Citation Nr: 1804304 Decision Date: 01/22/18 Archive Date: 01/31/18 DOCKET NO. 14-06 833A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for hypertension, to include as secondary to service-connected other specified trauma and stressor related disorder. 3. Entitlement to service connection for obstructive sleep apnea, to include as due to herbicide exposure. 4. Entitlement to an initial evaluation in excess of 30 percent for adjustment disorder with mixed anxiety and depressed mood. REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD M. Wulff, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1966 to November 1968, which included service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In the June 2011 rating decision, the RO, in relevant part, denied service connection for bilateral hearing loss, obstructive sleep apnea, and hypertension. The RO also granted service connection for an adjustment disorder with mixed anxiety and depressed mood and assigned a 10 percent evaluation effective from March 7, 2011. The Veteran testified at a hearing before the undersigned Veterans Law Judge in April 2016. A transcript of that proceeding is associated with the record. In August 2016, the Board dismissed the issue of entitlement to service connection for posttraumatic stress disorder (PTSD) and remanded the remaining issues on appeal for further development. That development was completed as to the claims decided herein, and the case has since been returned to the Board for appellate review. In a March 2017 rating decision, the RO increased the evaluation assigned for adjustment disorder with mixed anxiety and depressed mood to 30 percent effective from March 7, 2011. Nevertheless, the issue remains in appellate status, as the maximum schedular rating has not been assigned. AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board notes that the Veteran's appeal originally included the issue of entitlement to service connection for tinnitus. However, in a January 2014 rating decision, the RO granted service connection for tinnitus. The RO's grant of service connection constitutes a full award of the benefits sought on appeal. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). Therefore, that matter is no longer on appeal, and no further consideration is necessary. This appeal was processed using the Veterans Benefits Management System (VBMS) electronic claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. The issues of entitlement to service connection for hypertension and obstructive sleep apnea are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran does not currently have a bilateral hearing loss disability for VA compensation purposes. 2. The Veteran's adjustment disorder with mixed anxiety and depressed mood has been productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, but not productive of occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. Bilateral hearing loss was not incurred in active service. 38 U.S.C. § 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.385 (2017). 2. The criteria for an initial evaluation in excess of 30 percent for adjustment disorder with mixed anxiety and depressed mood have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.130, Diagnostic Code 9440 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). I. Service Connection for Bilateral Hearing Loss Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131 (2012). That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303 (d) (2017). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. Sensorineural hearing loss is an organic disease of the nervous system and is considered to be a chronic disease for VA compensation purposes. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303 (b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities are presumed to have been incurred in service if they manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. For the purpose of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, and 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). In considering the evidence of record under the laws and regulations as set forth above, the Board finds that service connection for bilateral hearing loss is not warranted. The Veteran has contended that he has bilateral hearing loss as a result of in-service noise exposure, including from mortars, rockets, and weapons fire. See, e.g., August 2011 notice of disagreement; March 2014 substantive appeal. The Veteran's service treatment records are negative for any complaints, treatment, or diagnoses of hearing loss. An August 1966 pre-induction examination noted a normal clinical evaluation of the Veteran's ears and drums. In an accompanying report of medical history, the Veteran also denied having hearing loss. Pure tone thresholds, in decibels, were as follows at that time: HERTZ 500 1000 2000 3000 4000 RIGHT 5 (20) 0 (10) 0 (10) 0 (10) 0 (5) LEFT 10 (25) 0 (10) 0 (10) 0 (10) 0 (5) (NOTE: Prior to January 1967, audiometric results were reported in standards set forth by the American Standards Association (ASA). Since January 1, 1967, those standards have been set by the International Standards Organization (ISO)-American National Standards Institute (ANSI). For audiometric test results dated between January 1967 and December 1970, the Board will consider the recorded data under both ASA and ISO-ANSI standards. In order to facilitate data comparison, the ASA standards have been converted to ISO-ANSI standards and are represented by the figures in parentheses.) In a July 1968 report of medical history, the Veteran denied having ear, nose, or throat trouble. A September 1968 separation examination again noted a normal clinical evaluation of the Veteran's ears and drums, and in an accompanying report of medical history, the Veteran denied having hearing loss and ear, nose, or throat trouble. Pure tone thresholds, in decibels, were as follows at that time: HERTZ 500 1000 2000 3000 4000 RIGHT 15 (30) 15 (25) 15 (25) - 15 (20) LEFT 15 (30) 15 (25) 15 (25) - 15 (20) In a November 1968 statement, the Veteran denied having any changes to his medical condition since his last examination. In support of his claim, the Veteran submitted an August 2011 private audiology report. The private audiologist stated that the Veteran's bilateral hearing appeared within normal limits, with the exception of 40 decibels at 8000 Hertz for the right ear. She further noted that his discrimination among spoken words appeared good, bilaterally. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 20 15 15 30 LEFT 5 15 15 15 25 The Veteran was afforded a VA examination in June 2011. Audiometric testing did not reveal a bilateral hearing loss disability for VA purposes. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 20 15 15 35 LEFT 10 15 20 15 30 The Maryland CNC Word List Speech Recognition testing scores were listed as 96 percent for the right ear and 100 percent for the left ear. During the April 2016 Board hearing, the Veteran testified that his hearing loss had not been present for long and had worsened in severity since the June 2011 VA examination. The Veteran's spouse testified that he exhibited symptoms of hearing loss after returning from service; however, at that time, she believed that he was just trying to avoid confrontation. The Veteran was afforded an additional VA examination in November 2016. Audiometric testing again did not reveal a bilateral hearing loss disability for VA purposes. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 15 15 30 LEFT 10 15 15 25 35 The Maryland CNC Word List Speech Recognition scores were listed as 96 percent, bilaterally. Applying the pertinent facts in this case to the legal criteria set forth above, the Board concludes that the preponderance of the evidence is against the claim for service connection for bilateral hearing loss. As discussed above, service connection for impaired hearing is subject to the requirements of 38 C.F.R. § 3.385, a provision which specifically defines the level of impaired hearing which constitutes a disability for VA compensation purposes. In this case, the Board has carefully reviewed the record on appeal, but finds no probative evidence showing that the Veteran currently has bilateral hearing loss to the extent necessary to constitute a disability for service connection purposes under 38 C.F.R. 3.385. In this regard, the audiometric findings and speech recognition testing results from the June 2011 VA examination did not reveal bilateral hearing loss for VA purposes. In addition, the August 2011 private audiologist indicated that the Veteran's hearing appeared within normal limits with the exception of the right ear at 8000 Hertz. However, the audiometric findings at 8000 Hertz do not show right ear hearing loss for VA purposes. The Veteran subsequently testified that his hearing loss had increased in severity. However, the audiometric findings and Maryland CNC speech recognition results from the November 2016 VA examination revealed that the Veteran's right and left ear hearing acuity was not severe enough to constitute a disability for VA compensation purposes. In Palczewski v. Nicholson, 21 Vet. App. 174, 178-80 (2007), the Court specifically upheld the validity of 38 C.F.R. § 3.385 to define hearing loss for VA compensation purposes. The Board acknowledges the Veteran's reported history of hearing difficulties, as well as his spouse's testimony. Nonetheless, while laypersons are sometimes competent to provide opinions regarding etiology and diagnosis, see Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007), in this case, the Board finds that the VA examination audiometric findings of record are more probative in assessing whether the Veteran has current bilateral hearing loss for VA purposes. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1110, 1131; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that the Veteran currently has the disability for which benefits are being claimed. In this case, the evidence shows that the Veteran does not have bilateral hearing loss for VA purposes. As such, the Board concludes that service connection is not warranted, and no discussion of the remaining elements is necessary. See Coburn v. Nicholson, 19 Vet. App. 427, 431 (2006) (the absence of any one element will result in denial of service connection). As the preponderance of the evidence is against the claim of service connection for bilateral hearing loss, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). II. Increased Evaluation for Adjustment Disorder Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 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. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where the question for consideration is the propriety of the initial rating assigned, evaluation of the evidence since the effective date of the grant of service connection is required. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). However, where the question for consideration is a higher initial rating since the grant of service connection, evaluation of the medical evidence since the grant of service connection to consider the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's adjustment disorder with mixed anxiety and depressed mood is currently assigned a 30 percent evaluation effective from March 7, 2011, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9440. Under Diagnostic Code 9440, a 30 percent evaluation is warranted when the psychiatric disorder results in 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). A 50 percent evaluation is warranted when the psychiatric disorder results in 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 and maintaining effective work and social relationships. A 70 percent evaluation is warranted when the psychiatric disorder results in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent evaluation is warranted when the psychiatric disorder results in 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. The use of the term "such as" in the general rating formula for mental disorders 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 symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Id. In Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013), the Federal Circuit stated 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." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." The Board notes that the regulations were recently revised to incorporate the Fifth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-V) rather than the Fourth Edition (DSM-IV). However, these provisions only apply to cases received by or pending before the AOJ on or after August 4, 2014. The change does not apply to cases certified to the Board prior to that date. In this case, the Veteran's claim was certified to the Board prior to August 4, 2014; therefore, the regulations pertaining to the DSM-IV are for application. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the DSM-IV, GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126 (a). Historically, in a February 2011 private medical record, the Veteran denied having symptoms of depression and anxiety. On examination, he was also alert and generally oriented with a normal mood. An April 2011 VA screen for depression was negative. The Veteran reported having little interest or pleasure in doing things, but he denied feeling down, depressed, or hopeless. He also denied having difficulty sleeping, appetite problems, difficulty concentrating, feeling restless, suicidal ideations, and prior suicide attempts. In a May 2011 VA mental health note, the Veteran reported that he was married and had two daughters. He described his support system as "good." The Veteran reported having pervasive sadness, anxiety, irritability, fluctuating appetite, decreased energy, insomnia, sleep disturbances, and nightmares. He denied having a history of suicidal ideation, suicide attempts, cycling mood swings, hallucinations, psychotic episodes, violent behavior, and panic attacks. He attributed his symptoms of stress, anger, and aggression to his military service. During a mental status examination, the VA psychologist noted that the Veteran appeared clean, neat, and oriented, and his speech was regular. His mood was angry, but his thought processes and associations were logical, and his thought content was relevant. The Veteran's insight was moderate, and his judgement was intact. He reported having some memory problems, such as occasionally forgetting why he walked into a room. The VA psychologist also noted that the Veteran was able to focus and that his behavior was not influenced by internal stimulation. The VA psychologist noted that the Veteran was experiencing recurrent intrusive distressing recollections and dreams; flashbacks; avoidance behaviors; marked diminished interest or participation in significant activities; feelings of detachment or estrangement; restricted range of affect; difficulty sleeping; irritability or outbursts of anger; hypervigilance; and night sweats. The Veteran also reported experiencing increased physical arousal, such as seeing shadows or hearing things in the house. The VA psychologist diagnosed the Veteran with mild depression and PTSD. She assigned a GAF score of 49 and noted that the score reflected the impact of the Veteran's PTSD alone. However, she also indicated that the Veteran had mild impairment in psychosocial functioning as a result of his symptoms of PTSD. During a June 2011 VA examination, the Veteran reported that he was married and described his marital relationship as "wonderful." He also reported that he had a very good relationship with his adult daughters and that he visited with his three grandchildren three times per year. The Veteran also had friends with whom he did a variety of activities, such as going to restaurants and traveling. He stated that he worked for a tire and electrical company in customer service after his separation from service. He retired in June 2009 because he was eligible by age or duration or his work. The Veteran attended two years of trade school to become a coach and physical education instructor, but he did not complete the program. His leisure activities included attending bluegrass festivals, exercising, going to movies, and watching sports on the television. He described his psychosocial functioning as satisfactory. The Veteran reported that he experienced symptoms of anxiety, depression, and difficulty sleeping. He stated that he tended to sit with his back to the wall in restaurants and that he was hypervigilant in unfamiliar public places. He also reported awakening during the night and ruminating about the challenges of his life. The Veteran denied having a history of suicide attempts or violence. He also denied having any issues associated with alcohol use or other substance use. On mental status examination, the June 2011 VA examiner noted that the Veteran was clean, neatly groomed, and appropriately dressed. His attitude was cooperative, friendly, and relaxed. His psychomotor activity and speech were unremarkable. His affect was normal, and his mood was good. He was oriented in time, place, and person. His thought process and content were unremarkable, and there was no evidence of delusions, hallucinations, or inappropriate behavior. There was also no evidence of impaired judgment or insight. He interpreted proverbs appropriately. His attention was intact, and his remote, recent, and immediate memory was normal. The Veteran was unable to perform serials 7's, but he was able to spell a word forward and backwards. There was no evidence of obsessive or ritualistic behavior, panic attacks, homicidal thoughts, or suicidal thoughts. The Veteran also displayed good impulse control with no episodes of violence. The examiner noted that he was able to maintain minimum personal hygiene and that he did not have problems with activities of daily living. The June 2011 VA examiner diagnosed the Veteran with chronic adjustment disorder with mixed anxiety and depressed mood. He also determined that the Veteran's symptoms were not of sufficient number, frequency, or severity to warrant a diagnosis of PTSD. In so finding, the examiner noted that the Veteran was experiencing recurrent distressing recollections, avoidance behavior, difficulty sleeping, hypervigilance, and an exaggerated startle response. However, he indicated that the disturbances did not cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The examiner also stated that there was no evidence of reduced reliability and productivity due to PTSD symptoms The June 2011 VA examiner also noted that the Veteran experienced significant post-military traumas, including the death of his infant son and his spouse undergoing multiple brain surgeries. The examiner stated that the Veteran did experience some subsyndromal trauma-related symptoms, such as hypervigilance in some settings, occasional intrusive thoughts, and effortful avoidance of thoughts. However, he reiterated that such symptoms were not sufficient in intensity and frequency to meet the full criteria for a diagnosis of PTSD. He noted that the Veteran experienced depressive and anxious ruminations about his spouse's health problems and, at times, past traumas, including his wartime experience. The examiner further stated that the Veteran experienced an increase in symptoms since his retirement, which represented a chronic adjustment disorder related to his retirement and health of his spouse. He indicated that there was very little impact on the Veteran's psychosocial functioning and that he had meaningful interpersonal relationships and enjoyed social and leisure activities. The June 2011 VA examiner assigned a GAF score of 73. He opined that the Veteran's depressive and anxious ruminations caused occasional transient distress that would result in decreased efficiency in occupational tasks during periods of significant stress. He further stated that the Veteran's symptoms resulted in interrupted sleep and occasional insomnia, which would also impact his occupational functioning. In an August 2011 VA mental health note, the Veteran reported having pervasive sadness, recurrent feelings of anger and grief, anxiety, night sweats, irritability, fluctuating appetite, insomnia, nightmares, and restlessness. A VA psychologist noted that the Veteran continued to experience symptoms of recurrent nightmares and flashbacks, guilt, sleep disturbances, night sweats, avoidance behavior, hypervigilance, exaggerated startle response, and claustrophobia. The Veteran also reported increased physical arousal, such as seeing shadows or hearing things in the house. He denied having suicidal and aggressive ideation, intent, or plans. On mental status examination, the Veteran's speech was regular, and his thought process, content, and associations were logical and relevant. His judgment and insight were moderate, and his memory was intact. He was able to focus, and his behavior was not influenced by internal stimulation. The VA psychologist diagnosed him with PTSD, anxiety, and mild depression. She assigned a GAF score of 55 and noted that the score only reflected the impact of his PTSD. In a January 2013 VA mental health note, the Veteran reported that he was doing well with no prominent mental health symptoms. He indicated that he was very engaged in his church and that his congregation was a primary source of social support. He also reported having a supportive relationship with his wife, children, and grandchildren. On mental status examination, the Veteran was oriented to person, place, and time, and he was well-groomed and articulate. His thoughts were neither loose nor tangential. He denied any feelings of sadness beyond his baseline level of occasional "blues." He also denied any suicidal ideation or homicidal ideation. In a November 2014 VA mental health note, the Veteran reported symptoms of pervasive sadness, recurrent feelings of anger and grief, anxiety, night sweats, irritability, insomnia, nightmares, recurrent flashbacks, avoidance behavior, hypervigilance, exaggerated startle response, claustrophobia, an inability to relax, and fluctuating appetite. He also reported increased physical arousal, such as seeing shadows or hearing things in the house. He denied any physical violence, suicide ideation, or suicide attempts. In a September 2015 VA mental health note, the Veteran reported symptoms of pervasive sadness; recurrent feelings of guilt, shame, and worthlessness; insomnia; nightmares; night sweats; reactivity to unexpected noises; anxiety; and weight loss or gain. He denied having suicidal or homicidal ideation. In a December 2015 VA mental health note, the Veteran stated that he attended church regularly and that he relied on his church and family for support. The Veteran also reported having insomnia, nightmares, anxiety, and weight loss or gain. He indicated that he had ongoing problems sleeping, but noted that his nightmares were not as severe and only occurred one to two times per week. He denied having suicidal or homicidal ideation. On mental status examination, the Veteran was cooperative, alert, and oriented, and his speech was within normal limits. His affect was congruent, and his mood was bright. His thought process was logical and goal oriented. His insight was good, and his judgment was adequate. His behavior was not influenced by internal stimulation, and his cognition was grossly intact. A March 2016 VA screen for depression was negative. The Veteran denied having little interest or pleasure doing things. He also denied feeling down, depressed, or hopeless. During the April 2016 hearing, the Veteran testified that the June 2011 VA examination occurred on one of his "good days" and that he experienced increased symptoms of irritability and anger on "bad days." He also stated that he became more isolated during such periods, but indicated that he generally did not have a problem with social interaction. The Veteran further reported having increased anxiety and panic attacks multiple times per week. He also had memory problems, such as forgetting names, phone numbers, and addresses. The Veteran's spouse testified that his irritability and anger increased over the last five or six years. She also testified that he confused people with others at times. In addition, the Veteran testified that his symptoms played a role in his decision to retire. He stated that he had a very stressful job that involved cutting off the electricity of customers who were delinquent on payments. He stated that he had disciplinary problems work, as well as conflicts with his co-workers. The Veteran testified that his marriage of 50 years was stressful due to his spouse's physical problems, but he described their relationship as "pretty good." He also indicated that he stayed in touch with his family and friends. During a November 2016 VA examination, the Veteran reported that he lived with his spouse and recently celebrated his 50th anniversary. He stated that his spouse had significant health problems, but he described their relationship as "pretty good." He also reported having a good relationship with his daughters and grandchildren. He indicated that his sisters lived nearby and that he spoke with them or visited with them at least once per month. He also recounted that he recently visited his spouse's cousin. In addition, the Veteran reported that he had numerous friends at his church and that he was very involved in a small church group. He stated that he got together with his friends two or more times per month. He also maintained contact with his former co-workers and indicated that they spent time together a couple times per week. The Veteran further reported that he enjoyed buying and selling antiques, as well as bidding for items online. He indicated that he met a few friends through online bidding websites. He also attended church regularly and was a member of the American Legion. The Veteran denied any change in his education or training since the June 2011 VA examination. He stated that he worked in customer service for 18 years and that he retired in 2009 due to eligibility by age and duration. He stated that he occasionally worked on a part-time basis for his former company. The Veteran reported having a depressed mood, anxiety, and chronic sleep impairment. He identified his major life stressors as his spouse's health, being far away from his children and grandchildren, and sleep disturbances. The Veteran denied any suicide attempts or any psychiatric hospitalizations. He recounted having one verbal disagreement in public with a friend over politics, but denied involvement in any physical fights or incidents of road rage. He also denied alcohol or illicit drug use. On mental status examination, the November 2016 VA examiner noted that the Veteran was clean, casually dressed, and well groomed. He ambulated independently, and there was no evidence of psychomotor agitation or slowing. He was alert, pleasant, and cooperative, and his affect was appropriately full in range. The Veteran described his mood as "pretty fair." His speech was unremarkable, and his thought processes were logical and goal directed. His insight and judgment were good. There was no overt evidence of mental content symptomatology, perceptual disturbance, or gross cognitive confusion. The Veteran was oriented and correctly named the current president and vice president. His mental calculations were, for the most part, good with one miscalculation early in task. There were no errors in backward spelling. His verbal abstract reasoning was within normal limits, and his interpretation of proverbs was moderately concrete. His attention and concentration were "fair." The Veteran denied having problems staying focused when reading, watching television, or during conversations. He reported that he was occasionally distracted during task performance. He described his memory as "good." The Veteran recalled 3 out of 3 words immediately after presentation and 2 out of 3 words after a delay, but identified the remaining word with a semantic cue. The examiner noted that he described very mild normal age-related cognitive changes, such as writing down lists and appointments as reminders. His remote memory was good. The Veteran endorsed having an intermittent mildly depressed mood. He also endorsed occasional crying spells, which he related to memories of his childhood. He indicated that he enjoyed traveling, eating, and singing, as well as spending time with his daughters, grandchildren, and spouse. The examiner noted that the Veteran described a good range of interests. He reported that his motivation fluctuated. He denied feelings of helplessness or hopelessness, but endorsed some feelings of guilt. He denied suicidal and homicidal ideation. He reported that his symptoms of irritability and anger were "not often." He also denied having verbal outbursts or physically acting out in anger. He stated that most of his irritability occurred while driving, but denied inappropriate acting out in response to other drivers. The Veteran described his appetite as good, but expressed frustration with his weight. He reported sleeping 6 to 7 hours per night with some disruption, and he indicated that he nightmares about his service in Vietnam approximately 3 times per week. He stated that he experienced anxiety "not very often" and indicated that it occurred mainly while driving. He also reported feeling anxious prior to singing at funerals, but he denied having significant anxiety in other settings. He further denied having specific fears or phobias, excessive worry, panic attacks, and obsessive compulsive disorder symptoms. The Veteran endorsed having avoidance behaviors and an increased startle response to loud noises. He stated that he needed to sit with his back to the wall in restaurants, but indicated that he was able to sit at the front of the church to lead singing. There was no evidence of hallucinations, delusions, or paranoid ideation. The November 2016 VA examiner diagnosed the Veteran with other specified trauma and other stressor related disorder. In so doing, the examiner explained that the current diagnosis replaced the prior diagnosis of an adjustment disorder. She explained that the new diagnosis incorporated symptoms of anxiety and some depressed mood in conjunction with identifiable stressors and/or traumatic events. She noted that stressors contributing to the assignment of the diagnosis included the Veteran's military service. The examiner indicated that the Veteran did not have more than one mental disorder diagnosed. The November 2016 VA examiner stated that the Veteran's other specified trauma and stress related disorder caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. She opined that the Veteran's symptoms resulted in no more than mild impairments in psychosocial functioning. A March 2017 VA screen for depression and PTSD was negative. The Veteran denied having symptoms of depression, nightmares, avoidance, and hypervigilance. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to an evaluation in excess of 30 percent. The Board finds that the evidence demonstrates that the Veteran's overall disability picture, to include the severity, frequency, and duration of his symptoms, as well as the resulting impairment of social and occupational functioning, is consistent with a 30 percent rating throughout the period on appeal. Throughout the entire appeal, the Veteran has maintained a history of symptoms that predominantly include sleep disturbance, anxiety, depression, nightmares, hypervigilance, irritability, anger, and avoidance. These symptoms support a 30 percent evaluation. The evidence of record does not demonstrate that the Veteran's overall disability picture is consistent with a 50 percent rating or higher during the appeal period, to include consideration of the Veteran's lay statements, statements made by the Veteran's spouse, treatment records, and the VA examination reports. A 50 percent evaluation is warranted where there is 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 and maintaining effective work and social relationships. With regard to occupational impairment, the Board notes that the Veteran reported having difficulty with stress during his employment. In this regard, during the April 2016 hearing, the Veteran testified that his job was very stressful and that his mental health symptoms played a role in his decision to retire. He reported having disciplinary problems and conflicts with his co-workers. However, during the June 2011 and November 2016 VA examinations, the Veteran reported that he retired from his job due to eligibility by age or duration of work. In addition, during the November 2016 VA examination, the Veteran reported that he continued to work for his former employer on an occasional part-time basis and indicated that he had ongoing relationships with several of his former co-workers. The Veteran also reported signing at funerals and participating in numerous recreational activities. In addition, the June 2011 VA examiner opined that the Veteran's depressive and anxious ruminations caused occasional transient distress that would result in decreased efficiency in occupational tasks during periods of significant stress. He further stated that the Veteran's symptoms of interrupted sleep and occasional insomnia would also impact his occupational functioning. Moreover, the November 2016 VA examiner opined that the Veteran's other specified trauma and stress related disorder caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. She further stated that the Veteran's symptoms resulted in no more than mild impairments in psychosocial functioning. These opinions are contemplated by the Veteran's current 30 percent evaluation. With regard to social impairment, the evidence shows that the Veteran has maintained relationships with his family throughout the appeal. In this regard, the Veteran has been married for over 50 years. Although the Veteran reported having marital stress due to his spouse's health problems, he consistently described his marital relationship in positive terms and indicated that his spouse was supportive. For example, during the June 2011 and November 2016 VA examinations, the Veteran described his marital relationship as "wonderful" and "pretty good." The Veteran has also reported having a positive relationship with his adult children, grandchildren, and extended family members. See, e.g., June 2011 VA examination; January 2013 VA mental health note; April 2016 Board hearing transcript; November 2016 VA examination. The evidence also shows that the Veteran has maintained a supportive social network of friends. The June 2011 VA examination noted that the Veteran visited and traveled with several friends on a regular basis. During the April 2016 hearing, the Veteran testified that he experienced increased isolation at times, but he stated that he generally did not have problems with social interaction. The November 2016 VA examination noted that the Veteran reported having a strained relationship with a friend due to an argument about politics. However, the Veteran also reported having other friends that he spent time with on regular basis, as well as a few friends online. Moreover, the Veteran has consistently reported having numerous friends through his church and identified his congregation as one of his sources of social support. See, e.g., January 2013, December 2015 VA mental health records; and April 2016 Board hearing transcript. He also reported having ongoing friendships with his former co-workers. See, e.g., November 2016 VA examination. Although the Veteran may have some degree of social impairment, the evidence does show that he has maintained relationships with some family members and friends throughout the appeal. Indeed, the June 2011VA examiner indicated that the Veteran's symptoms had very little impact on his psychosocial functioning and noted that he maintained meaningful interpersonal relationships and participated in social and leisure activities. Similarly, the November 2016 VA examiner stated that the Veteran's symptoms resulted in no more than mild impairments in psychosocial functioning. Further, the Veteran's symptomatology has not been similar to that of the 50 percent criteria. The Veteran's speech and behavior have been consistently noted as normal. His thought processes and content have also been consistently noted as relevant and logical. He has repeatedly denied suicidal ideation and homicidal ideation. The Board notes that a May 2011 VA mental health record indicated that the Veteran's affect was restricted. However, VA mental health records thereafter consistently noted that the Veteran's affect was appropriate and within normal limits. See, e.g., August 2012, November 2013, May 2014, November 2014, September 2015, and December 2015 VA mental health records. The Veteran's VA mental health records also consistently noted that his insight and judgement were moderate or good. In addition, the June 2011 VA examiner noted no evidence of impairment judgement or insight. Similarly, the November 2016 VA examiner noted that the Veteran's insight and judgment were good. The Veteran has reported symptoms of memory loss throughout the appeal period. However, the June 2011 VA examiner noted that the Veteran's remote, recent, and immediate memory was normal. The Veteran's VA mental health records dated from 2011 to 2015 also consistently noted that his memory was intact. In addition, during the November 2016 VA examination, the Veteran described his memory as "good." At that time, the examiner noted that the Veteran described very mild normal age-related cognitive changes and that his remote memory was good. Thus, the Board finds that the Veteran's memory loss more closely approximates the severity contemplated in the 30 percent rating criteria. Additionally, during the April 2016 hearing, the Veteran reported having panic attacks more than once per week. However, the Veteran denied having panic attacks during the November 2016 VA examination. In addition, his VA mental health records do not otherwise suggest that he had panic attacks more than once a week. Thus, the Board finds that the severity of the Veteran's panic attacks did not rise to the level contemplated by the 50 percent rating criteria. Moreover, to the extent that any of the symptoms of a 50 percent rating may be shown or argued, the Board again emphasizes that the Veteran's adjustment disorder with mixed anxiety and depressed mood has not been shown to be productive of occupational and social impairment with reduced reliability and productivity; occupational and social impairment with deficiencies in most areas; or total occupational and social impairment to warrant a higher rating. Indeed, the Veteran has maintained effective social relationships, including with his family, friends, and fellow members of his church. He also participates in a variety of recreational activities and has worked on a part-time basis. There is no also indication that the Veteran has had any of the other symptoms of the 70 or 100 percent criteria, such as suicidal ideation; obsessional rituals; illogical, obscure, or irrelevant speech; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of his personal appearance and hygiene; homicidal ideation; or inability to establish and maintain effective relationships. The Board acknowledges that the Veteran has been assigned GAF scores ranging from 49 to 73. A GAF score between 41 and 50 reflects 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 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 peer or coworkers). A GAF score ranging from 61 to 70 indicates 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, has some meaningful interpersonal relationships. A GAF score ranging from 71 to 80 represents no more than slight impairment of in social, occupational or school functioning. See DSM-IV. Although the lower GAF scores may suggest some impairment greater than that contemplated in the rating assigned, it is but one factor for consideration in assigning a rating. The Board finds the narratives contained in the lay statements, treatment records, and examination reports to be the most probative evidence of the Veteran's psychological symptomatology. The evidence does not suggest that the Veteran had such serious social or occupational impairment. As discussed above, the Veteran has maintained a good marital relationship, as well as a relationship with his children and grandchildren. He also reported having supportive relationships with friends and members of his church. The Board does acknowledge the GAF score of 49 noted in the May 2011 VA mental health record. However, the narrative contained in that record also indicated that the Veteran had only mild impairment in psychosocial functioning. In addition, the June 2011 VA examination noted a GAF score of 73. Moreover, VA medical records thereafter show GAF scores ranging from 55 to 60. See, e.g., August 2012, January 2013, November 2013, August 2014, and September 2015 VA mental health records. As such, while considering the GAF scores of record as part of the total social and occupational functioning picture, the Board finds that the Veteran's other specified trauma and stress related disorder more generally reflects mild to moderate symptoms. After considering the evidence of record, the Board finds that the Veteran's symptoms more closely approximate the criteria for the currently assigned 30 percent disability rating. Overall, the Veteran has not demonstrated a level of impairment consistent with the 50 percent criteria, nor have the Veteran's symptoms caused occupational and social functioning in most of the areas referenced by the 70 and 100 percent evaluation criteria. Mauerhan, supra, Vazquez-Claudio, supra. The criteria for the next higher rating of 50 percent have not been met or approximated. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Thus, the Board concludes that the weight of the evidence is against a rating in excess of 30 percent for adjustment disorder with mixed anxiety and depressed mood is denied. As such, the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. at 53. ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to an initial evaluation in excess of 30 percent for adjustment disorder with mixed anxiety and depressed mood is denied. REMAND Regarding the claim for service connection for obstructive sleep apnea, the Veteran was afforded a VA examination in November 2016. The examiner opined that the Veteran's obstructive sleep apnea was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. However, she did not address the lay statements regarding the Veteran's symptoms of rapid inhalation. Moreover, the examiner's supporting rationale regarding the Veteran's in-service environmental exposures was general in nature and did not fully address his contentions. Therefore, a remand is necessary to obtain an additional VA medical opinion. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stegall v. West, 11 Vet. App. 268, 271(1998). Regarding the claim for service connection for hypertension, the Veteran was afforded a VA examination in November 2016, and an addendum medical opinion was obtained in April 2017. In rendering her opinion, the examiner stated that there was no evidence of a diagnosis or treatment for hypertension until 2006. However, the examiner did not explain the medical significance of the time gap between service and the diagnosis of hypertension. Moreover, the examiner's supporting rationale regarding secondary service connection did not adequately address the issue of causation. In particular, she did not explain the relevance of the quoted medical literature to the particular facts of the Veteran's case. Therefore, a remand is necessary to obtain an additional medical opinion. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stegall v. West, 11 Vet. App. 268, 271 (1998). Accordingly, the case is REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for obstructive sleep apnea and hypertension that are not already of record. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records. 2. After completing the foregoing development, the AOJ should refer the Veteran's claims file to a suitably qualified VA examiner for a clarifying opinion as to the nature and etiology of the Veteran's obstructive sleep apnea. A physical examination is only needed if deemed necessary by the VA examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should also note that the Veteran served in the Republic of Vietnam during the Vietnam Era. Thus, he is presumed to have been exposed to herbicide agents during service. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's obstructive sleep apnea manifested in or is otherwise causally or etiologically related to his military service, including any symptomatology or exposure to herbicide agents/environmental hazards therein (notwithstanding the fact that it may not be a presumed association). In rendering his or her opinion, the examiner should consider the following: 1) the Veteran's April 2016 hearing testimony that others told him that he snored loudly during his active duty service and his spouse's testimony regarding his symptoms of snoring and rapid inhalation; and 2) the September 2011 notice of disagreement in which the Veteran asserted that the Center for Disease Control indicated that sleep apnea can be caused by exposure to toxic environments. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. After any additional records have been associated with the claims file, the AOJ should refer the Veteran's claims file to a suitably qualified VA examiner for a clarifying medical opinion regarding the Veteran's hypertension. A physical examination is only needed if deemed necessary by the VA examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that any current hypertension manifested in or is otherwise causally or etiologically related to the Veteran's military service, to include any symptomology therein. In rendering his or her opinion, the examiner should discuss the medical significance, if any, of the time gap between the Veteran's military service and post-service treatment and diagnosis. The examiner should also provide an opinion as to whether it is at least as likely as not (50 percent probability or more) that any current hypertension was either caused or aggravated by the Veteran's service-connected adjustment disorder with mixed anxiety and depressed mood. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 4. The AOJ should review the reports to ensure compliance with this remand. If the reports are deficient in any manner, the AOJ should implement corrective procedures. 5. After completing the above actions and any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs, the claims should be readjudicated. If the benefits sought are not granted, the Veteran and his representative should be furnished a supplemental statement of the case (SSOC) and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. 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). ______________________________________________ J.W. ZISSIMOS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs