Citation Nr: 1753879 Decision Date: 11/24/17 Archive Date: 12/01/17 DOCKET NO. 09-27 362 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for ischemic heart disease, to include as due to exposure to herbicides. 2. Entitlement to an initial compensable rating for bilateral hearing loss. 3. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) with dysthymia prior to March 13, 2008, and a rating in excess of 50 percent thereafter. 4. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran and his spouse ATTORNEY FOR THE BOARD J. T. Brant, Counsel INTRODUCTION The Veteran served on active duty from May 1968 to May 1970. This appeal comes before the Board of Veterans' Appeals (Board) from December 2007, February 2008, and August 2011 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). The December 2007 rating decision granted service connection for PTSD and assigned a 30 percent rating effective January 3, 2007. The February 2008 rating decision granted service connection for bilateral hearing loss and assigned a noncompensable rating effective January 3, 2007. The August 2011 rating decision denied entitlement to service connection for ischemic heart disease. The Board notes that in a September 2011 rating decision, the rating for PTSD was increased to 50 percent, effective from March 13, 2008. As this increase did not constitute a full grant of the benefit sought, the Veteran's claim for a higher initial evaluation remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). In May 2013, the Veteran also filed a claim for a TDIU on a VA Form 21-8940. In June 2013, the Veteran provided testimony at a Travel Board hearing before a Veterans Law Judge. The Board notes that the Veterans Law Judge who conducted the June 2013 hearing is no longer employed by the Board. The Veteran was notified in an August 2017 letter that he was entitled to another hearing before the Board. See 38 C.F.R. § 20.707. In September 2017, the Veteran indicated that he did not want another hearing. As such, the Board may proceed on the appeal. In November 2013, the Board remanded the matters for further development. The Board finds there has been substantial compliance with its November 2013 remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268 (1998)) violation when the examiner made the ultimate determination required by the Board's remand.) FINDINGS OF FACT 1. Audiometric examinations correspond to no greater than a level I hearing loss for the right ear, and no greater than a level II hearing loss for the left ear. 2. For the appeal period prior to January 14, 2008, the preponderance of the evidence shows that the Veteran's PTSD with dysthymia symptomatology more nearly approximated occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 3. Resolving reasonable doubt in the Veteran's favor, beginning January 14, 2008, the preponderance of the evidence shows that the Veteran's PTSD with dysthymia more nearly approximates occupational and social impairment with deficiencies in most areas, but less than total social and occupational impairment. 4. Beginning April 1, 2011, the Veteran was unable to obtain or retain substantially gainful employment due to his service-connected PTSD and bilateral hearing loss. 5. The preponderance of the evidence of record is against a finding that the Veteran has ischemic heart disease. CONCLUSIONS OF LAW 1. The criteria for an initial compensable evaluation for bilateral hearing loss have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.7, 4.85, Diagnostic Code 6100 (2017). 2. For the period prior to January 14, 2008, the criteria for an initial disability rating in excess of 30 percent, for the Veteran's service-connected PTSD with dysthymia, were not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code (DC) 9411 (2017). 3. For the period beginning January 14, 2008, the criteria for an initial disability rating of 70 percent, but no higher, for the Veteran's service-connected PTSD with dysthymia, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code (DC) 9411 (2017). 4. Beginning April 1, 2011, the criteria for entitlement to TDIU are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16 (2017). 5. The criteria for service connection for ischemic heart disease are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. § 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The initial increased rating claims arise from the Veteran's disagreement with the ratings assigned following the grants of service connection. Because service connection has already been granted, the claims have been substantiated and no additional notice is required. Rather, any defect in the notice is deemed not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). With respect to the claim for service connection for ischemic heart disease, VA's duty to notify was satisfied by a letter dated in May 2011. See 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Veteran has not 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 duty to assist argument). II. Rating Principles A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. 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 their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). III. Initial Compensable Rating - Bilateral Hearing Loss The Veteran contends his bilateral hearing loss warrants an initial compensable rating. He has reported trouble understanding speech and great difficulty hearing in noisy environments. Evaluations for defective hearing are based upon organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests, along with the average hearing threshold level as measured by pure tone audiometric tests in the frequencies of 1000, 2000, 3000, and 4000 Hertz. 38 C.F.R. § 4.85, Tables VI, VII. To evaluate the degree of disability for service-connected bilateral hearing loss, the rating schedule establishes eleven auditory acuity levels, designated from level I for essentially normal acuity, through level XI for profound deafness. Table VI is used to determine the Roman numeric designation, based on test results consisting of puretone thresholds and Maryland CNC test speech discrimination scores. The numeric designations are then applied to Table VII to determine the appropriate rating for hearing impairment. Id. Where there is an exceptional pattern of hearing impairment, a rating based on pure tone thresholds alone may be assigned (Table VIA). This alternative method for rating hearing loss disability may be applied if the puretone thresholds at 1000, 2000, 3000, and 4000 Hertz are all at 55 decibels or higher, or if the puretone threshold at 1000 Hertz is 30 or less and at 2000 Hertz is 70 or more. 38 C.F.R. § 4.86. Each ear is to be evaluated separately under this part of the regulations. Ratings for hearing impairment are derived by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345 (1992). The Veteran was afforded a VA audiological examination in October 2007. Puretone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 RIGHT 5 25 55 50 LEFT 5 25 55 55 The average of the puretone thresholds findings at 1000, 2000, 3000, and 4000 Hertz was 34 decibels in the right ear, and 35 decibels in the left ear. The speech recognition scores on the Maryland CNC word list were 96 percent for the right ear and 94 percent for the left ear. Applying the test results of the October 2007 VA audiometric examination to Table VI of the Rating Schedule results in a Roman numeric designation of Level I for the right ear, and Level I for the left ear. 38 C.F.R. § 4.85, Table VI. Applying the Roman numeric designations to Table VII, the result is a noncompensable rating for the Veteran's service-connected bilateral hearing loss. 38 C.F.R. § 4.85, Table VII, Diagnostic Code 6100. As puretone thresholds at each of the four specified frequencies were not 55 decibels or more in either ear, and the puretone thresholds at 1000 Hertz were not 30 or less and at 2000 Hertz were not 70 or more, an exceptional pattern of hearing impairment was not shown. Thus, findings on this examination do not warrant consideration under 38 C.F.R. § 4.86. The Veteran was afforded another VA audiological examination in March 2011. Puretone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 RIGHT 10 25 55 60 LEFT 10 50 60 65 The average of the puretone thresholds findings at 1000, 2000, 3000, and 4000 Hertz was 37.5 decibels in the right ear, and 46.25 decibels in the left ear. The speech recognition scores on the Maryland CNC word list were 100 percent for the right ear and 94 percent for the left ear. Applying the test results of the March 2011 VA audiometric examination to Table VI of the Rating Schedule results in a Roman numeric designation of Level I for the right ear, and Level I for the left ear. 38 C.F.R. § 4.85, Table VI. Applying the Roman numeric designations to Table VII, the result is a noncompensable rating for the Veteran's service-connected bilateral hearing loss. 38 C.F.R. § 4.85, Table VII, Diagnostic Code 6100. As puretone thresholds at each of the four specified frequencies were not 55 decibels or more in either ear, and the puretone thresholds at 1000 Hertz were not 30 or less and at 2000 Hertz were not 70 or more, an exceptional pattern of hearing impairment was not shown. Thus, findings on this examination do not warrant consideration under 38 C.F.R. § 4.86. Pursuant to the Board's remand, the Veteran was afforded another VA audiological examination in April 2016. Puretone thresholds, in decibels, were as follows: HERTZ 1000 2000 3000 4000 RIGHT 20 60 65 65 LEFT 25 65 70 70 The average of the puretone thresholds findings at 1000, 2000, 3000, and 4000 Hertz was 53 decibels in the right ear, and 58 decibels in the left ear. The speech recognition scores on the Maryland CNC word list were 96 percent for the right ear, and 94 percent for the left ear. Applying the test results of the April 2016 VA audiometric examination to Table VI of the Rating Schedule results in a Roman numeric designation of Level I for the right ear, and Level II for the left ear. 38 C.F.R. § 4.85, Table VI. Applying the Roman numeric designations to Table VII, the result is a noncompensable rating for the Veteran's service-connected bilateral hearing loss. 38 C.F.R. § 4.85, Table VII, Diagnostic Code 6100. As puretone thresholds at each of the four specified frequencies were not 55 decibels or more in either ear, and the puretone thresholds at 1000 Hertz were not 30 or less and at 2000 Hertz were not 70 or more, an exceptional pattern of hearing impairment was not shown. Thus, findings on this examination do not warrant consideration under 38 C.F.R. § 4.86. There are no other audiometric testing results for the remainder of the appeal period which comply with the requirements of 38 C.F.R. § 4.85 for rating purposes. Although the Veteran has indicated that his hearing is worse than the criteria associated with a noncompensable evaluation, the rating criteria for hearing loss, as addressed above, requires the mechanical application of rating criteria to objectively-obtained audiometric testing results. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). The current noncompensable evaluation is reflected by the rating evidence of record and there is no indication that the findings on the October 2007, March 2011, and April 2016 VA audiological examinations are inadequate. Thus, the Veteran's claim for an initial compensable evaluation for his bilateral hearing loss disability cannot be granted. Accordingly, the evidence of record does not support an initial compensable rating for the Veteran's bilateral hearing impairment. IV. Initial Increased Rating - PTSD PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. The rating criteria provide that a 30 percent evaluation is warranted for 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). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent evaluation is warranted for 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 in establishing effective work and social relationships. Id. A 70 percent evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. 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. The use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to 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 (2002). A GAF (Global Assessment of Functioning) score is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994). This is more commonly referred to as DSM-IV. A GAF of 21 to 30 is defined as behavior considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriate, suicidal preoccupation) or an inability to function in almost all areas (e.g., stays in bed all day, no job, home or friends). A GAF of 31 to 40 is indicative of some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or any major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF of 41 to 50 is indicative of serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF of 51 to 60 is defined as 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). A GAF of 61 to 70 is indicative of 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, has some meaningful interpersonal relationships. A GAF of 71 to 80 indicates that if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). 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. Effective March 19, 2015, VA amended the portion of the Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations to remove outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), and replaced them with references to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). See 80 Fed. Reg. 53, 14308 (March 19, 2015). The provisions of the final rule apply to all applications for benefits that are received by VA or that were pending before the Agency of Original Jurisdiction on or after August 4, 2014. As the Veteran's claim was pending before this date, the amendment is not applicable. Here, a December 2007 rating decision granted service connection for PTSD, and assigned a 30 percent evaluation, effective January 3, 2007, the date of the claim for service connection. During the pendency of the appeal, in September 2011, the RO increased the evaluation for PTSD to 50 percent beginning March 13, 2008, noting that this was the date the Veteran was last treated for PTSD in his outpatient treatment records. However, the Board finds that the outpatient treatment records contain evidence of worsening symptomatology dating back to January 14, 2008. See January 14, 2008 VA treatment record (Veteran reported he was feeling depressed and it was getting worse). As will be discussed in more detail below, the Board is resolving reasonable doubt in the Veteran's favor and granting a 70 percent evaluation for the service-connected PTSD with dysthymia beginning January 14, 2008. For the period prior to January 14, 2008, taking into account all relevant evidence, the Board finds that an initial evaluation in excess of 30 percent for the Veteran's service-connected PTSD with dysthymia is not warranted. As noted above, in order to warrant an increased evaluation for this period, the Veteran would have to be found to have 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 judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. The Board finds that these criteria have not been met. The Board has considered the March 2007 private psychological evaluation, the October 2007 VA examination, and the lay statements from the Veteran regarding the impact of his PTSD with dysthymia on his occupational and social impairment during this timeframe. The Board finds the type and degree of symptomatology contemplated by a 50 percent disability rating is not shown for the period prior to January 14, 2008. The Veteran's reported psychiatric symptoms during this timeframe consisted of depressed mood, sleep impairment, nightmares, restlessness, inability to express feelings, social avoidance, persistent symptoms of increased arousal, and loss of interest in usual activities. Moreover, the Veteran received GAF scores of 52 (March 2007 private psychologist) and 62 (October 2007 VA examiner), which indicates "mild" to "moderate" symptoms, and which is consistent with a 30 percent rating. Thus, while the Veteran did at times have some moderate PTSD symptomatology during this timeframe, his overall symptomatology was generally mild, with no evidence of significant interference with his social and occupational life. He was able to maintain his activities of daily living, work full-time, and have a good relationship with his wife of 25 years. Moreover, the October 2007 VA examiner indicated that the Veteran's PTSD symptoms appeared to have little impact on his functioning. The examiner noted that the Veteran reported little effect on his day-to-day life due to his experience with symptoms. She noted that he appeared to have coped with some of these symptoms through behavioral strategies, such as going to dinner earlier to avoid crowds. The examiner noted that while it was possible and even likely that the Veteran's guarded presentation hindered his ability to convey the impact of his symptoms on his functioning, he did not indicate there were significant effects on his occupational, social, or personal functioning. The Board notes that the Court has held that the symptoms enumerated under the schedule for rating mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular disability rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Although not dispositive, the evidence of record does not show that the Veteran's psychiatric disability was manifested by such symptoms as 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; or impaired abstract thinking. 38 C.F.R. § 4.130, 9411. Review of the evidence of record shows that for the period prior to January 14, 2008, the Veteran's PTSD caused mild to moderate symptoms of occupational and social impairment such as depressed mood, sleep impairment, nightmares, restlessness, inability to express feelings, social avoidance, excessive jumpiness, loss of interest in usual activities, and some difficulty with memory, but other, more severe, symptoms were absent. Indeed, the evidence of record only reveals 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. Although the Veteran's mood and affect were constricted and he reported some difficulties maintaining effective work and social relationships, the nature, severity, and frequency of his symptoms overall did not more nearly approximate reduced reliability and productivity to warrant a 50 percent rating. The clinical assessments for this period showed that the Veteran was oriented times three, with adequate judgment. The Veteran did not display or report memory impairment. There was no evidence of panic attacks more than once per week, and the Veteran reported behavioral strategies such as going to dinner earlier to avoid crowded public settings to limit these occurrences. Moreover, the Veteran was not found to be suicidal or homicidal, and there was no evidence of obsessive/ritualistic behavior, impaired impulse control, hallucinations, or delusions. Therefore, the nature, severity, and frequency of his symptoms, overall, do not more nearly approximate reduced reliability and productivity to warrant a 50 percent rating. The Board acknowledges that the March 2007 private psychologist found that the Veteran's PTSD symptomatology caused significant distress and marked impairment in social, occupational, and other important areas of functioning, while the October 2007 VA examiner found that the Veteran's PTSD symptomatology did not have any significant effects on his occupational, social, or personal functioning. However, the March 2007 psychologist also found that the Veteran had been gainfully employed since 1973, had his wife as a support system, and was able to manage his own self-care in all major areas of daily living. The Board finds that ultimately, the Veteran's overall disability picture during this timeframe more nearly approximated the criteria for a 30 percent rating. While the Veteran exhibited some deficiencies in occupational and social functioning, the symptomatology was not of sufficient severity, frequency, and duration to result in a higher rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013) (holding that a veteran "may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration"). At worst, his symptoms appeared consistent with no more than occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The criteria for a finding of a 50 percent evaluation, the next higher evaluation, were not met. In light of the foregoing, the Board finds an evaluation in excess of 30 percent for PTSD is not warranted for the period prior to January 14, 2008. As noted above, the Board finds that the outpatient treatment records contain evidence of worsening symptomatology beginning on or around January 14, 2008. See January 14, 2008 VA treatment record (Veteran reported he was feeling depressed and it was getting worse). Beginning January 14, 2008, upon careful review of the evidence of record, the Board finds that the objective medical evidence, and the Veteran's statements regarding his symptomatology, more nearly approximate symptoms associated with a 70 percent disability rating. In other words, resolving reasonable doubt in favor of the Veteran, the Board finds that the evidence supports a 70 percent rating beginning January 14, 2008. 38 U.S.C.A. § 5107; Gilbert, supra; Mauerhan, supra. However, the Board finds that the preponderance of the evidence is against an evaluation in excess of 70 percent. Neither the lay nor the medical evidence of record more nearly approximates the frequency, severity or duration of psychiatric symptoms required for a 100 percent disability evaluation based on total occupational and social impairment. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. The Board has considered the VA outpatient treatment records, the March 2011, March 2016, and August 2016 VA examination reports, the January 2013 private psychological assessment, the February 2013 disability benefits questionnaire, and the hearing testimony and lay statements by the Veteran and his wife regarding the impact of his PTSD with dysthymia on his occupational and social impairment. During this timeframe, the Veteran has competently and consistently reported significant symptoms related to his PTSD with dysthymia. Although the evidence shows that there have been some instances during the rating period when the Veteran's PTSD with dysthymia was not quite as severe as noted in the January 2013 evaluation by Dr. W. C., the Veteran has consistently reported significant symptoms related to his PTSD with little or no improvement. The Board notes at this juncture that VA will handle cases affected by change in medical findings or diagnosis so as to produce the greatest degree of stability of disability evaluations consistent with the laws and regulations governing disability compensation and pension. See 38 C.F.R. § 3.344(a). As such, the Board finds that the 70 percent rating for PTSD pursuant to Diagnostic Code 9411 is warranted for the entire timeframe beginning January 14, 2008. The Board finds, however, that a disability rating greater than 70 percent is not appropriate because the Veteran does not have total social and occupational impairment. During this timeframe, the Veteran's PTSD has been manifested by symptoms such as depressed mood, anxiety, chronic sleep impairment and nightmares, constricted affect, mild memory loss, some suicidal ideation with no intent, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and impaired impulse control, all resulting in deficiencies in most areas, but less than total social and occupational impairment. Although the Veteran clearly has a serious disability, he exhibits few of the symptoms noted as applicable for a 100 percent rating. There has been no indication of gross impairment of 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, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. Although the Veteran has consistently denied suicidal or homicidal ideation in his examinations, he recently reported some suicidal ideation and thoughts of death. In this regard, in his January 2013 private psychological assessment, the Veteran reported current thoughts of death but no suicidal ideation. In a September 2017 statement, he reported suicidal ideation, noting that "I have and do at times think I may be better off not being on this earth." However, the medical evidence of record does not indicate that the Veteran is a persistent danger of harm to himself or others. In this regard, he has consistently denied a plan or intent to harm himself or others. As such, his symptoms appear to more nearly approximate those for a 70 percent rating, specifically suicidal or homicidal ideation, but without rising to the level required for a 100 percent rating, specifically a persistent danger of hurting self or others. Moreover, although the evidence of record suggests some memory and cognitive problems, the Veteran has never forgotten the names of close relatives, his own occupation, or his own name. He has also always been oriented times three. As such, his symptoms appear to more closely approximate those for a 50 or 70 percent rating, specifically impairment of short and long-term memory and difficulty understanding complex commands, but without rising to the level required for a 100 percent rating, specifically gross impairment of thought processes or communication or memory loss for names of close relatives, own occupation, or own name. Finally, the Board acknowledges that during the appeal period, Dr. W. C. assigned the Veteran a GAF score of 44, suggesting serious symptoms. The Board also acknowledges that in the February 2013 disability benefits questionnaire, Dr. W. C. found total occupational and social impairment, while the March 2011 VA examiner found occupational and social impairment with deficiencies in judgment, thinking, family relations, work, and mood, causing reduced reliability and productivity; the March 2016 VA examiner found occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; and the August 2016 VA examiner found occupational and social impairment with reduced reliability and productivity. The Board finds that these findings, and the Veteran's competent and credible reports of his symptoms and their effect on his functioning, indicate serious symptoms, and the evidence of record indicates that such problems adversely affect his social and occupational functioning to warrant a 70 percent disability rating, but no higher. The Board finds the totality of the evidence of record indicates that the Veteran has impairment in his occupational functions due to his psychological symptoms throughout the appeal period, and total occupational impairment beginning in April 2011, due at least in part, to his PTSD. In this regard, the March 2011 examiner noted that the Veteran was currently employed as a welder for 38 years. The examiner noted the following problems related to occupational functioning: decreased concentration, difficulty following instructions, memory loss, and poor social interaction. The Veteran retired in April 2011. In the January 2013 private psychological assessment, the Veteran reported that he had not maintained gainful employment for two years because he was having trouble with others. The Veteran noted that his primary occupation was a skilled labor position for the past 30 years. He indicated that he was usually able to be on time and do what was expected of him until the end of his career. He recalled trouble remembering tasks and not completing tasks in a timely manner. He noted that he received formal reprimands for performance related issues. Moreover, in the August 2016 VA examination, the examiner found that the Veteran's PTSD symptomatology would likely make it difficult for the Veteran to function appropriately and effectively at work and to complete tasks in a timely manner. The examiner noted that the Veteran indicated he was most distressed by having to work with others. However, she noted that he also reported difficulties with motivation and recalling specific instructions for completion of job tasks, which suggests he may also experience problems with attention and focus. The examiner noted that the Veteran reported that he believed he would have been fired from his job if he did not choose to retire. The examiner noted that per the Veteran's report, his mental health symptoms negatively impacted his work performance (requiring counseling) and his ability to interact with others in a professional manner in the past. She found that given that these symptoms have persisted, it would be expected that he would continue to experience hardship during future employment. However, the Board finds that the evidence of record does not indicate that the Veteran also experiences total social impairment due to his PTSD. In this regard, the Veteran has been married to his wife for more than 30 years. He has also indicated that he remains in occasional contact with his daughter, who lives in Florida, and his stepdaughter, who lives nearby. The Board acknowledges that poor social interaction problems have been noted throughout the appeal period, and have recently appeared to worsen. In this regard, in the March 2011 VA examination, the Veteran described a satisfactory marriage and an "okay" relationship with his offspring. He denied having any friends, and indicated that he no longer went to church. He described his social life as "inadequate." In the January 2013 private psychological assessment, the Veteran reported that he avoided people and had given up a number of friendships. He noted that he had a limited support system, and his wife was his main source of support. He described frequent arguments with friends, emotional issues interfering with his marriage, and social isolation. The examiner noted that it appeared that the Veteran's relationship with his wife had worsened. In his August 2016 VA examination, the Veteran indicated that he did not really have any close friends, and he preferred to stay home. Nonetheless, the Board finds that despite the reported difficulties, the Veteran has continued to sustain a meaningful relationship with his wife and some of his children; therefore, total social impairment is not shown. For these reasons, the evidence of record indicates the Veteran has social impairment with deficiencies in most areas, including social and family relations, but not total social impairment, commensurate with a 70 percent rating, but no higher. Although the Veteran may meet some of the criteria for a 100 percent rating, see Mauerhan, 16 Vet. App. at 442, the Board concludes his overall level of disability does not exceed a 70 percent rating. Again, in determining that a rating in excess of 70 percent is not warranted, the Board has considered the Veteran's complaints, his private evaluation by Dr. W. C., and the VA examination reports, regardless of whether these symptoms are listed in the rating criteria. However, the Board concludes that the Veteran's level of social and occupational impairment does not warrant a rating in excess of 70 percent. The Board has considered the Veteran's claim and the lay and medical evidence, and concludes the evidence of record more nearly approximates the criteria for a 70 percent rating, but no higher, for the Veteran's PTSD beginning January 14, 2008. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). V. TDIU Total disability will be considered to exist where there is present any impairment of mind and body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that the Veteran meets the schedular requirements. Specifically, if there is only one such disability, this disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability that is 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 unemployability exists, consideration may be given to the veteran's level of education, special training, and previous work experience, but not to his age or to any impairment caused by non service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2017). Here, the Board finds that a TDIU is warranted based on the Veteran's service-connected PTSD with dysthymia and bilateral hearing loss. At the outset, the Board notes that the Veteran is in receipt of service connection for PTSD with dysthymia, rated at 70 percent; tinnitus, rated at 10 percent; and bilateral hearing loss, rated as noncompensable. As such, his combined evaluation beginning January 14, 2008, meets the schedular percentage requirements for a TDIU. Additionally, the evidence demonstrates that the Veteran is unable to obtain or retain substantially gainful employment due to his service-connected PTSD with dysthymia and bilateral hearing loss. On the Veteran's VA Form 21-8940, Veteran's Application for Increased Compensation based on Unemployability, the Veteran reported that he worked full-time as a laborer from 1973 until his retirement on April 1, 2011, which he indicated was the date his disabilities affected his full-time employment. He listed his PTSD and bilateral hearing loss as the disabilities preventing him from maintaining gainful employment. He reported that he could not get along with other employees. He noted that he had a high school education. In lay statements, the Veteran reported that he worked for 30 years as a laborer before retiring in 2011. He indicated that he retired because he had "trouble getting alone with everybody." He noted that he was not aware of these issues until he was counseled several times related to the way he did things. He noted that he was written up a couple of times for not getting along with people and having difficulty completing his work tasks because he could not remember what to do on the job. The Veteran indicated that he felt forced to retire. The Veteran's PTSD causes occupational and social impairment with deficiencies in most areas. In particular, the August 2016 VA examiner found that the Veteran's PTSD symptomatology appeared to be moderate in severity. The examiner found that these symptoms would likely make it difficult for the Veteran to function appropriately and effectively at work and to complete tasks in a timely manner. The examiner noted that the Veteran indicated he was most distressed by having to work with others. However, she noted that he also reported difficulties with motivation and recalling specific instructions for completion of job tasks, which suggests he may also experience problems with attention and focus. The examiner noted that the Veteran reported that he believed he would have been fired from his job if he did not choose to retire. The examiner noted that per the Veteran's report, his mental health symptoms negatively impacted his work performance (requiring counseling) and his ability to interact with others in a professional manner in the past. She found that given that these symptoms have persisted, it would be expected that he would continue to experience hardship during future employment. Therefore, the examiner opined that it was more likely than not that the Veteran's PTSD symptoms would render him unemployable if provided with the opportunity to work again, taking into consideration his education and work experience. Moreover, in a private psychological assessment dated in January 2013, Dr. W. C. found that the Veteran was unable to maintain gainful employment. Dr. W. C. noted that the Veteran had retired two years ago after 30 years of employment as a laborer because he was "having trouble with others." Dr. W. C. noted that the Veteran reported that he was usually able to be on time and do what was expected of him until the end of his career, when he began experiencing trouble remembering tasks and not completing tasks in a timely manner. In addition, the physical limitations from his bilateral hearing loss limits his ability to perform jobs in noisy environments, such as his prior job performing factory work, because he would not hear instructions or might miss safety alerts. It would also limit his ability to perform jobs requiring talking on the telephone, as he would have difficulty understanding conversations. See, e.g. April 2016 VA examination. Given the Veteran's credible lay statements regarding the impact of his service-connected disabilities on his ability to work and the functional limitations described by the VA examiners, the Board finds that the Veteran's service-connected disabilities likely prevented him from obtaining and maintaining gainful employment beginning April 1, 2011. The preponderance of the evidence establishes that beginning April 1, 2011, the Veteran, given his occupational history and functional limitations, was unable to obtain or retain substantially gainful employment due to the combined effects of his service-connected disabilities. The Board notes that entitlement to TDIU for the period prior to April 1, 2011, is not established, as the Veteran was gainfully employed during this time. See VA Form 21-8940 dated in May 2013. VI. Service Connection - Ischemic Heart Disease A veteran is entitled to VA disability compensation if there is disability resulting from personal injury suffered or disease contracted in line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active service. 38 U.S.C.A. § 1110. Generally, to establish a right to compensation for a present disability, a veteran must show: (1) a present disability; (2) an 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, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Degmetich v. Brown, 104 F.3d 1328 (1997). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (the Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Veteran seeks entitlement to service connection for ischemic heart disease, claimed as a result of his exposure to herbicides in service. VA regulations provide that a Veteran who had active military, naval, or air service in the Republic of Vietnam during the Vietnam Era shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. See 38 C.F.R. § 3.307(a)(6)(iii). In such circumstances, service connection may be granted on a presumptive basis for the diseases listed in 38 C.F.R. § 3.309(e). Ischemic heart disease is a disease listed in § 3.309 for which presumptive service connection is available based on in-service herbicide exposure. See 38 C.F.R. § 3.309(e). The Veteran served in Vietnam from October 13, 1968 to October 12, 1969. Although exposure to herbicides is presumed, the relevant medical evidence of record does not include any diagnosis for ischemic heart disease. In fact, in a disability benefits questionnaire completed in July 2011, the examiner specifically indicated that the Veteran did not have ischemic heart disease. The examiner instead noted diagnoses of hypertension and hyperlipidemia. The Board observes that the Veteran has not filed a claim for hypertension or hyperlipidemia, and hypertension and hyperlipidemia are not considered an ischemic heart disease. 38 C.F.R. § 3.309(e), Note 2. Likewise, VA treatment records do not contain a diagnosis of ischemic heart disease. In a September 2011 comprehensive assessment, it was noted that the Veteran did not have any known heart problems. It was also noted that he had a stress test many years ago that was normal. The Veteran was diagnosed with hypertension and hyperlipidemia. To the extent that the Veteran has reported symptoms of chest pain, VA does not generally grant service connection for symptoms alone, without an identified basis for those symptoms. Here, the evidence unequivocally shows that the Veteran has not established a diagnosis of ischemic heart disease at any time during the course of the appeal. The existence of a current disability is the cornerstone of a claim for VA disability compensation, and without a current disability, service connection is not warranted. 38 U.S.C.A. § 1110; see also Brammer, 3 Vet. App. at 225. Accordingly, the claim is denied. There is no doubt to resolve as the evidence is not roughly in equipoise. 38 U.S.C.A. § 5107; Gilbert, supra. ORDER Entitlement to an initial compensable rating for bilateral hearing loss is denied. For the appeal period prior to January 14, 2008, entitlement to a rating higher than 30 percent for PTSD with dysthymia is denied. For the appeal period beginning January 14, 2008, entitlement to a 70 percent rating, but no higher, for PTSD with dysthymia, is denied. Beginning April 1, 2011, entitlement to a TDIU is granted. Entitlement to service connection for ischemic heart disease is denied. ____________________________________________ S. HENEKS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs