Citation Nr: 1436525 Decision Date: 08/14/14 Archive Date: 08/20/14 DOCKET NO. 07-31 368A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to service connection for left ear hearing loss. 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for a sleep disorder. 4. Entitlement to service connection for a reproductive system disability. 5. Entitlement to service connection for hyperthyroidism. 6. Entitlement to a rating in excess of 70 percent for posttraumatic stress disorder (PTSD) with major depression prior to February 5, 2010. 7. Entitlement to a rating in excess of 20 percent for lumbar spine degenerative disc disease (DDD). ATTORNEY FOR THE BOARD James R. Siegel, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from August 2002 to August 2005. These matters are before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Seattle, Washington, Department of Veterans Affairs (VA) Regional Office (RO). A January 2007 rating decision reduced the rating for adjustment disorder from 10 to 0 percent, effective April 1, 2007. A June 2009 rating decision denied the claims seeking service connection and an increased rating for lumbar spine DDD. A November 2009 rating decision assigned a 10 percent rating for adjustment disorder, effective August 31, 2009. A December 2009 rating decision recharacterized the Veteran's service-connected psychiatric disability as PTSD with major depression and assigned a 70 percent rating effective January 25, 2006; a July 2012 rating decision made the 70 percent rating retroactive to October 7, 2005, and assigned a 100 percent rating effective February 5, 2010. [The Veteran was also awarded a total disability rating based on individual unemployability due to service-connected disability for the period from October 7, 2005 to February 5, 2010.] In June 2013 the Board remanded the case for additional development. The issues of service connection for reproductive system and thyroid disorders are being REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if action on her part is required. FINDINGS OF FACT 1. The Veteran is not shown to have a left ear hearing loss disability. 2. The Veteran is not shown to have hypertension. 3. The Veteran is not shown to have a sleep disorder/sleep apnea. 4. Prior to February 5, 2010, the Veteran's service-connected psychiatric disability was manifested by panic attacks, occasional suicidal ideation and hallucinations, that caused occupational and social impairment in most areas, but did not result in total occupational and social impairment. 5. The Veteran failed to report for VA examinations scheduled in 2013 in connection with her claim for an increased rating for lumbar spine DDD; good cause for her failure to appear is neither shown, nor alleged. CONCLUSIONS OF LAW 1. Service connection for left ear hearing loss is not warranted. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2002); 38 C.F.R. § 3.303 (2013). 2. Service connection for hypertension is not warranted. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2002); 38 C.F.R. §§ 3,303, 3.307, 3.309, 3.310 (2013). 3. Service connection for a sleep disorder/sleep apnea is not warranted. 38 U.S.C.A. § 1110, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2013). 4. A rating in excess of 70 percent for PTSD with major depression was not warranted prior to February 5, 2010. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.30, Diagnostic Code (Code) 9411 (2013). 5. The Veteran's claim seeking an increased rating for lumbar spine DDD must be denied because she has failed (without good cause) to report for a VA examination scheduled to determine her entitlement to an increase. 38 C.F.R. §§ 3.326(a), 3.655 (2013); Sabonis v. Brown, 6 Vet. App. 426 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to the instant claims. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and her representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and 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. 38 C.F.R. § 3.159(b)(1). VCAA notice requirements apply to all five elements of a service connection claim: 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The appellant was advised of VA's duties to notify and assist in the development of these claims. Letters dated in April 2006 and January 2009, prior to the adjudication of the claims, explained the evidence necessary to substantiate the claims, the evidence VA was responsible for providing and the evidence she was responsible for providing, and informed her of disability rating and effective date criteria. She has had ample opportunity to respond/supplement the record, and has not alleged that notice was less than adequate. Any notice timing error was cured by subsequent readjudication. The Veteran's service treatment records (STRs), Social Security Administration records and pertinent post-service treatment records have been secured. She has been afforded examinations for her hearing loss, hypertension and service-connected disabilities. Following and pursuant to the June 2013 remand, she was scheduled for various further examinations. She failed (without giving cause) to report for such examinations (as was explained in a supplemental statement of the case (SSOC) issued in May 2014-which she has acknowledged that she received). Given these circumstances, the Board finds that no further development of the evidentiary record is necessary. See generally 38 C.F.R. § 3.159(c)(4). VA's duty to assist is met. Factual background, Legal criteria and Analysis The Board has reviewed all of the evidence in the appellant's record. Although the Board has an obligation to provide adequate reasons and bases supporting its decision, there is no requirement that each item of evidence submitted by the appellant or obtained on her behalf be discussed in detail. Rather, the Board will summarize the evidence as deemed appropriate, and the Board's analysis will focus specifically on what the evidence of record shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Veteran's STRs are silent regarding complaints or findings pertaining to a left ear hearing loss, hypertension, and a sleep disorder/sleep apnea. In a May 2005 report of medical history, she denied having a hearing loss and high blood pressure. On May 2005 service separation examination, her heart and vascular system were normal; her blood pressure was 110/36. An audiogram showed that left ear puretone thresholds, in decibels, were 15, 5, 20, 25 and 10, at 500, 1,000, 2,000, 3,000 and 4,000 Hertz, respectively. On July 2005 VA general medical examination the Veteran's blood pressure was 110/70. On June 2006 VA psychiatric evaluation, the Veteran reported she constantly worried without sufficient cause. She stated she does well when she feels good, but when she is depressed, she feels overwhelmed with depressed mood, low self-esteem and suicidal ideation. She avoids people, other than her spouse. On mental status evaluation, the Veteran's orientation was within normal limits. Her appearance, hygiene and behavior were appropriate. Affect and mood were abnormal with flattened affect. Concentration was within normal limits. She seemed bewildered about some events in service. She had panic attacks, occurring more than once a week. The attacks included spontaneous crying, tachycardia, restlessness, rapid breathing and cold sweat. There were no delusions of hallucinations, and no obsessional rituals. Her thought processes were grossly impaired with guilt and low self-esteem. Her judgment was skewed by depressive ruminations, low energy and dim future. Memory was within normal limits. She had current suicidal ideation, but no plan. She felt depressed and hopeless. The diagnoses were PTSD and major depressive disorder. The Global Assessment of Functioning score was 42, with serious symptoms. The examiner commented the Veteran was intermittently unable to perform activities of daily living because of the symptoms and impairment described above. She was able to provide self-care. He added that her psychiatric symptoms caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and mood. Her symptoms included suicidal ideation, difficulty in adapting to stressful circumstances, inability to establish and maintain effective relationships, irritability and outbursts of anger. She had no difficulty understanding commands. She appeared to pose a threat of persistent danger or injury to self or others because of her depressed moods, guilt, low self-esteem, loss of her daughter (who was sent to her spouse's parents) and not feeling adequate to visit or contact her. It was also noted that she isolated herself. VA outpatient treatment records show the Veteran was seen in October 2005, when she reported she felt overwhelmed and unable to cope. She stated she was depressed, had episodes of panic and had not been able to sleep for more than four hours at a time. On mental status evaluation, she was described as neatly groomed and made good eye contact. She was tearful at times. Her thoughts were well organized and goal-directed without tangentiality or circumstantiality. There was no evidence of psychosis, and she did not have suicidal or homicidal ideation. Insight and judgment were fair. The Global Assessment of Functioning score was 52. Later that month, the assessment was the Veteran continued to be depressed with poor sleep, decreased appetite, irritability, poor concentration and an inability to cope with everyday stressors. She reported she was mildly depressed and felt very lonely in January 2006. In March 2006, she stated she was becoming more isolative. On mental status evaluation, she was appropriately groomed and had good eye contact. The 2006 treatment reports show she reported paranoia and panic on some visits. She generally denied suicidal or homicidal ideation and audio and visual hallucinations. In November 2006, she stated she had a recent panic attack and mentioned she saw a "shadow person." On examination, her mood was depressed and she had significant amotivation. There was concern for possible audio or visual hallucinations. She denied suicidal or homicidal ideation. The next month the Veteran reported her nightmares had increased, that she never felt rested and that she had no energy. The assessment was that she appeared to have an exacerbation of PTSD symptoms. A January 2007 statement by a VA physician notes he had been treating the Veteran since early 2006. It was indicated she had experienced a significant depressive episode in the fall with exacerbation of her PTSD symptoms. The symptoms necessitated the start of anti-depressant medications. Her symptoms had since improved and she was doing quite well. The physician stated the Veteran was competent to continue to attend a university, but that she might have mild difficulties with concentration and anxiety, which were chronic and prominent symptoms of PTSD. Additional VA outpatient treatment records from 2007 to 2009 a January 2007 report that shows the Veteran was doing well, with improvement in her mood and vegetative symptoms. She continued to have trouble sleeping. She had become more social, going out with friends more. On mental status evaluation she was described as appropriately groomed and having fair to good eye contact. She denied suicidal or homicidal ideation and audio and visual hallucinations. The following month, she stated she had superficially cut her wrist in a semi-asleep state. A mental status evaluation showed she was alert and oriented. Her mood was good and affect was euthymic. She denied suicidal or homicidal ideation and audio and visual hallucinations. In April 2008, the Veteran reported she had had a difficult few weeks, with a number of psychosocial stressors. About one week earlier, she cut her wrist when she was so emotionally dysregulated and unable to get her husband to talk her through her anger. Her thought content was positive for passive suicidal ideation. She denied audio and visual hallucinations. She was alert and oriented times three. In May 2007, the Veteran related she had been fired from a class she was helping to teach and, because this was emotionally draining for her, she withdrew from her classes. When this happened, she felt very depressed with little energy. She had some self-harm thoughts and urges. On mental status evaluation, she denied suicidal or homicidal ideation and audio and visual hallucinations. Her mood was calm and affect was constricted. She was appropriately groomed. The assessments were major depressive disorder and PTSD, with a recent exacerbation that was resolving. The following month, she admitted to having weird dreams, but denied continued nightmares. Her blood pressure was 109/61 in March 2008. In February 2009, the Veteran reported feeling depressed on and off for at least a year. She reported hypersomnolence, anergia, increased appetite, decreased concentration and anhedonia. She said she had hypervigilance which she described as paranoia, and that she had been having more frequent nightmares recently. On mental status evaluation, she was not well groomed and had fair to good eye contact. Her mood was depressed and her affect constricted. She denied suicidal or homicidal ideation and audio and visual hallucinations. On mental status evaluation on December 2008 private psychiatric evaluation, the Veteran was described as having good grooming and hygiene. She was polite and cooperative and maintained good eye contact. There were no suicidal or homicidal ideation, audio and visual hallucinations or paranoid delusions. Her mood was dysthymic and her affect was congruent with her mood. She was fully oriented. She stated that for the past few months, she had almost no motivation, but had occasional energy spurts. She was able to concentrate appropriately during the evaluation. The diagnoses were PTSD and major depressive disorder, moderate. The Global Assessment of Functioning score was 65. The examiner stated he did not think the Veteran could maintain regular attendance in the workplace or complete a normal workday/workweek routine without interruptions from her psychiatric condition. On VA audiological evaluation in February 2009, the Veteran reported she had engaged in combat. She stated her hearing problems began gradually when she was serving in Iraq. She described difficulty with conversations in both ears. An audiogram showed that left ear puretone thresholds were 20, 25, 25, 25 and 25 decibels, at 500, 1,000, 2000, 3,000 and 4,000 Hertz, respectively. The examiner commented that the Veteran's left ear hearing acuity was within normal limits. In February 2009, a VA physician spoke to the Veteran's private therapist who said the Veteran was having significant anxiety and had engaged in self-harm behavior a few days earlier. The Veteran denied this was a suicide attempt. It was noted she was unable to control her temper, and had yelled at her daughter that she wanted to bash her (the daughter's) head against the wall. When seen the following month, she reported an episode of feeling "sad," which led to an episode of cutting with stenciling tools. Her sleep was up and down. On mental status evaluation, she showed less attention to her appearance than in the past. Her mood was good and her affect constricted. She admitted to passive suicidal ideation, but denied homicidal ideation. She denied audio and visual hallucinations. She was alert and oriented. A mental status evaluation in April 2009 showed the Veteran's mood was good and her affect slightly constricted. She denied suicidal or homicidal ideation and audio and visual hallucinations. Her insight and judgment were fair. She was alert and oriented. In May 2009, the Veteran reported she had had two "rage attacks" which ended with her breaking property. On mental status evaluation, she displayed fair eye contact. Her mood was okay, and her affect slightly constricted. She denied suicidal or homicidal ideation and audio and visual hallucinations. She was alert and oriented. The assessments were that the Veteran had PTSD, bipolar II, obsessive-compulsive disorder and cluster B traits. The examiner noted her mood had stabilized, but she continued to have poor frustration tolerance. Her nightmares had improved. She had no recent self-harm episodes and her suicidal ideation had resolved. On February 5, 2010 VA psychiatric evaluation the Veteran reported she goes into a complete rage under pressure. She stated she goes for days without sleep and that she has extreme nightmares that are graphic and disturbing. On mental status evaluation, her appearance, hygiene and behavior were appropriate. She maintained good eye contact. She had mood swings ranging from normal to enraged and anxiety. Her mood was depressed. She lacked the ability to function independently, and it was noted she goes for days without showering. She had impaired impulse control, unprovoked irritability and periods of violence. She showed impaired attention and/or focus. She had nearly continuous panic attacks, with racing heart, shortness of breath, shakiness and a weird feeling. There were signs of suspiciousness and paranoia. No delusions were observed on the examination. It was indicated she heard voices when stressed. Obsessional rituals were present and interfered with routine activities. Her judgment was impaired. When her rage was really bad she had suicidal and homicidal ideation. She also reported she had nightmares, flashbacks and insomnia. The diagnosis was PTSD. The Global Assessment of Functioning score assigned was 30. The examiner stated the Veteran was not able to tolerate normal workplace stresses, and was unable to tolerate interactions with people. On April 2010 VA audiological evaluation audiometry revealed that left ear puretone thresholds, in decibels, were 20, 20, 25, 25 and 25, at the 500, 1,000, 2,000, 3,000 and 4,000 Hertz frequencies , respectively. The examiner stated that under VA criteria, the Veteran's left ear hearing acuity was within normal limits. On August 2013 VA examination for hypertension, the Veteran denied she had ever received a diagnosis of hypertension. The examiner noted he reviewed the record. He observed she was nine months pregnant and, therefore, her current blood pressure readings would not be representative of her usual state of health. He stated the STRs and current medical records showed no elevated blood pressure readings. The Veteran reported for a VA spine examination scheduled in August 2013. The examiner noted that she was nine months pregnant and, therefore, could not participate in a physical examination or be X-rayed. He also noted her symptoms were exacerbated by the pregnancy and would not represent her usual state. The Veteran described chronic low back pain that radiated to the buttocks. She denied having had any incapacitating episodes of DDD in the preceding 12 months. The diagnosis was DDD. In May 2014 the Veteran failed (without giving cause) to report for scheduled VA examinations for her hearing loss, hypertension and low back disability. Service connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires evidence of: (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a nexus between the claimed disability and the disease or injury in service. See Shedden v, Principi, 381 F.3d 1153, 1166-1167 (Fed. Cir. 2004). Certain listed chronic diseases (among them sensorineural hearing loss (SNHL) as an organic disease of the nervous system and hypertension) may be service-connected on a presumptive basis if manifested to a compensable degree within a specified period of time postservice (one year for SNHL and hypertension). 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. The elements of a successful secondary service connection claim are: Evidence of a disability for which service connection is sought; a disability that is already service connected; and competent evidence that the service connected disability caused or aggravated the disability for which service connection is sought. The Veteran asserts service connection is warranted for hearing loss in the left ear. The following regulations are pertinent to this claim. Hearing loss disability for VA compensation purposes is defined in 38 C.F.R. § 3.385. Impaired hearing is considered to be a disability when the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000 and 4,000 Hertz is 40 decibels or greater; or when the thresholds for at least three of these frequencies 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. To establish service connection for hearing loss, it is not required that a hearing loss disability under 38 C.F.R. § 3.385 be demonstrated during service, although a hearing loss disability by such standards must be currently present; service connection is possible if a current hearing loss disability can be adequately linked to service. Ledford v. Derwinski, 3 Vet. App. 87 (1992). In Hensley v. Brown, 5 Vet. App. 155, the United States Court of Appeals for Veterans Claims (Court) held that the threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Left Ear Hearing Loss, Hypertension, Sleep Apnea A hearing loss disability (as defined in 38 C.F.R. § 3.385) was not manifested in service, including on May 2005 service separation examination. Twice postservice the Veteran was afforded VA audiological evaluations (with audiometry). Neither found a hearing loss disability. The Veteran argues that there is no reason that the acoustic trauma that resulted in her service-connected hearing loss would not have similarly affected the right ear. The fact remains, however, that a hearing loss disability has not been shown at any time during the pendency of this claim. The Veteran's STRs, including the report of her May 2005 service separation examination, do not show elevated (hypertensive) blood pressure readings. Postservice treatment and examination reports likewise do not show any elevated blood pressure readings. On August 2013 VA examination, the Veteran acknowledged that she had never had hypertension diagnosed. She is not showing to have had hypertension during the pendency of the instant claim. The Board notes that the issue of service connection for a sleep disorder/sleep apnea was inadvertently omitted from the June 2013 Board remand. It had been addressed in the October 2012 SSOC, and was certified on appeal to the Board (by the RO). In her December 2008 claim of service connection for a sleep disorder, the Veteran stated she believed she had sleep apnea because she sometimes woke up gasping for air. She acknowledged she had not been treated for sleep apnea. The December 2009 rating decision that recharacterized the Veteran's service-connected psychiatric disability as PTSD with major depression, rated 70 percent, effective January 25, 2006, noted that problems with insomnia and interrupted sleep were reported (and considered in the rating). The July 2012 rating decision that made the 70 percent rating for PTSD with major depression retroactive to October 7, 2005, and assigned a 100 percent rating effective February 5, 2010 also noted that sleep impairment was encompassed in rating for PTSD. In a July 2011 letter, the RO asked the Veteran to submit evidence of a sleep study that diagnosed sleep apnea. She did not respond. There is no evidence of record that the Veteran has, or ever had, sleep apnea. No separate sleep disorder entity has been documented. The Board observes that the Veteran's symptoms of disturbed sleep and insomnia are considered service-connected and encompassed in the rating for her service-connected PTSD with major depression. Service connection, whether direct or secondary, is limited to those cases where disease or injury has resulted in a disability (and by extension where a service connected disability has caused or aggravated a claimed disability). In the absence of proof of a present disability (for which service connection is sought), there is no valid claim [of service connection]. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). The preponderance of the evidence is against a finding that the Veteran has hearing loss, hypertension, and/or a sleep disorder/sleep apnea disabilities. Hence, she has not presented valid claims of service connection for such disabilities, and the appeals seeking service connection for left ear hearing loss in the, hypertension and a sleep disorder/sleep apnea must be denied. Increased rating for PTSD prior to February 5, 2010 Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting examination reports 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; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning the higher of the two where the disability picture more nearly approximates the criteria for such rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The analysis is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Hart v. Mansfield, 21 Vet. App. 505 (2007). A 100 percent evaluation is warranted for PTSD with total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. A 70 percent rating 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 worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A factor for consideration in rating psychiatric disability 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)). GAF scores ranging 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, and has some meaningful interpersonal relationships. A score of 51 to 60 indicates 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 peer or coworkers). A GAF score of 41 to 50 indicates serious symptoms and serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep job), while a GAF score of 31 to 40 indicates major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). See DSM-IV. In Mauerhan v. Principi, 16 Vet. App. 436 (2002), the Court noted that the list of symptoms in the VA's general rating formula for mental disorders is not intended to constitute an exhaustive list, but rather is to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. It was indicated the regulation requires an evaluation of the effects of the symptoms, and not a search for a set of particular symptoms. As the Veteran's service-connected psychiatric disability is rated 100 percent from February 5, 2010, the issue before the Board is whether such (next higher) rating may be warranted prior to that date. The 70 percent rating currently in effect for that period was assigned primarily on the basis of the findings on June 2006 VA psychiatric evaluation. That examination found the Veteran had occasional suicidal ideation (but no current plan for such), and panic attacks, but no delusions or hallucinations. There were no obsessional rituals or neglect of personal appearance. The examiner concluded the Veteran had deficiencies in most areas, including work, school and family (but, by inference, that she did not have manifestations productive of total occupational and social impairment). The Board acknowledges that the Veteran's 2005 to 2009 treatment records show that her psychiatric symptoms varied in severity. However, those records do not show a psychiatric disability picture consistent with total disability. Notably, in October 2005 she had no suicidal or homicidal ideation or evidence of a psychosis. The examiner assigned a Global Assessment of Functioning score of 52 (reflecting only moderate symptoms). Most treatment records from 2006 state she had no suicidal or homicidal ideation or audio and visual hallucinations. She did cut herself several times and reported paranoia on occasion, and in November 2006 there was a concern for hallucinations as she said she saw a "shadow person." A VA physician noted in January 2007 that the Veteran had suffered an exacerbation in the fall, but that her symptoms had improved and she was doing quite well. No distinct period of total occupational and social impairment is shown. While she reported in May 2007 that she felt depressed after she had lost her job, there were suicidal or homicidal ideations or audio and visual hallucinations. When the Veteran was seen by a private examiner in December 2008, it was noted that she had good grooming and hygiene and was fully oriented. She did not have suicidal or homicidal ideation, audio or visual hallucinations, or paranoid delusions. While the examiner commented that he did not believe the Veteran was able to maintain regular attendance in the workplace or complete a normal workday routine without interruption from her psychiatric disability, that assessment was not reconciled with the no more than moderate clinical findings he reported and the fact he assigned a Global Assessment of Functioning score of 65 (reflecting only mild symptoms). This suggests a much less serious impairment resulting from the PTSD, and certainly does not reflect a disability picture of total occupational and social impairment, so as to warrant a 100 percent rating. It was not until the February 5, 2010 VA psychiatric evaluation that the findings reported support a rating in excess of 70 percent for PTSD. As noted above, that examination revealed the Veteran had severely impaired impulse control with periods of violence, near continuous panic attacks, suspiciousness, paranoia, suicidal ideation and hallucinations. The Global Assessment of Functioning score of 30 assigned represented a significant deterioration her ability to function. In summary, prior to February 5, 2010, the Veteran's PTSD may have resulted in deficiencies in most areas, but did not have manifestations productive of total occupational and social impairment. Throughout the appeal period she appeared goal-oriented (whether pursuing education, employment, or benefits); did not have persistent delusions or hallucinations; did not present persistent danger of hurting herself or others; and was not disoriented. In reviewing the present appeal, the Board has considered all psychiatric symptoms, not merely those in the examples set forth in the rating criteria. However, the symptoms shown prior to February 5, 2010 do not warrant a rating in excess of 70 percent, and the effect of those symptoms shown is not a disability picture of total social and occupational impairment, so as to warrant a 100 percent schedular rating. Finally, the Board has considered whether referral for extraschedular consideration is warranted. The Board notes that all findings and impairment (disturbed sleep, panic attacks and occasional suicidal ideation) associated with the Veteran's PTSD during the period under consideration are encompassed by the schedular criteria for the 70 percent rating assigned. Therefore, those criteria are not inadequate, and referral for consideration of an extraschedular rating is not necessary. See Thun v. Peake, 22 Vet. App. 111 (2008). Rating for Lumbar spine DDD Under the General Rating Formula for Diseases and Injuries of the Spine which became effective September 26, 2003, a 50 percent evaluation is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 40 percent evaluation requires evidence of forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 20 percent evaluation is warranted where there is evidence of forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (2). When entitlement or continued entitlement to a benefit cannot be established or confirmed without a current VA examination or re-examination and a claimant, without good cause, fails to report for such examination, or reexamination, action shall be taken in accordance with paragraph (b) or (c) of this section as appropriate. Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant, death of an immediate family member, etc. 38 C.F.R. § 3.655(a) (2010). When a claimant fails to report for an examination scheduled in conjunction with a claim for increase, the claim "shall" be denied. (emphasis added.) 38 C.F.R. § 3.655(b). In light of the Veteran's allegation of worsening of the disability the Board's June 2013 remand ordered an examination to assess the disability. The Veteran presented for such examination scheduled in August 2013. However (as the examination report reflects) she was nine months pregnant at the time and therefore could not be examined or X-rayed. The examiner recommended that the examination be rescheduled when she returned to her usual state of health (following the pregnancy). Thereafter, VA spine examinations were scheduled in March and in April 2014, but on each occasion the Veteran failed (without giving cause) to report. A May 2014 SSOC noted she had not reported for examinations to evaluate her low back disability, and advised her of the provisions of 38 C.F.R. § 3.655 (consequences of a failure to report for the examination). She has acknowledged she received the SSOC, and has not since provided a reason for her failure report for the examinations or expressed an intent to appear for an examination if one were to be rescheduled. The governing regulation in such circumstances (outlined above) is clear and unequivocal; it mandates that the claim for increase must be denied. See 38 C.F.R. § 3.655. Accordingly, the Board has no discretion in the matter; the law is dispositive. Sabonis v. Brown, 6 Vet. App. 426 (1994). ORDER The appeals seeking service connection for left ear hearing loss, hypertension and a sleep disorder/sleep apnea are denied. The appeal seeking a rating in excess of 70 percent for PTSD with major depression prior to February 5, 2005 is denied. A rating in excess of 20 percent for lumbar spine DDD is denied. REMAND The Veteran seeks service connection for reproductive system and thyroid disabilities. She claims that such disabilities were either incurred in service or are secondary to a service-connected disability. The STRs show the Veteran was seen in December 2003 and reported a history of an abnormal pap smear. The assessment was normal pelvic examination. In December 2004, she presented for a routine gynecological examination. She denied a history of abdominal or pelvic pain. She stated she had had only approximately two or three menses during her deployment secondary to stress. It was noted she had a normal pap in December 2003. The assessment was the examination was within normal limits. It was indicated she had oligomenorrhea which was probably due to the emotional and physical stress of deployment. On a report of medical history in May 2005, the Veteran reported a change in her menstrual pattern. She denied thyroid trouble. On service separation examination in May 2005, the endocrine system was normal. The pelvic and external genatalia examinations were abnormal. The notes indicated a January 2005 gynecological examination was normal, to include a normal pelvic examination and normal pap. VA outpatient treatment records show the Veteran was seen in March 2007 for follow-up of abnormal laboratory studies. It was also noted her menstrual cycle was abnormal and irregular. The assessment was hyperthyroidism. In September 2008, it was noted the Veteran had hypothyroidism clinically and biochemically after a transient phase of hyperthyroidism in March 2007. It was also reported she had amenorrhea, secondary in her case. The Veteran stated in November 2008 that her irregular periods coincided with her PTSD and anxiety symptoms after she returned from Iraq. The assessment was irregular periods, possibly related to PTSD. In December 2008 the Veteran was seen for infertility [the Board notes that, as indicated above, she presented for a VA orthopedic examination 9 months pregnant].. She had recently been seen in the endocrine clinic for thyroid issues and stated at that time she was having amenorrhea and infertility. She stated she had about a year of amenorrhea. During this time, she was not euthyroid. With respect to infertility, it was noted the Veteran had been pregnant in the past and her recent amenorrhea might still be from not being euthyroid. Her laboratory results were consistent with anovulation. The record suggests that the Veteran had amenorrhea in service and following her separation from service. It was stated that her irregular periods might be associated with her service-connected PTSD. In addition, it was also suggested in December 2008 that her amenorrhea might be related to her thyroid condition. In view of the findings in service, and the current record, a VA examination is needed to adequately address the claims of service connection for thyroid and reproductive system disabilities. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the case is REMANDED for the following action: 1. The AOJ should ask the Veteran to identify all providers of evaluation and/or treatment (VA and non-VA) she has received for a thyroid condition or a disability of the reproductive system since 2012, and to submit authorization forms for VA to secure records of all such evaluations and treatment from any (and all) private providers. The AOJ should secure complete clinical records of the evaluations and treatment from all providers identified. 2. After the development ordered above has been completed, the AOJ should arrange for a gynecological examination of the Veteran to determine whether she has a reproductive system disability, and if so its likely etiology. The Veteran's entire record must be reviewed by the examiner in conjunction with the examination. Any tests or studies indicated must be done. Based on a review of the record and examination of the Veteran, the examiner should: (a) Indicate whether or not the Veteran has a reproductive system disorder, and if so identify any (and each) such disorder by diagnosis. (b) Identify the likely etiology of any (and each) reproductive system disorder found. Specifically, is it at least as likely as not (a 50% or higher probability) that such disorder was incurred or aggravated in service or was caused or aggravated by a service-connected disability, to include PTSD. The examiner should also opine whether any reproductive system disorder present is related to any thyroid disorder. The examiner must explain the rationale for all opinions. 3. Thereafter, the AOJ should arrange for the Veteran to be examined by an appropriate physician to determine the nature and likely etiology of her thyroid disability. The Veteran's entire record must be reviewed by the examiner in conjunction with the examination, and any tests or studies indicated must be completed.. Based on review of the record and examination of the Veteran, the examiner should: (a) Identify the Veteran's thyroid disorder by diagnosis. If a thyroid disorder is not diagnosed, reconcile that finding with the treatment records suggesting otherwise. (b) Identify the likely etiology for the thyroid disorder diagnosed. Specifically is it at least as likely as not (a 50% or higher probability) that such disorder was incurred or aggravated in service, was caused or aggravated by a service-connected disability, to include PTSD (or is related to any reproductive disorder found pursuant to the directive above). The examiner must explain the rationale for all opinions. 4. The AOJ should then review the record and adjudicate the claims of service connection for reproductive system and thyroid disabilities. If either remains denied, the AOJ should issue an appropriate SSOC, and afford the appellant the opportunity to respond. The case should then be returned to the Board. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ____________________________________________ GEORGE R. SENYK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs