Citation Nr: 1800866 Decision Date: 01/08/18 Archive Date: 01/19/18 DOCKET NO. 14-12 838 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for obstructive sleep apnea. 2. Entitlement to an initial disability rating greater than 50 percent before November 1, 2016, and to a rating greater than 70 percent thereafter, for posttraumatic stress disorder (PTSD) with generalized anxiety disorder and panic disorder without agoraphobia (hereafter "psychiatric disorder.") ATTORNEY FOR THE BOARD N. Stevens, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1986 to June 2006. This matter comes before the Board of Veterans' Appeals (Board) from a November 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The rating decision of November 2010, granted PTSD at 50 percent disabling effective, October 25, 2010, and denied service connection for sleep apnea. The AMC in November 2016 increased the 50 percent rating for PTSD to 70 percent disabling, effective November 1, 2016, and continued the denial of sleep apnea. The issue of entitlement to service connection for sleep apnea is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Beginning October 25, 2010, the probative evidence of record shows that the Veteran's PTSD symptoms manifested as occupational and social impairment with reduced reliability and productivity. 2. Beginning November 1, 2016, the probative evidence of record shows that the Veteran's PTSD symptoms manifested as occupational and social impairment with deficiencies in most areas. CONCLUSION OF LAW 1. Before November 1, 2016, the criteria for an initial disability rating greater than 50 percent for service-connected PTSD with generalized anxiety disorder and panic disorder without agoraphobia have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.125, 4.130, Diagnostic Code 9434 (2017). 2. Beginning November 1, 2016, the criteria for a disability rating greater than 70 percent for service-connected PTSD with generalized anxiety disorder and panic disorder without agoraphobia have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.125, 4.130, Diagnostic Code 9434 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duty to Notify and Assist VA's duty to notify was fulfilled by a November 2010 and March 2011 letters. 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017). Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). With regard to the duty to assist, the Veteran's service treatment records, VA medical treatment records and private treatment records have been obtained. Hurd v. West, 13 Vet. App. 449, 452 (2000). The Veteran was afforded VA examinations in November 2010 and November 2016. The examinations also took into consideration the Veteran's pertinent medical history, his lay assertions and complaints, and a review of the record. Ardison v. Brown, 6 Vet. App. 405, 407 (1994). Thus, the Board finds that the VA has complied with its duty to notify and assist in the development of a claim. Hence, no further notice or assistance is required to fulfill that duty. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Disability Ratings for PTSD Disability ratings are determined by applying the criteria established in VA's Schedule for Rating Disabilities, which is based upon the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.20 (2017). When a question arises as to which of two ratings applies under a particular Diagnostic Code, the higher evaluation is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the claimant. 38 C.F.R. § 4.3 (2017). Consideration must be given to increased evaluations under other potentially applicable Diagnostic Codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Furthermore, when it is not possible to separate the effects of the service-connected disability from a non service-connected condition, such signs and symptoms must be attributed to the service-connected disability. 38 C.F.R. § 3.102 (2017); Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007) (citing Fenderson v. West, 12 Vet. App. 119, 126 (1999)). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a competent source. Second, the Board must determine if the evidence is credible. Barr v. Nicholson, 21 Vet. App. 303 (2007). Third, the Board must weigh the probative value of the evidence in light of the entirety of the record. The Veteran's psychiatric disorder was initially assigned a 50 percent disability rating under Diagnostic Code 9411. 38 C.F.R. § 4.130 (2017). PTSD is evaluated under the General Rating Formula for Mental Disorders. Under the General Rating Formula for Mental Disorders, a 50 percent rating 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; and difficulty in establishing effective work and social relationships. Id. A 70 percent rating 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 work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. Symptoms listed in the General Rating Formula for 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 rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). 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. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). Additionally, while symptomatology should be the primary focus when deciding entitlement to a given disability rating, § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused the requisite occupational and social impairment. Id. The American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, (4th ed. 1994) (DSM- IV) contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. Higher scores correspond to better functioning of the individual. During the appeal period, the Veteran's GAF scores ranged from 50 to 90. GAF scores ranging between 41 and 50 are assigned when there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores ranging between 61 and 70 are assigned when there are some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but when the individual is functioning pretty well and has some meaningful interpersonal relationships. GAF scores ranging 71 and 80 are assigned when there 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 failing behind in schoolwork). GAF scores ranging 81 and 90 are assigned when there absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g. an occasional argument with family members). Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). A. Period before November 1, 2016 The Veteran underwent a VA examination for service-connection for PTSD in November 2010. The Veteran reported flashbacks of his stressors. The Veteran reported ongoing symptoms of PTSD, such as hypervigilance, being very easily startled when people pass him by and specifically, on one occasion when a neighbor handed him something. The Veteran reported that he avoided dealing with anything to do with his time in Iraq and Afghanistan. Specifically, he reportedly rejected a "friend request" on Facebook from the mother of someone who was lost in combat. The Veteran reported that his symptoms were severe, ongoing, and they were day-to-day. He avoided people, "pushe[d] away" his loved ones and had conflictual relationship with others. The Veteran reported that in his day to day activities, he was irritable and aloof in his relationships. He reported, however, being able to meet deadlines at work. The Veteran reported that when his baby daughter was in the hospital, he did not take time off from work to see her and that this was very irksome to his colleagues who had noticed a change in his personality. His reported having good relationships with his father, mother, and siblings. The Veteran reported being single, but had an "off and on" relationship because of poor communication skills with his partner. He indicated that he tried to avoid telling her of his problems, but his behavioral manifestations made it obvious. The Veteran reported working at the same job for 10 years and described a fair relationship with his supervisor and coworkers. The Veteran reported a history of violent behavior. He threw a stack of papers down at work. He reported ongoing problems with initial insomnia, secondary to anxious ruminations and middle insomnia, dating back to 2003. His ruminations were about the future, past, and present. The examiner noted that the Veteran exhibited evidence of re-experiencing the event in the form of recurrent recollections, recurrent distressing dreams, and physiological hyperactivity to cues that symbolize the event as well as avoidance of thoughts feelings and conversations, activities, places and people that arouse recollections of the event. The Veteran also exhibited persistent markedly diminished interest or participation in significant activities, and feeling detached and estrangement from others as well as a restricted range of affect. The examiner noted that the Veteran cited several examples whereby he would misread cues. For example, hearing a whistling sound of an air conditioner, the Veteran overreacted in a very startled and exaggerated fashion. The examiner noted that the Veteran was a reliable historian. His orientation was normal. His appearance and hygiene are appropriate, as was his behavior. His affect indicated anxiety. His communication was normal, as was his speech and concentration. The examiner noted that the Veteran had panic attacks about 3-4 times a week during which time he experienced palpitation sweat, flutters, and panicky feelings. The examiner noted that suspicion has been with the Veteran scanning things in his environment. No history of delusions hallucinations and obsessive-compulsive behavior were noted. The Veteran's thought processes were normal as was his memory. There was no evidence of any impaired judgment, impaired abstract thinking, suicidal or homicidal ideations. The examiner noted that Veteran experienced recurrent recollections of the event in the form of dreams, flashbacks, and physiological hyperactivity, and often feeling as if the events were recurring, along with intense distress at exposure to the events that remind him of the event. The examiner noted that the Veteran experienced persistent avoidance of stimuli, specifically people, places, and conversations, as well as other situations that could arouse memories of the event. The Veteran indicated a sense of foreshortened future as a result of seeing death on a regular basis, as well as feeling detached and not participating in activities. He evidenced symptoms of increased arousal, having difficulty falling and staying asleep, irritability, outburst of anger, exaggerated startle response, difficulty concentrating and ongoing hypervigilance. The examiner noted that the Veteran's work performance had not been impacted. His work colleagues, however, noticed changes in his personality and a level of irritability that has impacted his ability to relate appropriately in the workplace. The examiner noted that he was capable of managing his benefits in his interest. He had no difficulty performing activities of daily living. The examiner noted at the time that the psychiatric symptoms caused occupational and social impairment with reduced reliability and productivity as evidenced by panic attacks more than once a week, disturbance in mood and difficulty establishing and maintaining effective work and social relationships. The Veteran had ongoing difficulty in establishing and maintaining effective work and social relationships, as well as difficulty maintaining his family role functioning, as evidenced by his estrangement from his one-year-old daughter. He also had intermittent inability to perform recreational and leisurely pursuits since returning from the wars. He had no difficulty in understanding simple or complex commands. A GAF score of 50 was assigned, indicating serious symptoms. In addition to the VA examinations, the Veteran's VA medical records show treatment for PTSD. Prior to November 1, 2016, the evidence showed consistent reports of anxiety, irritability, hypervigilance, sleep problems, startle reflex, and recurrent nightmares. In December 2010, the Veteran reported feeling more "upbeat" and in "good spirits." He also reported less hypervigilance and being less jumpy. His sleeping was reported as improved and no nightmares were reported. He reported, however, that he continued to be awakened twice per night. The physician noted no homicidal indent or ideation. A GAF 70 was assigned, indicating some mild symptoms. In March 2011 the physician noted that the Veteran's mood and irritability had improved, as was a reduction in hypervigilance. The Veteran's energy was good, and he reported sleeping well. No suicidal or homicidal ideations were reported. The Veteran reported having flashbacks, however, while watching a documentary about his unit. He reported functioning well at work and receiving an award for employee of the quarter. The physician noted his affect was euthymic. His insight and judgment were good. A GAF 81-90 was assigned, indicating absent or minimal symptoms. In October 2011, the Veteran reported improved mood, irritability, and energy. He also reported sleeping well, with occasional flashbacks. He also reported functioning well at work. No suicidal or homicidal ideation was reported. A GAF score of 81-90 was assigned, indicating absent or minimal symptoms. In March 2012, the Veteran reported that he felt like he was managing his PTSD symptoms. He reported spending time with a group of veterans but removed himself after noticing that they were doing a lot of binge drinking. He reported having irritability and short temper at work. He reported still having problems with sleeping only 3-4 hours at most, with frequent middle insomnia. The Veteran denied suicidal ideation. A GAF score of 70 was assigned, indicating some mild symptoms. In August 2012, the Veteran reported that he was still having problems with recurrent nightmares and falling, and staying asleep. He also reported that he was trying to be more social and involved. He reported tensions with his supervisor at work and noted the upcoming anniversary in September of a fallen soldier. The physician noted no impairment of judgment or memory. His mood was euthymic, and he was not anxious. His affect was reported as normal. The physician noted that he showed no irritability. He also noted no delusions, suicidal or homicidal ideation or plans. The physician noted a "[d]angerousness assessment: suicide risk," but noted that the Veteran denied intent. A GAF score of 70 was assigned. Notes dated in March 2013 indicate that the Veteran reported that it was the 10th anniversary of the invasion of Iraq. The Veteran reported going out more to the bars, about three nights per week and drinking about 4-5 drinks per night. His mood was reported as good. He reported that he still got easily frustrated and hypervigilant but learned to cope with it. He also reported a "current" romance, where he talked about open communication. The physician noted no impairment of judgment or memory. His mood was euthymic, and he was not anxious. His affect was reported as normal. The physician noted that he showed no irritability. He also noted no delusions, suicidal or homicidal ideation or plans. The physician noted a "[d]angerousness assessment: suicide risk," but noted that the Veteran denied intent. A GAF score of 70-75 was assigned. Notes dated in February 2014 indicate that the Veteran was assigned a GAF score of 70-75. After a review of the evidence presented above, the Board finds that the frequency, severity, and duration of the Veteran's PTSD symptoms reported or shown are suggestive of occupational and social impairment with reduced reliability and productivity, the level of impairment contemplated by a 50 percent rating. The 50 percent rating is consistent with the description of his symptoms by examiners and other treating professionals. Over the course of this period, beginning October 25, 2010, the Veteran's GAF scores ranged from 50 to 81-90, indicating at certain times fluctuation of his PTSD symptoms from mild, moderate and transient. The Veteran's PTSD disorder is not more closely described by occupational and social impairment in most areas. During the period before November 1, 2016, the VA examiner and physicians noted no suicidal or homicidal ideation. In August 2012 and March 2013, the physician noted "[d]angerousness assessment: suicide risk," but also noted that the Veteran denied intent. As there was no intent or plan, the Veteran's suicidal ideation was not severe enough to result in deficiencies in most areas. Further, this was only noted twice during a period beginning in 2010 through 2016, making it not frequent. Furthermore, without intent or plan, the record does not show that the Veteran is a persistent danger to himself. Throughout this period, although the Veteran was described as being alone, he maintained a good relationship with his parents and his siblings, even having a romantic relationship in March 2013, but was estranged from his baby daughter. Additionally, the Veteran experienced difficulty with sleep disturbance and recurrent nightmares, and reported ongoing difficulty with his supervisor at work. Nonetheless, the evidence of record does not show that they are severe enough to cause occupational and social impairment with deficiencies in most areas. Neither the examiner nor physicians noted the Veteran's neglect of personal hygiene; impaired impulse control; depression affecting his ability to function independently; or obsessional rituals, interfering with his activities of daily living. During this period, the Board notes that the Veteran reported tension with his supervisor. However, in March 2011, he received an award for employee of the quarter. Given the frequency, nature, and duration of the Veteran's symptoms, the Board finds that they do not result in occupational and social impairment for the period before November 1, 2016. They do not more closely approximate the types of symptoms contemplated by the 70 percent rating, and therefore, a 70 percent rating is not warranted. Vazquez-Claudio, 713 F.3d at 114 (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"). The Board finds that Veteran's symptoms from PTSD have not more closely approximated the criteria for a rating greater than of 50 percent during the period before November 1, 2016. Therefore, the Board may not stage his rating. Fenderson, 12 Vet. App. at 125-26. The probative evidence of record does not show that the particular symptoms associated with the higher percentage or others of similar severity, frequency, and duration result in occupational and social impairment. Therefore, a 70 percent rating is not warranted. B. Period Beginning November 1, 2016 The Veteran underwent a second VA examination in November 2016. The Veteran reported having a seven-year-old daughter, with whom he has "on and off" contact. He has not seen his daughter in almost a year. She lives with her mother in South Carolina. The Veteran reported that he is not currently in a romantic relationship, has no friends, and has limited contact with his two siblings, and occasional contact with his parents. He does not participate in family gatherings or holiday celebrations. The Veteran reported no "current" hobbies or interests, and stated, "I have just back[ed] away from the hobbies and things I used to do." He reported being in the same job for 10 years and having had conflicts with co-workers and supervisors which resulted in his either calling off work or not being as engaged in work activities. He reported feeling rage toward a co-worker who commented that the war had no meaning for her. He reported there is a lack of understanding in the workplace and he "does" not feel a part of the organization. He may go two weeks without talking to his co-workers. The Veteran reported frequent intrusive thoughts of combat experiences. When he closes his eyes and tries to sleep, he has vivid memories of body parts and blood. He has re-occurring nightmares, at least four times a week, of fire, black smoke, and blood on his boots and the smell of burnt blood. Hearing loud noises, music similar to the music he heard when he was deployed, noises in the street, someone running or crowds, trigger the thoughts. He becomes anxious and has difficulty focusing when he is triggered. His speech becomes more rapid, and he has trouble staying on topic. The Veteran avoids social gatherings, even with family, crowds and trauma-focused therapy. He retired shortly after his last deployment to Afghanistan despite being in line for a promotion and having all excellent on his performance evaluations. He stated, "I just walked away," not even wanting a retirement ceremony. The Veteran reported difficulty falling asleep and staying asleep, with increased feelings of fatigue, irritability, and anger which impacted his work performance and interaction with co-workers. The Veteran reported his experiences changed him as a person, in the ability to establish and maintain a relationship with his family and his daughter. He reported feelings of guilt about the death of a soldier who was on routine patrol in Veteran's vehicle when it was hit in an IED. He wonders why he was not in the vehicle when it was hit. He reported feelings of guilt and shame, "we made a promise to bring everyone from the deployment, and we failed that mission." He reported being emotionally detached from everyone. When he attended a family Thanksgiving dinner, he stood at the counter and ate instead of sitting at the table; he has not gone to another family dinner since then. His sister, who lives 35 miles away, invites him but he always declines, even for holidays like Christmas and Thanksgiving, "I stay home." "I do everything alone." The Veteran reported feeling numb, like in a zombie state, and has not been able to maintain a relationship. He finds it hard to feel close to his daughter. The Veteran reported increased irritability. He reported verbal outbursts and "heated discussions" with his supervisor, with the result of the meeting being terminated and Veteran asked to leave the office. The Veteran reported constantly being on guard. He has developed regimented routines, i.e., looking out the window, making his bed with the lights off, turning off the ceiling fan, and having a specific routing for personal hygiene every day. He cleans his house constantly when he is home to distract himself. He always fills his car when it down to a 1/4 of gas, so he is prepared. When he is in a store, he starts to feel dizzy and anxious. He will act as if he is on his phone to focus on something and then leave the store. He becomes anxious in the crowd because he is not able to monitor everyone. The Veteran recently purchased firearms and sleeps with a pistol, and keeps one next to the couch. He reported that having a weapon decreases his anxiety. He becomes startled easily and reacts if someone claps their hands, or people walk by his cubicle. He reported decreased concentration, which worse when he is startled. He finds it difficult to stay on topic at times and feels like his mind is "racing." Veteran reported thoughts of suicide but denied any intent or plan. He also reported increased alcohol use, to help him sleep and to cope with intrusive thoughts, especially feelings of guilt about his stressors. The examiner noted that the presence of intrusive distressing memories of the stressors, recurrent distressing dreams about the stressors, intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the stressors, and marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the stressors. The examiner noted that the Veteran had persistent avoidance of stimuli associated with the stressors. The examiner noted that the Veteran had negative alterations in cognitions and mood associated with the stressors, persistent negative emotional state, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, and persistent inability to experience positive emotions. The examiner noted that the Veteran had marked alterations in arousal and reactivity associated with the stressors, irritable behavior and angry outbursts, hypervigilance, exaggerated startle response, problems with concentration, and sleep disturbance. The Veteran had depressed mood; anxiety, suspiciousness; panic attacks more than once a week; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; flattened affect; impaired judgment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work-like setting; inability to establish and maintain effective relationships; suicidal ideation; and obsessional rituals which interfere with routine activities. Upon examination, the Veteran was alert and oriented to person, place, time and situation. The Veteran was noted as cooperative and attentive. He was well dressed and adequately groomed. His eye contact was appropriate. No communication barriers were reported. His speech was reported as rapid, within normal limits for volume, production, prosody. The examiner reported his mood was extremely anxious and his affect was constricted. The Veteran's thought content was within normal limits; no auditory or visual hallucinations, apparent delusions or paranoia was reported. His thought process was reported as tangential at times but able to redirect back to topic. His judgment was impaired, using alcohol to self-medicate. His insight was reported as fair. The Veteran reported thoughts of suicide but denied intent or plan. He denied homicidal ideation. The examiner noted that the Veteran was capable of managing his financial affairs and his PTSD symptoms significantly impacted his occupational functioning. After a review of the evidence presented above, the Board finds that the frequency, severity, and duration of the Veteran's PTSD symptoms reported or shown are suggestive of occupational and social impairment with deficiencies in most areas, the level of impairment contemplated by a 70 percent rating. The Veteran's psychiatric disorder is not more closely described by both total occupational and total social impairment. During the period the November 2016 VA examiner noted that the Veteran reported having suicidal thoughts and even purchasing firearms, one of which he sleeps with; the other, next to his couch. Although the Veteran reported thoughts of suicide, he denied any intent or plan. The Board notes that thoughts of suicide are contemplated by the 70 percent criteria and can cause occupational and social impairment with deficiencies in most areas. However, the November 2016 VA examiner noted that he denied intent or plan. The severity of his suicidal thoughts is not such that it is more closely described as causing total occupational and social impairment. Risk of self-harm is contemplated by the 100 percent criteria, which addresses whether one is a persistent danger to himself or others. Bankhead v. Shulkin, 29 Vet. App. 10 (2017). Here, the record does not show that the Veteran is a danger to himself or others. Throughout the period beginning November 01, 2016, the VA examiner did not report that the Veteran exhibited gross impairment in his thought process. The examiner also did not report persistent delusions or grossly inappropriate behavior. It was noted that the Veteran was capable of managing his financial affairs. The examiner noted that his judgment was impaired, by the use of alcohol to self-medicate, and his mood was extremely anxious. However, the evidence of record does not show severity, enough to cause occupational and social impairment. Given the frequency, nature, and duration of the Veteran's symptoms, the Board finds that they do not result in occupational and social impairment for the period beginning November 1, 2016. They do not more closely approximate the types of symptoms contemplated by the 100 percent rating, and therefore, a 100 percent rating is not warranted. Vazquez-Claudio, 713 F.3d at 114 (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"). The Board finds that Veteran's symptoms from PTSD have not more closely approximated the criteria for a rating greater than of 70 percent during this period beginning November 1, 2016. Therefore, the Board may not stage his rating. Fenderson, 12 Vet. App. at 125-26. The probative evidence of record does not show that the particular symptoms associated with the higher percentage or others of similar severity, frequency, and duration result in occupational and social impairment. Therefore, a 100 percent rating is not warranted. Lastly, a claim for individual unemployability due to service-connected disabilities (TDIU) is part of an increased rating claim when the record raises such a claim. Rice v. Shinseki, 22 Vet. App. 447 (2009). A TDIU is not warranted in this case because the Veteran has not contended nor does the evidence show that his service-connected disabilities render him unemployable. Rice v. Shinseki, 22 Vet. App. 447 (2009); see also Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). ORDER Before November 1, 2016, an initial rating greater than 50 percent for PTSD with generalized anxiety disorder and panic disorder without agoraphobia is denied. Beginning November 1, 2016, an increased rating greater than 70 percent for PTSD with generalized anxiety disorder and panic disorder without agoraphobia, is denied. REMAND The Veteran has a current diagnosis of sleep apnea. In his August 2012 notice of disagreement, he stated that his sleep apnea is a result of his deployment in the middle of a war zone, in Southwest Asia. Additionally, a Report of Medical History dated in December 2005 indicates that the Veteran reported sleeping problems due to deployment conditions. The file also contains evidence that he was "often" exposed to smoke from burning trash or feces. Since the Veteran's statement and the Report of Medical History indicate that his sleep apnea disability may be associated with his active military service, a remand is warranted for a medical examination to determine the etiology thereof. McLendon v. Nicholson, 20 Vet. App. 79, 86 (2006). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for an examination with an appropriate clinician for his sleep apnea. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. The examiner must take a detailed history from the Veteran. If there is any clinical or medical basis for corroborating or discounting the reliability of the history provided by the Veteran, the examiner must so state, with a complete explanation in support of such a finding. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's sleep apnea began during active service or is related to any incident of service. The examiner must provide all findings, along with a complete rationale for his or her opinion(s), in the examination report. If the above-requested opinion cannot be made without resort to speculation, the examiner must state this and specifically explain whether there is any potentially available information that, if obtained, would allow for a non-speculative opinion to be provided. 2. Then, readjudicate the claim. If any decision is adverse to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ D. Martz Ames Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs