Citation Nr: 1135577 Decision Date: 09/22/11 Archive Date: 10/03/11 DOCKET NO. 08-23 230 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to an increased initial rating for posttraumatic stress disorder (PTSD), currently evaluated as 50 percent disabling. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for bilateral hearing loss. 4. Entitlement to service connection for a mid back condition. REPRESENTATION Veteran represented by: Colorado Division of Veterans Affairs WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD G. Jivens-McRae, Counsel INTRODUCTION The Veteran served on active duty from November 1967 to September 1969. He served in Vietnam and was awarded a Purple Heart. This matter comes before the Board of Veterans' Appeals (Board) on appeal from November 2006 and June 2008 rating decisions of the San Diego, California, Department of Veterans Affairs (VA) Regional Office (RO). In November 2006, the Veteran was awarded service connection for PTSD and awarded a 30 percent rating, effective March 20, 2006. By rating decision of July 2007, the RO increased his rating for PTSD to 50 percent, effective March 20, 2006. The Veteran disagreed with the initial rating awarded and the current appeal ensued. By rating decision of June 2008, service connection for bilateral hearing loss, tinnitus, and a mid back condition were denied. The Veteran also disagreed with these denials and the current appeals ensued. The Denver, Colorado, RO currently has jurisdiction over this case. In April 2011, the Veteran testified at a Travel Board hearing before the undersigned Acting Veterans Law Judge (VLJ). A transcript of that hearing is of record and associated with the claims folder. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a claim for a total rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. Here, the Veteran specifically stated in a December 2009 statement to VA, that he does not want to be considered for a TDIU at this time. Therefore, the issue of a TDIU is not specifically before the Board and the Rice case is not for application. The issue of service connection for a mid back condition is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's PTSD is productive of occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood; due to such symptoms as: suicidal ideation; impaired impulse control (such as unprovoked irritability with periods of violence); neglect of personal appearance; difficulty in adapting to stressful circumstances (including work or worklike setting); inability to establish and maintain effective relationships; total occupational and social impairment has not been shown. 2. The Veteran's tinnitus is as likely as not causally related to his military service. 3. The evidence of record does not demonstrate that bilateral hearing loss was manifested during active service, was manifested within the first post-service year, or developed as a result of an established event, injury, or disease during active service, including in-service noise exposure or acoustic trauma. CONCLUSIONS OF LAW 1. The criteria for a 70 percent rating for PTSD, but not higher, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.130, Diagnostic Code 9411 (2010). 2. Resolving reasonable doubt in favor of the Veteran, tinnitus was incurred in service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1154, 5103, 5103A, 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2010). 3. Bilateral hearing loss was not incurred in or aggravated by active service, nor may it be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1154, 5103, 5103A, 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.385 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Assist and Notify As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2010). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. In light of the full grant of benefits sought on appeal for the Veteran's service connection for tinnitus claim, no further notification or assistance is necessary to develop facts pertinent to this claim. As to the initial increased rating claim for PTSD on appeal, the Board notes that where service connection has been granted and an initial rating and effective date have been assigned, the claim of service connection has been more than substantiated, it has been proven. As such, 38 U.S.C.A. § 5103(a) notice is no longer required since the purpose that the notice was intended to serve has been fulfilled. Furthermore, once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. Therefore, any defect as to 38 U.S.C.A. § 5103(a) notice is nonprejudicial. See Dingess v. Nicholson, 19 Vet. App. 473, 490-491 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); Goodwin v. Peake, 22 Vet. App. 128 (2008) (where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to any downstream elements). As to the service connection claim for bilateral hearing loss claim, the VCAA duty to notify was satisfied by way of a letter sent to the Veteran in January 2008. The letter fully addressed all notice elements and was sent prior to the initial RO decision in this matter. It informed him of what evidence was required to substantiate the claim and of his and VA's respective duties for obtaining evidence. The letter also provided notice with respect to how VA assigns ratings and effective dates. With that letter, the RO effectively satisfied the notice requirements with respect to the issue on appeal. Under these circumstances, the Board finds that adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). Next, VA has a duty to assist a veteran in the development of the claims. This duty includes assisting him or her in the procurement of service treatment records and other pertinent VA treatment records, and providing an examination when necessary. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2010). In this case, the Veteran's service treatment records, VA treatment records, Vet Center records, Social Security Administration (SSA) records, and private treatment records have all been obtained. Moreover, neither the Veteran nor his representative have identified any outstanding evidence that has not already been obtained, and, in fact, up to date treatment records were presented at the Veteran's hearing before the Board (and the Veteran's waived RO consideration of those records). The Veteran was also provided with VA examinations in March 2008 for his bilateral hearing claim, and in September 2006 and March 2009 for his PTSD claim. Further, in April 2011, the Veteran was provided an opportunity to set forth his contentions during a Travel Board hearing before the undersigned VLJ. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the U.S. Court of Appeals for Veterans Claims held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the April 2011 hearing, the VLJ cited the issues on appeal. See Hearing Transcript (T.) at p. 2. Information and additional evidence was solicited regarding the symptoms of his disabilities. Under these circumstances, nothing gave rise to the possibility that evidence had been overlooked with regard to the Veteran's claims. As such, the Board finds that, consistent with Bryant, the Acting VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. In view of the foregoing, the Board finds no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Increased Rating Disability ratings are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating 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. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In determining the level of impairment, the disability must be considered in the context of the whole recorded history. 38 C.F.R. §§ 4.2, 4.41 (2010). An evaluation of the level of disability present also includes consideration of the functional impairment of the appellant's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When the appeal arises from an initial rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are also appropriate in increased- rating claims in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Veteran claims that his PTSD, is more severe than the current evaluation reflects. He testified at a hearing before the Board that he has nightmares, sleep disturbance, an inability to communicate well with others, anger and irritability, and no social life. The Veteran's PTSD was initially rated as 30 percent, by rating decision of November 2006. By rating decision of July 2007, the Veteran's PTSD was increased from 30 to 50 percent, effective in March 2006. The Veteran's PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411, for PTSD. Under the General Rating Formula for Mental Disorders, Diagnostic Code 9411. A 10 percent rating is assigned when PTSD causes 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, or when symptoms are controlled by continuous medication. A 30 percent rating is assigned when PTSD causes 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, or mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is assigned when PTSD causes 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-term 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; or difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is assigned when PTSD causes occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or an inability to establish and maintain effective relationships. A 100 percent rating is assigned when PTSD causes total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; danger of hurting self or others; intermittent inability to perform activities of living (including maintenance of minimal hygiene); disorientation to time or place; or, memory loss for names of close relatives, occupation, or own name. Id. After scrutinizing the evidence - which includes VA outpatient treatment records, Vet Center records, and VA examination reports dated in September 2006 and July 2009, the Board finds that the totality of the evidence supports the assignment of a rating of 70 percent, and no more, for the Veteran's PTSD. The Veteran underwent VA psychiatric examination in September 2006. He reported that he had been seen at the Boulder Vet Center since March 2006; and he reported that therapy had helped him realize what he was going through and helped him to cope. He stated that he had tried another medication at first for his nightmares, but it did not work. He was now prescribed Prazosin which helped his nightmares, but he felt cognitively slow and disconnected the next day in terms of the efficacy of the medication. He denied his symptoms had been in remission at any time since Vietnam, and he stated that he thought his depressive symptoms had been present for at least three years. The depression seemed to coincide with the war in Iraq and some deaths in his family. He related that he had been married three times and that his present wife was a nurse. They had no children together. He stated he was close to his wife, but he had problems with his libido and only had sex a few times per year. He stated that he had a daughter who moved in with him and his wife after her divorce. He stated that his failed marriages and the death of his father were stressful to him. He also found it stressful to be taunted at work and labeled as an "angry" Vietnam Veteran. He managed the bills in his household. He managed his activities of daily living including personal hygiene without problem. In the past, the Veteran indicated that he had enjoyed remodeling cars, but he had begun to lose interest over the last few years and sold most of his cars. He stated that he had only one friend and he was socially isolated. Nevertheless, he indicated that after work he would play with his grandchildren, watch TV, and check his email. He stated that he shared the yard work duties with his spouse. At the examination, the Veteran was wearing nice, clean work clothing. His affect was sad and his speech was nonpressured. His thought process was linear and goal directed. There was no impairment in his communication. He reported his mood as "depressed that I am alive" and he reported feeling survivor's guilt that he was here and others did not come home from Vietnam. He reported experiencing nightmares on an almost nightly basis, and stated that he frequently woke up screaming. He also reported daytime traumatic memories that were frequently triggered and a day did not go by that he did not think about Vietnam. He continued to have avoidance symptoms including people, places, and feelings, as well as conversations associated with the military. He had increased startle reflex and hypervigilance. His sleep was poor without Prazosin, as he frequently had nightmares. His energy was low and his appetite was normal. His concentration and short term memory were worse. He had symptoms of anhedonia. He denied suicidal and homicidal ideation. He had no paranoid ideation or auditory or visual hallucinations. He denied ever having had any panic attacks. The examiner stated that at the time of the examination, the Veteran was employable. Although the Veteran got into angry situations where he yelled at co-workers and customers, he had a very tolerant boss that continued to allow him to work. His anger, according to the examiner, seemed to be a part of his PTSD. The diagnoses were PTSD, chronic, moderate to severe and major depressive disorder, single episode, moderate without psychotic features. His global assessment of functioning (GAF) was 53. A rating between 51 and 60 is assigned when an individual presents either moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks); or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with co-workers). In January 2007, the Veteran submitted a statement in support of his claim. He stated that he disagreed with some of the statements reported in his VA psychiatric report of December 2006. He asserted that he had frequent flashbacks, nightly nightmares, weekly homicidal and/or suicidal thoughts, daily anger episodes, panic attacks, and depressed moods. He related that sometimes, he was so depressed after an anger outburst that he did not want to go on and felt it would be better if he ceased to exist. He indicated that he could see himself trying to harm someone in the midst of his rages and that this was why he gave his co-workers wide berth. He avoided war movies and had intrusive thoughts which were reportedly triggered by certain smells like diesel fuel, gun powder, and Vietnam spices. He indicated that he did not get excited about life anymore, and he did not like to leave the house or take vacations. He preferred to stay to himself, and did not want to associate with family or to make friends. He stated he had become short tempered and irritable, and he had lost interest in his antique cars. He lost the desire for intimacy; and, although he loved his grandchildren, he did not want to be around them as much as he used to. Noises at work reportedly triggered anxiety attacks and he had lost interest in his appearance and no longer liked to exercise. His spouse and his daughter submitted statements with similar reportings in support of the Veteran's claim. A coworker also wrote a letter detailing the Veteran's decline over the previous three years from being a top employee and mentor to having considerable difficulty making it through the work day. In January 2007, a treatment update from the Boulder, Colorado Vet Center was submitted on behalf of the Veteran's claim. It was reported that he had been a client of the Vet Center since March 2006. He underwent one on one and group sessions which were ongoing. The counselor indicated that the Veteran experienced intrusive thoughts and behavior of hyperarousal and avoidance from his war experiences. It was noted that he had haunting images of the death of his platoon sergeant and guilt associated with his sergeant's death; experienced difficulty with the anniversary of an intense firefight which happened the day before his birthday, keeping him from enjoying his birthday since; experiencing depression and nightmares, resulting in being prescribed Prazosin for nightmares and Bupropion for mood; increased irritability at work, from one conflict with his boss in six months, to three to four conflicts with his boss per week. The counselor indicated that it was his opinion that the Veteran was experiencing worsening dysfunction regarding work and social functioning as an unresolved consequence of his PTSD. He provided a GAF of 41. A rating between 41 and 50 is assigned when an individual presents either serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting); or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). In July 2009, the Veteran underwent VA psychiatric examination. He denied any psychiatric hospitalizations and any suicide attempts. He was prescribed Bupropion and Prazosin which he stated was helpful and indicated that therapy was beneficial. He gave a history of being in his 4th marriage which was of 21 years duration. He related that she was a nurse and understood his PTSD symptoms. He stated that he kept in close contact with his 34 year old daughter. He stated that he sometime experienced irritation and anger with his wife and that he had a low sex drive. He related that he was unemployed with his last position as that of a mechanic in November 2007. He worked as a mechanic for 23 years. He stated that he quit the job because he was having problems getting along with his coworkers and his supervisor. He was not currently looking for employment. Mental status examination revealed that he was casually and appropriately dressed in jeans, a polo shirt, and hiking boots. His clothing appeared stained and torn. His hair and nails were clean and well-groomed. He presented a restricted range of affect throughout the interview. His tone and rate of speech were normal and his eye contact was good. He was a good historian of his past and he was able to relate that history in a logical and sequential manner. He was oriented to date, time, and place. He endorsed symptoms to include depressed mood, diminished interest in activities, sleep disturbance with middle awakening, fatigue, suicidal ideation, loss of joy in everything, and low sex drive. He endorsed nightly nightmares, flashbacks, anger and irritation, avoidance of crowds, war movies, and reading the newspaper, diminished interest in activities, and a sense of foreshortened future and concentration problems. His symptoms had remained consistent. The examiner stated that he was employable from a psychiatric standpoint. He would benefit from loose supervision and working independently as he had difficulty getting along with others and had episodes of anger and irritation. The diagnosis was PTSD. His GAF was 53. Vet Center records dated from March 2006 to April 2011 were associated with the claims folder. These records showed one on one and group therapy treatment records for ongoing treatment for PTSD. Of import was that in July 2006, he was treated with Cyproheptadine and had an adverse experience. He was groggy and irritable for two days. He was changed to Prazosin. In December 2006, his Bupropion and Prazosin were both increased. In December 2007, his Bupropion was increased and his Prazosin was kept at the same dosage. In March 2009, he noted he quit his job in November 2007 because he had difficulty dealing with supervisors and he stated he felt calmer now that he was at home. In October 2010, his GAF was recorded to be 30. In November 2010, his Bupropion was again increased and another medication, Temazepam was added to help him sleep. In April 2011, the Veteran testified at a Travel Board hearing before the undersigned Acting VLJ. He related he had nightmares, sleep disturbance, and made perimeter checks of his home on a nightly basis. He stated that he had one friend, did not socialize, and would take his wife to Wendy's for lunch, but not out to dinner. He testified that he did not communicate well with others and that he had a service dog, Duke, that kept him grounded. He related that he had been receiving an increase in medication and that he had suicidal thoughts one to two times a month. He testified that his weekly group meetings with other Veterans at the Vet Center is the only place that he feels slightly understood. On this record, the Board concludes that the Veteran's PTSD is productive of social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood; and, therefore a 70 percent rating is warranted. Thus, in so finding, the Board also concludes that the Veteran's PTSD has not has not caused total occupational and social impairment, and therefore a 100 percent rating is not warranted. The Veteran had no homicidal ideation. He did exhibit suicidal ideation at times, indicating that he wish he would cease to exist. The record also fails to show that he experiences obsessional rituals which interfere with routine activities. His personal hygiene was always intact. Sometimes, he was not able to keep his attire clean. He had problems with anger and impulse control, and as a result, he quit his job. He also indicated that he had bouts of irritability and anger with his wife. He had problems with sleeping. His medication was continually increased because of sleep disturbance and depressed mood. He was oriented to time and place, however, there has been some impairment of concentration on occasion. He also indicated that he had short term memory loss. He had only one friend and tended to isolate himself from family and others. As such, the Board considers that the Veteran's disability picture exhibits that of 70 percent, and no more, throughout the rating period. The Board recognizes that the failure to meet the enumerated criteria of 38 C.F.R. § 4.130 does not preclude the Veteran from receiving a higher disability rating. However, as discussed, the totality of the evidence does not rise to the level of a 100 percent rating, as his symptomatology has not shown total occupational and social impairment. In reaching this decision, the Board also notes that, under 38 C.F.R. § 4.130, the nomenclature employed in this portion of the rating schedule is based upon the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, Fourth Edition, of the American Psychiatric Association (DSM-IV). As indicated in Carpenter v. Brown, 8 Vet. App . 240, 242 (1995), the GAF is a scale reflecting the psychological, social and occupational functioning on a hypothetical continuum of mental health-illness. A 51-60 score indicates moderate symptoms, e.g., flattened affect, circumstantial speech, occasional panic attacks, or moderate difficulty in social, occupational or school functioning; e.g., having few friends or having conflicts with peers or co-workers. A GAF score of 41 to 50 reflects a serious level of impairment, e.g., suicidal ideation, severe obsessive rituals, frequent shoplifting or serious impairment in social, occupational or school functioning, e.g., no friends, unable to keep a job. A GAF score of 31 to 40 reflects some impairment in reality testing or communication, e.g., speech is illogical at times, obscure or irrelevant, or major impairment in several areas such as work, school, family relations, judgment, thinking or mood, e.g., depressed man avoids friends, neglects family, and is unable to work. A GAF score of 21 to 30 reflects behavior that is considerably influenced by delusions or hallucinations or serious impairment, in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends). In this case, the Veteran's GAF score has been depicted at a high of 53 which reflected moderate symptoms to a low of 30. He stated that he had no friends, except one, and he isolated himself from his family. He was irritable and angry with his wife, and although he loved his grandchildren, he started to not want to be around them. He also quit his job because he could not cope with his coworkers and supervisor and he did not like being portrayed as the "angry Vietnam Veteran." Put another way, the Board finds that the totality of the evidence shows serious impairment. The Board has considered the Veteran's statements that his PTSD is worse than it is currently rated. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Next, the Board will consider whether referral for an extraschedular evaluation is warranted. The question of an extraschedular rating is a component of a claim for an increased rating. Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). Under the provisions of 38 C.F.R. § 3.321(b)(1) (2010), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if 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 Court clarified the analytical steps necessary to determine whether referral for such consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). A determination of whether the available applicable schedular rating criteria are inadequate because they do not contemplate the Veteran's level of disability and symptomatology first must be made by the RO or Board. If the rating criteria are inadequate, the RO or Board must proceed to determine whether the Veteran exhibits an exceptional disability picture indicated by other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for extraschedular consideration. However, in this case, the medical evidence fails to show anything unique or unusual about the Veteran's PTSD that would render the schedular criteria inadequate. The Veteran's main symptoms include problems with work and family, as well as symptoms such as suicidal ideation, nightmares, flashbacks, and hypervigilance, all of which are contemplated in the rating assigned. As such, it would not be found that his disability met the "governing norms" of an extraschedular rating. Accordingly, an extraschedular rating is not warranted. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2010). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2010). Generally, the evidence 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. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004) (citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002); Caluza v. Brown, 7 Vet. App. 498, 505 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (table)). If a chronic disease is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). However, continuity of symptoms is required where a condition in service is noted but is not, in fact, chronic or where a diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). In addition, certain chronic diseases, including other organic diseases of the nervous system, may be presumed to have been incurred or aggravated during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Additionally, some degree of hearing loss is considered to be present when the auditory threshold at any of the frequencies is greater than 20 decibels. See Hensley v. Brown, 5 Vet. App. 155, 157-8 (1993). In each case where a veteran is seeking service connection for any disability, due consideration shall be given to the places, types, and circumstances of such veteran's service as shown by such veteran's service record, the official history of each organization in which such veteran served, such veteran's treatment records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a). Pursuant to 38 U.S.C.A. § 1154(b), with respect to combat veterans, "[VA] shall accept as sufficient proof of service-connection of any disease or injury alleged to have been incurred in or aggravated by such service satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions and hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service, and to that end, shall resolve every reasonable doubt in favor of the veteran. Service-connection of such injury or disease may be rebutted by clear and convincing evidence to the contrary." See also 38 C.F.R. § 3.304(d). However, the Court has held that 38 U.S.C.A. § 1154(b) can be used only to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service, not to link the claimed disorder etiologically to the current disorder. See Libertine v. Brown, 9 Vet. App. 521, 522-23 (1996). Section 1154(b) does not presumptively establish service connection for a combat veteran; rather, it aids him by relaxing the adjudicative evidentiary requirements for determining whether an injury occurred in service. A veteran must still generally establish his claim by competent medical evidence tending to show a current disability and a nexus between that disability and those service events. See Gregory v. Brown, 8 Vet. App. 563, 567 (1996); Kessel v. West, 13 Vet. App. 9 (1999). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has rejected the view that competent medical evidence is required when the determinative issue in a claim for benefits involves either medical etiology or a medical diagnosis. Under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d. 1313 (Fed. Cir. 2009); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). Finally, in a claim for service connection, the ultimate credibility or weight to be accorded evidence must be determined as a question of fact. The Board determines whether (1) the weight of the evidence supports the claim, or (2) the weight of the "positive" evidence in favor of the claim is in relative balance with the weight of the "negative" evidence against the claim: the appellant prevails in either event. However, if the weight of the evidence is against the appellant's claim, the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. In this case, the Veteran asserts that service connection is warranted for tinnitus and bilateral hearing loss, claiming that he has had them since service. He has related that his tinnitus was periodic and he has not been exposed at any other time to any noise exposure, except in service. He claims that he has bilateral hearing loss as a result of service. He indicated that he first noticed hearing loss right after service and that as a result of the noise exposure in service, he warrants service connection for bilateral hearing loss. Service treatment records do not reflect any complaints, findings, or diagnosis of tinnitus. Audiometric findings at service discharge showed no finding greater than 15 db. Service personnel records in the claims file verify his status as a combat veteran, specifically his receipt of the Combat Infantryman Badge (CIB) and the Purple Heart. It shows that his principal duties in Vietnam were mortar carrier driver and gunner. 38 U.S.C.A. § 1154(b). The Veteran's DD-214 indicates that his military occupational specialty (MOS) was Indirect Fire Crewman. In December 2007, audiology testing performed by Kaiser Permanente revealed decreased hearing acuity in both of the Veteran's ears. There was no pain or pressure in the ears. The examination was also positive for tinnitus. He had no history of ear infection, ear drainage, or ear surgery. His history was positive for head trauma during a motor vehicle accident when he was rendered unconscious. He had a history of noise exposure during the military with explosions. He also had a family history of hearing loss with his mother, that the examiner stated was likely due to aging. The findings were normal sloping to severe sensorineural hearing loss. In March 2008, the Veteran underwent a VA audiology examination. The examiner noted that at separation from service, audiometric testing had shown the Veteran to have normal hearing sensitivity, bilaterally. The examiner also reviewed the December 2007 hearing test showing normal hearing through 1,500 Hz sloping to severe hearing loss in the right ear and normal hearing through 1,000 Hz sloping to a moderately severe hearing loss in the left ear. The Veteran reported a gradual decrease in hearing acuity in both ears since the time he spent in Vietnam. He reported experiencing daily high pitched ringing in his right ear greater than the left ear which would comes and go, since his time in Vietnam. He denied vertigo, dizziness, otalgia, otorrhea, chronic ear infections, known ototoxic medications, familial history of hearing loss, and otologic surgery. The Veteran gave a history of noise exposure from serving in the infantry as a mortar man and in Vietnam. Occupational noise exposure included working as a mechanic for 24 years, and recreational noise exposure included shooting with hearing protection. Audiometric testing revealed, with pure tone thresholds in decibels: HERTZ 500 1000 2000 3000 4000 RIGHT 25 20 40 45 70 LEFT 25 20 25 35 65 Speech audiometry revealed speech recognition ability of 96 percent in his right ear and 96 percent in his left ear. The examiner diagnosed normal hearing sensitivity sloping to a mild to moderately severe sensorineural hearing loss rising to moderate hearing loss, bilaterally. The examiner also stated that the ringing the Veteran described in his ears was significant enough to be considered "tinnitus" for rating purposes. The examiner opined that due to the documentation of normal hearing sensitivity at the time of separation from service, hearing loss was not the result of service. The examiner also stated that service medical records were negative for any complaints, treatment, or diagnosis of tinnitus. Due to a lack of documentation, it was the examiner's opinion that it was less likely than not that the Veteran's tinnitus was the result of his military service. The Veteran testified at a Travel Board hearing before the undersigned Acting VLJ in April 2011. He testified that he noticed hearing loss shortly after leaving the military. He stated that he had high frequency hearing loss, which made it difficult for him to hear his grandchildren and his wife, persons with high pitched voices. He stated that his hearing loss had worsened a little since service. He also testified that he had noticed the ringing in his ears in service, but he did not think anything of it at the time, assuming that it would go away. He added that it was still happening and he had simply gotten used to it. He also related that his first treatment for hearing loss was one to two years ago. He also related that he started working as a mechanic in 1982, 15 years after service. He had no real noise exposure after service. He worked a short time for the railroad. As for service connection for tinnitus, the Board has also considered the Veteran's statements concerning in-service noise exposure as well as his documented duty assignments and status as a combat veteran. Under 38 U.S.C.A. § 1154(b), in-service incurrence of injury is met as to tinnitus. Since service, the Veteran has testified, and the record showed on private examination in December 2007, and by VA examination in of March 2008, he had complaints of tinnitus. Moreover, the Veteran has asserted that he has had tinnitus since active service. Tinnitus is subjective and the type of condition to which lay testimony is competent to diagnose. Charles v. Principi, 16 Vet. App. 370, 374 (2002) (finding the veteran competent to testify to symptomatology capable of lay observation); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting competent lay evidence requires facts perceived through the use of the five senses). The VA examiner based his conclusion that the Veteran's tinnitus was not caused by the Veteran's military on the fact that there was no documentation of tinnitus in service. However, as noted above, 38 U.S.C.A. § 1154(b) provides a presumption for combat veterans with regard to injuries they experienced during combat. In this case, the Veteran testified that while serving in combat he recalled experiencing ringing in the ears. Ringing in the ears is a symptom that a lay person such as the Veteran is competent to report; and the Board has found no reason to doubt the Veteran's credibility with regard to his report that he experienced ringing in his ears while in service, as such a contention is not contradicted anywhere in the record. As such, the examiner's opinion appears to be based on an incomplete/inaccurate factual history, and as such, is of little probative value. See Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005) (citing Reonal v. Brown, 5 Vet. App. 458, 461 (1993) and Swann v. Brown, 5 Vet. App. 229 (1993)). The Veteran has asserted that his tinnitus began in service and has continued since that time. This assertion is considered to be credible, and is sufficient to form the basis for service connection. As such, service connection is granted for tinnitus. With regard to the Veteran's claim for service connection for bilateral hearing loss, this claim must fail. The evidence of record does not show findings, treatment, or diagnoses of bilateral hearing loss in service or for many years after service. In fact, the first medical evidence of bilateral hearing loss is not of record until December 2007, more than thirty years after the Veteran separated from service, and after more than twenty years working as a mechanic. Although the private examiner indicates at that time that the Veteran has positive history for noise exposure in service, at no time does he attribute the hearing loss to service. He also noted a positive history of hearing loss in the Veteran's family. Moreover, the March 2008 VA audiology examiner specifically states that due to normal hearing sensitivity at the time of separation from service, it was his opinion that hearing loss was not due to service. The lack of disability or injury in service does not in itself preclude a grant of service connection. Indeed, service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d). Nevertheless, a review of the post-service evidence does not support the conclusion that any current bilateral hearing loss is causally related to active service for the reasons discussed below. The post-service evidence does not show hearing loss until 38 years after active duty service. As such, the objective evidence does not reflect continuity of symptomatology. While no medical evidence documents post-service symptomatology related to his bilateral hearing loss for many decades, the Veteran nevertheless asserts that he has experienced hearing loss since active duty service. The Veteran is competent to report symptoms of difficulty hearing because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 at n.4 (Fed. Cir. 2007) ("Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer."). In such cases, the Board is within its province to weigh that testimony and to make a credibility determination. However, it is important to note that the Veteran is not competent to establish that he had hearing loss for VA purposes, as this requires audiometric testing, and is therefore considered a medically complex determination. The Board acknowledges that lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir.1996) (table); Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Here, the Board finds that the Veteran's reported history of continued bilateral hearing loss since active service, while competent, is nonetheless not credible. First, emphasis is placed on the multi-year gap between discharge from active duty service (1969) and initial reported symptoms and diagnosis as early as 2007, over 38 years after service separation. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim). There is simply no evidence, other than his own statements, to support his assertions of experiencing bilateral hearing loss since service. Accordingly, the Board finds the Veteran's statements asserting in-service incurrence or continuity of symptomatology since service lack credibility and are without probative value. See, e.g. Madden v. Gober, 125 F.3d 1477, 1481 (1997) (the Board is entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Pond v. West, 12 Vet. App. 341 (1999) (although Board must take into consideration a veteran's statements, it may consider whether self-interest may be a factor in making such statements). Next, service connection may be granted when the evidence establishes a causal relationship between active duty service and current complaints. In this case, the Board finds that the weight of the competent evidence does not attribute the Veteran's bilateral hearing loss to active service, including in-service noise exposure. To that end, the Board places significant probative value on the March 2008 VA examination undertaken to specifically address the Veteran's bilateral hearing loss claim. The VA examiner indicated that due to the normal audiometric data demonstrated prior to service discharge in 1969, it was less likely as not that the Veteran's hearing loss was the result of or caused by his military duty. The Board finds that the March 2008 VA examination and opinion are adequate for evaluation purposes. Specifically, the examiner reviewed the claims file; interviewed the Veteran; and conducted a physical examination. There is no contradicting medical evidence of record; and the examiner grounded his conclusion in the medical evidence of record. Therefore, the Board finds the VA examiner's opinion to be of great probative value. The Board has also considered the Veteran's statements asserting a nexus between his currently-diagnosed bilateral hearing loss and active duty service. The Federal Circuit recently held in Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010) and in Waters v. Shinseki, 601 F.3d 1274, 1278 (2010) that the Board errs when it suggests that lay evidence can never be sufficient to satisfy the requirement of 38 U.S.C.A. § 5103A(d)(2)(B) that there be a nexus between military service and a claimed condition. Although the Veteran is competent to report that he has hearing problems, he is not competent to render a medical opinion as to the etiology of his claimed disorder. Moreover, the Board finds that the March 2008 VA examiner's opinion is the most probative evidence of record, as he reviewed the records, considered his reported history, and conducted a detailed examination. The Board does not find the Veteran's statements concerning the etiology of his claimed bilateral hearing loss to be credible, as they are not consistent with probative and objective medical evidence of record which concluded that his claimed bilateral hearing loss was not a result of events in service. Thus, the Board attaches greater probative weight to the clinical findings discussed at length above than to the Veteran's lay statements. Differing from tinnitus, bilateral hearing loss is not a subjective injury capable of lay diagnosis. As stated before, the Veteran is not competent to render a medical opinion as to the etiology of his hearing loss. As such, the preponderance of the evidence weighs against a finding that the Veteran's bilateral hearing loss developed in service or is due to any event or injury in service. Further, the Board has considered whether presumptive service connection for a chronic disease is warranted. Service connection may be established under the provisions of 38 C.F.R. § 3.303(b) when the evidence, regardless of its date, shows that a veteran had a chronic condition in service or during the applicable presumptive period. Certain chronic diseases, including other organic diseases of the nervous system, may be presumed to have been incurred or aggravated during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309 (2010). As the evidence of record fails to establish any clinical manifestations of sensorineural hearing loss within the applicable time period, the criteria for presumptive service connection on the basis of a chronic disease have also not been satisfied. For the foregoing reasons, the claim for entitlement to service connection for bilateral hearing loss is not warranted on a direct or presumptive basis. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). As such, service connection for bilateral hearing loss is denied. ORDER A 70 percent rating for PTSD is granted, subject to the laws and regulations governing the payment of monetary benefits. Service connection for tinnitus is granted. Service connection for bilateral hearing loss is denied. REMAND The Veteran alleges that a mid back condition is warranted due to service incurrence. He related that he injured his back when he was involved in a mine explosion in Vietnam and that he still has back problems, including spasms, as a result of that injury. A review of the evidence of record shows that the Veteran testified at his Travel Board hearing in April 2011, that he was seen by VA for back school prior to 2009. He stated that he received physical therapy on his back for several weeks and he was taught exercises to perform in connection with his back complaints. The Board emphasizes that records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file. Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). Those VA outpatient treatment records should be obtained and associated with the claims folder. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should seek any VA outpatient treatment records related to back school or physical therapy prior to 2009 for treatment and/or therapy of the Veteran's back and associate those records with the claims folder. 2. The Veteran should then undergo a VA orthopedic examination to determine the etiology of his mid back (thoracic) condition. All indicated studies should be performed. The examiner should review the claims folder in connection with the examination. After examination, the examiner should diagnose any current back disability and then should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any diagnosed back disability either began during or was otherwise caused by the Veteran's military service. 1154(b) but is it refuted by service treatment records. Consideration should be made of the Veteran's statements that he injured his back during an explosion in service and of service medical records which show the same. All opinions provided must be thoroughly explained, and an adequate rationale for any conclusions reached should be provided. If an opinion cannot be rendered without resort to speculation, the examiner should so state and explain why an opinion cannot be provided without resort to speculation. 3. Then readjudicate the appeal. If the claims remain denied, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate time for response. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ MATTHEW W. BLACKWELDER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs