Citation Nr: 1751072 Decision Date: 11/08/17 Archive Date: 11/17/17 DOCKET NO. 13-35 504 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to a rating in excess of 50 percent for service-connected posttraumatic stress disorder (PTSD) with depression and sleep impairment for the period prior to February 7, 2012, and in excess of 70 percent thereafter. 2. Entitlement to an initial compensable rating for service-connected dermatitis for the period prior to April 26, 2011, and in excess of 30 percent thereafter. 3. Entitlement to service connection for a spinal disorder, to include a T-12 compression fracture and lumbar spine degenerative arthritis and disc disease. 4. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Veteran represented by: Colorado Division of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Elizabeth Jamison, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty in the United States Army from June 1970 to December 1971. These matters come before the Board of Veterans' Appeals (Board) on appeal from multiple rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. Specifically, a July 2010 rating decision granted an increased rating for PTSD with depression and sleep impairment, rated 50 percent disabling, effective February 10, 2010 (date of claim). Within one year of the July 2010 rating decision, on October 28, 2010, the Veteran filed a claim for service connection for a spinal disorder and a claim for TDIU. As part of the TDIU claim, additional evidence was received that was pertinent to the claims addressed in the July 2010 rating decision. See 38 C.F.R. § 3.156(b) (2016). Accordingly, in July 2011, the RO issued a rating decision that, in pertinent part, continued the 50 percent rating assigned for the Veteran's PTSD; granted service connection for dermatitis, rated 0 percent, effective October 28, 2010 (date of claim); denied service connection for a spinal disorder; and denied entitlement to TDIU. The Veteran's notice of disagreement (NOD) with the July 2011 rating decision was received in July 2012. A statement of the case (SOC) was issued in October 2013, and a substantive appeal was received in December 2013. In March 2016, a videoconference hearing was held before the undersigned. A transcript of the hearing is associated with the Veteran's claims file. The claims were remanded for further development in May 2016. Thereafter, an August 2016 supplemental SOC granted an increased rating of 70 percent for PTSD effective February 7, 2012; an increased rating of 30 percent for dermatitis effective April 26, 2011; and a TDIU effective February 7, 2012. The claim of entitlement to service connection for a spinal disorder remained denied. As these decisions do not represent a total grant of the benefit sought on appeal, the claims for increased ratings remain in appellate status. AB v. Brown, 6 Vet. App. 35 (1993). The issues have been amended on the title page of this decision accordingly. This appeal was processed using the Virtual Benefits Management System and Legacy Content Manager (formerly Virtual VA) paperless claims processing systems. The issue of entitlement to service connection for a spinal disorder is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. For the period prior to February 7, 2012, the Veteran's PTSD manifested through isolation, depression, anxiety, sleep disorder, and chronic pain; these symptoms more nearly approximate the degree of occupational and social impairment contemplated by a 50 percent schedular rating, but no higher. 2. For the period beginning February 7, 2012, the Veteran's PTSD manifested through anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty in adapting to stressful circumstances, depressed mood, and suicidal ideation; the symptoms more nearly approximate the degree of occupational and social impairment contemplated by a 70 percent schedular rating, but no higher. 3. For the period prior to April 26, 2011, the Veteran's dermatitis manifested through intermittent active eczema affecting less than one percent of the entire body or exposed areas. 4. For the period beginning April 26, 2011, the Veteran's dermatitis manifested through subtle papules and plaques along with mild erythema affecting less than five percent of the entire body and none of the exposed areas with nightly flare-ups. 5. The evidence of record is in relative equipoise as to whether the Veteran is unable to secure and follow a substantially gainful occupation due to service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent prior to February 7, 2012, and in excess of 70 percent thereafter, for service-connected PTSD are not met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321, 4.1-4.14, 4.130, Diagnostic Code 9411 (2016). 2. The criteria for an initial compensable rating prior to April 26, 2011, and a rating in excess of 30 percent thereafter, for service-connected dermatitis are not met. 38 U.S.C.A. §§ 1155 (West 2014); 38 C.F.R. §§ 4.1-4.14, 4.118, Diagnostic Code 7806 (2016). 3. Resolving all reasonable doubt in the Veteran's favor, the criteria for entitlement to a TDIU are met as of February 10, 2010. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2016). Letters sent to the Veteran, including those dated February 2010, November 2010, and March 2011, provided him with compliant notice. Neither the Veteran, nor his representative, has alleged prejudice with regard to notice. The Federal Court of Appeals 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). The record reflects that VA has made reasonable efforts to obtain or assist in obtaining the records relevant to the matter decided herein. The pertinent evidence associated with the claims consists of the service treatment records, private treatment records, VA treatment records, and the Veteran's statements. Here, VA has adequately discharged its duty to locate records and afforded the Veteran notice and opportunity to submit any identified records that may be in his possession. The Veteran has not identified any outstanding records that have not been requested or obtained. The Board therefore finds that VA has met its duty to assist in obtaining the relevant records. In summary, the duties imposed by the VCAA have been considered and satisfied. There is no additional notice that should be provided, nor is there any indication of further existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim. Thus, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter herein decided. See Mayfield v. Nicholson, 20 Vet. App. 539, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error); see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Increased Ratings The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss every item of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). The Board will summarize the relevant evidence and focus specifically on what the evidence shows or fails to show as to the claims. When there is an approximate balance of evidence regarding an issue material to the determination of a matter, the benefit of the doubt in resolving the issue shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3 (2016); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). General rating principles Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R. Part 4. The basis of disability evaluations is the ability of the body as a whole to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history and reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability; resolving any reasonable doubt regarding the degree of disability in favor of the claimant; 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; and evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.2, 4.3, 4.7, 4.10. Where entitlement to compensation has already been established, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994); 38 C.F.R. § 4.2. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. See Hart v. Mansfield, 21 Vet. App. 505 (2007). For an initial rating claim, consideration will be given to "staged ratings" since service connection was made effective. See Fenderson v. West, 12 Vet. App. 119 (1999). In other words, where the evidence contains factual findings demonstrating distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of a staged rating would be necessary. Id. When there is a question as to which of two ratings to apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating shall be assigned. 38 C.F.R. § 4.7. PTSD criteria The Veteran's PTSD is evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411. Under the General Rating Formula For Mental Disorders, to include PTSD, a 50 percent evaluation is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. 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); and inability to establish and maintain effective relationships. Id. A 100 percent evaluation is assignable 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); and disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran's capacity for adjustment during periods of remission. An evaluation shall be assigned based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. See 38 C.F.R. § 4.126 (2016). Furthermore, when evaluating the level of disability arising 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. Id. It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. The symptoms associated with the psychiatric rating criteria are not intended to constitute exhaustive lists, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002). Thus, the Board will consider whether "the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code," and, if so, the "equivalent rating will be assigned." Id. The Federal Circuit held previously that a Veteran may only qualify for a given disability rating "by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) ("Reading [38 C.F.R. §§ 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."). Prior to August 4, 2014, VA's Rating Schedule that addresses service connected psychiatric disabilities was based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "DSM-IV"). 38 C.F.R. § 4.130. As in this case, diagnoses many times included an Axis V diagnosis, or a Global Assessment of Functioning ("GAF") score (explained in more detail below). The DSM was recently updated with a 5th Edition ("DSM-V"), and VA issued an interim final rule amending certain provisions in the regulations to reflect this update, including the Schedule for Rating Disabilities. 70 Fed. Reg. 45093 (Aug. 4, 2014). This updated medical text recommends that GAF scores be dropped due to their "conceptual lack of clarity." See DSM-V, at 16. However, since the Veteran's PTSD claim was originally certified to the Board prior to the adoption of the DSM-V, the DMS-IV criteria will be utilized in the analysis set forth below. With regard to GAF scores, the GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. Carpenter v. Brown, 8 Vet. App. 240 (1995). GAF scores ranging from 61 to 70 indicate that a veteran has some mild psychiatric symptoms (e.g., depressed mood and mild insomnia) or experiences some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household); however, the veteran is found to generally be functioning pretty well and has some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 indicate moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social or occupational functioning (e.g., few friends, conflicts with peers and co-workers). GAF scores of 41 to 50 indicate serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social or occupational functioning (e.g., no friends, unable to keep a job). 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. PTSD analysis The Veteran contends that the 50 and 70 percent ratings assigned for his service-connected PTSD do not adequately reflect the severity of his disability during the respective periods. The Veteran submitted a claim of entitlement to an increased rating for his service-connected PTSD in February 2010. In conjunction with his claim, the Veteran submitted a statement in which he described more nightmares than ever before. He stated that he wished to have no contact with people and only left his home when he had to, which was generally not more than once per month and as needed for medical care. VA treatment records from February 2009 reflect that the Veteran presented as agitated with tangential thought process, pressured speech, paranoia, and obsession with post-surgical problems. The primary care provider noted that it was very difficult to direct the interview with the Veteran in any other direction than his post-surgical concerns and stated that his mental issues may be moderate to severe. The Veteran underwent VA examination in conjunction with his claim in May 2010. He reported nightmares, avoidance, and social isolation; he described his symptoms as severe and constant. The Veteran reported that he was still close with his brother and went fishing with him. He also said friends from church would come by and he would fish or pan for gold with them. His social activities included church, fishing, and caring for his mother. No history of hospitalization or suicide attempts was noted. PTSD symptoms included trauma re-experienced on a nightly basis, resulting in sleep impairment and chronic fatigue. The examiner noted that the Veteran was able to maintain minimal personal hygiene and other basic activities of daily living. His orientation to person, place, and time was normal. Moderate depression was present but anxiety and panic attacks were not. The resulting diagnosis was PTSD with depression and sleep impairment. A GAF of 85 was assigned. The examiner stated that the Veteran's PTSD resulted in reduced reliability and productivity due to PTSD signs and symptoms (primarily fatigue due to sleep impairment from nightmares two to three times per week). He further stated that the PTSD symptoms were not severe enough to interfere with occupational and social functioning, as the Veteran was able to live independently, help care for his mother, and socialize with friends and brother. In a June 2010 addendum, the VA examiner corrected the GAF score assigned in May 2010 to 50, rather than 85, based on the severe sleep impairment and moderate depression, as well as chronic pain syndrome. Later in June 2010, the Veteran submitted a statement in which he described depression, anxiety, panic attacks, nightmares, suspiciousness, memory issues, lack of motivation, and intrusive thoughts. Private treatment records contain a brief neuropsychological assessment conducted in August 2010 to address concerns regarding his memory. He presented as a casually dressed man who appeared his chronological age. He was pleasant, cooperative, and able to focus his attention on the task at hand. No vision, hearing, gait, or pain behaviors were noted. He denied any suicidal or homicidal ideation. Testing indicated average abilities in visuospatial, planning, naming, memory, abstraction, orientation, and immediate memory. Impairments were noted in long-term memory and language. Results suggested that the Veteran was not currently experiencing symptoms of depression, but that he was experiencing clinical symptoms of anxiety. The psychologist concluded that he not experiencing significant cognitive impairment, but would benefit from therapy to address his anxiety. A December 2010 letter from a private care provider indicated that the Veteran attended six VA behavioral health sessions between August and December 2010. At the conclusion of the sessions, the provider stated that the Veteran was motivated to improve his mental health and had made considerable gains, but continued to struggle with anxiety and depression, attributed to financial and health stressors. In February 2011, the Veteran underwent a general VA examination, including evaluation of his PTSD. Reported psychiatric symptoms included depression and mood swings, described as constant and moderate. The Veteran reported that counseling was helpful for his symptoms. He denied suicidal or homicidal thoughts or intent. The examiner noted that he was able maintain minimal personal hygiene and other basic activities of daily living. Orientation to person, place and time was normal. No memory loss or impairment was present. Panic attacks and anxiety were absent. Depressed mood was noted. Nightly sleep impairment was deemed moderate to severe. A GAF score of 50 was assigned. The examiner stated that the Veteran experienced decreased enjoyment of life, decreased socialization, depression with moderate to severe sleep disorder, nightmares, and chronic pain disorder due to his combat and injuries in Vietnam. The effects of his PTSD were reduced reliability and productivity. In August 2011, VA treatment records reflect the Veteran's report of frequent nightmares and isolation but no serious thoughts of self-harm. In February 2012, the Veteran underwent further VA examination in conjunction with his PTSD claim. The diagnosis was PTSD with depressive disorder; a GAF score of 52 was assigned. The examiner attributed the symptoms of hyperarousal, re-experiencing, and avoidance to PTSD; low energy and motivation to depression; with insomnia and irritability overlapping. These symptoms resulted in occupational and social impairment with deficiencies in most areas. The Veteran described living alone for the past 20 years, but having a good relationship with a neighbor who helped drive the Veteran. Since the last examination, the Veteran had been seen on an intermittent basis at the Colorado Springs VA and began working with Dr. E. in approximately November 2011 for visits 1-2 times per month. He reported that his sleep had improved due to the current medication regimen. He stated that he occasionally experienced hypnagogic hallucinations, thinking that he heard voices talking as he is trying to fall asleep. He also described anxiety and irritability. He denied suicidal or homicidal intent or plan. The examiner indicated symptoms of anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances. A private treatment note from March 2012 described the Veteran's PTSD as profound, very severe, deep-seated, and permanent. The note described the Veteran as well groomed, casually dressed, and wearing chest and back brace with considerable depression, anxiety, numbing, and nightmares. The Veteran reported that he tried to reconnect with son and was going to a new church. He further reported suicidal thoughts but said he would never go through with it. In a July 2012 statement, the Veteran stated that he had few friends and mostly stayed home since Vietnam. He indicated that PTSD was the reason for his unemployment. VA treatment records from 2012 contain GAF scores of 51 to 60. In August 2012, a GAF score of 41 was assigned. The Veteran completed several sessions of group therapy through a VA PTSD program; he continued to receive treatment through one-on-one counseling. In October 2012, a VA treatment note contains a GAF score of 41-50. The Veteran reported sleeping well with medication. The treatment provided noted his thoughts were logical and goal oriented with a euthymic mood and anxious affect. No suicidal or homicidal intent was present. The assessment of the Veteran was stable but fragile. A December 2012 VA treatment note diagnosed the Veteran with PTSD and major depressive disorder. The treatment provider stated that it was more clear that the Veteran was meeting the traits of paranoid personality disorder, give his statements about that have rejected and persecuted him, unusual stories about VA surgeons trying to kill him, the military not wanting him to come back alive, VA changing his medical records, etc. A GAF score of 50 was assigned. A September 2013 VA treatment note described the Veteran's anxiety when coming in to town and driving in traffic. He was dressed casually, neat and clean in appearance, was alert and oriented but lethargic and depressed with poor eye contact. His short-term and long-term memory appeared intact. His speech was clear and normal rate. His thought process appeared somewhat incoherent, goal-directed, and content of thought was paranoia for circumstances. His insight and judgment appeared compromised. Following a cancer diagnosis, the Veteran was seen in 2014, 2015, 2016, and 2017 by VA mental health providers on a regular basis. He regularly denied suicidal and homicidal ideations and did not appear to be gravely disabled. He was generally noted as being appropriate in grooming and attire with a consistently anxious mood. He described avoidance and isolation. In March 2016, the Veteran testified regarding his PTSD during a hearing before the Board. He described significant sleep problems and nightmares. He also reported suicidal ideation and significant isolation/avoidance of people. The Veteran indicated that his symptoms had worsened in the years since the previous VA examination. His lawyer indicated that he had to be calmed down before the hearing because he was so anxious. In June 2016, the Veteran underwent further VA examination in conjunction with his claim. The examiner diagnosed PTSD with MDD. Hyperarousal, hypervigilance, memory and concentration problems, panic-like symptoms, and most of irritability symptoms were attributed to PTSD; low mood, low motivation, low energy, and a small portion of irritability symptoms were attributed to MDD. The examiner described the effects of the Veteran's symptoms as occupational and social impairment with deficiencies in most areas. He stated that the majority of the impairment related to PTSD, with a lesser portion relating to MDD. Hyperarousal and anxiety appear to cause most of the Veteran's impairment. The Veteran reported being very isolated and spending little time with others. He has declined invitations to go fishing with friends. He reported that he just started going to a new church that has about 30 members, but found it very difficult to be around people. The Veteran reported difficulty falling asleep as well as frequent awakening, averaging a few hours of sleep per night without his sleep medication and good sleep with his sleep medication. He endorsed nightmares several times per week, almost nightly, about his experiences in Vietnam. He also described short term memory issues such as problems with conversations, tasks, and where he put things such as his glasses or his keys. His report did not indicate problems with judgment, decision-making, orientation, visuospatial skills, prioritizing, or malaise. He reported clinically significant intrusion symptoms, avoidance symptoms, negative alterations in cognition or mood related to traumatic events, and arousal/reactivity symptoms. He reported intermittent passive suicidal ideation but denied intent or plan, and also denied homicidal ideation, intention, or plan. He reported that he had thoughts of suicide but his faith stopped him from acting. The examiner found him to be independent with his activities of daily living from a mental health standpoint. The Veteran denied symptoms of mania and hypomania and psychosis. There was no evidence of delusion, hallucinations, or other psychotic symptoms. The examiner reported the Veteran's symptoms manifested as depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, flattened affect, and suicidal ideation. After thorough review of the evidence of record, the Board finds that the currently assigned ratings of 50 percent for the period prior to February 7, 2012, and 70 percent thereafter, but no higher, are warranted. For the period prior to February 7, 2012, the Veteran's symptoms overall more closely approximate the criteria for the assigned 50 percent disability rating. 38 C.F.R. § 4.130, Diagnostic Code 9411. Collectively, the VA examination reports, treatment records, and Veteran's lay statements do not reflect findings of a severity to warrant a 70 percent rating for this period. While a February 2009 VA treatment note indicates a tangential thought process, the majority of the evidence for this period indicates that the Veteran was normally oriented, albeit experiencing intrusive thoughts and memory problems. He consistently denied any suicidal or homicidal thoughts during this period. While the evidence reflects bouts of obsessive behavior and anxiety, there is no evidence of obsessive ritualistic behavior, impaired impulsive control, or near-continuous panic or depression which interfered with routine ability to function. During this time, the Veteran reported attending church, fishing with his brother and friends, and caring for his mother. The May 2010 examiner noted moderate depression without anxiety or panic attacks and stated that the PTSD symptoms were not severe enough to interfere with occupational and social functioning. The February 2011 examiner found that his decreased enjoyment of life, decreased socialization, depression, sleep disorder, and chronic pain resulted in reduced reliability and productivity. Medical professionals regularly found the Veteran to be appropriately dressed and able to perform all activities of daily living. Thus, the evidence for the period prior to February 7, 2012 has not shown the Veteran's disability to be manifested by social and occupational impairment in most areas or totally so as to warrant a 70 or 100 percent rating. However, as of February 7, 2012, a 70 percent rating is warranted. The Board has considered all of the evidence of record in light of the rating criteria, and finds the Veteran's overall PTSD symptomatology for the period beginning February 7, 2012 more nearly approximates occupational and social impairment exhibited by deficiencies in most areas, such as work, family relations, judgment, thinking, or mood, but not a higher level of total occupational and social impairment (as required for the assignment of a 100 percent disability rating). The evidence shows that during the relevant period, the Veteran's PTSD manifested through symptoms such as anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances, depressed mood, and suicidal ideation. These symptoms do not reflect the severity, frequency, and duration of the symptoms associated with a 100 percent rating, including 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 personal hygiene), disorientation to time or place, or memory loss for own name or names of close relatives. In contrast, the Veteran was repeatedly noted as oriented and only mild memory loss was indicated by testing. The June 2016 VA examiner indicated that his judgment, decision-making, and orientation were normal. Additionally, he was able to maintain his personal hygiene and understand the outcome of his behavior. Furthermore, although describing isolation and avoidance in his social behavior, the Veteran also reported a good relationship with his neighbor and attending a new church. While the evidence indicates significant anxiety, the Board finds that the currently assigned 70 percent rating is most appropriate based on the overall disability picture during this period. The Veteran is competent to provide evidence about his disability; for example, he is competent to describe symptoms related to his PTSD. See Layno v. Brown, 6 Vet. App. 465 (1994). He is also credible to the extent that he sincerely believes he is entitled to a higher rating. However, he is not competent to identify a specific level of disability according to the appropriate Diagnostic Code. Competent evidence concerning the nature and extent of the Veteran's PTSD was provided by the VA examiner who have interviewed and evaluated him during the current appeal. The medical findings as provided in the various VA examination reports directly address the criteria under which this disability is evaluated. Thus, the competent lay evidence is outweighed by the competent medical evidence that evaluates the true extent of his disabilities. Taking into account the competent and probative evidence of record, the Board finds that the collective medical and lay evidence does not indicate that the Veteran's PTSD meets the rating criteria for an evaluation in excess of 50 percent prior to February 7, 2012, or in excess of 70 percent thereafter. The effects of the Veteran's PTSD symptoms are not described to be of a type, frequency, and severity in accord with the impairment contemplated by the criteria for a schedular rating higher than 50 or 70 percent disabling for the respective periods. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Accordingly, the Veteran's claim for an increased rating is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, supra. Dermatitis criteria The Veteran's skin disability is rated under Diagnostic Code 7806 for dermatitis or eczema. This regulation provides that where there is less than five percent of the entire body or less than five percent of exposed areas affected, and; no more than topical therapy required during the past 12-month period, a noncompensable evaluation is warranted. When at least five percent, but less than 20 percent, of the entire body, or at least five percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such corticosteroids or immunosuppressive drugs required for a total duration of less than six-weeks during the past 12-month period, a 10 percent rating is assigned. Where there is 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period, a 30 percent rating is assigned. Where there is more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period, a 60 percent rating is assigned. 38 C.F.R. § 4.118, Diagnostic Code 7806. The Court of Appeals for Veterans Claims ("Court") previously held that topical use of corticosteroids constitutes systemic therapy under this diagnostic code. Johnson, 27 Vet. App. at 497. The Federal Circuit, however, reversed the decision by the Court. Johnson v. Shulkin, 2016-2144, 2017 U.S. App. LEXIS 12601 (Fed. Cir. 2017). In reversing, the Federal Circuit agreed with the Secretary that the Court erred when it "read DC 7806 as unambiguously elevating any form of corticosteroid treatment, including any degree of topical corticosteroid treatment, to the level of 'systemic therapy.'" The Federal Circuit noted that DC 7806 "draws a clear distinction between 'systemic therapy' and 'topical therapy' as the operative terms of the diagnostic code." The Federal Circuit went on to explain that "systemic therapy means 'treatment pertaining to or affecting the body as a whole,' whereas topical therapy means 'treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied." Although a topical corticosteroid treatment could meet the definition of systemic therapy if it was administered on a large enough scale such that it affected the body as a whole, this possibility does not mean that all applications of topical corticosteroids amount to systemic therapy. Id. Dermatitis analysis The Veteran contends that the initial non-compensable rating prior to April 26, 2011 and the 30 percent rating assigned thereafter do not adequately reflect the severity of his skin condition. A March 2010 private treatment note contains the Veteran's report of a rash on his right thigh, ankles, and hair since a MRI about two years prior. Upon examination, the treatment provider noted no evidence of a rash on the scalp and right lower leg at the time. In October 2010, a private treatment note indicated that the Veteran reported that the rash was bad in both groins. Triamcinalone/nystatin were recommended for treatment. Active eczema was documented. Upon VA examination in February 2011, the examiner noted eczema on the left calf affecting less than 1 percent of the entire body. The frequency was described as intermittent based upon the Veteran's report of periodic break out of pustules on the skin. Upon further VA examination in April 2011, the examiner noted suspected tinea versicolor/tinea corporis. The Veteran reported a rash that flared intermittently over the years, but had flared every night for the past year. He describes flares as "red, burning, spreads rapidly over chest and thighs" occurring mostly at night. Treatment for the dermatitis was documented as Griseofulvin (systemic but neither a corticosteroid nor an immunosuppressive) twice a day, Nystatin/Triamcinolone (topical corticosteroid) five times a day, and Clotriamzole (topical and neither a corticosteroid nor an immunosuppressive) every other day. Upon physical examination, the examiner found subtle erythematous papules and plaques in the left axilla along with mild erythema in the right axilla and in the groin. Less than five percent of the entire body and none of the exposed areas were affected per the examination report. A VA treatment note from September 2012 contains the Veteran's report that his rash continued to improve. In August 2014, the Veteran's prescriptions included Triamcinolone, with directions to apply a small amount to the affected area twice a day. In March 2016, VA treatment records document a physical examination showing a white patch on the right calf, groin site odor, mild pinkness under the abdominal pendulum, and no sores or patches of scales on the scalp. The treatment provided prescribed Nystatin powder twice a day, coal tar shampoo weekly, and Flucinolone cream for application to the affected area. During his testimony to the Board in March 2016, the Veteran stated that his skin condition was always flared up. He further stated that it affected his entire body, requiring application of medication every night. He estimated that it covered over 50 percent of his body, including his head, thumbs, groin, armpits, legs, and feet. The Veteran underwent further VA examination in conjunction with his claim in July 2016. He described treatment for his skin conditions over the years with various creams. He reported that when it flared, the groin rash turned purple and red and spread down his legs. The examination was not conducted during a flare up. Only a few spots on his left lower leg and scalp were visible. Current treatments indicated were Griseofulvin (taken orally for six weeks or more, but not constantly) and Triamcinolone (a topical corticosteroid applied constantly/near-constantly). The examiner estimated that the total body area and total exposed areas affected were less than 5 percent. The examiner stated that the service connected dermatitis was not deep, painful or unstable; does not result in limited range of motion; and at the time of the examination, covered a total of four square inches. After thorough review of the evidence of record, the Board finds that a non-compensable rating, but no higher, is warranted for the period prior to January 18, 2011; thereafter, a rating of 30 percent, but no higher, is warranted. The Board notes the assignment of the 30 percent rating as of April 26, 2011, due to the use of systemic therapy for more than six weeks, but not constantly, based on the Veteran's use of Griseofulvin. As indicated in the April 2011 VA examination report, Griseofulvin is systemic but neither a corticosteroid nor an immunosuppressive. VA's Adjudication Manual provides that "[t]he term "systemic therapy such as corticosteroids or other immunosuppressive drugs," that is contained in certain [diagnostic codes] under 38 C.F.R. § 4.118, refers to any oral or parenteral medication(s) prescribed by a medical professional to treat the underlying skin disorder," and that "[f]or more information on the meaning of 'such as' in the rating schedule, see Mauerhan v. Principi, 16 Vet. App. 436 (2002)." M21-1, Part III, subpt. iv, ch. 4, sec. J(3)(f) (October 5, 2015). In Mauerhan, the Court held that, because the use of the term "such as" in the general rating formula for mental disorders demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442. Thus, the use of Griseofulvin does warrant the assignment of a 30 percent rating. Accordingly, the Board assigns an effective date for this increased rating based upon the evidence of record reflecting that Griseofulvin was first prescribed in January 2011. To warrant a 10 percent rating or higher for the period prior to January 18, 2011, the evidence must show that the Veteran's skin condition affected at least five percent of the entire body or exposed areas or required usage of intermittent systemic therapy such corticosteroids or immunosuppressive drugs for a duration of less than six-weeks during the past 12-month period. Here, the March 2010 treatment provider found no evidence of a rash on the scalp and right lower leg. Triamcinalone/nystatin (topical corticosteroids) were used for treatment during this period. Griseofulvin (systemic but neither a corticosteroid nor an immunosuppressive) was also prescribed as of January 18, 2011, as discussed above. The medical evidence does not support a finding that more than five percent of the body was affected during this period. The Board has considered the Veteran's statements that his entire body is affected. However, the medical evidence from both VA and private sources are consistent in their findings and are based on clinical assessments. While the Veteran is competent to report his symptoms, the Board finds that the objective medical evidence from VA and private physicians is more probative in this analysis. The use of topical medications prior to January 18, 2011 does not qualify as systemic therapy, as it was applied only to the affected areas of the body. As the objective evidence of record reflects that this was less than five percent of the Veteran's body during this period, a finding of systemic therapy for topical application of Triamcinolone is not warranted. See Johnson v. Shulkin, 2016-2144, 2017 U.S. App. LEXIS 12601 (Fed. Cir. 2017). Accordingly, the criteria for a compensable rating were not met for this period. For the period beginning January 18, 2011, the Board finds that a rating in excess of 30 percent is not warranted. In order to warrant the next higher rating of 60 percent rating (the highest available under Diagnostic Code 7806), there must be a showing that more than 40 percent of the entire body or exposed areas are affected, or that constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs was required during the past 12-month period. Upon VA examination in February 2011, the examiner noted eczema on the left calf affecting less than one percent of the entire body. The April 2011 examination report stated that less than five percent of the entire body and none of the exposed areas were affected. Again, in July 2016, a VA examiner found that the total body area and total exposed areas affected were less than five percent. As discussed above, the use of topical medications during this period does not qualify as systemic therapy, as it was applied only to the affected areas of the body. See Johnson v. Shulkin, 2016-2144, 2017 U.S. App. LEXIS 12601 (Fed. Cir. 2017). While systemic therapy in the form of Griseofulvin was prescribed, it was not required constantly or near-constantly to warrant a 60 percent rating. Accordingly, the criteria for a rating in excess of 30 percent were not met for this period. The Board acknowledges the Veteran's belief that his skin condition is more severe than reflected by the assigned evaluations. In this regard, the Board must consider the entire evidence of record when analyzing the criteria set forth in the ratings schedule. Although the Veteran is competent to provide evidence regarding his symptomatology, as a lay person without demonstration of requisite training, he is not competent to assess whether the symptomatology due to a skin condition meets a specific disability rating under the applicable diagnostic code criteria. Competent evidence concerning the nature and extent of the skin condition was provided by the VA examiner who interviewed and evaluated the Veteran and provided the clinical findings to rate his disability with respect to the rating criteria. Therefore, the objective medical evidence is deemed more persuasive than the Veteran's statements regarding his increased symptomatology. For the reasons stated above, the Board finds that the preponderance of the evidence is against an initial compensable rating prior to January 18, 2011, or an increased rating in excess of 30 percent from January 18, 2011 onward. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. For these reasons, the claim for an increased rating for the Veteran's service connected skin condition is denied. Other considerations All potentially applicable diagnostic codes have been considered, and there is no basis to assign an evaluation in excess of the ratings assigned herein for the Veteran's disabilities. See Schafrath, 1 Vet. App. at 593. The issue of TDIU is addressed separately, below. The Veteran has not raised any other issues with respect to the increased rating claim for his PTSD or skin condition, nor have any other assertions been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (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). III. Total disability rating due to individual unemployability The Veteran contends that he is unable to maintain employment due to his service-connected PTSD and chronic pyloric spasms. An August 2016 rating decision granted entitlement to a TDIU effective February 7, 2012. After thorough review of the evidence of record, the Board finds that a TDIU is warranted as of February 10, 2010. A total disability evaluation may be assigned when the schedular evaluation is less than 100 percent where a Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In determining whether a Veteran is unemployable for VA purposes, consideration may be given to the Veteran's level of education, special training, and previous work experience, but not to age or any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Hersey v. Derwinski, 2 Vet. App. 91, 94 (1992); Faust v. West, 13 Vet. App. 342 (2000). Here, as of February 10, 2010, the Veteran was service-connected for PTSD, evaluated as 50 percent disabling; chronic pyloric spasms, evaluated as 30 percent disabling; tinnitus, evaluated as 10 percent disabling; and bilateral hearing loss, evaluated as non-compensable. A combined disability evaluation of 70 percent was in effect. 38 C.F.R. § 4.25 (2016). He first met the threshold criteria for a TDIU as of February 10, 2010. See 38 C.F.R. §§ 4.16(a). Thus, the remaining inquiry is whether he is unable to secure or follow substantially gainful occupation due solely to his service-connected disabilities as of that date. In an October 2010 Application for Increased Compensation Based on Unemployability (VA Form 21-8940), the Veteran reported that he had last worked in 1985. The evidence of record reflects that the Veteran was employed following his return from Vietnam as a handyman in his father's business. Following his father's passing in approximately 1988, the Veteran was not employed again. He served as a missionary in South America for many years before returning home to help care for an ill family member. The Board notes the evidence of the Veteran's fall from a barn while helping a neighbor in 2006, resulting in three days of hospitalization for a broken back and contributing to his occupational limitations. However, the evidence also reflects that the Veteran's PTSD is the cause of isolationism and anxiety, affecting his ability to function in an occupational setting. In a February 2010 statement, he wrote, "I wish to have no contact with people. I only leave my home when I have to, but generally not more than once per month or to receive medical care." A May 2010 VA examination noted only reduced reliability in occupational tasks due to PTSD symptoms. However, a February 2011 VA examiner found that the Veteran's PTSD/mental condition symptoms were severe enough to interfere with occupational and social functioning. He stated that the Veteran was totally disabled from all and any work due to his multiple physical disorders that result in chronic pain, dependency on narcotic pain medications, his inability to neither stand nor walk for brief periods of time, his chronic fatigue due to PTSD, and his chronic depression. Based on the foregoing, the Board finds that a TDIU is warranted as of February 10, 2010. While the evidence suggests that the Veteran's unemployment is due, in part, to nonservice-connected issues, the evidence also shows that the Veteran is unable to work due to his service-connected PTSD and chronic pyloric spasms. Based on these factors, a reasonable doubt arises as to his employability, which must be resolved in favor of the Veteran. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Therefore, resolving all reasonable doubt in the Veteran's favor, the Board finds that the Veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disabilities; and, as such, a TDIU is warranted as of February 10, 2010. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. ORDER Entitlement to a rating in excess of 50 percent for PTSD with depression and sleep impairment for the period prior to February 7, 2012, and in excess of 70 percent thereafter is denied. Entitlement to an initial compensable rating for service-connected dermatitis for the period prior to April 26, 2011, and in excess of 30 percent thereafter is denied. Entitlement to TDIU is granted effective February 10, 2010, subject to the laws and regulations governing the award of monetary benefits. REMAND Entitlement to service connection for a spinal disorder The Veteran's claim of entitlement to service connection for a spinal disorder was previously remanded in May 2016 to obtain a medical opinion on the potential nexus between an in-service injury to his back and his current spinal diagnoses. The Veteran was afforded a new VA examination in July 2016. The examiner stated, "The veteran himself admits he worked in his father's construction business for the 25 years after he left the service. These are all activities that would have been prohibited by any chronic pain from a back injury in the service. Instead, the 25 years of civilian construction work and ranch work most likely caused the current DJD/DDD, and the 2006 50 foot fall was the most likely cause of the compression fracture(s)." The record contains the Veteran's explanation that he worked for his father's handyman business after leaving the service until the time of his father's passing in approximately 1988. He then lived in Brazil doing missionary work for the next 14 years, until he returned to care for an elderly grandparent. The examiner's statement that the Veteran worked in a construction business for 25 years is factually inaccurate. While he did fall from a barn in 2006 while helping a neighbor, the Veteran's application for a TDIU in October 2010 reflects that he last worked doing construction in 1985. Thus, the examiner's reliance upon a 25 year career in construction as a basis for the nexus opinion is misplaced. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (VA examinations and opinions based on an inaccurate factual premise have no probative value and are therefore inadequate). Additionally, the May 2016 remand directed that x-rays from Memorial Hospital were to be obtained for the examiner's consideration in forming an opinion regarding a nexus. It appears that these x-rays were submitted by the Veteran on a CD in October 2010, subsequent to the July 2010 VA examination. Therefore, in light of the inaccurate facts utilized by the examiner in forming an opinion and the receipt of relevant medical evidence following the examination, the Board finds that a remand is warranted to obtain an addendum opinion regarding the etiology of the Veteran's spinal disorder. Accordingly, the case is REMANDED for the following action: 1. Return the file, to include a copy of this remand, to the July 2016 examiner for an addendum opinion as to the etiology of the Veteran's spinal disorder. If the examiner who drafted the July 2016 opinion is unavailable, the opinion should be rendered by another appropriate medical professional. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. The examiner is asked to review all pertinent records and evidence associated with the claims file and address the following: Is it at least as likely as not (50 percent or better probability) that the Veteran's claimed spinal disorder is related to his combat-related military active duty service? In addressing this question, the examiner should determine whether there is any medical reason to accept or reject the Veteran's account of having sustained a back injury in service, and whether the X-rays of his back associated with the claims file in October 2016 show the residuals from a prior vertebrae fracture. The examiner should cite to the medical and competent lay evidence of record and provide reasons for all opinions. The examiner should comment on the medical opinions already of record (i.e., the June 2007 and February 2011 VA medical opinions), expressing agreement or disagreement with the conclusions reached in those opinions, and explaining the rationale for the agreement or disagreement. The examiner should address the post-service injury to the back in 2006, but note that the Veteran was only employed by his father in a construction/handyman business until approximately 1988, followed by 14 years of missionary service in Brazil. The examiner must also provide reasons for all opinions. If any requested opinion cannot be provided without resort to speculation, the examiner should explain whether the inability to provide the opinion is due to the limits of the examiner's medical knowledge, the limits of medical knowledge in general, or there is additional evidence that would permit the opinion to be provided. 3. After completing the above, and any other development deemed necessary, readjudicate the Veteran's claim of entitlement to service connection for a spinal disorder based on the entirety of the evidence. If the benefits sought on appeal are not granted to the Veteran's satisfaction, he and his representative should be provided with a Supplemental Statement of the Case. An appropriate period of time should be allowed for response before the matter is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or 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). ______________________________________________ DEBORAH SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs