Citation Nr: 1715321 Decision Date: 05/08/17 Archive Date: 05/22/17 DOCKET NO. 12-35 036 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for headaches, to include as secondary to a traumatic brain injury (TBI). 3. Entitlement to a rating in excess of 70 percent for service-connected posttraumatic stress disorder (PTSD). 4. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service connected disabilities. ATTORNEY FOR THE BOARD L. Connor, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1968 to September 1970. He is a Purple Heart recipient. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida that, in pertinent part, granted service connection for PTSD and assigned a 50 percent disability rating, effective September 20, 2010. During the pendency of the appeal, a November 2012 rating decision granted an increased initial rating of 70 percent for the Veteran's service-connected PTSD. The Veteran continues his appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1998). This case was previously before the Board in February 2015 when it was remanded for additional development. The issues of entitlement to service connection for headaches and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. A chronic low back disability was not manifest during active service; arthritis to the low back was not manifest within one year of service; and, the preponderance of the evidence fails to establish that a present low back disability is etiologically related to service. 2. The Veteran's PTSD is manifested by occupational and social impairment, with deficiencies in most areas, but not by total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for service connection for a low back disability have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113 (West 2014); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2016). 2. The criteria for a rating in excess of 70 percent for PTSD are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2014); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.130, Diagnostic Code (DC) 9411 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2016). The duty to notify has been met. See October 2010 VCAA correspondence. The Veteran has not alleged prejudice with regard to notice. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that "absent extraordinary circumstances...it is appropriate for the Board and the Veterans Court to address only those procedural arguments specifically raised by the veteran...." See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). In light of the foregoing, nothing more is required. VA also has a duty to assist a claimant in the development of a claim. That duty includes assisting the claimant in the procurement of service and other relevant records and providing an examination when necessary. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159 (2016). Here, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has associated the Veteran's VA treatment records and available private treatment records with the claims file. The Veteran was also afforded adequate examinations. The examiners considered the relevant history, provided a detailed description of the conditions, and provided an extensive analysis to support the conclusions reached. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). Regarding the duty to assist, the Veteran's service treatment records are unavailable. In cases where a Veteran's service treatment records are unavailable through no fault of a Veteran, there is a heightened obligation on the part of VA to assist the claimant in the development of his case, explain findings and conclusions, and to consider carefully the benefit of the doubt rule. See Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); 38 U.S.C.A. § 5107 (a) (West 2014); 38 C.F.R. § 3.303 (a) (2016). The Board is satisfied that a diligent effort, though unavailing, was undertaken to acquire the service treatment records. A January 2014 letter notified the Veteran that his service treatment records were unavailable for review. That letter indicated that the facility was searched in December 2013, a request was made to the National Personnel Records Center was made in January 2014 with a negative response, and that the facility was searched again in January 2014. The Veteran was contacted with respect to the missing service treatment records in November 2013 and December 2013. Correspondence from the Veteran dated in December 2013 indicates that he does not have copies of his service treatment records. As noted above, this case was remanded by the Board in February 2015. In compliance with the remand directives, the Veteran was afforded examinations in April 2016 addressing the claims on appeal. The examinations were adequate, as the examiner considered the relevant history of the Veteran's symptoms, provided sufficiently detailed descriptions of any disability, and included clear conclusions with supporting data. The Veteran argued that previous examinations were inadequate as they were too brief and relied on previous examination reports rather than a review of the medical record. The Board finds that when read in the aggregate, the examinations are adequate for adjudication of the claims decided herein. Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007); Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (holding that once VA undertakes the effort to provide an examination when developing a claim, even if not statutorily obligated to do so, VA must ensure that the examination provided is adequate). Although the February 2015 remand also directed the RO to issue a formal finding of unavailability of the Veteran's service treatment records, the RO failed to do so. However, the Board finds that a remand to issue a formal finding of unavailability would cause undue delay for no benefit to the Veteran. As the Board is satisfied that there has been an extensive search for the Veteran's service treatment records without success, a remand would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (remand is unnecessary when it would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran; see also Sabonis v. Derwinski, 6 Vet. App. 426, (1994). The Board finds there has been substantial compliance with the February 2015 Board remand. See Stegall v. West, 11 Vet. App. 268 (1998) (finding that a remand by the Board confers on the appellant the right to compliance with the remand orders). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this claim, the Board finds that any such failure is harmless. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Service Connection for a Low Back Disability Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110 (West 2014). 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). Certain chronic diseases, including arthritis, are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1112, 1113 (West 2014); 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (2016). 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 listed in 38 C.F.R. § 3.309(a). Arthritis is a qualifying chronic disease. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As a result, service connection via the demonstration of continuity of symptomatology of arthritis is applicable here. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 C.F.R. § 3.102 (2016). In this case, the Veteran contends that he has a low back disability as a result of active service. In a February 2011 statement in support of his claims, he reported that he had low back problems in service due to "the traumatic force from a 200 lb mine, 100 feet from [him] and the violent force." During the April 2016 VA examination, imaging studies of the thoracolumbar spine showed arthritis. Accordingly, the requirements for Shedden element (1) have been met. The Veteran's service treatment records are unavailable but his personnel records reflect that he was awarded the Purple Heart. Such indicates that the Veteran was involved in combat during service. The Veteran stated that while in service, his tractor hit a bomb which threw him to the ground approximately 40 feet away. He is currently service connected for a traumatic brain injury in connection with that event. In affording the Veteran the benefit of the doubt, and finding such incident consistent with the circumstances of his service, the requirements for Shedden element (2) have been met. Notwithstanding the above, the Board finds that the Veteran's claim fails on element (3), evidence of a nexus. VA treatment records from May 2003 note that the Veteran denied back pain. In April 2010 he denied any "new back pain". Imaging studies of the lumbosacral spine were taken in March 2011 after the Veteran reported back pain. The impression was "mild degenerative changes". During a VA general medical examination in June 2011, the Veteran reported lower back pain and stiffness and a 20 year history of neck pain and stiffness. The Veteran was afforded a VA examination in April 2016. The examiner reviewed the claims file and examined the Veteran. The examiner noted the Veteran's history of developing low back pain after a mine explosion about half way through service. The Veteran reported that he did not seek treatment until about 2002. However, the examiner noted that the first reference to back pain in the treatment records was in March 2011. At that time, he had x-rays of the lumbar spine which revealed mild degenerative changes. The next reference to back pain was in April 2013. In October 2013, the Veteran reported taking over-the-counter acetylsalicylic acid (ASA) for his back pain. The examiner was unable to find any reference to back pain thereafter. Results of imaging studies of the thoracolumbar spine taken during the examination showed arthritis. The examiner indicated that he accepted the Veteran's history of injury due to a land mine in service. However, the examiner found that the Veteran's back disability was less likely than not incurred in or caused by the in-service injury. The examiner indicated that he was unable to find any evidence of a chronic back condition since service. Rather, the Veteran drove a truck for 30 years which is "one of the most common causes of low back pains." The examiner further highlighted that the Veteran admitted to not seeking treatment until about 2011. As such, no nexus could be established between the in-service accident and his current arthritis pain. Based upon the evidence of record, the Board finds that a low back disability was not manifest during active service and that arthritis or degenerative changes were not manifest within a year of discharge. The preponderance of the evidence also fails to establish that present low back disability is etiologically related to service. There is no competent evidence of any symptoms or treatment attributable to low back pain until March 2011, over 40 years after service discharge. Additionally, the April 2016 VA opinion in this case is persuasive and based upon adequate rationale. The examiner is shown to have reviewed the evidence of record and to have adequately considered the credible lay statements and reported symptom manifestation history of record, including the Veteran's reports of the in-service mine explosion. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). Despite acknowledging his reports of an in-service injury and continued back pain, the examiner was unable to find a nexus between the Veteran's current arthritis and the in-service incident. This opinion was based on a review of the record showing little treatment for back pain and the Veteran's occupational history as a truck driver. The examiner attributed the Veteran's current back pain to his career, using training and knowledge to explain that was the "most common" cause of back pain. The Board finds that the Veteran's statements as to his in-service injury are consistent with the circumstances of his service. In other words, the Board finds that the Veteran's reports of an in-service mine explosion incident are credible. To the extent, however, that he contends that he experienced in-service back pain that continued after service, the Board finds such statements to be not credible due to inconsistency with the other evidence of record. Significantly, he specifically denied back pain in 2003. He also reported having a 20 year history of neck pain in June 2011, but only noted current back pain and stiffness. It is additionally significant to note that the March 2011 X-ray studies of the back showed "minimal" degenerative changes. As such, the Board finds the Veteran's specific statements as to having back pain that continued since service to be not credible. In determining whether evidence submitted by a claimant is credible, VA may consider internal consistency, facial plausibility, and consistency with other evidence. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (superseded by statute for an unrelated point of law as stated by Duenas v. Principi, 18 Vet. App. 512 (2004)); see also Buchanan, 451 F.3d at 1337 (VA can consider bias in lay evidence and conflicting statements of the veteran in weighing credibility); Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor); Pond v. West, 12 Vet. App. 341, 345 (1999) (holding in a case where the claimant was also a physician, and therefore a medical expert, that the Board should properly consider the appellant's own personal interest in the outcome of the case). Consideration has been given to the Veteran's personal assertions that he has a present low back disability as a result of an in-service injury. However, while lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issues in this case fall outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Arthritis is not a condition readily amenable to lay diagnosis or probative comment regarding etiology. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). The Veteran is competent to report observable symptoms like back pain. However, there is no indication that the Veteran is competent to link etiologically any such symptoms to a current diagnosis. He is not shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that he received any special training or acquired any medical expertise as to musculoskeletal disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Accordingly, the lay evidence does not constitute competent medical evidence and lacks probative value. In conclusion, the Board finds that service connection for a low back disability is not warranted. When all the evidence is assembled, VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). The preponderance of the evidence is against the claim. III. Increased Rating for PTSD Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2016). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 (2016). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran's disability. 38 C.F.R. §§ 4.1, 4.2 (2016); Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If two ratings are potentially applicable, the higher rating is assigned if the disability more nearly approximates the criteria required for it. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Different ratings may be assigned for different periods of time for the same disability, a practice known as staging the rating. Hart v. Mansfield, 21 Vet. App. 505 (2007); Francisco v. Brown, 7 Vet. App. 55 (1994). The Veteran's PTSD is currently evaluated as 70 percent disabling under Diagnostic Code 9411. Pursuant to this diagnostic code, PTSD is considered under the criteria set out in the General Formula for Mental Disorders (General Formula). 38 C.F.R. § 4.130 (2016). According to the General Formula, a 70 percent evaluation is warranted where there is 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; intermittently illogical obscure, or irrelevant speech; 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 evaluation is warranted where there is 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. Id. Although PTSD is rated under the General Formula, the use of the term "such as" in 38 C.F.R. § 4.130 indicates that the listed symptoms are not intended to constitute an exhaustive list. Rather, the symptoms listed are to serve as examples of the type and severity of symptoms or their effects that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The Federal Circuit emphasized that the list of symptoms under a given rating is a non exhaustive list, as indicated by the words "such as" that precede each list of symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). It held that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage or others of similar severity, frequency, and duration. Other language in the decision indicates that the phrase "others of similar severity, frequency, and duration," can be thought of as symptoms of like kind to those listed in the regulation for a given disability rating. Within the DSM-IV, Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). A GAF score is just one part of the medical evidence to be considered and is not dispositive. The same is true of any physician's statement as to the severity of a disability. It remains the Board's responsibility to evaluate the probative value of any doctor's opinion in light of all the evidence of record. GAF scores ranging between 61 and 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional...at a level of disability equivalent to reduced reliability and productivity. Scores ranging between 51 and 60 reflect more 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 peers or co- workers). Scores ranging from 41 to 50 reflect 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). See Diagnostic and Statistical Manual of Mental Disorders. The Veteran submitted private treatment records from W.A., Psy.D. dated in September 2010. The Veteran reported a good relationship with his son and adopted daughter. He also noted a good relationship with his wife, indicating that she and his dogs tended to "get out of the way" of his physical acting out in his sleep. The Veteran reported persistent reexperiencing of the in-service stressors, persistent avoidance or numbing, sleep difficulties, irritability, concentration problems, hypervigilance, exaggerated startle responses, fatigue and loss of energy, cognitive difficulties, impulsive homicidal ideation when angry, and anxiety attacks occurring every other month. He denied suicidal ideation. On observation, the Veteran was pleasant and cooperative, speech was normal, and his affect was somewhat blunted. The Veteran was oriented to person, place, and time. His attention and concentration fell below normal limits as did his recent memory. Judgment and insight were also below normal limits. A GAF of 49 was assigned. The Veteran was seen for an update of his psychological assessment in March 2011. He reported leaving his job due to the stress and his nerves, stating that he was "easier" since his retirement. His shift in mood was aided by the use of an antidepressant. He was referred to group counseling but had chosen not to follow up with the treatment at that point. The Veteran's wife reported ceasing to hold family events at their home due to her husband's reactions to other people. She stated that he was not as difficult and somewhat calmer, indicating that the medication had helped the condition but had not fully treated it. Ongoing difficulties with sleep were described. W.A. reported that the Veteran was engaged in the evaluation and particularly pleasant and cooperative throughout the interview. His impulse control was below normal limits. His speech was normal and he continued to have thought content consistent with intermittent impulsive homicidal ideation. Specific means, plans, time frames, and immediate intent were denied, however, as were suicidality and any evidence of psychosis. His affect was somewhat blunted but appropriate for the discussion at all times. The Veteran was oriented to person, place, and time. His attention, concentration, and memory were within normal limits. Judgment and insight appeared to fall below normal limits. A GAF score of 49 was assigned. During a VA examination in August 2012, the examiner reviewed the Veteran's claims file and took a history of the Veteran. The examiner found the Veteran's overall level of occupational and social impairment consistent with deficiencies in most areas, such as work, school, family relations, judgment, and thinking or mood. The Veteran reported tension with his spouse and that family get-togethers were getting on his nerves more easily. He also indicated that he did not have any friends. He reported that he stopped working because he "got to the point where [he] was more mad than glad." He denied a history of mental health treatment. The Veteran endorsed recurrent and distressing recollections and dreams of the event, avoidance of thoughts and reminders of the in-service stressor, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, restricted range of affect, difficulty falling or staying asleep, irritability, difficulty concentrating, hypervigilance, exaggerated startle response, depressed mood, anxiety, suspiciousness, chronic sleep impairment, memory loss, circumstantial, circumlocutory, or stereotyped speech, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work like setting, and impaired impulse control. A GAF score of 50 was assigned. A follow-up psychological update from W.A., Psy.D. dated in January 2013 indicates that the Veteran continued to have nightmares and make efforts towards avoidance. He also described problems with hyperarousal, including insomnia, and continued feelings of road rage, reporting an attempt to "run somebody off the road" one year prior to the assessment. The Veteran reported an inability to focus, diminished interest in activities, auditory perceptual abnormalities, and panic attacks. W.A. noted that the Veteran's speech and form of thought were circumstantial. The Veteran was engaged in the evaluation, described as pleasant and cooperative. His impulse control fell below normal limits but his speech and thought content were normal. Suicidal ideation, homicidal ideation, and perceptual abnormalities with psychosis were not apparent. His affect was blunted and appropriate for the discussion at all times. The Veteran was oriented to person, place, and time. His attention and concentration fell below normal limits. His recent memory, judgment, and insight fell below normal limits. A GAF score of 44 was assigned. VA treatment records show ongoing mental health treatment. In October 2015, he reported that medication stabilized his mood but stated he had night time sedation until the next day. He denied mood swings, active suicidal or homicidal ideation, feelings of helplessness, hopelessness, worthlessness, or other mood exacerbations. The Veteran stated that his sleep pattern was better. He was alert, oriented, well-groomed, and in no acute distress. He maintained good eye contact, was cooperative, and his speech was articulate, clear, and normal in rate, tone, and volume. His mood was stable and his affect was congruent to his mood. His concentration and attention were intact. His thought processes were goal directed and logical. During the VA examination in April 2016, the examiner found the Veteran's overall level of occupational and social impairment consistent with deficiencies in most areas, such as work, school, family relations, judgment, and thinking or mood. This was based on a review of the Veteran's claims file and interview of the Veteran. The Veteran reported being married for 23 years. He stated that he and his wife got along "good" and that they enjoyed going out to eat together, going fishing, visiting with family, and he would go shopping with her. He reported that he had "quite a few friends" and was regularly involved with their church. He also noted that he enjoyed woodworking. He stopped working in October 2010 as a truck driver, stating that he retired in part due to his "nerves". He was a firefighter paramedic for 10 years in the 1960s and then following his military service in the early 1970s. The Veteran endorsed recurrent, involuntary, and intrusive destressing memories, recurrent distressing dreams, avoidance of memories and external reminders, persistent, distorted cognitions about the in-service event, hypervigilance, exaggerated startle response, problems with concentration, sleep disturbance, depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances, including work or a work like setting. On observation, the Veteran was oriented to all spheres. His affect was congruent with his stated mood and symptoms and the Veteran was "relatively calm and responsive." His speech was of normal rhythm and content and the Veteran maintained focus on topics, responding appropriately to questions. There was no evidence of a formal thought disorder and insight and judgment were grossly intact. Active suicidal ideation, planning, and intent was denied. The Veteran also reported depressive and anxiety symptoms related to difficulty coping with physical impairments and associated limitations. The weight of the competent and credible evidence shows that the service-connected PTSD does not cause impairment greater than social and occupational impairment with deficiencies in most areas. In this regard, both the August 2012 and April 2016 VA psychiatric examination reports indicate that the VA examiners, psychologists, opined that the Veteran's level of occupational and social impairment with regard to the mental disorders was occupational and social impairment with deficiencies in most areas such as work school family relations judgment thinking and/or mood. Similarly, the evidence does not establish that the Veteran's overall impairment due to psychiatric disability is severe enough to warrant assignment of a higher, 100 percent rating. Notably, the record does not contain any evidence of gross impairment in thought processes or communication; grossly inappropriate behavior or memory loss for names of close relatives, one's own occupation, or one's own name. Although there are indications of impulsive homicidal thoughts, there is no evidence of an active plan or intent. He was also regularly found not to be in persistent danger of hurting himself or others. Further, the inability to perform activities of daily living is neither shown nor alleged. Moreover, although the Veteran's speech was circumlocutory at times, he did not exhibit gross impairment in thought processes or communication throughout the appeal period. More generally, the Veteran's mental impairment has not been shown to result in total occupational and social impairment. In this regard, the Veteran has been able to maintain a significant level of social functioning, allowing him to maintain a meaningful relationship with his wife of over 20 years and children. Also, he recently reports involvement at church, having friends, and even enjoying fishing and woodworking. Such does not indicate total occupational and social impairment. The Board has considered the GAF scores assigned to the Veteran. The Veteran was assigned GAF scores ranging from 40 to 50, reflecting serious symptomatology. However, although this is indicative of a serious impairment in social, occupational, or school functioning, it does not tend to indicate total occupational and social impairment. Also, as noted above, the GAF score is not determinative of the rating to be assigned. See VAOPGCPREC 10-95. The Board has also considered the Veteran's contentions that his PTSD warrants a higher rating. The Board acknowledges that the Veteran is competent to report symptoms of his psychiatric disability. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465 (1994). In other words, the Veteran is competent to report feelings of anxiety and sleep impairment. He is not, however, competent to identify a specific level of disability according to the applicable diagnostic code. Such competent evidence concerning the nature and extent of the Veteran's service-connected disability has been provided by the VA medical professionals who examined him. The medical findings adequately address the criteria under which this disability is evaluated. The Board accords the objective medical findings greater weight than subjective complaints of increased symptomatology. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). Neither the Veteran nor his/her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, No. 15-2818, 2017 U.S. App. Vet. Claims LEXIS 319, *8-9 (Vet. App. March 17, 2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER Service connection for a low back disability is denied. A rating in excess of 70 percent for service-connected PTSD is denied. REMAND Unfortunately, an additional remand is required in this case. The April 2016 VA examiner was unable to find a nexus between the Veteran's headaches and service because the Veteran offered "no history of any head injury or trauma while in the service." However, as noted in the February 2015 Board remand, the Veteran is service-connected for a traumatic brain injury and previously reported a head injury in service resulting in headaches. As the Veteran is service-connected for traumatic brain injury, secondary service connection must be contemplated. Secondary service connection is warranted where a disability is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). Although the April 2016 examiner opined on direct causation to service, the examiner did not address whether the Veteran's headaches are related to or aggravated by his service-connected traumatic brain injury. Accordingly, an addendum opinion should be obtained. The evidence of record also indicates that the Veteran retired from his employment as a truck driver in 2010 in part due to his "nerves". Although the Veteran filed a formal claim for a TDIU during the pendency of this appeal, which was denied by the RO in April 2014, a TDIU claim has also been raised by the record as part of his increased rating claim for PTSD. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). As indicated above, there is some evidence that the Veteran's service-connected PTSD has impacted his employability. The issue of entitlement to a TDIU has thus been raised by the evidence of record. The Court has made it clear in a series of memorandum decisions its view that even where a formal claim for a TDIU has been adjudicated and not appealed, the issue of entitlement to a TDIU raised as part and parcel of an increased rating claim exists independent of the formal TDIU claim and must be separately adjudicated. This issue should again be adjudicated by the AOJ. While in remand status, any additional treatment records should be obtained regarding the Veteran's headache disability. Accordingly, the case is REMANDED for the following action: 1. After obtaining any necessary releases, obtain updated VA and private treatment records related to the Veteran's headache disability. 2. After any additional records are associated with the claims file, return the claims file to the examiner who performed the April 2016 VA examination, if available, for an addendum opinion. If the April 2016 examiner is unavailable, the claims file should be provided to another appropriate examiner. The examiner must review pertinent documents in the Veteran's claims file in conjunction with the addendum opinion. This must be noted in the report. The Veteran may be recalled for an examination if deemed necessary. The examiner is asked to opine whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's headache disability was: a. incurred in or aggravated by his period of active service? The examiner should note that the Veteran is service-connected for traumatic brain injury and the June 2011 VA examination report documenting the Veteran's reports of headaches following losing consciousness after a mine explosion in service. b. proximately due to, or caused by, the Veteran's service-connected traumatic brain injury? c. aggravated (increased in severity beyond the normal progress of the disorder) by the service-connected traumatic brain injury? If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation. 38 C.F.R. § 3.310 (2016). If the examiner finds that he/she cannot provide an opinion without resorting to speculation, he/she should explain the inability to provide an opinion and identify precisely what facts could not be determined. He/she should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. Jones v. Shinseki, 23 Vet. App. 382, 389 (2010). The AOJ should ensure that any additional evidentiary development suggested by the examiner be undertaken so that a definite opinion can be obtained. 3. Then, undertake any appropriate development for the Veteran's TDIU claim. 4. After completing the above actions and any other development that may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims should be readjudicated. If any claim remains denied, a supplemental statement of the case should be provided to the Veteran. After he has had an adequate opportunity to respond, all issues properly on appeal should be returned to the Board for further appellate review. 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). 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 2014). ______________________________________________ KELLI A. KORDICH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs