Citation Nr: 1751586 Decision Date: 11/09/17 Archive Date: 11/17/17 DOCKET NO. 07-00 273 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to a disability evaluation in excess of 30 percent for depression, PTSD and alcoholism prior to March 13, 2009. 2. Entitlement to a disability evaluation in excess of 50 percent for depression, PTSD and alcoholism since March 13, 2009. 3. Entitlement to service connection for peripheral neuropathy of the bilateral upper and lower extremities, to include as secondary to service-connected disabilities. 4. Entitlement to service connection for sleep apnea, to include as secondary to service-connected disabilities. 5. Entitlement to a total disability rating for compensation based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: John S. Berry, Esq. ATTORNEY FOR THE BOARD K. M. Georgiev, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1966 to May 1968. This matter is before the Board of Veterans' Appeals (Board) on appeal from multiple rating decisions of the Lincoln, Nebraska, Regional Office (RO) of the Department of Veterans Affairs (VA). In its July 2014 decision, the Board denied, in part, the issues of entitlement to service connection for alcoholism, to include as secondary to depression and PTSD or erectile dysfunction, entitlement to a disability evaluation in excess of 30 percent for depression prior to March 13, 2009, entitlement to a disability evaluation in excess of 50 percent for depression and PTSD since March 13, 2009, and entitlement to TDIU. Subsequently, the Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court) in September 2014. In a Memorandum Decision of August 2015, the Court, in part, set aside the issues noted above and remanded the matters to the Board. The Board remanded the claims in March 2016; remand instructions are complete. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions). By July 2016 rating decision, the RO granted service connection for alcoholism and the appeal is no longer before the Board. The issue of service connection for peripheral neuropathy of the bilateral upper and lower extremities is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran has a sleep apnea disability that is etiologically related to a disease, injury, or event which occurred in service, or service-connected disability. 2. For the duration of the appeals period, the symptomology associated with the Veteran's PTSD, major depressive disorder, and alcoholism more nearly approximates occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for sleep apnea have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2016). 2. The criteria for a 50 percent rating, but no more, for the service-connected PTSD, major depressive disorder, and alcoholism have been met prior to March 13, 2009. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. § 4.114, Diagnostic Code 9411. 3. The criteria for a rating of in excess of 50 percent for the service-connected PTSD, major depressive disorder, and alcoholism have not been met for the duration of the appeal. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. § 4.114, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2016). See October 2015, September 2012 and October 2007 VCAA letters which comply with the requirements. The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records (STR) and VA medical records are in the file. Private medical records identified by the Veteran have been obtained, to the extent possible. The Veteran has not referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4)(i) (2016). The Veteran was provided relevant VA examinations in November 2015 and May and July 2016 for sleep apnea, and many examinations for psychiatric conditions, as detailed below. The examiners took into account the Veteran's reported history, current symptoms, and review of the available private and VA treatment records. Therefore, the Board finds the examination reports to be thorough and complete and sufficient upon which to base a decision with regards to these claims. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). 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 case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Legal Criteria for Service Connection Pertinent VA law and regulations provide that service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2016). Generally, this requires (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, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303(d). Alternatively, service connection may be established either by showing that a chronic disability or disease was incurred during service and later manifestations of such chronic disability or disease are not due to intercurrent cause(s) or that a disorder or disease was incurred during service and there is evidence of continuity of symptomatology which supports a finding of chronicity since service. 38 C.F.R. § 3.303(b). When a chronic disease becomes manifest to a degree of 10 percent within one year of a veteran's discharge from service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the veteran's period of service. 38 U.S.C.A. § 1112 (West 2014); 38 C.F.R. §§ 3.307, 3.309 (2016). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be more persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Service connection may also be established for any disability which is proximately due to or the result of a service-connected disease or injury. See 38 C.F.R. § 3.310 (2014). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2014). Sleep Apnea The Veteran appeared for a VA examination as to sleep apnea in November 2015. Sleep apnea was noted as diagnosed in 2013. The examiner stated that obstructions in the upper airways are not caused by mental health diseases or prostate cancers. The obstructions are mechanical in origin, with specific risk factors the Veteran has (i.e. obesity and large neck size). Therefore, the examiner opined the obstructive sleep apnea was not caused by the Veteran's PTSD/depression/prostate cancer, as PTSD and depression and prostate cancer do not cause changes/obstructions in the upper airways. Likewise, the examiner found there is no evidence to suggest true aggravation beyond natural progression. In February 2016, another VA examiner's opinion was entered. The examiner found it less likely as not that the obstructive sleep apnea was proximately due to or the result of service-connected disabilities. The examiner noted extensive review of medical literature and stated there is no evidence linking PTSD as a cause of obstructive sleep apnea. The examiner explained the mechanics of obstructive sleep apnea as a respiratory disorder. The examiner also found no clinical evidence that the sleep apnea was aggravated beyond its natural progression by service-connected PTSD. The Veteran appeared for a VA examination as to sleep apnea in May 2016. He Veteran reported difficulty falling and staying asleep with daytime sleepiness since service. He began snoring 5 years ago. Service treatment records reflect no sleep issues. The Veteran reported difficulty sleeping in 2013. In 2013, the Veteran was diagnosed with mild sleep apnea. The examiner opined it is less likely than not that the Veteran's obstructive sleep apnea had its onset during or is otherwise related to active service. The Veteran reports onset of fatigue after leaving the service. The service treatment records are silent with regards to any sleep disorder. His separation examination reports he denied frequent trouble sleeping. He was initially suspected of having obstructive sleep apnea in 2013 and at that time the Veteran denied fatigue. In April 2007, a VA treatment note reflects that the Veteran denied sleep apnea and the Veteran was not diagnosed with sleep apnea. The May 2016 examiner also opined it is less likely than not that the Veteran's obstructive sleep apnea was aggravated beyond its natural progression or caused by depression and PTSD, reasoning that there is no evidence generally accepted by the medical community connecting depression or PTSD with obstructive sleep apnea. Obstructive sleep apnea is a condition in which the upper airway is blocked during sleep, usually caused by physical factors such as soft tissue blocking the airway and not by psychological factors. The examiner discussed several scholarly works regarding possible connection between obstructive sleep apnea and psychiatric conditions, including articles provided by the Veteran, and concluded the medical evidence for such a link is insufficient. The VA examiner was also asked if the Veteran's sleep apnea at least as likely as not (50 percent or greater probability) was proximately due to or the result of alcohol abuse, and at least as likely as not aggravated beyond its natural progression by his service connected alcohol abuse. In a July 2016 opinion, the VA examiner noted that the Veteran has numerous risk factors for developing sleep apnea. A review of the literature does mention that alcohol, sedatives, and tranquilizers can be risk factors for the development of sleep apnea, amongst numerous other risk factors. However, looking at all medical information and risk factors the Veteran has for developing sleep apnea, the examiner opined it would not be possible to separate all of his risk factors out and clearly state his alcoholism is the specific causation to his sleep apnea. In fact, with so many other clear risk factors he has, it is not possible to say it is at least as likely as not his alcohol consumption is responsible for his sleep apnea. Likewise, because of numerous risk factors, one cannot state any level of aggravation, as all of his risk factors for developing sleep apnea can be contributors. The Board finds the greater weight of evidence of record supports the finding that the Veteran's sleep apnea was incurred post service and is unrelated to service or to the service-connected psychiatric disability or alcoholism. The Board acknowledges that the Veteran has stated he suffered difficulty falling and staying asleep with daytime sleepiness since service. However, the Veteran is not competent to diagnose himself with sleep apnea or to opine as to when his sleep apnea likely began. In this regard, the Board acknowledges that the Veteran is competent to give evidence about what he experienced. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, in most cases, the Veteran is not competent to render an opinion as to the cause or etiology of any current disorder because he does not have the requisite medical knowledge or training. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (stating that competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence). In this instance, therefore, the Veteran, as a lay person, has not been shown to be capable of making medical conclusions, especially as to complex medical diagnoses such as a link between his current sleep apnea and his military service. As such, the Board ascribes far more weight to the conclusions of the VA examiner, who concluded that the Veteran's currently diagnosed sleep apnea was not caused by his active military service or caused or aggravated by service-connected psychiatric disability or alcoholism. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). In short, the most probative medical evidence specifically rules out a relationship between the Veteran's current sleep apnea and his active military service and service-connected psychiatric disability or alcoholism. The only evidence of record which links obstructive sleep apnea to active duty is the Veteran's own allegations. The Board places more probative weight on the opinion of the competent VA medical professional who provided the medical opinions, based on stated review of the medical records and claims file and physical examination of the Veteran, than on the Veteran's lay assertions that his current sleep apnea is related to his military service or service-connected psychiatric disability or alcoholism. The Veteran is not competent to link obstructive sleep apnea to active duty and his allegations have not probative value. The preponderance of the evidence demonstrates that the Veteran's sleep apnea was not caused or aggravated by his military service or caused or aggravated by service-connected psychiatric disability or alcoholism. As such, the Board finds that the benefit of the doubt doctrine is not for application, and that the claim must be denied. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). Legal Criteria for Increased Rating for Psychiatric Condition Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2014). Percentage evaluations are determined by comparing the manifestations of a particular disorder with the requirements contained in the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2016). The percentage ratings contained in the Rating Schedule represent, as far as can practically be determined, the average impairment in earning capacity resulting from such disease or injury and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2016). VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Schafrath, 1 Vet. App. at 589. The degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2014). The Veteran's psychiatric disorder is currently rated under 38 C.F.R. § 4.130, Diagnostic Code 9411-9434 (2016). PTSD is to be rated under the general rating formula for mental disorders under 38 C.F.R. § 4.130. Ratings are assigned according to the manifestation of particular symptoms. Notably, the term "such as" in 38 C.F.R. § 4.130 precedes lists of symptoms that are not exhaustive, but rather serve as examples of the type and degree of symptoms and their effects that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Id. Accordingly, the evidence considered in determining the level of impairment under 38 C.F. R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's disability that affect the level of occupational and social impairment. The pertinent provisions of 38 C.F.R. § 4.130 concerning the rating of psychiatric disabilities read in pertinent part as follows (See 38 C.F.R. § 4.130, Diagnostic Code 9411): 30 percent: Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 50 percent: Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty establishing effective work and social relationships. 70 percent: Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. 100 Percent: 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. 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) [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. GAF scores ranging between 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Scores ranging from 51 to 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 38 C.F.R. § 4.130 (incorporating by reference the VA's adoption of the DSM-IV for rating purposes). The Board notes that an examiner's classification of the level of psychiatric impairment by a GAF score is to be considered, but is not determinative of the percentage rating to be assigned. VAOPGCPREC 10-95. Increased Rating for PTSD, Depression, and Alcoholism At issue is entitlement to a disability evaluation in excess of 30 percent for depression, PTSD and alcoholism prior to March 13, 2009, and in excess of 50 percent for depression, PTSD and alcoholism since March 13, 2009. As explained, the Board finds that the Veteran's depression, PTSD and alcoholism most closely match the criteria required for a 50 percent rating for the duration of the appeal. Therefore a grant of a 50 percent rating for the time period prior to March 13, 2009 is appropriate. By means of a March 2007 rating decision, stemming from a July 2006 claim, the Veteran was granted service connection for depression, with an initial disability rating of 30 percent. Thereafter, in a May 2009 rating decision, he was granted a rating of 50 percent, effective March 13, 2009. By means of a November 2012 rating decision, the Veteran was granted service connection for PTSD, which was combined with his service-connected depression disability due to overlapping symptomatology. By July 2016 rating decision, the RO granted service connection for alcoholism effective August 2006, rating the alcoholism with the psychiatric condition. In July 2006, the Veteran reported sleep disturbance and nightmares, avoidance, anxiety, heavy drinking and awaking to find himself in a strange location. The Veteran reported his belief that medical professionals disbelieve him that he suffers from mental problems and as such he avoids treatment and often chooses to suffer in silence. The Veteran was afforded a VA mental disorder examination in February 2007. The Veteran essentially reported experiencing fear of hostile military activity involving the Viet Cong. He reported that he had been married for 39 years and had a good relationship with his adult children and young grandchildren. He said he had a few friends and enjoyed golfing and fishing. He said he had been taking medication for depression since 2006, but was not in psychotherapy. His reported symptoms included nightmares, intrusive memories of service, mild sleep disorder, infrequent anger/irritability and hyperarousal. During the mental status evaluation, the Veteran was found to be clean, neat, fully-oriented to person, place and time, and reported no delusions or hallucinations, and no suicidal or homicidal ideations. His memory was found to be normal. The diagnoses were PTSD and intertwined depression, not otherwise specified ("NOS"), and alcohol dependence. His assigned GAF was 60, reflecting moderate symptoms. The Veteran was afforded a second VA examination in April 2009, at which time, he reported sleep problems, irritability and depression. He also reported substantial alcohol abuse. He said he had been married for over 41 years and had one close friend. He said he regularly attended meetings at the Disabled American Veterans. However, he said he had been unemployed since November 2008 as a result of quitting his previous job at the veterans' home canteen because he needed a job that provided health insurance. The Veteran did not contend unemployment due to mental disorder. During the mental status evaluation, he was found to be clean, neat, fully-oriented to person, place and time, and had a good sense of humor. He reported no delusions or hallucinations, and no suicidal or homicidal ideations. His memory was found to be normal. He had stopped taking medication to treat his mental disorder. The diagnoses were PTSD and major depressive disorder, recurrent, moderate, and alcohol dependence. His assigned GAF score was 55, reflecting moderate symptoms. In July 2009, the Veteran indicated he had attempted suicide and he continues to experience frequent suicidal thoughts. He indicated that he missed many DAV meetings. He described sleep impairment, obsessive/ritual behavior, weekly panic attacks, and anger that strains relationships with his family. In a December 2010 statement, the Veteran's wife indicated the Veteran has struggled with alcohol abuse and this has strained family relationships. In April 2011, the Veteran was afforded another VA examination. At that time, he reported that he was not receiving any mental health treatment. He reported that he was drinking 40-45 mixed drinks per week, which he said caused some marital discord, as his wife was contemplating divorce. His reported mental health symptoms involved depression, mild concentration problems, mild sleep problems, anxiety with chest pain (which the examiner attributed to coronary artery disease), and passing suicidal ideation about a year earlier. He said that he did not want to take antidepressants because they would interfere with his drinking. During the mental status evaluation, he was noted to be clean, neat, friendly, fully-oriented to person, place and time, had an intact memory and denied delusions, hallucinations, and current suicidal/ homicidal ideations. He reported periodic suicidal thoughts while intoxicated. He said he had been employed for the past year as a part-time bookkeeper. The examiner diagnosed the Veteran with major depressive disorder and alcohol dependence. He noted that the symptomatology from the Veteran's depression was moderate and assigned a GAF score of 56, reflecting moderate symptoms. The examiner further opined that the Veteran was not unemployable as a result of major depressive disorder, noting that there had been no increase in the Veteran's depression, as the condition had not risen to a level where he had been willing to seek treatment. Finally, he noted that major depressive disorder would cause some decrease in work efficiency, but by itself would not cause unemployability. The examiner found no deficiency in judgment, thinking, family relations, work, mood or school due to the mental disorders. VA treatment records show that, beginning in May 2011, the Veteran began receiving mental health counseling treatment. During a telephone therapy appointment in May, he reported that he was very depressed. He said he had been married 40 years and suggested that his wife enabled his drinking by driving him to bars and other locations and waiting while he drank. He complained of poor sleep and frequent suicidal ideations. The clinician diagnosed him with depression, alcohol abuse, bipolar disorder and suicidal ideations. In June 2011, the Veteran reported himself as "somewhat suicidal" with no plan. He stated he had no intention of taking the "easy" way out. In July 2011, he reported nightmares, the frequency/intensity of which were dependent on his alcohol consumption, and anger. He stated he takes over 10 shots of alcohol daily on average. In September 2011, he discussed a trip he had taken with his wife to visit his son's family in South Dakota. He spoke highly of their stay and how much he enjoyed visiting his two grandchildren. In November 2011, the Veteran reported that his transition from unemployment to working had been unsuccessful and he was lacking motivation. He also reported worsening sleep difficulties. In February 2012, he reported that communication with his wife had improved somewhat. He also said that he had applied as a volunteer van driver with VA and was hopeful of being hired. In April 2012, he reported that all of his children and grandchildren had visited for Easter. He also reported continuing sleeping difficulties and nightly drinking. Throughout this period, his assigned GAF score was 65, suggestive of mild symptoms. In May 2012, the Veteran was afforded another VA mental disorders examination, at which time, he reported that he was still married to his wife of 45 years and said he had been employed by the Disabled American Veterans for 18 months, but had been asked to resign and had been unemployed since November 2011. The Veteran reported frequent socializing with alcohol and occasional reading as a hobby. The examiner noted depressed mood, chronic sleep impairment, disturbances in mood and motivation, difficulty establishing social and work relationships and adapting to stressful circumstances, suicidal ideations. The examiner diagnosed the Veteran with major depressive disorder, severe without psychosis and alcohol dependence. He added that it was possible to separate the symptoms from each disorder, noting that the symptoms from the Veteran's depression included a loss of pleasure, feeling of punishment, suicidal ideation, agitation, irritability, concentration difficulties and fatigue. The Veteran's alcohol dependence is chronic and would lead to occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgement, thinking. The examiner noted that the Veteran's GAF score throughout this period remained at 65 despite the fact that he was not taking antidepressants. He further observed that the Veteran said he was not feeling suicidal at that time. The Veteran did not take psychiatric medication. The examiner assigned a GAF of 50 for major depressive disorder and 50 for alcohol dependence. The examiner noted occupational and social impairment with deficiencies in most areas. In October 2012, the Veteran was afforded a VA PTSD examination, at which time, he reported that he expected to spend the Thanksgiving holiday with his family. He added that he was still participating in psychotherapy, but was also still drinking a substantial amount of alcohol. The examiner diagnosed him with PTSD, major depressive disorder, moderate, and continuous alcohol dependence. He noted the symptoms from PTSD and major depressive disorder were depressed mood, anxiety, chronic sleep impairment and difficulties in establishing and maintaining effective work and social relationships; he added that the symptomatology from these conditions demonstrated a level of occupational and social impairment in most areas, such as work, school, family relationships, judgment, thinking and/or mood. The Veteran reported he was last employed in 2011 at VFW. Alcohol dependence established difficulty in obtaining and sustaining effective work and social relationships. The assigned GAF score for major depressive disorder and PTSD was 58, reflecting moderate symptoms. In December 2012, a VA medical opinion included the opinion that objective evidence fails to indicate that the presence of his PTSD and MDD would render the Veteran unemployable for physical or sedentary employment. The examiner noted the Veteran's last GAF scores were 65, reflecting mild symptoms, and that the Veteran was not taking psychiatric medication, had not been hospitalized for psychiatric conditions, and his level of PTSD and MDD at that time was mild in intensity. VAMC treatment reports throughout 2012 reveal that the Veteran continued in psychotherapy, where his assigned GAF scores remained consistently at 65. During a July 2012 session, he reported that his previous suicidal ideation had improved, was much less frequent and intense, and he had no plan. In August, he spoke at length about a recent Nebraska Vietnam Veteran's reunion in Columbus, which both he and his wife attended. He added that he had numerous exchanges with dear friends and played golf. In December 2012, he reported an increase in the frequency of his suicidal ideation without any plan, continued anger, agitation and frustration, but said he had experienced no recent panic attacks, anxiety or severe mood swings. In February 2013, he reported that he was not smoking and his drinking habit had also been reduced, resulting in increased irritability. He also noted being angry at being left out of decision-making and not being allowed to drive due to health concerns. As noted above, the Veteran's assigned GAF scores remained at 65. The Veteran appeared for a VA examination in May 2016. The examiner stated that the Veteran's PTSD and major depressive disorder manifested as depressed mood, anxiety, panic attacks, and sleep problems. His alcohol use manifested as attention, difficulty in effective work social relationships. The examiner stated that the Veteran suffered occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. All of his psychiatric diagnoses are affecting his overall functioning leading to impairment in all domains. The Veteran reported that he retired 15 years ago and since worked different jobs; his last job was with VFW. The examiner noted depressed mood, anxiety, panic attacks that occur weekly or less often, chronic sleep impairment, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting. The examiner noted that the Veteran was polite and cooperative with exam. Speech was spontaneous and soft. His though processes was logical. His thought content was negative for psychosis. There was no suicidal ideation, mood was dysthymic and affect was reactive. He was fully oriented. His long and short term memories are intact. He has adequate insight and questionable judgment with ongoing alcohol use. The examiner stated in a June 2016 opinion that while it is most likely that PTSD and depression aggravated the Veteran's alcoholism, the examiner could not establish a baseline. Prior to March 2009, especially weighing that the Veteran's alcoholism is service-connected and the VA examiner was unable to establish a baseline of impairment, the evidence supports that the Veteran's mental disabilities most closely match occupational and social impairment with reduced reliability and productivity. In particular, the Board notes the presence of impaired judgment due to alcoholism; disturbances of motivation and mood due to major depressive disorder; and difficulty establishing effective work and social relationships. While the Veteran is not unable to establish effective relationships, the record establishes that the Veteran's psychiatric disabilities have put strain on relationships, namely with his family and spouse. With respect to a 70 percent disability rating for the Veteran's depression/ PTSD/ alcoholism, while there is evidence that he has reported suicidal ideations and difficulty in adapting to stressful circumstances, there is no competent medical evidence of obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; or inability to establish and maintain effective relationships. Moreover, in the context of awarding a 70 percent rating, 38 C.F.R. § 4.130 not only requires the presence of certain symptoms, but also that those symptoms have caused occupational and social impairment in most of the referenced areas, including work, school, family relations, judgment, thinking or mood. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). While the Veteran's psychiatric conditions, especially alcohol dependence, strain his relationships, especially his family relationships, he is able to establish and maintain those relationships, as evidenced by his long-standing marriage and good relationship with his children. The Veteran's thinking and memory have been consistently intact, his hygiene and communication consistently appropriate. In addition, while he clearly had some difficulties in maintaining employment, he has reported that he retired 15 years ago and after has had different jobs. The record reflects that he had chosen to quit one job due to a lack of health insurance and while he apparently was involuntarily terminated from a job at DAV, he subsequently worked at VFW. While there has been some fluctuation, the Veteran's symptoms under the GAF most closely match moderate symptoms. The symptoms he exhibits more closely match the 50 percent criteria, occupational and social impairment with reduced reliability and productivity, rendering that the more correct criteria with which to match his occupational impairment. With respect to the criteria for a 100 percent rating, the evidence does not show that the Veteran has symptoms at the level of severity associated with a 100 percent rating, and total occupational and/or social impairment. There is also no evidence showing that he suffers from gross impairment in thought processes or communication, persistent delusions or hallucinations, exhibits grossly inappropriate behavior, poses a persistent danger of hurting himself or others, or exhibits an intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. In addition, there is no evidence that the Veteran has disorientation to time or place, or memory loss for the names of close relatives, his own occupation, or his own name. Thus, the Veteran does not have any of the symptoms associated with a 100 percent rating. ORDER Service connection for sleep apnea is denied. Entitlement to a disability rating of 50 percent for depression, PTSD and alcoholism prior to March 13, 2009, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a disability rating in excess of 50 percent for depression, PTSD and alcoholism since March 13, 2009, is denied. REMAND In an October 2016 VA examiner's opinion, it was noted that the Veteran has a low normal B-12 level on his most recent labs. The examiner explained that B-12 deficiency due to alcoholism is known to contribute to peripheral neuropathies. However, the Veteran also has diabetes which also is known to contribute to peripheral neuropathies. Therefore, the examiner reasoned that the Veteran has several risk factors for the development of this condition. The examiner concluded that determining if his B-12 deficiency from his alcoholism specifically caused his peripheral neuropathy cannot be determined without resorting to speculation. Whether it has been aggravated is also unknown and speculative. In a March 2017 VA examination for diabetic peripheral neuropathy, the examiner diagnosed bilateral peripheral neuropathy of upper and lower extremities, noting that the onset of the Veteran's symptoms began in 2015. The Veteran was initially diagnosed with Vitamin B12 deficiency as a cause for his neuropathy. His diabetes was diagnosed after his neuropathy. The examiner noted that the Veteran's blood sugars were documented to be normal at that time peripheral neuropathy was diagnosed which would indicate another cause. Therefore, the Veteran's bilateral peripheral neuropathy of upper and lower extremities is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's diabetes. The Board finds that an additional, clarifying medical opinion is needed as to the Veteran's peripheral neuropathy's relationship to service-connected disabilities. The October 2016 examiner stated that an opinion as to the causation or aggravation of peripheral neuropathy would be speculative, while the March 2017 examiner opined the neuropathy is less likely than not proximately due to or the result of the Veteran's diabetes, which could constitute conflicting opinions. Further, the March 2017 examiner did not opine as to diabetes aggravating the neuropathy. The Veteran's claim for a TDIU is inextricably intertwined with the above claim; consideration of this matter must be deferred pending resolution of this claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Accordingly, the case is REMANDED for the following action: 1. Send the Veteran's claims file to an appropriate medical professional for an addendum opinion as to peripheral neuropathy of the bilateral upper and lower extremities. The entire electronic claims file must be reviewed by the examiner. Examination of the Veteran is at the medical professional's discretion if necessary to response to the following inquiries. The examiner is asked to address the following: a. Whether it at least as likely as not (50 percent or greater probability) that the currently identified peripheral neuropathy disability was caused or aggravated (increased in severity beyond the natural progress of the condition) by the Veteran's service-connected disabilities to include alcoholism and diabetes? If aggravation is found, the examiner should provide the baseline manifestations of the Veteran's peripheral neuropathy disability prior to aggravation by the service-connected alcoholism and/or diabetes. b. In providing this opinion, the examiner must address the October 2016 and March 2017 VA examiner's opinions, and to the extent possible, offer a clarifying opinion. The examiner should provide a comprehensive report including complete rationales for all opinions and conclusions. 2. Finally, readjudicate the appeal, to include entitlement for TDIU. If any of the benefits sought remain denied, issue a supplemental statement of the case and return the case to the Board. The Veteran and his representative have 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). ______________________________________________ G. A. WASIK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs