Citation Nr: 1803455 Decision Date: 01/18/18 Archive Date: 01/29/18 DOCKET NO. 10-19 916 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUES 1. Entitlement to an initial rating higher than 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to an initial higher (compensable) rating for bilateral hearing loss. 3. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. D. Regan, Counsel INTRODUCTION The Veteran served on active duty from February 1969 to February 1971, including combat service in the Republic of Vietnam. His decorations include the Combat Infantry Badge, the Purple Heart Medal and the Bronze Star Medal with "V" device. This matter is before the Board of Veterans' Appeals (Board) on appeal of a December 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Manchester, New Hampshire, that granted service connection and a 30 percent rating for PTSD, effective July 10, 2008, and granted service connection and a noncompensable rating for bilateral hearing loss, effective July 10, 2008. In September 2010, the Veteran appeared at a Board videoconference hearing before the undersigned Veterans Law Judge. In July 2013, the Board, in pertinent part, remanded the issues of entitlement to an initial rating higher than 30 percent for PTSD and entitlement to an initial higher (compensable) rating for bilateral hearing loss, for further development. In a March 2016 decision, the Board granted a 50 percent rating for the Veteran's service-connected PTSD. The Board also remanded the claim for entitlement to an initial higher (compensable) rating for bilateral hearing loss, for further development. The Veteran then appealed the Board's March 2016 decision, as to the issue of entitlement to an initial rating higher than 50 percent for PTSD, to the United States Court of Appeals for Veterans Claims (Court). In October 2016, the parties (the Veteran and the VA Secretary) filed a Joint Motion for Partial Remand (Joint Motion) which requested that the Board's decision, as to that issue, be vacated and remanded. An October 2016 Court Order granted the motion. In May 2017, the Board determined that the issue of entitlement to a TDIU was raised during the Veteran's previously appealed increased rating claims. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board remanded the issue of entitlement to an initial rating higher than 50 percent for PTSD, as well as the issue of entitlement to a TDIU, for further development. In July 2017, the Board remanded the issue of entitlement to an initial higher (compensable) rating for bilateral hearing loss for further development. The Board deferred the issues of entitlement to an initial rating higher than 50 percent for PTSD and entitlement to a TDIU as those issues had not yet been recertified to the Board, and it appeared that the RO was in the process of developing evidence in regard to those issues. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Since the effective date of service connection on July 10, 2008, the Veteran's PTSD has been manifested by occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood, due to various symptoms; total occupational and social impairment has not been shown. 2. The Veteran's service-connected bilateral hearing loss is manifested by no more than auditory acuity Level II in the right ear and auditory acuity Level III in the left ear. CONCLUSIONS OF LAW 1. The criteria for an initial 70 percent rating for PTSD, but no higher, have been met since service connection became effective on July 10, 2008. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2017). 2. The criteria for an initial higher (compensable) rating for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.85, Diagnostic Code 6100 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. PTSD Ratings for service-connected disabilities are determined by comparing the veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (2017). When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating 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 (2017). In view of the number of atypical instances, it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2017). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2009). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 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"). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). A 30 percent rating is warranted for PTSD where there is 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 conversion 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). A 50 percent rating requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating requires 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 affected 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); and inability to establish and maintain effective relationships. A 100 percent rating is assigned when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). See also Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (explaining that the symptoms that could give rise to a given rating are those in like kind, i.e., of similar duration, severity, and frequency, to those provided in the non-exhaustive lists). In evaluating the evidence, the Board has noted various Global Assessment of Functioning (GAF) scores which clinicians have assigned. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. See Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV); Carpenter v. Brown, 8 Vet. App. 240 (1995). For example, a GAF score of 31 to 40 is meant to reflect an examiner's assessment of some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or 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). A GAF score of 41 to 50 indicates 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). A GAF score of 51 to 60 indicates the examiner's assessment of moderate symptoms (e.g., a 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 score of 61 to 70 indicates the examiner's assessment of some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well and having some meaningful interpersonal relationships. An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. See 38 C.F.R. § 4.126. The Veteran contends that his PTSD is worse than contemplated by his currently assigned disability rating and that a higher rating is therefore warranted for that service-connected disability. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Private and VA treatment records dated from May 2007 to September 2008 show treatment for multiple disorders including PTSD. For example, a September 2008 statement from a VA counseling therapist indicates that the Veteran presented with chronic symptoms including nightmares; sleep disturbance; isolation; irritability; anxiety; hypervigilance; a lack of interest in activities; and a restricted range of affect. The therapist reported that although the Veteran had a stable marriage and solid relationships with his parents, children, and grandchildren, he found it difficult to experience a range of emotions and he remained unable to feel close to anyone. The therapist stated that it appeared that the Veteran managed his symptomatic, social, and interpersonal difficulties through the years by maintaining a strict adherence to his established routine. It was noted that the Veteran's routine included a complete immersion in his position as a manager of fleet operations at an automobile dealership where he had worked for almost forty years. The therapist indicated that the Veteran was responsible and hardworking, and that he had been successful in his career, as well as in his relationships with his immediate family. The therapist indicated that the Veteran had chronic symptoms for forty years, the most of severe of which included recurrent dreams; intrusive thoughts; avoidance of people and places that might cause adverse physiological or psychological responses; and chronic hyperarousal and hypervigilance that have provided ritualistic habits and have prevented him from adequate sleep. It was noted that the Veteran was often irritable, but that he denied any history of sudden outbursts of anger. The therapist maintained that although the Veteran cared deeply for his family, those closest to him cited his restricted range of affect and isolative nature as troublesome. The therapist reported that the Veteran was extremely guarded and that he was resistant to engage in the therapeutic process. It was recommended that the Veteran return for individual or group counseling as needed. An October 2008 VA psychiatric examination report includes a notation that the Veteran's claims file was reviewed. The Veteran reported that he was not currently in psychiatric treatment or counseling, but that he did go to a VA facility three times. He stated that he had trouble sleeping and that he could not be in crowded places. He indicated that he could not keep the lights on with the shades open and that he was very jumpy. The Veteran reported that he was currently in his second marriage and that he had been married to his current wife for thirty-three years. He maintained that he had no problems at all in his relationship with his wife. He stated that he had a son and two stepchildren and that his relationships with all of them were excellent. The Veteran indicated that he had two children from his first marriage and that he also had excellent relationships with those children. The Veteran reported that he was currently working full-time as a head of a commercial and fleet department for an auto dealership where he had worked for thirty-seven years. The Veteran maintained that his job performance was at the top of the industry and that, for the most part, he got along with everybody. He stated that he had never been in trouble with the law as either a teenager or as an adult. He stated that he did not drink alcohol and that he had never abused alcohol or drugs. The Veteran indicated that he did not have any psychiatric problems or any assaultive behavior prior to the military. The examiner reported that the Veteran's behavior was tense and rigid, and that is speech was metered. The examiner stated that the Veteran's mood was basically flat, and that his mood and affect were emotionless. It was noted that there was no indication or depersonalization. The examiner indicated that the Veteran had suffered two episodes of derealization in the previous six to eight months. The examiner reported that there were no hallucinations and illusions, and that the Veteran's thought processes were logical and goal directed. It was noted that the Veteran denied that he had any suicidal ideation, but that he did report that he had homicidal ideation of a passive nature. The examiner indicated that the Veteran was oriented times three, that his attention and concentration were intact, and that his short-term memory and long-term memory were also intact. The examiner stated that the Veteran's ability for abstract and insightful thinking was within the normal range, and that his commonsense reasoning and judgment were also within the normal range. The examiner reported that the Veteran was a light sleeper and that he slept about four to six hours each night. It was noted that the Veteran would awaken ten to twelve times per night, sometimes due to pain in his back and left shoulder. The examiner indicated that the Veteran had bad dreams and nightmares that resulted in night sweats. The examiner stated, as to his temper, that the Veteran described having a short-fuse over the previous few months. The Veteran denied that he had depression or anxiety. The examiner indicated that it was evident that the Veteran's combat trauma intruded on his thought process and that he tried his best not to think about such trauma at all. It was noted that the Veteran had been successful in that regard. The examiner reported that the Veteran had nightmares once or twice a month and that he was constantly hypervigilant. The examiner indicated that the Veteran kept a gun next to him in his bed and in his truck. The examiner stated that the Veteran had numbing of his general responsiveness, which his wife had complained about. The examiner reported that the Veteran had a bad temper, that he refused to go to events, that he did not like crowds, that he startled easily, and that he was bothered by loud noises. It was noted that there was no sense of disillusionment. The diagnosis was PTSD. A GAF score of 55 was assigned. The examiner maintained that the Veteran met the full criteria for PTSD. The examiner indicated that the Veteran's GAF score was in the moderate range because although he had a few friends, he did have some minor conflicts at work and at home. The examiner stated that for the most part, the Veteran was functioning adequately. The examiner indicated that the Veteran's PTSD symptoms only mildly interfered with his employment functioning, but that they moderately to seriously interfered with his social functioning. The examiner stated that the Veteran's PTSD symptoms resulted in a decrease primarily in social functioning. It was noted that the Veteran had been able to control his PTSD symptoms at work, but that they were starting to leak out in terms of difficulties with some new owners with whom he was trying to work things out. Private and VA treatment records dated from June 2009 to February 2013 refer to treatment for multiple disorders including PTSD. For example, a September 2010 VA treatment entry notes that the Veteran reported that he had nightmares and cold sweats. He indicated that he avoided crowds, which was more difficult as his grandchildren were growing older. The Veteran stated that he had been married to his second wife for thirty-five or thirty-six years and that he had five children from his first and second marriages. The examiner reported that the Veteran was alert and that his speech was fluid with a normal tone. It was noted that the Veteran's mood was easily irritable and that it had worsened in the previous few years. The examiner stated that the Veteran's affect was congruent, that his thoughts were organized and linear, and that there was no psychosis. The examiner indicated that the Veteran did not have suicidal or homicidal intent, but that he had thoughts to harm others without carrying any acts out. The examiner reported that the Veteran was oriented and that his memory was intact. It was noted that the Veteran's sleep was disturbed at times, that his energy and appetite were adequate, and that his insight and judgment were both good. The diagnosis was PTSD and a GAF score of 65 was assigned. A July 2013 VA psychiatric examination report includes a notation that the Veteran's claims file was reviewed. The Veteran reported that he had been married for thirty-six years and that he had an excellent relationship with his wife. He reported that he also had excellent relationships with his children and stepchildren. The Veteran indicated that he worked as a fleet and commercial manager at an automobile dealership and that he had been in that position since 1988. He related that he started working at the dealership in 1971. He indicated that his job performance was alright and that he was pretty much a one-man show. The examiner reported that the Veteran's appearance was appropriate, that he had difficulty getting up and down from a seated posture, and that he was rigid and tense. The examiner stated that the Veteran's speech was normal and that his mood was anxious, but that he attempted to show no emotion. It was noted that the Veteran's affect was congruent with mood and topic, as well as being in the full range. The examiner indicated that there were no preoccupations, hallucinations, or illusions, as well as no derealization. The examiner reported that the Veteran was oriented times four, and that his attention, concentration, short-term memory, and long-term memory were all within normal limits. The examiner maintained that the Veteran's abstract thinking, moral thinking, ethical thinking, and insight were all within normal limits. It was noted that the Veteran's commonsense reasoning and judgment were also within normal limits. The examiner reported that the Veteran slept a total of four to six hours per night and that he would awaken six times and did not know the reason that he awakened. It was noted that the Veteran reported that his appetite was declining. The examiner stated that the Veteran denied that he had depression, but that he reported that his wife claimed he didn't want to do anything. The examiner indicated that the Veteran admitted to having anxiety some of the time and to being short-tempered. It was noted that the Veteran reported that he would scream if he was alone in his car. The examiner related that the Veteran also stated that he was an overly conscientious worker and that he would go to work regardless of how he felt on an emotional basis. The examiner reported that the Veteran indicated that he could no longer do hobbies and that he had one close friend, but that he stayed in touch with and saw his extended family on a regular basis. As to PTSD criteria pursuant to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV), the examiner indicated that the Veteran met all aspects of Criteria A, and at least some of the aspects of Criteria B, C, D, E, and F. The examiner indicated, as to Criteria F, that the Veteran's PTSD caused significant distress or impairment in social, occupational, or other areas of functioning. The examiner indicated that the Veteran's current PTSD symptoms were a depressed mood, anxiety, and suspiciousness. The diagnosis was PTSD. A GAF score of 53 was assigned. The examiner indicated that the Veteran had occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks, although he was generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The examiner also reported that the Veteran had slightly worsened based on the progress notes from his two VA treatments in 2010, as well as based on his own report. The examiner commented that it was as likely as not that the Veteran was able to secure and maintain gainful employment. It was noted that the Veteran had sufficient intelligence; abstract reasoning abilities; analytical thinking and reasoning skills; memory; and an ability to follow instructions and work with others. The examiner indicated that the Veteran had been in a managerial position since 1988 and that he had been performing superbly in that position. The examiner reported that the Veteran stated that his wife and family claimed that he was very rigid and too focused on work rather than on his family and himself. Private and VA treatment records dated through August 2016 refer to continued treatment for multiple disorders. An August 2017 VA psychiatric examination report includes a notation that the Veteran's claims file was reviewed. The Veteran reported that he was married to his second wife for forty-six years and that they had an excellent relationship. He stated that he had an excellent relationship with his son from that marriage, and with his stepson, stepdaughter, and his son and daughter from his first marriage. He indicated that the daughter of his stepdaughter also lived with them. The Veteran related that he worked as a fleet manager for commercial vehicles for a large dealership for the previous forty-six-plus years and that he had an excellent job performance. It was noted that the Veteran had work-related education since his last VA examination in July 2013. The Veteran reported that he had trouble with crowded places and that he would keep the shades down in his house. The Veteran stated that he had a loaded gun close to him all the time. He indicated that he worked alone 99 percent of the time. The Veteran maintained that he thought about Vietnam when he was driving. It was noted that the Veteran was not in any type of psychiatric treatment. The Veteran reported that he had no relevant legal and/or behavioral problems, as well as no substance abuse problems, since the last examination. He indicated that he was a competent and reliable worker to a fault and that he helped with household chores and yardwork. He stated that he had no close friends and no hobbies. The examiner reported that the Veteran's appearance was within normal limits. The examiner indicated that the Veteran's behavior was tense, guarded, and cooperative. It was noted that the Veteran's speech was within normal limits and that his mood was irritable. The examiner stated that the Veteran's affect was congruent with his mood, and that his perceptions were unremarkable. The examiner related that the Veteran was oriented times four and that he had mild problems with attention, concentration, and short-term memory. It was noted that the Veteran's long-term memory was within normal limits. The examiner indicated that the Veteran's insight and abstract thinking were within normal limits, and that his moral and ethical thinking were within normal limits. The examiner stated that the Veteran's commonsense reasoning and judgment were both within normal limits. As to sleep, it was noted that the Veteran reported that he would sleep for five to six hours, but that he would be awakened every twenty to thirty minutes due to chronic pain in his hip and shoulder, as well as from noises. The examiner stated that the Veteran denied that he had anxiety and depression, and that he reported that his temperament was okay for eighty percent of the day. It was noted that the Veteran reported, as to anger, that he usually would run his mouth off with a bunch of things he should not say. As to PTSD criteria pursuant to Diagnostic and Statistical Manual of Mental Disorders (5th ed.) (DSM-5), the examiner indicated that the Veteran met some aspects of Criterion A and B; all aspect of Criterion C; most aspects of Criterion D; and all aspects of Criterion E, F, G, and H. The examiner indicated that the Veteran's PTSD symptoms were a depressed mood; anxiety; suspiciousness; chronic sleep impairment; and mild memory loss, such as forgetting names, directions, or recent events. The diagnoses were PTSD, as well as a depressive disorder due to another medical condition, mild, with depressive features. The examiner maintained that the Veteran's depressive disorder was secondary to combat related service-connected conditions of chronic pain in the back, hip, and left shoulder, as well as secondary to his service-connected PTSD since the chronic pain was due to shrapnel in the back and left shoulder, with the hip a residual of the back. The examiner indicated that the Veteran's depressive disorder symptoms were interrupted sleep; a low sex drive; no interest in socializing; irritability; and a loss of interest in activities. The examiner noted that the Veteran's PTSD symptoms were discussed above. The examiner indicated that the Veteran had occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks, although he was generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The examiner stated that it was not possible to differentiate what portion of the occupational and social impairment was caused by each mental disorder. The evidence shows that the Veteran has been married to his second wife for over forty-six years, and that he has an excellent relationship with his wife, and excellent relationships with his children and grandchildren. The Veteran has worked a fleet and commercial manager at an automobile dealership since 1988. The Veteran reports that he has no close friends and that he has no hobbies. An August 2017 VA psychiatric examination report relates diagnoses of PTSD, as well as a depressive disorder due to another medical condition, mild, with depressive features. The examiner maintained that the Veteran's depressive disorder was secondary to combat related service-connected conditions of chronic pain in the back, hip, and left shoulder, as well as secondary to his service-connected PTSD since the chronic pain was due to shrapnel in the back and left shoulder, with the hip a residual of the back. The examiner indicated that the Veteran had occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks, although he was generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Board observes that the examiner reported that the Veteran's PTSD symptoms were a depressed mood; anxiety; suspiciousness; chronic sleep impairment; and mild memory loss, such as forgetting names, directions, or recent events. The examiner reported that the Veteran met aspects of Criterion E, pursuant to DSM-5, which includes irritable behavior and angry outbursts, as well as aggression towards people or objects. The Board notes that a prior July 2013 VA psychiatric examination report indicates a GAF score of 53, which is suggestive of moderate symptoms (e.g., a 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). The diagnosis was PTSD, and the examiner indicated the Veteran that had occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks, although he was generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Board observes that the examiner also reported that the Veteran had PTSD symptoms of depressed mood, anxiety, and suspiciousness. The examiner further commented that it was as likely as not that the Veteran was able to secure and maintain gainful employment. Additionally, a prior October 2008 VA psychiatric examination report relates a GAF score of 55, which is also suggestive of moderate symptoms. The examiner, at that time, indicated that the Veteran's GAF score was in the moderate range because although he had a few friends, he did have some minor conflicts at work and at home. The examiner indicated that the Veteran's PTSD symptoms only mildly interfered with his employment functioning, but that they moderately to seriously interfered with his social functioning. The examiner reported that the Veteran denied that he had any suicidal ideation, but that he did report that he homicidal ideation of a passive nature. The Board observes that a September 2010 VA treatment report relates a GAF score of 64, suggestive of some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well and having some meaningful interpersonal relationships. The examiner, at that time, also reported that the Veteran did not have suicidal or homicidal intent, but that he did have thoughts to harm others without carrying any acts out. Viewing all the evidence, the Board finds that, continuously since the effective date for service connection for PTSD on July 10, 2008, there is a reasonable basis for finding that the Veteran's PTSD is productive of occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood, due to various symptoms supporting a higher rating of 70 percent. As discussed above, the Board observes that an October 2008 VA psychiatric examination report noted that the Veteran had homicidal ideation of a passive nature, and a September 2010 VA treatment report notes that he did not have suicidal or homicidal intent, but that he did have thoughts to harm others without carrying any acts out. Additionally, the most recent August 2017 VA psychiatric examination report relates a diagnosis of PTSD, as well as a diagnosis of a depressive disorder, which the examiner indicated was, at least in part, secondary to the Veteran's PTSD. The August 2017 VA psychiatric examination report also indicates that the Veteran met all aspects of Criterion E, pursuant to DSM-5, which includes irritable behavior and angry outbursts, as well as aggression towards people or objects. Therefore, there appears to be evidence of record indicating that the Veteran had PTSD symptoms such as continuous depression affecting his ability to function effectively, and impaired impulse control, which are clearly indicative of a 70 percent rating. However, the Board cannot conclude based on the psychiatric symptomology that the Veteran's PTSD is of such severity to produce total occupational and social impairment as required for a 100 percent rating. The evidence does not show symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of the Veteran hurting himself or others; intermittent inability to perform activities of daily living; disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name, that are indicative of a 100 percent rating. The Board observes that although the Veteran was noted in October 2008 and September 2009 to have homicidal ideation, he did not have any intent. There is no specific evidence of a persistent danger of the Veteran hurting himself or others. Thus, the 70 percent rating being assigned adequately addresses his PTSD symptomatology, which more closely approximates the 70 percent criteria compared to the 100 percent criteria. See 38 C.F.R. § 4.7. As this is an initial rating case, consideration has been given to "staged ratings" (different percentage ratings for different periods of time, since the effective date of service connection, based on the facts found). Fenderson, 12 Vet. App. at 119. The Board notes, however, that staged ratings are not indicated in the present case, as the Board finds the Veteran's PTSD has continuously been 70 percent disabling since July 10, 2008, when service connection became effective. Thus, a higher initial rating to 70 percent, continuously since July 10, 2008, is granted. The Board has considered the benefit-of-the-doubt rule in making the current decision, but the preponderance of the evidence is against a higher rating for PTSD for this period. 38 U.S.CA. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). II. Bilateral Hearing Loss A rating for hearing loss is determined by a mechanical application of the rating schedule to the numeric designations assigned based on audiometric test results. Lendenmann v. Principi, 3 Vet. App. 345 (1992). Evaluations of bilateral defective hearing range from noncompensable to 100 percent. The basic method of rating hearing loss involves audiological test results of organic impairment of hearing acuity as measured by the results of controlled speech discrimination tests (Maryland CNC), together with the average hearing threshold level as measured by pure tone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 Hertz. To evaluate the degree of disability from service-connected hearing loss, the rating schedule establishes eleven auditory acuity levels ranging from numeric Level I for essentially normal acuity, through numeric Level XI for profound deafness. 38 C.F.R. § 4.85. The rating criteria include an alternate method of rating exceptional patterns of hearing as defined in 38 C.F.R. § 4.86, but the Veteran's test results do not meet the numerical criteria for such a rating. In this regard, his pure tone thresholds at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz ) are not 55 decibels or more, nor are the average pure tone thresholds 30 decibels or less at 1000 Hertz , and 70 decibels or more at 2000 Hertz , in either ear. Thus, application of 38 C.F.R. § 4.86 is not warranted, and his bilateral hearing loss is to be rated by the usual method. The Veteran contends that his bilateral hearing loss is worse than contemplated by his currently assigned disability rating and that a compensable rating is therefore warranted for that service-connected disability. See Scott, 789 F.3d at 1375. An August 2008 statement from S. Mitsopoulos, M.D., indicates that the Veteran's hearing was evaluated in his office with a screening audiogram that confirmed the high frequency loss in the ranges of 3000 to 8000 Hertz. The Board observes that the only audiogram from Dr. Mitsopoulos of record is dated in July 2001, prior to the effective of date of service connection, which is July 10, 2008, in this case. An October 2008 VA audiological examination report reveals pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT N/A 25 35 55 65 LEFT N/A 25 35 55 65 The average pure tone threshold in the Veteran's right ear was 45 decibels and the speech recognition ability, using the Maryland CNC Test, was 84 percent. The average pure tone threshold in the Veteran's left ear was 45 decibels and the speech recognition ability, using the Maryland CNC Test, was 88 percent. The diagnosis was sensitivity within normal limits from 250 Hertz through 1000 Hertz, with a mild, sloping to severe sensorineural hearing loss from 2000 through 8000 Hertz, in both ears. The examiner stated that the Veteran reported that his bilateral hearing loss significantly interfered with his ability to communicate at work, particularly at meetings. An October 2010 VA audiological evaluation report indicates pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT N/A 20 25 55 65 LEFT N/A 20 35 55 70 The average pure tone threshold in the Veteran's right ear was 41 decibels and the speech recognition ability, using the Maryland CNC Test, was 92 percent. The average pure tone threshold in the Veteran's left ear was 45 decibels and the speech recognition ability, using the Maryland CNC Test, was 96 percent. The diagnosis was normal hearing acuity through 1500 Hertz in the left ear and through 2000 Hertz in the right ear, sloping to a mild to severe sensorineural hearing loss for the higher frequencies in both ears. A July 2013 VA audiological examination report reveals pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT N/A 25 25 60 70 LEFT N/A 30 45 75 85 The average pure tone threshold in the Veteran's right ear was 45 decibels and the speech recognition ability, using the Maryland CNC Test, was 88 percent. The average pure tone threshold in the Veteran's left ear was 59 decibels and the speech recognition ability, using the Maryland CNC Test, was 86 percent. The diagnoses were sensorineural hearing loss, in the frequency range of 500 to 4000 Hertz, as well as in the frequency range of 6000 Hertz or higher frequencies, in the Veteran's right ear, and sensorineural hearing loss, in the frequency range of 500 to 4000 Hertz, as well as in the frequency range of 6000 or higher frequencies, in his left ear. The examiner indicated that the Veteran's hearing loss impacted his conditions of daily life, including his ability to work. The examiner stated that the Veteran's bilateral hearing loss should not preclude him from working, but that it should make work more difficulty. It was noted that the Veteran stated that he had lost income from his sales jobs because he would get information incorrect on occasions. The examiner reported that the Veteran stated that he had difficulty in all situations, with particular difficulty on the phone. An April 2015 VA audiological evaluation report indicates pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT N/A 20 35 55 70 LEFT N/A 25 40 55 75 The average pure tone threshold in the Veteran's right ear was 45 decibels and the speech recognition ability, using the Maryland CNC Test, was 84 percent. The average pure tone threshold in the Veteran's left ear was 49 decibels and the speech recognition ability, using the Maryland CNC Test, was 100 percent. The diagnosis was normal hearing acuity through 250 to 1000 Hertz, sloping to a mild to severe sensorineural hearing loss for the higher frequencies, in both ears. A November 2016 VA audiological examination report reveals pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT N/A 25 40 60 75 LEFT N/A 35 45 65 75 The average pure tone threshold in the Veteran's right ear was 50 decibels and the speech recognition ability, using the Maryland CNC Test, was 92 percent. The average pure tone threshold in the Veteran's left ear was 55 decibels and the speech recognition ability, using the Maryland CNC Test, was 84 percent. The diagnoses were sensorineural hearing loss, in the frequency range of 500 to 4000 Hertz, as well as in the frequency range of 6000 Hertz or higher frequencies, in the Veteran's right ear, and sensorineural hearing loss, in the frequency range of 500 to 4000 Hertz, as well as in the frequency range of 6000 Hertz or higher frequencies, in his left ear. The examiner indicated that the Veteran's hearing loss impacted his conditions of daily life, including his ability to work. The examiner stated that the Veteran's bilateral hearing loss should not preclude him from working, but that it should make work more difficulty. The examiner reported that the Veteran stated that he had difficulty understanding what people were saying in all situations, more so if there was background noise. It was noted that the Veteran indicated that he had particular difficulties hearing at meetings as a manager at a car dealership and using the phone. The examiner maintained that the Veteran could be expected to have difficulty using the telephone because he was not given visual cues in that situation which he needed. It was noted that the Veteran might do better if his hearing aids were set up to stream directly from the phone. The examiner indicated that the Veteran's hearing was normal for the low frequencies, but that he had significant hearing loss for the high frequencies, which meant that he should be able to hear vowels and environmental noises, but that he would not hear consonants which would give him an incomplete message. The examiner commented that despite the limitations, the Veteran should be able to function in most situations where hearing was needed, but that did not need to be acute. It was noted that if the Veteran was wearing hearing aids, background noise was reduced and he was given access to visual cues. The Board notes that the October 2008 VA audiological examination report renders decibel averages and speech discrimination scores that correlate to auditory acuity Level II in the right ear and auditory acuity Level II in the left ear under Table VI of 38 C.F.R. § 4.85. Using Table VII of 38 C.F.R. § 4.85, those findings would warrant no more than a zero percent (noncompensable) rating under Diagnostic Code 6100. The Board observes that the October 2010 VA audiological evaluation report renders decibel averages and speech discrimination scores that correlate to auditory acuity Level I in the right ear and auditory acuity Level I in the left ear under Table VI of 38 C.F.R. § 4.85. Using Table VII of 38 C.F.R. § 4.85, those findings would also warrant no more than a zero percent (noncompensable) rating under Diagnostic Code 6100. Further, the Board notes that the July 2013 VA audiological examination report renders decibel averages and speech discrimination scores that correlate to auditory acuity Level II in the right ear and auditory acuity Level III in the left ear under Table VI of 38 C.F.R. § 4.85. Using Table VII of 38 C.F.R. § 4.85, those findings would warrant no more than a zero percent (noncompensable) rating under Diagnostic Code 6100. The April 2015 VA audiological evaluation report renders decibel averages and speech discrimination scores that correlate to auditory acuity Level II in the right ear and auditory acuity Level I in the left ear under Table VI of 38 C.F.R. § 4.85. Using Table VII of 38 C.F.R. § 4.85, and those findings would warrant no more than a zero percent (noncompensable) rating under Diagnostic Code 6100. Finally, the Board observes that the November 2016 VA audiological examination report renders decibel averages and speech discrimination scores that correlate to auditory acuity Level I in the right ear and auditory acuity Level II in the left ear under Table VI of 38 C.F.R. § 4.85. Using Table VII of 38 C.F.R. § 4.85. Those findings also warrant no more than a zero percent (noncompensable) rating under Diagnostic Code 6100. Based on the evidence during the period of the appeal, the Veteran's hearing tests do not support findings that would warrant more than the assigned zero percent (noncompensable) rating. The Board is sympathetic to the Veteran's contentions regarding the severity of his service-connected bilateral hearing loss. However, applying the rating criteria to the audiological test results does not warrant a higher (compensable) rating. The use of hearing aids does not affect the Veteran's rating, as hearing tests are conducted without hearing aids. 38 C.F.R. § 4.85(a). In sum, the preponderance of the evidence is against the claim for entitlement to an initial higher (compensable) rating for bilateral hearing loss; there is no doubt to be resolved; and a higher rating is not warranted. 38 U.S.CA. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 49. ORDER An initial higher rating of 70 percent is granted for PTSD continuously since the effective date of service connection on July 10, 2008, subject to the laws and regulations governing the payment of monetary awards. An initial higher (compensable) rating for bilateral hearing loss is denied. REMAND The remaining issue on appeal is entitlement to a TDIU. The Board has granted a higher initial rating of 70 percent for the Veteran's service-connected PTSD, effective April 20, 2009. Given this change in circumstances, and to accord the Veteran due process, the RO must readjudicate the issue of entitlement to a TDIU. Additionally, the Board observes that in June 2017, the RO provided the Veteran with a VA Form 21-8940, Application for Increased Compensation Based on Unemployability, and requested that he complete, sign, and return the enclosed form. The Board notes that the form was never completed and submitted to VA. The Board finds that the Veteran should be provided another VA Form 21-8940, and that he should be instructed that such form must be returned to VA. The RO should advise him that failure to do so will result in the denial of his claim. See 38 C.F.R. § 3.158 (a); see also Jernigan v. Shinseki, 25 Vet. App. 220, 229-30 (2012). Accordingly, the case is REMANDED for the following: 1. Ask the Veteran to identify other medical providers who have treated him for service-connected problems since June 2016. After receiving this information and any necessary releases, obtain copies of the related medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain the records, inform the Veteran of such, and advise him that he may obtain and submit those records himself. 2. Contact the Veteran and request that he complete and return an Application for Increased Compensation Based on Unemployability, VA Form 21-8940, identifying his previous employment since 2008, and when he was last gainfully employed. The Veteran should also be notified that under 38 C.F.R. § 3.158(a) that his claim for a TDIU will be considered abandoned if he fails to cooperate by providing the completed VA Form 21-8940. 3. Then readjudicate the issue on appeal. If the benefit sought remains denied, issue a supplemental statement of the case and 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.A. §§ 5109B, 7112 (West 2014). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs