Citation Nr: 1402006 Decision Date: 01/14/14 Archive Date: 01/31/14 DOCKET NO. 07-12 174 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to a higher initial evaluation for social phobia or paruresis and related psychiatric disabilities, rated at 10 percent prior to October 17, 2012 and 30 percent therefrom. 2. Entitlement to service connection posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Virginia Girard-Brady, Attorney ATTORNEY FOR THE BOARD Emily L. Tamlyn, Counsel INTRODUCTION The Veteran had active duty service from December 1973 to February 1976. These issues come before the Board of Veterans' Appeals (Board) on appeal from two separate rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). The December 2005 denied service connection for PTSD and a psychiatric disorder. The July 2009 decision granted service connection for social phobia (paruresis) (10 percent disabling). The Veteran initially filed a claim of service connection for urinary difficulties in October 2002; that claim was ultimately granted as a psychiatric disorder for a social phobia (paruresis) in a July 2009 rating decision. The RO assigned a 10 percent evaluation for that disability. Meanwhile, the Veteran separately claimed service connection for a psychiatric disorder and PTSD, for which he also perfected an appeal. The increased evaluation and the service connection claims were before the Board in October 2010. At that time, an increased evaluation was denied for the Veteran's social phobia. In that denial, the Board found that the Veteran's psychiatric symptomatology could not be separated and therefore all the psychiatric manifestations would be rated as attributable to the service-connected social phobia disability. The Veteran timely appealed that denial to the Court. During the pendency of that appeal, the Secretary of the Department of Veterans Affairs (Secretary) and the Veteran jointly agreed to remand the case back to the Board for further development and clarification. The Court vacated the October 2010 Board decision in a June 2011 Court order, and remanded the case back to the Board in compliance with the June 2011 Joint Motion for Remand. In December 2011, the Board separated the service connection and increased rating issues and remanded the claim for further development. Given the current psychiatric findings (as explained further below), the Board has again characterized the issues on appeal in compliance with Clemons v. Shinseki, 23 Vet. App. 1 (2009). FINDINGS OF FACT 1. Resolving doubt in favor of the Veteran, for the entire time period on appeal, social phobia and related psychiatric disabilities have been manifested by 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 being normal. 2. The Veteran does not have a diagnosis of PTSD. CONCLUSIONS OF LAW 1. For the entire time period on appeal, the criteria for an initial increased rating of 30 percent, but no higher, for social phobia and related psychiatric disabilities have been met. 38 U.S.C.A. §§ 1155, 5103, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9499-9403 (2013). 2. The criteria for entitlement to service connection for PTSD have not been met. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veteran's initial increased rating claim arises from an appeal of the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, and additional notice is not required as any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA for this claim. For the claim of service connection, in an August 2005 letter, the RO satisfied its duty to notify the Veteran under 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2013) and 38 C.F.R. § 3.159(b) (2013). The RO notified the Veteran of: information and evidence necessary to substantiate the claim; information and evidence that VA would seek to provide; and information and evidence that the he was expected to provide. VCAA 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). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by re-adjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In the instant case, the appellant was never informed of how VA determines disability ratings and effective dates. However, as the instant decision denies service connection, no disability rating or effective date will be assigned. Accordingly, any absence of Dingess notice is moot. Therefore, no further development is required regarding the duty to notify. The "duty to assist" contemplates that VA will help a claimant obtain records relevant to the claim, whether or not the records are in Federal custody, and that VA will provide a medical examination when necessary to make a decision on the claim. 38 C.F.R. § 3.159 (2013). VA has done everything reasonably possible to assist the Veteran with respect to his claim for benefits in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2013). Relevant service treatment and other medical records have been associated with the claims file. In the last Board remand, it was requested that the Veteran return authorization and consent forms so that medical evidence from private treatment providers could be obtained. The Veteran did not respond to this request. He was provided a VA examination in October 2012, which is fully adequate as the examiner interviewed the Veteran, performed a mental status examination, reviewed the file and provided a full explanation for all opinions reached. The Veteran withdrew a past request for a Board hearing in December 2009. The duties to notify and to assist have been met. The Board finds that there has been substantial compliance with the remand. See Stegall v. West, 11 Vet. App. 268 (1998). Initial Increased Rating Resolving doubt in favor of the Veteran, the Board finds an increase to 30 percent is warranted for the entire time period on appeal. The Veteran contended originally that he had a "total inability to urinate." He stated that this condition began in early 1974 and was exacerbated throughout military enlistment. He specifically mentioned that he was unable to urinate for drug testing. In December 2002, in the comment section on an authorization and consent form, the Veteran clarified he meant he had "an extreme case of paruresis." This meant that he cannot urinate without "ultimate privacy" and even then there is a strong possibility that he still could not empty his bladder. Other statements similarly showed the Veteran felt distressed over this problem (See September 2003 notice of disagreement). At a June 2006 Board hearing (for the original service connection claim) the Veteran stated he had lived with the problem of paruresis his whole life but managed to work as a carpenter for the past thirty years because he was familiar with his current work bathroom. (Transcript, pp 5-6.) He asserted that paruresis affected his social and sexual opportunities. (Transcript, p 7.) In December 2009, he submitted a statement asserting that his symptoms were extreme anxiety and depression exacerbated by the inability to freely urinate. He experienced these symptoms "constantly" and rated them as being 9/10. He described "flare ups" as extreme annoyance when he had to visit different bathrooms in order to void. He claimed he missed opportunities at work because he could not leave the comfort zone of his current structured environment as a carpenter. He did not tell his friends about his problem; only his brother and doctors knew of it. As for daily activities, he stated he declined to tell his son about his problem and missed out on doing things with him outside the home as a result. In November 2008, at a VA genitourinary examination, the Veteran stated that he was a danger to himself and others because he had to lift things with a full bladder. In March 2013, the Veteran disagreed that his lung cancer forced him to retire. If he was a field carpenter, he would have had to retire sooner. Paruresis was more debilitating than his (nonservice-connected) lung cancer. In adjudicating this claim, the Board must assess the competence and credibility of the Veteran. Washington v. Nicholson, 19 Vet. App. 362 (2005). Under 38 C.F.R. § 3.159(a)(2) (2012), competent lay evidence means any evidence not requiring that the proponent have specialized education, training or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person. Id. When deciding claims for increased disability ratings, the Board must particularly consider the credibility of a claimant's statements reporting symptoms of a "personal affliction." See Tatum v. Shinseki, 23 Vet. App. 152, 155 (2009) (noting that the Board's failure to discuss a veteran's report of constipation under DC 7903, combined with a failure to address her credibility, rendered its statement of reasons or bases inadequate). The Board must also assess the credibility, and probative value of the evidence of record in its whole. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant). The Board finds that the Veteran is competent to state what he experiences when he is unable to urinate in the presence of others and to explain the impact that paruresis has had on his life. 38 C.F.R. § 3.159(a)(2). The Board finds the Veteran's credibility in this case overall is undercut regarding the severity of his symptoms. For example, at the January 2003 VA mental health examination he denied any problems at work. He and his wife separated in 1991 and he gained custody of the children. He raised them himself; he stated this was the reason he was too busy for socializing. However, in September 2003, the Veteran stated his paruresis made it difficult to work and interact in social situations. Further May and June 2004 VA psychiatry records note that he could urinate in the presence of the psychiatrist. Other psychiatric records showed that while he reported sleep problems, he also stated he worked out at 10 PM, drank coffee prior to going to bed and had a meal at about 11 PM. (See August 2004 and January 2005 VA psychiatry records.) He went on vacations in March 2005 and 2004 while continuing to complain of severe impairment; he continued to work full time at this point. In a March 2005 VA psychiatrist record the Veteran stated that paruresis was still the issue "with possible response to therapy made less likely with the pt's (sic) intent of getting compensated for it as a service connected condition." At the October 2012 VA examination, the examiner noted: "Nonetheless, it appears that [the Veteran] continues to make an effort to engage socially-spoke about approaching women at the gym in an attempt to find a partner, taking dance classes three times a week and going to Atlantic City with his family." Given the sometimes conflicting testimony as well as the facts in comparison to the reports of the Veteran, the Board assigns the Veteran's statements less weight. Caluza, 7 Vet. App. at 511. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). Disabilities must be reviewed in relation to their history. Id. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2013); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2013); where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2013); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10 (2013). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The rating period was divided into two time periods, however, the entire period on appeal is considered for the possibility of further staged ratings. Consideration is given to the possibility of separate ratings for separate periods of time based on the facts found. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). Here, the Board will provide an increase for the earlier time period on appeal (prior to October 17, 2012); meaning the entire time period on appeal will be rated at 30 percent disabling. The Veteran is currently service-connected for chronic social phobia (paruresis), with depression. In Mittleider v. West, 11 Vet. App. 181, 182 (1998), the Court of Appeals for Veterans Claims (Court) held that where the record does not separate the effects of a service-connected disability from the effects of a non-service-connected disability, the effects must be attributed to the service-connected disability or a medical determination must be obtained. In Clemons, 23 Vet. App. 1, the Court held that the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. Here, the Board remanded to get an opinion regarding what psychiatric disabilities are related to the social phobia. The examiner explicitly stated that depressive disorder was related and that the Veteran did not have PTSD (see further below regarding service connection for PTSD). However, the record shows that over time other psychiatric disabilities have been diagnosed, such as dysthymic disorder (see March 2005 VA psychiatry record) and anxiety disorder (January 2003 VA examination report). To that extent, the Board accepts that such disabilities cannot be separated and are rated along with the social phobia diagnosis. Social phobia is an anxiety disorder characterized by fear and avoidance of social or performance situations in which the individual fears possible embarrassment and humiliation, e.g., fears of speaking, performing, or eating in public. See 38 C.F.R. § 4.130, DC 9403; Dorland's Illustrated Medical Dictionary, p 1455 (31st ed. 2007). Dysthymic disorder and depressive or major depressive disorder are mood disorders under 38 C.F.R. § 4.130, DC 9434. All of these disabilities are rated under the General Rating Formula for Mental Disorders. Id. According to this rating criteria, a 10 percent rating is assigned when there is 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. Id. A 30 percent rating is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent evaluation is assigned for 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. Id. A 70 percent disability evaluation is warranted for 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 work like setting); inability to establish and maintain effective relationships. Id. A 100 percent disability evaluation is warranted where the evidence shows total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity and duration of psychiatric symptoms, the length of remissions and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a) (2013). 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) (2013). Although the Rating Formula lists specific symptoms that are indicative of total impairment, the Court has held that the symptoms listed in the Rating Formula are only examples, and that evidence of those specific symptoms is not required to show that the veteran is totally disabled. In rating a mental disability VA is required to consider all symptoms that affect his social and occupational functioning, and not limit consideration to those symptoms listed in the Rating Formula. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In other words, the primary consideration is whether the manifestations of the service-connected psychiatric disorder result in total social and occupational impairment, regardless of whether the veteran demonstrates those symptoms listed in the Rating Formula. Further, 38 C.F.R. § 4.126(a) (2012), addressing evaluations of mental disorders, states: "[w]hen evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission." Reading §§ 4.126 and 4.130 together, it is evident that the "frequency, severity, and duration" of a veteran's symptoms must play an important role in determining his disability level. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). One other factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV)). While the Rating Schedule does indicate that the rating agency must be familiar with the DSM IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130 (2013). Here, the Veteran's GAF scores have ranged from 65 to 70. Scores from 61 to 70 reflect 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 generally functioning pretty well, has some meaningful interpersonal relationships. Records from 2003 to 2006 showed generally that the Veteran had occasional family problems, difficulty urinating when he "is upset," nervousness, irritability, anger, poor sleep, anhedonia, depressed mood, anxiety, limited insight, issues of rejection sensitivity and low self-esteem (see January 2003 Dr. A.R. record, January 2003 VA examination report, and VA mental health records from August 2003 to May 2006). These records also generally show a normal mental status examination and okay to good judgment; the January 2003 VA examination described his general psychiatric capacity as mild and assigned a GAF score of 65. The VA examination reports dated from November 2008 to October 2012, which both assessed a GAF score of 65, show that he became anxious if he had to use a public restroom. He had anxiety, avoidance, distress related to public restrooms and nightmares with bathroom themes. His social phobia resulted in anxiety, a depressed mood, anhedonia, suicidal ideation, ruminations about the negative impact the social phobia had on his life and amotivation. The October 2012 VA examiner noted occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks, although he generally functioned satisfactorily. He had aggravation and frustration related to his paruresis in that he felt uncomfortable when he did not have a full bladder and was not in a "good mood." When his bladder was empty his mood was okay. The example he gave was that when he was in Atlantic City with his children recently he had to wait until they were done before he could use the bathroom. In August 2011, Dr. R.F. stated that the Veteran had a problem urinating, as well as a recent diagnosis of lung cancer. Dr. R.F. then stated: "The above diagnosis has been considerable debilitating." In September 2011, Dr. J.Y. stated the Veteran had had significant depression and low energy. Regarding social contact, the Veteran has reported being close to his children, who still live with him. The January 2003 VA examination noted that he and his wife separated in 1991; she had mental health problems. He gained custody of the children and raised them himself and this was the stated reason why he was too busy for socializing. He did not date much but stayed in touch with his family. A March 2004 VA psychiatry record notes he had a great time on vacation because he did not have to use a public bathroom. Vacationing was also noted in March 2005 and at the October 2012 VA examination. Other records show the Veteran had a few close friends (see November 2008 VA examination report). Many records do show that voiding in a public restroom could be difficult (for example, see May 2006 and 2008 Dr. R.F. letters). The November 2008 VA genitourinary examiner stated: "He says very few people know of this, even his children with whom he lives does (sic) not know." The November 2008 VA psychiatric examination report noted traveling and being around others was uncomfortable. He felt he lost opportunities socially and occupationally due to his voiding problem. He was independent in activities of daily living and health was good except for his smoking. He asserted that he avoided parties and car/airplane trips. Similarly, in October 2012, the Veteran stated his kids were great and he got along well with his mother and brother, although they were "needy." He was diagnosed with lung cancer, so he was working out and going to dance classes to stay healthy-also so he could meet women. As mentioned above, the examiner noted the Veteran was making the effort to engage others (his family, potential dating partners). Occupationally, the Veteran worked full time successfully as a carpenter throughout the rating period on appeal until he retired in March 2011. While he has had to use a private bathroom (see November 2008 genitourinary examination report), his job was able to accommodate this (even without anyone knowing it). His psychiatric symptoms did not prevent him from performing his job functions while employed. As mentioned, at the January 2003 VA examination, he denied any problems at work, even though in June 2008 Dr. R.F. stated that his bashful bladder caused him "considerable stress particularly at work inasmuch as he tries to find places to void." The November 2008 VA psychiatric examination noted by his own admission, he did very well in his job and was good at it, but was hindered because of his social phobia. Dr. J.Y. stated his social phobia impaired his ability to function in social settings like the work environment. However, the October 2012 VA examination report showed that he retired from his job due to lung cancer, was supported by his retirement pension and indicated that he was not motivated to work as a carpenter anymore. The Veteran later denied that he quit work due to lung cancer and stated that his urinary problems were far more debilitating of the two disabilities. Given the above evidence, the Board finds that a 30 percent rating is warranted for the entire time period on appeal. In so concluding, the Board notes the symptoms of occasional suicidal ideation, depression, anxiety, a constricted or blunted affect, difficulty sleeping and avoidance of public or social situations. In the October 2012 VA examination report, the Veteran stated that he had no intention of acting on his suicidal ideation and that he "values life a lot." Overall, the occasional suicidal ideation, in and of itself, is not deemed to be significantly representative of the Veteran's disability picture and has not been shown to have caused social or occupational impairment such as to warrant a higher evaluation. Moreover, he has had no psychiatric hospitalizations. While avoiding public restroom is potentially an obsessional ritual, no clinician has characterized it as such and in any case it did not interfere with routine activity to the extent that the Veteran lacked functional relationships or had trouble at his job. Regarding difficulty adapting in stressful circumstances, the Board understands that it is not easy for him to function without a private restroom, but the evidence shows that he was indeed able to adapt, as he did a good job at his carpentry job for over 30 years and successfully raised his children. To this end, the Board declines to find reduced reliability and productivity, or difficulty in establishing and maintaining effective relationships beyond that already contemplated by a 30 percent evaluation. Again, the Board points to his success at raising his children. While disturbances of motivation and mood have been noted and there are times in the record where the disability impact has been characterized as significant, 38 C.F.R. § 4.130 directs that the Board focus on social and occupational impairment. As the record shows, virtually no one in the Veteran's life is able to discern he has paruresis (except for the people he has told) and the Board does not find total impairment, impairment in most areas, or even impairment in the form of reduced reliability and productivity. There is certainly some impairment, but, as detailed above, the Board finds it to be intermittent and a review of the Veteran's life shows he has coped with his disability. This is also supported by the assigned GAF scores in this case. Further, as mentioned, the August 2011 statement of Dr. R.F. is ambiguous as to what he is referring to-lung cancer or "a considerable problem urinating." Dr. R.F. did not provide support for his statements that he may have problems with the after effects of drugs from the psychiatrist (the Veteran seemed to not be taking psychiatric drugs according to the October 2012 VA examination) and that the Veteran had lost considerable amount of ability to function. The Board finds that being able to go to Atlantic City on vacation with his family is not consistent with a "considerable" lost amount of function; it seems more indicative of normal social interaction. The October 2012 is a better marker of the Veteran's symptoms given that it records the Veteran's history, considers his interview responses and the results of a mental status examination, reflects file review and that facts support the opinion rendered. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board does not find any further staged ratings to be appropriate for the time period on appeal. Hart, 21 Vet. App. at 509-510. Extraschedular consideration The Board will consider whether extraschedular consideration is required in this case. In Thun v. Peake, 22 Vet. App. 111 (2010), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration under 38 C.F.R. § 3.321 (2012) is warranted. Either the RO or the Board must first determine whether the schedular rating criteria reasonably describe a veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe a veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Here, the Board finds the schedular rating criteria reasonably describe the disability level and symptomatology during each stage of the rating. The Veteran's symptoms are accounted for in the schedular rating for all time periods on appeal because they demonstrate some occupational and social impairment which is covered in the rating schedule. See the October 2012 VA examination report. No further analysis is necessary for this period. Thun, 22 Vet. App. at 115. Regarding Rice v. Shinseki, 22 Vet. App. 447 (2009), the Board finds the Veteran retired from his job as a carpenter by choice and when he was working he did, in his own words, "a good job." (See the November 2008 and October 2012 VA examination reports.) Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military, naval or air service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2013). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease; such diseases are listed in 38 C.F.R. § 3.309(a); however, PTSD is not a listed disease in that regulation. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition to the general requirements for service connection, service connection for PTSD requires: (1) medical evidence diagnosing this disability in accordance with 38 C.F.R. § 4.125(a); (2) medical evidence of a link between current symptomatology and the claimed in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor actually occurred. 38 C.F.R. § 3.304(f) (2011). Other parts of § 3.304(f) are not applicable in this case. Part (1) addresses a situation where PTSD is diagnosed during active duty service. Id. Part (2) of § 3.304(f) covers a situation where the evidence shows a veteran served in combat. Part (3) provides a presumption for "fear of hostile military or terrorist activity". Parts (4) and (5) address prisoners of war and allegations of in-service personal assault. As explained further below, these provisions are not applicable here. 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 a veteran's service. This is shown by a veteran's service record, the official history of each organization in which such veteran served, medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a) (West 2002). As explained above, competency and credibility are considerations for the Board. 38 C.F.R. § 3.159(a)(2); Caluza, 7 Vet. App. at 511. The Veteran has not overtly alleged that he has PTSD; as explained, above he asserts that his problems are due to his social phobia. The RO adjudicated claims of service connection for PTSD and a psychiatric disability in December 2005. In May 2006, he declined PTSD screening by a VA clinician. His attorney re-raised the issue of PTSD in October 2011; for Clemons purposes, the issue was reconsidered on remand. Turning to the service treatment records, an April 1975 a consultation request noted difficulty urinating in the presence of others for six years. A May 1975 consultation notes an impression of detrusor/bladder neck dyssynergia. The doctor noted that the Veteran failed to cooperate and voided his bladder before testing. Follow up with "NP" was recommended, there was no objective evidence of voiding dysfunction. At separation on the report of medical history, he denied nervous trouble of any sort, stating that he was in good health except he smoked too much. A mental status examination in January 1976 showed normal findings. Medical records from the early 1990s show physical genitourinary treatment but not psychiatric treatment. The Veteran filed his claim for "total inability to urinate" in 2002. A January 2003 record from Dr. A.R. noted he had problems with his teenager and "crazy ex-wife." He didn't get some tests as directed prior because of his full time job. Dr. A.R. wrote that the Veteran had problems urinating when he "is upset." He was worried his coworkers would find out he had a claim for disability. Symptoms regarding his psychiatric problems are fully described above. At the October 2012 VA examination, the examiner found the Veteran did not meet the diagnostic criteria for PTSD. The examiner also explained that, his failure to urinate for a drug test was not a sufficient stressor and this was not exposure to a traumatic event. As noted, he does have other psychiatric disabilities and is service-connected for these problems. The Board finds that service connection for PTSD is not warranted. The elements lacking for a grant of the benefit include a diagnosis of PTSD. 38 C.F.R. § 3.304(f). The Board does not finding failing to urinate for a drug test, the sentinel event of the Veteran's service, to be "fear of hostile military or terrorist activity." Id. Further, the Veteran does not allege combat nor does the evidence show it. The combat presumptions under § 1154(b) or 38 C.F.R. § 3.304(f)(2) do not apply. The Board finds that a clear preponderance of the evidence shows the Veteran does not have PTSD. The benefit of the doubt rule is not for application. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2013). The claim is denied. ORDER For the entire time period on appeal, an initial increased rating of 30 percent, but no higher, for social phobia and related psychiatric disabilities is granted. Service connection for PTSD is denied. ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs