the Veteran was afforded a VA PTSD examination. At this examination, the Veteran reported being stationed in the Persian Gulf area from December 1990 through March 1991, and noted that he was with the 2nd Army division and saw action in Saudi Arabia against Saddam Hussein's Medina division. He reported that he was involved in a tank battle, and although he was not injured, his friend died when he was hit with two RPG rounds. The examiner noted that the Veteran had never been hospitalized for nervous or emotional illness and had never received outpatient treatment in a psychiatric setting. The Veteran reported that he began experiencing nightmares the night after the battle, and noted that when he nods off during the daytime, he can see the vision in his head of being in his tank and throwing grenades or his friend yelling help me. The examiner noted that this was a vague description of what might be considered a flashback. The Veteran reported that he jumps with any loud noise that sounds like a weapon, and noted that he is constantly looking around, and in church, he reported that he has to sit against a wall where he can see everything. On examination, the examiner rendered an Axis I diagnosis of a nightmare disorder, subclinical, and insomnia related to the nightmare disorder, subclinical, and assigned a GAF score of 85. The examiner noted that the Veteran presented with a parasomnia, nightmare disorder, along with a sleep disorder related to his parasomnia, insomnia; however, both conditions were subclinical- that is, not associated with impairment in social, occupational, or other areas of functioning. The examiner explained that although the Veteran presented with a number of symptoms commonly associated with PTSD, he did not evidence persistent avoidance of stimuli associated with his Gulf War trauma. To a certain extent he did exhibit symptoms of increased arousal, but these were low- grade in intensity. The examiner noted that the Veteran did demonstrate some re-experiencing, but by itself, it was not sufficient to warrant a diagnosis of PTSD. The examiner also pointed out that the Veteran had never found it necessary to seek treatment for his symptoms, and reported that he was a high functioning individual. A July 2003 VA PTSD examination again reflected no PTSD diagnosis. The examiner reported that although the Veteran met criteria A for a diagnosis of PTSD, he did not fully meet the DSM-IV criteria for reexperiencing, avoidance, and hyper arousal symptoms. The examiner also noted that the Veteran did not meet the criteria for an anxiety disorder not otherwise specified, as the most prominent symptom endorsed was sleep disturbance. The examiner again rendered an Axis I diagnosis of nightmare disorder-subsyndromal, and reported that in spite of the sleep disturbance, the Veteran generally had good social and occupational functioning. In January 2004, the Veteran was afforded a VA chronic fatigue examination. At this examination, he reported constant fatigue, and noted that any continuous activity caused fatigue and required him to stop and rest. The Veteran complained of poor sleep and noted that, although he was able to go to sleep, he wakes up with dreams/nightmares and cannot get back to sleep. He estimated averaging four to six hours of sleep per night. He related that some mornings he feels rested and other days he feels drained. He denied a history of low-grade fever, pharyngitis, adenopathy, and muscle aches (except for some complaints of some cramps in his legs). He reported being able to walk one and a half miles before having to take a break and being fine after a 45 minute rest. He did not describe any incapacitating episodes following exercise. He reported having headaches every other day since 1995 located in the frontal area described as throbbing and treated with Advil with relief. His daily activities consisted of sitting on the couch watching television and reading, and napping for one hour daily except for when he does not sleep the night before due to his nightmares. Physical examination was within normal limits. Laboratory test results, including a comprehensive metabolic panel, were essentially within normal limits, and his thyroid stimulating hormone was normal. The VA examiner did not diagnose the Veteran with chronic fatigue syndrome because he did not meet the criteria for such a diagnosis as the fatigue he experiences is related to his poor sleeping habits due to his dreams/nightmares. The Veteran was afforded a VA examination in July 2009. At this examination, the Veteran reported that he experienced nightmares where he awakens with the impression that he died due to being shot in combat, which recalls the history of his friend being shot. The Veteran reported that his nightmares occurred three to four times a week and he awakens clear headed from these dreams. He noted that his dreams of combat situations were troubling, but that he was not suicidal. The examiner also noted that the Veteran had a history of witnessed apneas, awakening short of breath, disruptive snoring, awakening fatigue, and sleeping during the day, and he is subject to irritability and anger outbursts. It was noted he had no clear history of hallucinations, panic attacks, or paranoia. The Veteran reported that his mood, energy, and concentration were not good lately. The examiner noted that the frequency of the symptoms was three to four times per week, the severity was mild, and the duration of the symptoms was since 1991. The examiner opined that the in-service stressor noted by the Veteran-a friend of his was killed in action by a rocket- propelled grenade round was not linked to his current nightmare condition. The examiner noted that the Veteran had been unemployed since 2002 due to fatigue during the day, and noted that the Veteran had no time off from work due to his mental health. In terms of social functioning, the Veteran reported that he was married and close to his family, but did not have too many friends. He reported that he was not a member of any organizations and occasionally attended church. The examiner noted that the Veteran had withdrawn socially and irritability affected his social interactions. However, the examiner reported that no other symptoms affected his social functioning, and the overall effect of his nightmare disorder was mild. Regarding his occupational functioning, the examiner noted that a lack of sleep caused fatigue and difficulty working. The examiner stated that the Veteran felt irritable and did not want to be bothered. No other symptoms affected the Veteran's ability to work. The examiner assessed the Veteran's overall impairment in work performance as mild. On mental status examination, the Veteran's communication was intact, speech was normal in speed and amount, psychomotor activity was within normal limits, mood and affect were within normal limits, thought processes were linear and thought content unremarkable. There was no evidence of psychosis and memory and judgment were intact. Insight was questionable and a cognitive screen was within normal limits. The VA examiner rendered an Axis I diagnosis of a nightmare disorder, reporting that it was mild, and assigned a GAF score due to the nightmare disorder of 70. The examiner explained that the claims file had been reviewed and noted that the GAF score of 70 reflected mild impairment in employment and social functioning. The examiner reported that the Veteran's nightmare disorder was only associated with two symptom criteria, and reported that no other details of a nightmare disorder are available or elicited. The examiner stated that social and occupational impairment due to nightmare disorder is mild at this time and has been mild since 1991. Overall, the examiner noted that the severity of the nightmare disorder was mild. Regarding PTSD, the examiner opined that the Veteran's symptoms did not meet the DSM-IV criteria for a diagnosis of PTSD. He explained that as noted by previous mental health examinations, the Veteran's symptoms were insufficient for a PTSD diagnosis because, although criterion A was met, criteria B, C, and D were not met, as was specifically noted in the August 2003 mental health VA examination. Therefore, the examiner stated that a diagnosis of PTSD could not be made. The examiner also explained that although sleep apnea was not currently diagnosed, this condition could be an alternate explanation for the Veteran's insomnia, fatigue, and irritability rather than the explanation of nightmare disorder. The examiner noted that a sleep study had been recommended but had not as yet been chosen by the Veteran. Statements submitted by the Veteran indicate that he worked up until he reached the point where he had to take medication to sleep and also to stay awake. He has reported that his nightmares are unbearable, noting that he is fatigued all the time, and reported that sometimes he did not feel like going on. See May 2006, September 2009, and July 2010 statements from the Veteran. The Veteran's girlfriend reported that he was unable to work a regular job without taking Vivarin to stay awake and Tylenol pm to go to sleep. She reported that he could not take care of himself, and noted that she dressed him, and paid his bills. She also noted that the Veteran only slept about three to four hours per night because of his nightmares. See July 2010 statement. The record also includes lay statements submitted by two of the Veteran's coworkers, L.H. and T.W. L.H. noted that he had worked with the Veteran for about six months during which time he witnessed the Veteran having several nightmares and taking No Doze and Vivarin medication to help him stay awake at night. L.H. noted that the Captain had sent the Veteran home about twice since he had been working with him because the Veteran could not stay up. T.W. noted that he had worked with the Veteran for about one year, during which time he noticed that the Veteran had a chronic sleep disorder. T.W. stated that the Veteran had several nightmares a week, and sometimes he had to be woken up. T.W. reported that one time he tried to wake the Veteran up and he started choking him. T.W. also noted that he witnessed the Veteran taking Vivarin to stay awake, and Nytol to sleep, and also stated that the Veteran was becoming very nervous and suspicious. See January 2003 coworker statements. III. Increased Disability Rating for Nightmare Disorder Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2010). Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Id. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2010). As noted in the introduction above, the Court has indicated that a distinction must be made between a Veteran's dissatisfaction with original ratings and dissatisfaction with determinations on later filed claims for increased ratings. Fenderson, supra. Accordingly, the Board will evaluate the Veteran's disability to determine if the evidence of record entitles him to a higher disability rating, for his service connected nightmare disorder at any point since the initial award of service connection (i.e. March 15, 2002.) The Veteran's nightmare disorder has been evaluated as 10 percent disabling by analogy under 38 C.F.R. § 4.130, Diagnostic Code 9413, pertaining to anxiety disorder, not otherwise specified. Under Diagnostic Code 9413, a 10 percent rating is for consideration where there is occupational and social impairment, due to mild or transient symptoms that decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A 30 percent rating is for consideration where 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, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events.) A 50 percent evaluation is warranted if the evidence establishes 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 (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. The nomenclature employed in the portion of VA's Schedule for Rating Disabilities ("the Schedule") that addresses psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "the DSM-IV"). 38 C.F.R. § 4.130 (2010). The DSM-IV contains a GAF scale, with scores ranging between zero and a 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. The higher the score, the better the functioning of the individual. The record demonstrates that the Veteran has been assigned GAF scores of 70 and 85 due to his nightmare disorder. GAF scores ranging between 81 and 90 are warranted when there is absen or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members). GAF scores ranging between 71 and 80 are warranted when if symptoms are present but they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); or there is no more than slight impairment in social, occupational or school functioning (e.g., temporarily falling behind in school work). GAF scores ranging between 61 and 70 are warranted when there are some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but when the individual is functioning pretty well and has some meaningful interpersonal relationships. American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th. ed., 1994). Consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. See 38 C.F.R. § 4.126(a). Furthermore, 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 solely on the basis of social impairment. 38 C.F.R. § 4.126(b). In this case, the Board finds that based on the medical evidence of record, the Veteran's disability picture is not productive of more than mild occupational and social impairment, which is consistent with the critieria for a 10 percent disability rating. The evidence does not show symptoms such as those contemplated by a 30 percent rating. More importantly, the Veteran's nightmare disorder has consistently been described as mild, and the lowest GAF score assigned being 70, which is indicative of mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social and occupational functioning but the individual is functioning pretty well. The VA examiners have consistently stated that the Veteran's nightmare disorder is subsyndromal. In other words, he has some symptoms but they are not associated with impairment in social, occupational, or other areas of functioning. In July 2003, it was again reported that, in spite of the sleep disturbance caused by the nightmare disorder, the Veteran generally had good social and occupational functioning. Finally, most recently, in July 2009, the VA examiner opined that after reviewing the claims file, the Veteran's nightmare disorder caused mild occupational and social impairment, and reported that the overall severity due to the nightmare disorder was mild, and had been since 1991. According to the Veteran's statements, he worked up until he reached the point where he had to take medication to sleep and also to stay awake, and noted that his nightmares were unbearable, and that he was fatigued all the time. See May 2006, September 2009, and July 2010 statements. The Veteran's girlfriend reported that the he was unable to work a regular job without taking Vivarin to stay awake and Tylenol pm to go to sleep, and reported that he could not take care of himself, and noted that she dressed him, and paid his bills. See July 2010 statement. The Veteran's coworkers, T.W., and L.H., also stated that they had witnessed his nightmares and him taking medication to stay awake and go to sleep. See January 2003 statements. In this case, the Board finds that the severity of the symptoms described by the Veteran, his girlfriend, and his coworkers are not supported by any of the objective medical evidence of record. The Veteran has been examined on numerous occasions (May 2002, November 2002, July 2003, and July 2009) by four different physicians, all of whom determined that the Veteran's nightmare disorder caused no more the mild occupational impairment. Although the Board reviewed the these lay statements and took them under consideration when evaluating the severity of the Veteran's nightmare disorder, the Board finds the assessments provided by the medical examiners regarding the severity of his nightmare disorder to be more probative than these statements, as all four examiners were in agreement as to the severity of the symptomatology caused by the Veteran's nightmare disorder. In fact, the Board find the credibility of the Veteran's statements regarding the severity of his nightmare disorder to be questionable due to the vast discrepancy in the severity of symptomatology noted in the four different VA examination reports as opposed to the severity of symptoms described by the Veteran in his statements submitted directly in support of his claim for an increased disability rating. After considering all the evidence, the Board does not find the Veteran's testimony to be credible. The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has held that lay evidence is one type of evidence that must be considered and competent lay evidence can be sufficient in and of itself. The Board, however, retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); also see Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (noting that the credibility of a witness may be impeached by a showing of interest, bias, inconsistent statements, and consistency with other evidence), aff'd, 78 F.3d 604 (Fed. Cir. 1996), superseded in irrelevant part by statute, VCAA, Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000). Thus, the probative value of the Veteran's statements as to the severity of his nightmare disorder is lessened and, consequently, the more probative evidence is the VA examination reports. As for the lay statements from the Veteran's girlfriend and coworkers, although competent and credible, the Board finds that they are not carry much weight when measured against the Veteran's self-report of symptoms made at the VA examinations. Consequently, their lay statements, on their own, are not sufficient to establish that a higher disability rating is warranted for the Veteran's service-connected nightmare disorder. Thus, the Board finds that the evidence does not show that the Veteran experiences anxiety, suspiciousness, panic attacks or mild memory loss (such as forgetting names, directions, or recent events) due to his nightmare disorder. Specifically, in May 2002, the Veteran denied anxiety related symptoms, and in a July 2003 VA examination, the examiner noted that the Veteran did not meet the criteria for an anxiety disorder, as the most prominent symptom endorsed was sleep disturbance. Although the 2009 VA examiner reported that the Veteran was subject to irritability and anger outbursts, none of the VA examiners endorsed anxiety or a depressed mood as symptoms of the Veteran's nightmare disorder. Further, the July 2009 VA examiner stated that the Veteran had no clear history of panic attacks or paranoia (suspiciousness), and reported that the Veteran's memory was intact. In summary, beyond evidence of sleep disturbance, there is no other evidence of symptoms indicative of the criteria for a 30 percent disability rating at any point since the initial award of service connection in March 2002. The Board acknowledges that the Veteran does experience chronic sleep impairment, which is a symptom noted under the criteria for a 30 percent evaluation. However, the overall disability picture evident in the record strongly suggests that the difficulties experienced by the Veteran are more consistent with the criteria for a 10 percent disability rating. No examiner has suggested that the Veteran's nightmare disorder resulted in intermittent periods of inability to perform occupational tasks. Although the 2009 VA examiner acknowledged that the Veteran's nightmare disorder resulted in difficulty at work at certain times due to lack of sleep, he still described the affect of the disability on the Veteran's employment as mild. Therefore, when taken together, the Board finds that the severity of the Veteran's nightmare disorder did not result in intermittent periods of inability to perform occupational tasks; rather his nightmare disorder is more properly characterized as resulting in mild symptoms that decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. In conclusion, the disability picture does not approximate the criteria for the next higher disability rating. In addition, the Board has considered whether the Veteran's Veteran's nightmare disorder should be evaluated by using any other applicable criteria such as those pertaining to chronic fatigue syndrome (CFS), evaluated at Diagnostic Code 6354; however, a higher disability rating of 20 percent under Diagnostic Code 6354 requires a showing that there is debilitating fatigue, cognitive impairments (such as inability to concentrate, forgetfulness, and confusion), or a combination of other signs and symptoms which are nearly constant and restrict routine daily activities by less than 25 percent of the pre- illness level, or; which wax and wane, resulting inperiods of incapacitation of at least two but less than four weeks total duration per year. 38 C.F.R. § 4.88b. It is noted that, for purposes of evaluating CFS, the condition will be considered incapacitating only while it requires bed rest and treatment by a physician. At the January 2004 VA examination, no such symptoms were found. Although the Veteran was noted to have fatigue, it was not daily as he also reported some mornings he feels rested. In addition, the Veteran did not report any periods of incapacitation lasting from two to four weeks a year. As such, a higher disability rating is not warranted under the diagnostic criteria pertaining to CFS. Finally, although the Veteran reported he has days when he sleeps because he got no sleep the night before because of nightmares, these are not consistent with bed rest as stated in above. Moreover, the Veteran has never sought treatment by a physician for his nightmare disorder much less for his fatigue related to it. As such, the Board finds that the evidence fails to establish that a higher disability rating would be warranted under Diagnostic Code 6354 as an alternative to the currently evaluation under Diagnostic Code 9413. Finally, the Board must consider whether referral for consideration of an extraschedular rating is warranted under 38 C.F.R. § 3.321(b). It is generally provided that the rating schedule will represent, as far as can practicably be determined, the average impairment in earning capacity in civil occupations resulting from a service-connected disability. 38 C.F.R. § 3.321(a). In the exceptional case, however, to accord justice, where the schedular evaluations are found to be inadequate, the Secretary is authorized to approve, on the basis of the criteria set forth in 38 C.F.R. § 3.321(b)(1), an extraschedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. 38 C.F.R. § 3.321(b). The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. Id. The Veteran's entire history is reviewed when making disability evaluations. See 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1995). Loss of industrial capacity is the principal factor in assigning schedular disability ratings. See 38 C.F.R. §§ 3.321(a), 4.1. Indeed, 38 C.F.R. § 4.1 specifically states: "[g]enerally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." See also Moyer v. Derwinski, 2 Vet. App. 289, 293 (1992) and Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). The Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). First, the RO or the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that disability are inadequate. In other words, whether the disability picture presented in the record is adequately contemplated by the rating schedule. In doing so, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. In the present case, the Board finds that the rating schedule is not inadequate to evaluate the Veteran's service-connected nightmare disorder because the Veteran's disability picture is contemplated by the rating criteria. Specifically, the rating criteria expressly consider loss of industrial capacity, and the primary symptom of the Veteran's nightmare disorder has been found to be daytime fatigue which causes mild occupational impairment. Consequently, the preponderance of the evidence is against referral for extraschedular consideration. Lastly, the Board finds that the record does not illustrate that the Veteran's service-connected nightmare disorder prevents him from obtaining and maintaining gainful employment. In fact, the Veteran's nightmare disorder has been consistently described as being productive of no more than mild occupational impairment. Thus, any further discussion of an issue of entitlement to a total disability rating based on individual unemployability is not necessary. Rice v. Shinseki, 22 Vet. App. 447 (2009). For the foregoing reasons, the Board concludes that the preponderance of the evidence is against finding that a disability rating in excess of 10 percent is warranted for the Veteran's service-connected nightmare disorder. As the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt doctrine is not for application. Consequently, the Veteran's claim must be denied. B. Service connection for PTSD Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any injury or disease diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Generally, service connection requires (1) medical evidence of a current disability, (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease, and (3) medical evidence of a nexus between the current disability and the in-service disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999). Further, it is not enough that an injury or disease occurred in service; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection for PTSD requires: (1) a medical diagnosis of PTSD utilizing the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria, in accordance with 38 C.F.R. § 4.125(a); (2) credible supporting evidence that the claimed in-service stressor occurred; and (3) medical evidence of a causal nexus between current symptomatology and the claimed in-service stressor. See 38 C.F.R. § 3.304(f) (2010). The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. § 1110, 1131; see Degmetich v. Brown, 104 F. 3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that the Veteran currently has the disability for which benefits are being claimed. In this case, the Veteran has not been diagnosed with PTSD at any point during the pendency of this appeal. In a November 2002 VA PTSD examination provided for the purpose of determining whether the Veteran suffered from PTSD, the examiner, R.H., M.D., explained that although the Veteran presented with a number of symptoms commonly associated with PTSD, he did not evidence persistent avoidance of stimuli associated with his Gulf War trauma. Dr. H. reasoned that to a certain extent the Veteran did exhibit symptoms of increased arousal, but these were low-grade in intensity. He noted that the Veteran did demonstrate some re- experiencing, but by itself, it was not sufficient to warrant a diagnosis of PTSD. A July 2003 VA PTSD examination conducted by a different physician again reflected no PTSD diagnosis. The examiner, R.T., M.D., reported that although the Veteran met criteria A for a diagnosis of PTSD, he did not fully meet the DSM-IV criteria for reexperiencing, avoidance, and hyper arousal symptoms. Dr. T. instead rendered an Axis I diagnosis of nightmare disorder. Finally, in July 2009, another VA examiner, R.K., M.D., opined that the Veteran's symptoms did not meet the DSM-IV criteria for a diagnosis of PTSD. Dr. K.'s opinion is supported that of Dr. H. and Dr. T., in that he also found that although criteria A was met, criterion B, C, or D, were not met, and therefore, a diagnosis of PTSD could not be made. In summary, during the pendency of this appeal, three different physicians determined that the Veteran's symptomatology was not sufficient to meet the DSM-IV criteria for PTSD. Therefore, without evidence of a current disability diagnosed at some point during the pendency of the appeal, the analysis ends, and service connection cannot be awarded. ORDER Entitlement to an initial disability rating in excess of 10 percent for service-connected nightmare disorder is denied. Service connection for posttraumatic stress disorder (PTSD) is denied. ____________________________________________ SARAMAE KREITLOW Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs