Citation Nr: 1751883 Decision Date: 11/14/17 Archive Date: 11/22/17 DOCKET NO. 13-14 697 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon THE ISSUES 1. Entitlement to service connection for tinnitus. 2. Entitlement to service connection for bilateral hearing loss. 3. Entitlement to service connection for irritable bowel syndrome, to include as secondary to PTSD. 4. Entitlement to service connection for erectile dysfunction, to include as secondary to heart disease, and/or PTSD and/or medications taken for PTSD. 5. Entitlement to service connection for skin cancer. 6. Entitlement to service connection for degenerative joint disease of the left knee. 7. Entitlement to service connection for degenerative joint disease of the right knee, to include as secondary to left knee pathology. 8. Entitlement to an initial disability rating greater than 30 percent for post-traumatic stress disorder (PTSD) prior to June 8, 2015, and to a disability rating greater than 70 percent after June 8, 2015. 9. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) prior to June 8, 2015. 10. Entitlement to service connection for hypertension, to include as secondary to PTSD. REPRESENTATION Veteran represented by: Oregon Department of Veterans' Affairs ATTORNEY FOR THE BOARD Heather J. Harter, Counsel INTRODUCTION The Veteran served on active duty from January 1968 to May 1971, to include service in Vietnam from March 1969 to December 1969. He was awarded the Vietnam Campaign Medal with device, among other service awards and decorations. This matter comes before the Board of Veterans' Appeals (Board) from RO decision of August 2011, July 2015, and May 2017. The issue of entitlement to service connection for hypertension 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 evidence is in equipoise as to whether the Veteran's tinnitus is associated with combat-related acoustic trauma during service. 2. The Veteran does not currently manifest a hearing disability in either ear for VA compensation purposes. 3. Service connection is already in effect for gastroesophageal reflux disease (GERD) with functional diarrhea; and the Veteran is not currently diagnosed with irritable bowel syndrome. 4. Erectile dysfunction was not incurred in service, and is not secondary to PTSD or to medications taken for PTSD. 5. Skin cancer was not shown in service, or for many years afterward, and is not otherwise related to service. The Veteran's squamous cell carcinoma and actinic keratosis are not among the disabilities for which presumptive service connection for herbicide agent exposure is warranted. 6. The Veteran sustained a soft tissue/muscular injury to his left quadricep proximate to the knee during service; no permanent bony injury is shown during service; and arthritis of the left knee was not shown within one year of service and is not shown to be otherwise related to service. 7. No right knee disability was shown during service, arthritis of the right knee was not shown within one year of service, and right knee disaiblty is not shown to be otherwise related to service. 8. Throughout the appeal period, the Veteran's service-connected PTSD has caused occupational and social impairment, with deficiencies in most areas, but has not resulted in total occupational and social impairment. 9. The Veteran was employed on a full time basis until December 2011, at which time his service connected disabilities precluded gainful employment. CONCLUSIONS OF LAW 1. Service connection for tinnitus is warranted. 38 U.S.C.A. §§ 1110, 1154, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2017). 2. Service connection for bilateral hearing loss is not warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.385 (2017). 3. Service connection for irritable bowel syndrome, to include as secondary to PTSD, is not warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 4. Service connection for erectile dysfunction, to include as secondary to PTSD and/or medications taken for PTSD is not warranted. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 5. Service connection for skin cancer is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 6. Service connection for degenerative joint disease of the left knee is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 7. Service connection for degenerative joint disease of the right knee is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). 8. A disability rating of 70 percent for PTSD, but no higher, is warranted for the entire appeal period, from June 1, 2010. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.126, 4.130, Diagnostic Code 9411 (2017). 9. The TDIU award is effective from January 1, 2012, forward. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matters In this case, neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). The Board thoroughly reviewed all the evidence in the Veteran's VA files. In every decision, the Board must provide a statement of the reasons or bases for its determination, adequate to enable an appellant to understand the precise basis for the Board's decision, as well as to facilitate review by the Court. 38 U.S.C. § 7104(d)(1); see Allday v. Brown, 7 Vet. App. 517, 527 (1995). Although the entire record must be reviewed by the Board, the Court has repeatedly found that the Board is not required to discuss, in detail, every piece of evidence. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) (rejecting the notion that the Veterans Claims Assistance Act mandates that the Board discuss all evidence). Rather, the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake, infra. Pertinent Laws and regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303 (a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). To establish entitlement to compensation for a present disability on a direct basis, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A Veteran who served in the Republic of Vietnam between January 9, 1962, and May 7, 1975, is presumed to have been exposed to certain herbicide agents (e.g., Agent Orange) during such service, absent affirmative evidence to the contrary. 38 U.S.C.A. § 1116 (f); 38 C.F.R. § 3.307 (a)(6)(iii). Service connection based on herbicide exposure will be presumed for certain specified diseases that become manifest to a compensable degree within a specified period of time in the case of certain diseases. 38 U.S.C.A. § 1116 ; 38 C.F.R. §§ 3.307 (a)(6), 3.309(e). Even if a Veteran is not entitled to presumptive service connection for a disease claimed as secondary to herbicide exposure, VA must also consider the claim on a direct service-connection basis. When a disease is first diagnosed after service but not within the applicable presumptive period, service connection may nonetheless be established by evidence demonstrating that the disease was in fact incurred in service. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Veteran may benefit from a presumption of service connection based on a chronic disease, such as arthritis (degenerative joint disease), sensorineural hearing loss and tinnitus (as organic diseases of the neurologic system), and cancer (malignant tumor). 38 C.F.R. § 3.309(a). When a Veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the chronic disease becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Even if a chronic disease is not shown within one year of discharge, service connection may be established by showing continuity of symptomatology. Continuity of symptomatology may be shown by demonstrating "(1) that a condition was 'noted' during service or any applicable presumption period; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology." Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); see also Davidson v. Shinseki, 581 F.3d 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). However, the Federal Circuit held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A combat veteran's assertions of an event occurring during combat are to be presumed true if consistent with the time, place and circumstances of such service. See 38 U.S.C.A. § 1154 (b); Collette v. Brown, 82 F.3d 389 (Fed. Cir. 1996). However, 38 U.S.C.A. § 1154 (b) can be used only to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service, not to link the claimed disorder etiologically to a current disorder. See Libertine v. Brown, 9 Vet. App. 521, 522-23 (1996). Disability which is proximately due to or the result of a service-connected disease or injury also shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Once service connection has been granted, disability evaluations are assigned to reflect levels of current disability. The appropriate rating is determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In evaluating claims for increased ratings, VA must evaluate the Veteran's condition with a critical eye toward the lack of usefulness of the body or system in question. 38 C.F.R. § 4.10. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service- connected disability exhibits symptoms that would warrant different ratings.); see also Fenderson v. West, 12 Vet. App. 119, 126 (2001). A disability may require re-evaluation in accordance with changes in a veteran's condition. It is thus essential, in determining the level of current impairment, that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the Veteran. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). In doing so, equal weight is not accorded to each piece of evidence in the record as every item of evidence does not have the same probative value. Gilbert, supra. . Hearing loss and tinnitus The Veteran service treatment records reflect that he was fitted for earplugs in January 1971. This statement conflicts somewhat with the Veteran's current recollection that he had never worn ear protection. It confirms, however, that he was exposed to acoustic trauma during the course of his duties as a Marine, however. The report of the general medical examination conducted at discharge from service in May 1971 shows that the Veteran's hearing acuity in both ears was entirely within normal limits. During a February 2011 VA audiological examination, the Veteran's hearing acuity was tested and the results were interpreted as indicating mild sensorineural hearing loss in both ears, although worse in the right ear. Speech recognition ability was 96 percent in the right ear and 100 percent in the left ear. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 25 20 35 35 LEFT 20 25 15 20 20 For the purposes of applying the laws administered by the VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 200, 3000, or 4000 hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The audiometric results in this case show that the Veteran does not meet the minimum criteria for having a current hearing loss disability by VA standards. Absent a current disability according to VA standards, service connection is not warranted. Hensley v. Brown, 5 Vet. App. 155, 157 (1993); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). However, as to the Veteran's claim for tinnitus, the Board finds that service connection is warranted. The Veteran has a current diagnosis of tinnitus, a diagnosis that is capable of lay observation. He asserts that he initially had tinnitus during combat service in Vietnam, and that it has worsened over the past fifteen or twenty years. The Board acknowledges that combat service, such as the Veteran's, is consistent with extreme noise exposure. Collette, supra. The Veteran is therefore competent to report that he experienced tinnitus during combat service and the Board has no reason to doubt the credibility of his statements in this regard. With regard to the medical nexus requirement for service connection, the February 2011 VA examiner opined that the Veteran's tinnitus was not caused by noise exposure in service. However, the Board places less probative weight on this opinion, because the opinion was premised upon in-service exposure to noise from engine repair, rather than combat, and the examiner did not take into account the Veteran's competent and credible statement that he had initially experienced tinnitus during and after combat noise trauma. In consideration of the unfavorable VA opinion and the probative lay statements provided by the Veteran, the Board finds that the evidence both for and against the question of whether the Veteran has tinnitus due to combat noise exposure during active service is in relative equipoise. Resolving all reasonable doubt in the Veteran's favor, the Board concludes that service connection for tinnitus is warranted. 38 U.S.C.A. §§ 1110, 5107; 38 C.F.R. § 3.102, 3.303; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Irritable Bowel Syndrome The Veteran contends he has irritable bowel syndrome related to his PTSD. According to the report of a February 2011 VA examination, the examiner found that the Veteran does not fully meet the diagnostic criteria for irritable bowel syndrome. The laws authorizing Veterans' benefits provide benefits only where there is current disability, as identified by a medical diagnosis. In the absence of proof of a current disability, there is no valid claim of service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board concludes that the Veteran has not presented competent evidence showing that he currently has been diagnosed with irritable bowel syndrome. See 38 U.S.C. § 5107 (a) ("[A] claimant has the responsibility to present and support a claim for benefits."); Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009) (holding that it is the claimant's general evidentiary burden to establish all elements of the claim). In analyzing this claim, the Board recognizes that the Veteran is competent to report his observable gastrointestinal symptoms and signs; however, his lay statements are not competent to establish that he currently has irritable bowel syndrome, as he is not shown to be competent to render a medical diagnosis. Moreover, the record reflects that his gastrointestinal complaints are attributed to, and are already being compensated for by his receipt of service connection for GERD with functional diarrhea. See May 2017 Rating Decision awarding service connection for noncompensable functional diarrhea and combining it with the already service-connected GERD disability. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). For the reasons and bases discussed above, the preponderance of the evidence is against the Veteran's irritable bowel syndrome claim, and it therefore must be denied. See 38 U.S.C.A. § 5107 (b) (West 2014); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Hypertension The Veteran contends his hypertension is also related to PTSD. The medical evidence of record does not support this assertion, however. In March 2017, the Veteran's claims file, including his medical records, was reviewed by a VA medical expert. In response to the query as to whether the Veteran's high blood pressure could be related wholly or in part to his PTSD, the reviewer opined that the Veteran's blood pressure is more likely the result of obesity and excessive alcohol intake in the past. The reviewer noted that the Veteran had had at least a 38 percent weight gain since leaving active service, and that weight gain is a well-established cause of hypertension, while PTSD has not been medically established as a cause of hypertension. Nothing in the rest of the Veteran's voluminous medical records tends to suggest a causal relationship between his hypertension and PTSD. The Board finds the March 2017 opinion probative as it is factually accurate and contains sound reasoning. Therefore, based upon this informed medical opinion, the Board holds that the preponderance of the evidence is against service connection for hypertension. Review of the Veteran's service treatment records shows his blood pressure readings were within normal limits throughout his service period and upon his discharge examination. There is no evidence indicating hypertension within one year of discharge from service. Therefore direct service connection is not warranted, and service incurrence cannot be presumed under law. Erectile dysfunction The Veteran contends his erectile dysfunction is also related to PTSD, or to medications taken for PTSD. It is undisputed that the Veteran is currently diagnosed with erectile dysfunction. Again however, the medical evidence of record does not support his assertion that it is related to his service connected PTSD. In the same March 2017 medical opinion, the reviewer also addressed the question of whether PTSD could have caused or contributed to the Veteran's erectile dysfunction. Following review of the evidence the reviewer concluded that the Veteran's erectile dysfunction is unrelated to his PTSD. "It is well-established in the private medical records that the Veteran's erectile dysfunction is due to low testosterone (hypogonadism). This is supported by the fact that it improved with treatment with testosterone and worsened again when the testosterone was stopped. There was no change reported in erectile dysfunction with any changes in other medications." Nothing else in the Veteran's medical evidence contradicts this statement. Thus, in addressing the question of aggravation, the examiner explained that there has been no change reported in Veteran's erectile dysfunction with changes in any other medications, which the Board notes would include those prescribed for his PTSD. The Board therefore concludes that the preponderance of the evidence is against a claim for service connection for erectile dysfunction as due to PTSD or to medications taken for PTSD, or by way of aggravation. The Veteran does not assert and the evidence does not show any indication of erectile dysfunction during service or until many years after service. Direct service connection is not warranted either. The preponderance of the evidence is against the claim for entitlement to service connection for erectile dysfunction. Skin cancer The Veteran's service treatment records are entirely negative for evidence of skin cancer or indeed, any skin complaints. Skin cancer was initially identified in his medical records many years after service, as he had a squamous cell carcinoma removed in August 2010, and actinic keratoses in March 2013. Nothing in the medical records reflecting these skin cancers could be interpreted as indicating a link of any kind to service, many years previously. Therefore, service connection on a direct basis, or as presumed under law due to a chronic disease initially manifested within one year of service, is not warranted. Although the Veteran is presumed under law to have been exposed to herbicide agents in Vietnam, the list of cancers which are subject to this presumption are quite specific and do not include squamous cell carcinoma or actinic keratosis. See 38 C.F.R. § 3.309(e). Therefore, as he does not have and has not had a skin cancer which may be presumed under law to have been caused by herbicide agent exposure in Vietnam, service connection on this basis is not warranted either. The preponderance of the evidence is against the claim for entitlement to service connection for skin cancer. Knees The Veteran is seeking service connection for disability of his left knee as related to a left knee injury during service. He asserts that his right knee disabilities are secondary to, or proximately caused by, the left knee disability. In August 1970, the Veteran reported for medical care with swelling in his left knee. According to the report, a rock had fallen on his knee while he was chasing a lizard. Upon examination, the joint was deemed stable. He had a hematoma at the lateral aspect of his right quadricep muscle. He was instructed to use an ice pack followed by a heat pack, and was given light duty for two days. In October 1970, he complained again of swelling and pain in the knee and was sent for further evaluation. The report reflecting the additional evaluation is handwritten and difficult to read, but it appears to place the contusion above the knee with a finding of no effusion involving the knee itself. The Veteran was instructed to use an Ace Bandage and to report to duty. The Veteran's lower extremities were deemed normal upon clinical examination in May 1971 just prior to the Veteran's discharge from service. In June 2011, the Veteran's medical records, to include his service treatment records were forwarded to a VA orthopedic examiner for review. The examiner highlighted the absence of findings indicating an orthopedic problem during service, noting that the injuries recorded were to a muscle and a soft tissue hematoma. The examiner noted the absence of any notations regarding knee x-rays or orthopedic specialty care in the Veteran's service treatment records. Based upon the absence of any ortho-evidence based knee findings, the orthopedic reviewer opined that the Veteran's currently-shown left knee degenerative joint disease is less likely to be related to service. The Board finds the June 2011 VA opinion probative as it is factually accurate and contains sound reasoning. The Veteran has not submitted a nexus opinion favorable to his claim. Moreover, because arthritis in either knee is not shown during service or within one year of discharge from service, service incurrence cannot be presumed under law. . Based on the foregoing and upon careful review of all the evidence of record, the Board holds that the preponderance of the evidence is against service connection for a left knee disability. Absent a grant of service connection for the left knee, the Veteran's service connection for right knee disability as secondary to the left knee disability must fail. 38 C.F.R. § 3.310. The preponderance of the evidence is against the claims for entitlement to service connection for left and right knee disabilities. Increased Rating Claim for PTSD Service connection for PTSD was granted effective in June 2010 based upon the Veteran's traumatic combat-related experiences in Vietnam. A 30 percent disability rating was assigned based upon the report of a February 2011 VA examination in conjunction with his private primary care medical records. The Veteran perfected a timely appeal as to the disability rating, arguing that his PTSD was significantly worse than the 30 percent disability rating would indicate. He was given another VA examination in June 2015, and based upon the report of this examination, the RO increased his disability rating to 70 percent. Thus, the issue currently before the Board is entitlement to an initial rating greater than 30 percent from June 2010 through June 2015, and entitlement to a disability rating greater than 70 percent from June 2015. In support of his claim for an increased disability rating, the Veteran asserts he has suicidal thoughts, that he cannot function without his medication, that he requires regular treatment and group therapy, and that he has regular panic attacks, as well as re-experiencing episodes. He states he uses alcohol to soothe the anxiety and stress related to PTSD, as well as taking multiple medications for PTSD. He also asserts that he is only comfortable around his therapy group, and that his social interactions are otherwise impaired, as he has been married six times and has very few close relationships, to include strained relationships with his children. He asserts the only reason he was able to work as long as he did was because he had an isolated job as a truck driver, which did not require interaction with others. Even so, he states he continues to have difficulty with bad drivers on the road and people who do not do their jobs conscientiously. In his written substantive appeal, he provided several examples of these difficult interactions. The February 2011 VA examination was accomplished when the Veteran was still working. During the examination he described his job as not requiring interaction with others. He also stated he did not get along with people, and he did not like making friends. He had been married six times, and at that time was married to his sixth wife. He reported that he frequently experienced passive thoughts of suicide, and that when he ran out of his psychiatric medication once he formulated an active plan. These thoughts stopped as soon as he was stabilized on medication again. He discussed his road rage, which was also ameliorated by medication. The second VA examination, in June 2015 was conducted several years after he stopped working and began drawing Social Security Disability benefits. The Veteran reported he had divorced his sixth wife and was living with another ex-wife, because he needed a place to live. (VA treatment reports reflect he had moved in with his third wife.) He reported having no friends and isolating himself at home. The examiner assessed that the Veteran's PTSD symptoms caused clinically significant distress or impairment in social, occupational, and other important areas of functioning. The examiner also assessed that this disturbance is not attributable to the physiological effects of a substance such as medication or alcohol or another medical condition. The examiner identified the Veteran's PTSD symptoms as including depressed mood, 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, including work or a work like setting, inability to establish and maintain effective relationships, suicidal ideation, impaired impulse control, and neglect of personal appearance and hygiene. The examiner also noted that the Veteran's PTSD symptoms had increased since the February 2011 examination was conducted. VA and private outpatient treatment records throughout the time period at issue confirm the Veteran's report of taking medication for control of PTSD symptoms throughout the appeal period. They also reflect personal consultations and group therapy. Because this appeal has been ongoing for a lengthy period of time, and because the level of a Veteran's disability may fluctuate over time, the VA is required to consider the level of the Veteran's impairment throughout the entire period. In this respect, staged ratings are a sensible mechanism for allowing the assignment of the most precise disability rating-one that accounts for the possible dynamic nature of a disability while the claim works its way through the adjudication process. O'Connell v. Nicholson, 21 Vet. App. 89 (2007). In another relevant precedent, the Court noted that 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. 38 U.S.C.A. § 5110; Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation 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. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. Under the governing regulatory criteria, mental disorders are rated under a "General Rating Formula for Mental Disorders". 38 C.F.R. § 4.130. The pertinent provisions of the General Formula are as follows: 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). [30 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; impaired judgement; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. [50 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. [70 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. [100 percent] 38 C.F.R. § 4.130, Diagnostic Code 9411. The "such symptoms as" language of the diagnostic codes listed above means "for example" and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). However, the list of examples "provides guidance as to the severity of symptoms contemplated for each rating." Id. Accordingly, while each of the examples needs not be proven in any one case, the particular symptoms must be analyzed in light of those given examples. Put another way, the severity represented by those examples may not be ignored. Effective August 4, 2014, VA amended the regulations regarding the evaluation of mental disorders by removing outdated references to DSM-IV. The amendments replace those references with references to the recently updated "DSM-5." In this case, the Veteran's appeal was certified to the Board in August 2017, therefore the revised regulations are applicable to this case to include the guidance provided in DSM-5. Upon careful review, the evidence supports the current award of a 70 percent disability rating throughout the entire appeal period. Although the recent VA examiner specified that his symptoms had worsened since the initial grant of service connection, upon careful review, the Board finds that his symptoms have been and remain more nearly analogous to those set forth for the 70 percent disability rating, although there is some apparent variation in his functionality, both up and down. The Board finds that this variation was slight, and overall, his functioning falls within the 70 percent criteria throughout. In particular, his difficulty in adapting to stressful circumstances and his inability to establish and maintain effective relationships stand out. His symptoms of depression, panic, and impaired impulse control are reflected in the many stories he related to his care providers and therapy group over the years. His social impairment is reflected in his isolation and poor relationships. His own statements, the VA and private treatment records, and the VA examination reports buttress the finding that he has occupational and social impairment with deficiencies in most areas due to his PTSD. Mauerhan, supra. However, the Veteran does not manifest total occupational or social impairment related to PTSD in any way. He is consistently deemed able to manage his money, and noted to be mostly well-groomed and appropriately attired. He interacts sincerely and appropriately with his VA care providers. He does not manifest symptoms comparable to 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, his own occupation, or his own name. Therefore the preponderance of the evidence is against a 100 percent schedular disability rating for PTSD. Analysis - TDIU Prior to June 8, 2015 Total disability ratings for compensation based on individual unemployability may be assigned when the combined schedular rating for the service-connected disabilities is less than 100 percent and when it is found that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age, provided that, if there is only one such disability, this disability is ratable at 60 percent or more, or if there are two or more disabilities, there is at least one disability ratable at 40 percent or more and additional disabilities to bring the combined rating to 70 percent or more. Alternatively, a total disability rating for compensation based on unemployability may be assigned to a Veteran who is unable to secure and follow a substantially gainful occupation by reason of his/her service-connected disabilities. The Veteran's employment history, educational and vocational attainment as well as his particular physical disabilities are to be considered in making a determination on unemployability. 38 C.F.R. §§ 3.340, 3.341, 4.16. In determining whether the Veteran is entitled to a total disability rating based upon individual unemployability, neither his nonservice-connected disabilities nor his advancing age may be considered. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment. Van Hoose, ibid. According to information submitted by the Social Security Administration and confirmed by the Veteran's most recent employer, the Veteran last worked in December 2011, when he was laid off. The employer did not specify why he was laid off, although the Veteran contends he was unable to continue to work due to his knees (not service-connected) and his PTSD, which is service connected. The RO granted TDIU effective as of June 8, 2015, as this is the date the RO had granted a 70 percent disability rating for PTSD, meaning that the Veteran initially met the schedular criteria for the award of TDIU in June 2015. However, in this decision, the Board has granted a 70 percent disability rating for PTSD, effective in June 2010. Therefore, following this decision, the Veteran met the schedular criteria for the award of a TDIU in June 2010. This does not support the award of a TDIU in June 2010, however, because the Veteran was in fact employed on a full-time basis until December 2011 Because the purpose of a TDIU award is to compensate for actual unemployment, the earliest effective date which can be granted for the Veteran's award of TDIU is January 2012, the month after his employment was terminated. Therefore, the Board holds that an earlier effective date of January 1, 2012, for the award of TDIU is granted. An earlier date is denied. Additional matters Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (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). ORDER Service connection for tinnitus is granted. Service connection for bilateral hearing loss is denied. Service connection for irritable bowel syndrome is denied. Service connection for erectile dysfunction is denied. Service connection for skin cancer is denied. Service connection for a left knee disability is denied. Service connection for a right knee disability is denied. An initial disability rating for PTSD of 70 percent, effective from June 1, 2010, to the present, is granted, subject to the laws and regulations governing the award of monetary benefits. A disability rating for PTSD greater than 70 percent is denied. The TDIU award is granted effective January 1, 2012, but not earlier, subject to the laws and regulations governing the award of monetary benefits. REMAND Remand is necessary to obtain a medical opinion regarding whether the Veteran's hypertension could be associated with herbicide agent exposure during service. The medical evidence currently in the file does not support a connection directly between hypertension and service, or between hypertension and PTSD or medications taken for PTSD. However, another potential basis for entitlement has not yet been explored. The Veteran is presumed to have been exposed to herbicides in service as his service personnel records reflect that he served in the Republic of Vietnam during the Vietnam War Era. Current VA regulations do not provide hypertension as a presumptive disability associated with herbicide exposure. However, the National Academy of Sciences (NAS), in 2006 and 2008 updates, concluded that there was "limited or suggestive evidence of an association" between hypertension and herbicide exposure. See 75 Fed. Reg. 32,540, 32,549 (June 8, 2010); 75 Fed. Reg. 81,332, 81,333 (December 27, 2010). As there is evidence indicating that there may be an association between hypertension and herbicide exposure, a VA opinion must be obtained. Accordingly, the case is REMANDED for the following action: 1. The Veteran's claims file should be provided to a VA medical expert with appropriate expertise for review. The reviewer is requested to: Provide an opinion as to whether it is more, less, or equally likely that the Veteran's hypertension is due, wholly or in part, to his herbicide agent exposure in Vietnam. In providing the opinion, the examiner should consider the NAS 2006 and 2008 updates cited above, which concluded that there was "limited or suggestive evidence of an association" between hypertension and herbicide exposure. A complete rationale must be provided. IF the reviewer determines that additional tests or studies are warranted, and/or that a clinical examination would be helpful, then such tests/studies/examination should be arranged. 2. After the development requested above has been completed to the extent possible, the RO should again review the record and readjudicate the hypertension claims. If any benefit sought on appeal remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. The Veteran has the right to submit additional evidence and argument on the matter 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 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). ______________________________________________ S. B. MAYS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs