Citation Nr: 18141454 Decision Date: 10/10/18 Archive Date: 10/10/18 DOCKET NO. 16-08 676 DATE: October 10, 2018 ORDER Entitlement to service connection for left ear hearing loss is granted. Entitlement to service connection for right ear hearing loss is denied. Entitlement to a 50 percent rating, but no higher, for PTSD, for the period prior to March 29, 2013, is granted. Entitlement to a rating greater than 70 percent, for PTSD, for the period from March 29, 2013 to March 17, 2016, is denied. Entitlement to a 100 percent rating (exclusive of the period where a temporary total rating has been assigned) for PTSD, for the period beginning on March 18, 2016 is granted. REMANDED 1. Entitlement to service connection for a right shoulder disability is remanded. 2. Entitlement to service connection for a back disability is remanded. FINDINGS OF FACT 1. The Veteran’s left ear hearing loss is etiologically related to service. 2. The Veteran does not have right ear hearing loss for VA disability purposes. 3. For the period prior to March 29, 2013, the Veteran’s PTSD manifested with symptoms of nightmares, flashbacks, avoidance of crowds, feelings of detachment, irritability, hypervigilance, and isolation causing occupational and social impairment with reduced reliability and productivity, but not deficiencies in most areas. 4. For the period from March 29, 2013 to March 17, 2016, the Veteran’s PTSD manifested with symptoms causing occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, but not total and occupational impairment. 5. For the period beginning March 18, 2016, the Veteran’s PTSD manifested with symptoms of hallucinations, gross impairment in thought processes, persistent danger of hurting self or others, and substance/alcohol abuse with periods of hospitalization. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for left ear hearing loss have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2017). 2. The criteria for service connection for right ear hearing loss have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2017). 3. For the period prior to March 29, 2013, the criteria for a 50 percent rating, but no higher, for PTSD, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411 (2017). 4. For the period from March 29, 2013 to March 17, 2016, the criteria for a rating greater than 70 percent, for PTSD, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411 (2017). 5. For the period beginning March 18, 2016, the criteria for a 100 percent rating, for PTSD, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from May 2005 to March 2009. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or “nexus” between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Service connection may be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 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, including other organic diseases of the nervous system, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. As an organic disease of the nervous system 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 is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Daye v. Nicholson, 20 Vet. App. 512 (2006). Under the benefit-of-the-doubt rule embodied in 38 U.S.C. § 5107(b), in order for a claimant to prevail, there need not be a preponderance of the evidence in the veteran’s favor, but only an approximate balance of the positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for the benefit to be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1994). 1. Entitlement to service connection for bilateral hearing loss. The Veteran seeks service connection for bilateral hearing loss contending that his condition is a result of acoustic trauma from having served in combat while in service. The evidence shows that the Veteran received a VA audiology examination in January 2013 which revealed the following pure tone thresholds, in decibels, for the frequencies of interest, in Hertz: 500Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Average Right 10 10 10 10 10 10 Left 10 10 20 25 30 21 Speech recognition scores based on the Maryland CNC Test were 98 percent in the right ear and 94 percent in the left ear. The examiner found that the Veteran had normal hearing for his right ear, and sensorineural hearing loss for the Veteran’s left ear in the 6000 Hz or greater. The examiner noted that the Veteran had some threshold shifts over the course of his military service, and found that the Veteran’s left ear hearing loss was related to service due to the Veteran’s exposure to IEDs, grenades, and gunfire, all without hearing protection. Although the examiner provided a positive nexus for the Veteran’s left ear hearing loss, the Veteran’s audiology results do not qualify as a disability for VA compensation purposes. For the purposes 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, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Therefore, given the probative evidence from the Veteran’s January 2013 audiology examination, service connection is not warranted based on these results for the Veteran’s right or left ear as the Veteran does not have a current disability for VA compensation purposes. In March 2016, the Veteran received a second audiology examination in which he was diagnosed with sensorineural hearing loss in the left ear, while his right ear was found to be within normal limits. The audiology examination revealed the following pure tone thresholds, in decibels, for the frequencies of interest, in Hertz: 500Hz 1000 Hz 2000 Hz 3000 Hz 4000 Hz Average Right 10 10 10 15 10 11 Left 35 20 35 40 40 34 Speech recognition scores based on the Maryland CNC Test were 92 percent in the right ear and 92 percent in the left ear. A review of the Veteran’s audiology results shows that unlike his previous examination, his March 2016 auditory thresholds for his left ear meets the VA standard for impaired hearing, and therefore, qualifies as a disability. Alternatively, the Veteran’s right ear reflects normal acuity. Considering these results, the Board finds that service connection is warranted for the Veteran’s left ear hearing loss. As noted previously, the Veteran was subjected to noise exposure while in service. The Veteran’s military personnel records confirm that the Veteran served in combat while in Iraq; therefore, the Board finds that acoustic trauma is conceded and an in-service injury has been established. Moreover, the January 2013 examiner provided a positive nexus finding that the Veteran’s current left ear hearing loss is at least as likely as not related to the Veteran’s in-service acoustic trauma. As a result, the Board finds the evidence is sufficient to grant service connection for the Veteran’s left ear hearing loss. In contrast, the Veteran is not entitled to service connection for his right ear. Service treatment records do not show any complaints, treatment, or diagnosis for right ear hearing loss; nor does his in-service audiograms show a threshold shift. Post-service VA examinations have shown that the Veteran’s hearing for his right ear is within normal limits. Therefore, as the Veteran does not have a current disability for right ear hearing loss for VA purposes, the claim must be denied. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 2. Increased rating for post-traumatic stress disorder (PTSD). Disability ratings are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2017). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical, as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10 (2017). 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 required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2017). Reasonable doubt regarding the degree of disability will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3 (2017). Separate ratings can be assigned for separate periods of time based on facts found, a practice known as “staged” ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran’s service-connected disability. 38 C.F.R. § 4.14 (2017); see Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102 (2017). In this case, the Veteran’s PTSD has been evaluated under Diagnostic Code 9411. Diagnostic Code 9411 uses the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). Under the General Rating Formula, a 50 percent rating is assigned when a veteran’s PTSD causes 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-term 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; or difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). A 70 percent evaluation is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). The maximum schedular rating of 100 percent is warranted 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; and memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). In addition, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the lengths of remissions, and the Veteran’s capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a) (2017). The rating agency shall assign an evaluation based on all evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b) (2017). Use of the term “such symptoms as” in § 4.130 indicates that the list of symptoms that follows is “non-exhaustive,” meaning that VA is not required to find the presence of all, most, or even some of the enumerated symptoms to assign a particular evaluation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013); see Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir.2004); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). However, because “[a]ll nonzero disability levels [in § 4.130] are also associated with objectively observable symptomatology,” and because the plain language of the regulation makes clear that “the veteran’s impairment must be ‘due to’ those symptoms,” a veteran “may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” Vazquez-Claudio, 713 F.3d at 116-17. Global Assessment of Functioning (GAF) scores are a scale reflecting the “psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness.” See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), p. 32. Scores ranging from 41 to 50 are assigned when there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). See 38 C.F.R. § 4.130 (incorporating by reference the VA’s adoption of the DSM-IV for rating purposes). Lower numbers on the GAF scale reflect more severe symptoms; higher numbers reflect less severe symptoms. The Board notes that although the DSM has been updated with a 5th Edition (“DSM-V”), to include GAF scores being dropped due to their “conceptual lack of clarity,” since some of the Veteran’s examinations took place prior to the adoption of the DSM-V, the DMS-IV criteria will be utilized in conjunction with all other pertinent evidence of record. The Board has reviewed all of the evidence in the Veteran’s claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a Veteran or obtained on his behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). As an initial matter, the Board notes that the Veteran is currently in receipt of staged ratings. Specifically, the Veteran has been rated as 10 percent disabling prior to March 29, 2013, and 70 percent thereafter, aside from receiving a temporary total rating of 100 percent for hospitalization from August 29, 2017 to November 1, 2017. The Board notes that the period covered by a temporary total rating will not be discussed as the Veteran was receiving the maximum rating during this period. However, with regard to the remaining periods on appeal, as the Veteran is presumed to be seeking the maximum allowable benefit and the 70 percent rating is not a full grant of the benefit sought, the claim for increase remains on appeal. AB v. Brown, 6 Vet. App. 35 (1993). In determining whether the Veteran’s PTSD was rated appropriately, the Board has thoroughly reviewed the evidence of record and finds that staged ratings are appropriate. However, the Board finds that the Veteran’s PTSD more nearly approximated the criteria for a 50 percent rating for the period prior to March 29, 2013. Additionally, for the period beginning March 29, 2013, the Board finds that the Veteran was appropriately rated at 70 percent disabling, and a higher rating is not warranted. However, as of March 18, 2016, the Veteran’s PTSD more nearly approximated the criteria for a 100 percent rating as the Veteran exhibited total occupational and social impairment due to symptoms of gross impairment in thought processes, hallucinations, persistent danger of hurting self or others, and grossly inappropriate behavior. The Board’s conclusion is supported by the reasons and bases that follows. Factual Background Factual background shows that from March 2013 to June 2013, the Veteran saw a private psychologist for psychiatric services. In his assessment summary, the examiner noted that during the sessions, the Veteran was appropriately dressed, maintained eye contact, speech was logical and coherent. The Veteran exhibited preoccupation with current stressors, internal feelings of self-anger, guilt, shame, and stressors related to war experiences. The Veteran’s mood was highly anxious, and irritable, depressed, and unhappy at times. The examiner noted symptoms of near continuous panic attacks with high levels of anxiety, impaired impulse control with irritability and violence, high levels of adapting to stressful circumstances, with difficulty to near inability to establish and maintain effective relationships. However, the examiner noted no signs of illusions, delusions, or hallucinations, and suicide risk was minimal to mild. The examiner diagnosed the Veteran with PTSD, panic disorder with agoraphobia, anxiety disorder, and dysthymic disorder, and characterized the Veteran’s symptoms as severe with a corresponding GAF score of 40. In October 2013, the Veteran received a VA examination for PTSD in which he reported symptoms of sleep difficulty, insomnia, and nightmares, and that he was currently living in a half-way house since August 2013. He further reported activities outside of working include going to school and doing homework, attending 12 step meetings, and that he interacts some with other residents of the house. Upon examination, the examiner found the Veteran to be alert, coherent, responsive, and cooperative throughout the interview. Hygiene and grooming were good, and mood was depressed. There was no evidence of delusions or hallucinations, and the Veteran denied any intent or plan for suicidal ideation. The examiner noted symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, flattened affect, difficulty in adapting to stressful circumstances, including work or a work-like setting, inability to establish and maintain effective relationships, impaired impulse control, and persistent danger of hurting self or others. The examiner diagnosed the Veteran with PTSD, polysubstance dependence, early partial remission, and anti-social personality disorder, assigning a GAF score of 60. The examiner concluded that the Veteran’s psychiatric disorders cause occupational and social impairment with reduced reliability and productivity. In October 2015, the Veteran received a PTSD Disability Benefits Questionnaire (DBQ) in which the Veteran reported that he may not graduate as expected due to his low grades and the need to repeat some courses. He further reported having lost three jobs in the past eighteen months. Upon examining the Veteran, the examiner noted symptoms of depressed mood, anxiety, panic attacks more than once a week, chronic sleep impairment, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. The examiner diagnosed the Veteran with PTSD, cannabis use, and alcohol use disorder and found that the Veteran’s substance abuse disorders are likely an attempt to self-medicate his PTSD symptoms; as such, they are a progression of his PTSD symptoms. The examiner further found that the Veteran’s symptoms cause occupational and social impairment with deficiencies in most areas. The examiner noted that the Veteran’s TBI is also relevant to his PTSD as it affects memory problems, headaches, and disorientation. Additionally, TBI causes difficulties in focusing, impaired concentration, and missing assignments/examinations due to impaired focus. In May 2017, the Veteran received a DBQ for mental disorders other than PTSD in which the Veteran was diagnosed with PTSD, polysubstance abuse, and major depressive disorder. The examiner noted symptoms of depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, impaired judgment, disturbances of motivation and mood, and inability to establish and maintain effective relationships. The examiner found that the Veteran’s PTSD, major depression, and polysubstance abuse are proximately due to the result of the Veteran’s TBI, and cause occupational and social impairment with deficiencies in most areas. Like the previous examiner, this examiner also found that the Veteran’s TBI is relevant to the management of his mental disorders, and that the stress from the TBI and PTSD likely exasperate his polysubstance abuse. Legal Analysis Period prior to March 29, 2013 Considering the above and remaining evidence, the Board finds that prior to March 29, 2013, the Veteran’s PTSD more nearly approximated the criteria for a 50 percent rating, but no higher, as the Veteran’s symptoms were moderate in nature causing occupational and social impairment of reduced reliability and productivity. As noted above, the Veteran was initially rated as 10 percent disabling with a subsequent increase to 70 percent effective March 29, 2013. However, the evidence supports a 50 percent rating for the period prior to March 29, 2013. In so finding, the Board notes that the Veteran’s 10 percent evaluation was based on findings from an October 2013 examination in which the examiner found that the Veteran’s polysubstance abuse was less likely than not related to service, and that at least 90 percent of the Veteran’s impairment is shared by polysubstance dependence and antisocial personality disorder. In addition, the examiner found a GAF score of 60, indicative of mild symptoms. However, the Board notes a July 2012 psychiatric evaluation in which the Veteran reported symptoms of sleep disturbance, nightmares, flashbacks, lost in interest in pleasurable activities, avoidance of crowds, feelings of detachment, irritability, hypervigilance, and isolation. As a result, the Veteran was referred to a trauma recovery program. In a subsequent August 2012 evaluation for treatment, the Veteran reported symptoms of flashbacks, intrusive thoughts, feelings of detachment, sleep disturbance, and depression. The Veteran further reported symptoms of obsessive rituals to include having monthly AIDS tests, regardless of his possibility of exposure, for fear of contracting the virus; biting his nails until they bleed, and checking his locks over and over to make sure they are secure. The Veteran was diagnosed with PTSD, depressive disorder, NOS, alcohol abuse, and cannabis abuse, both in sustained remission, with an assigned GAF score of 55, indicative of moderate symptoms. Moreover, although the October 2013 examiner noted that the Veteran’s impairment is shared by polysubstance dependence and antisocial personality disorder, and found that these conditions were not likely related to service, the Board notes that this finding is contrary to the evidence of record. As noted above, the October 2015 examiner found that the Veteran’s substance abuse disorders are likely an attempt to self-medicate his PTSD symptoms. In addition, based on the medical evidence of record, VA recharacterized the Veteran’s PTSD to include substance use and TBI. Moreover, despite the examiner’s findings, the examiner assigned a GAF score of 60, which is essentially borderline between mild to moderate symptoms. Considering the evidence as a whole, the Board finds the preponderance of evidence shows that the Veteran was moderately impaired due to his PTSD; thus, warranting a rating of 50 percent, but no higher. The Veteran is not entitled to a higher rating as he did not exhibit symptoms causing total occupational and social impairment, or deficiencies in most areas. This finding is evidenced in an October 2012 letter written by a psychologist from the Veteran’s trauma recovery program. In the letter, the psychologist noted that the Veteran was attending group therapy and was compliant in his medication. In November 2012, during a medication management visit, the Veteran also noted a reduction in the frequency of his nightmares, anxiety, and better sleep. In a December 2012 mental health visit, the Veteran reported that he was in school and taking five classes. Moreover, in a February 2013 medication management visit, the Veteran reported feeling more “even” and less anxious, and that he has not had any nightmares since increasing his medication. Furthermore, during this visit, the examiner assigned a GAF score of 58 to 62, indicative of mild to moderate symptoms. Moreover, mental examinations from July 2012 to March 2013 found that the Veteran’s thought process was coherent, insight and judgment were good, and attention, concentration, and memory were intact. The Veteran also consistently denied suicidal/homicidal ideations, delusions, and hallucinations. In light of the above, the Board finds that for the period prior to March 29, 2013, the Veteran’s symptoms were moderate in nature as the Veteran reported experiencing a decrease in nightmares, less anxiety, and the Veteran was able to attend school. In addition, the Veteran’s GAF scores ranged from 55 to 62, indicative of mild to moderate symptoms. Therefore, the Board finds the Veteran’s symptoms more nearly approximated the criteria for a 50 percent rating as his symptoms were not of the frequency, severity, or duration that would warrant a higher rating. Accordingly, a 50 percent rating, but no higher, for the period prior to March 29, 2013, is granted. Period beginning March 29, 2013 For the period beginning March 29, 2013, the Board finds the Veteran was appropriately assigned an increase to 70 percent; but, a higher rating is not warranted as the Veteran was not totally social and occupationally impaired. The pertinent evidence shows that on March 29, 2013, the Veteran saw a private physician who evaluated the Veteran from March to June 2013. In his evaluation summary, the examiner noted that the Veteran had severe symptoms of occupational and social impairment, and assigned a GAF score of 40. In September 2013, the examiner updated his summary to include a report that the Veteran had been kicked out of rehab and was incarcerated with legal and substance abuse problems. In a May 2015 VA examination, the examiner found that the Veteran exhibited occupational and social impairment with deficiencies in most areas, and that the Veteran used substance abuse to self-medicate. Further, in a January 2016 mental health visit, the Veteran reported that in early December, he started to become depressed, and stopped taking his medications and going to AA meetings. He further reported that he relapsed, which resulted in him arriving to work in a drunken state, and ultimately being fired. The Board recognizes that the afore-mentioned evidence clearly shows a worsening of the Veteran’s symptoms; thus, warranting his assigned 70 percent rating. However, the Veteran was not totally impaired socially or occupationally. Contrary to the above, the evidence also shows that the Veteran successfully completed a 28 day substance abuse program in 2014. In a March 2015 medication management note, the Veteran reported being 90 days sober, and that he had recently completed the SATP program. He further reported recently finishing a semester at school with A’s and B’s, and that his mood is better. In an April 2015 mental health visit, the Veteran reported that he would complete school in July and that he was taking his medications as prescribed. He further denied suicidal/homicidal ideations, hallucinations, and substance abuse. Finally, employment documentation shows that the Veteran had periods of employment from 2014 to early 2016. Therefore, notwithstanding the evidence noted above which show a worsening of the Veteran’s symptoms, to include relapsing due to alcohol abuse, increased depression, and medical evidence showing social and occupational impairment severe in nature, the evidence shows that the Veteran was able to complete several substance abuse treatment programs, attend school, and maintain employment. As such, the Veteran did not exhibit total and social occupational impairment from March 29, 2013 until March 17, 2016 that would warrant a 100 percent rating. However, as of March 18, 2016, the Board finds that the Veteran’s impairment more nearly approximated the criteria for a 100 percent disability rating for the remainder of the appeal period (aside from the temporary total rating period). The Board notes that as of March 18, 2016, and throughout the remainder of the appeal, the evidence is significant for substance/alcohol abuse, suicide attempts, hallucinations, and hospitalizations. The Board recognizes that while the Veteran is not directly service-connected for substance/alcohol abuse disorders, said disorders have been associated with his PTSD. As explained above, VA has included the Veteran’s TBI, substance use disorder, and depression as being intertwined with his PTSD disorder. To that end, the Board notes that although the RO granted a temporary total disability rating on August 29, 2017, based on the Veteran’s hospitalization for PTSD and substance abuse, the evidence shows that prior to this date, the Veteran’s impairment warranted a 100 percent rating as the totality of his PTSD symptoms, to include substance abuse, TBI, and depression caused total occupational and social impairment. In support thereof, the Board notes that on March 18, 2016, the Veteran was admitted for hospitalization as a result of relapsing on alcohol. The Veteran reported that he was hearing voices that were telling him to kill himself and other people. During an interview with a social worker, the Veteran’s father reported that the Veteran was “off the charts,” very agitated, physically threatening, throwing items, and the Veteran was banging his head against the wall. He further reported that after talking the Veteran into going to the hospital, the Veteran attempted to jump out of the car twice while on the interstate. The Veteran was ultimately hospitalized, and a higher level of care was recommended. Ironically, the Veteran attended a SATP group session earlier that day where it was noted that the Veteran’s thought content was within normal limits, and the Veteran denied suicidal/homicidal ideation and hallucinations. In May 2016, the Veteran was hospitalized from an overdose on heroin. In June 2016, the Veteran was admitted to a substance abuse treatment program, but was discharged due to medical concerns. Specifically, the Veteran left the program after complaining of being “bitten all over,” and having scabies. In July 2016, the Veteran was assessed for a mental health evaluation where the Veteran again reported that he was hearing voices telling him to commit suicide and to hurt others. After evaluation, a treatment plan was created which included stabilizing suicidal ideations, controlling/eliminating auditory hallucinations, and controlling his depressive symptoms. Further, in December 2016, the Veteran attempted to commit suicide after cutting his arm open with a bottle. In a March 2017 incident, it was determined that the Veteran was attempting suicide after he became extremely intoxicated and kept hitting his head; and, in July 2017, he threatened to cut his arm again after he reported that he was off his meds, had relapsed, and was feeling suicidal. Finally, the Board notes that although the Veteran was hospitalized on August 29, 2017 for PTSD and substance abuse (for which a temporary total rating was awarded), the Veteran relapsed and was ultimately discharged and arrested for public intoxication. Considering the above and remaining evidence, the Board finds that a 100 percent rating is warranted as of March 18, 2016. The evidence shows that the Veteran’s PTSD has been severely compromised by a combination of TBI, depression, and primarily, his substance abuse issues. Although VA has already recognized that the Veteran’s substance abuse and TBI are intertwined with his PTSD, the Board notes an October 2016 written medical opinion where a VA examiner found that the Veteran’s high risk behavior is a direct result of his PTSD and TBI. Further, as referenced previously, the May 2017 examiner found that the stress from PTSD and TBI exasperate the Veteran’s polysubstance abuse. The Board also notes a March 2017 neuropsychological evaluation, where the examiner concluded that the Veteran has not received optimum treatment for his PTSD due to the severe nature of his substance abuse issues. The examiner explained that while the substance abuse treatment has been necessary, there has not been a focused approach in treating the Veteran’s PTSD; thus, causing severe impairment from a cognitive standpoint due to the emotional issues. Given the evidence above, the Board finds that the evidence overwhelmingly shows that since March 18, 2016, the Veteran’s PTSD, substance abuse, TBI, and depression caused total social and occupational impairment to include anxiety, substance abuse overdose, hallucinations, multiple hospitalizations, and suicide attempts. As a result, the Board finds the preponderance of evidence weighs in favor of the claim and a 100 percent disability rating is warranted as of March 18, 2016. The Board notes that this is the maximum schedular amount the Veteran can receive; therefore, a full grant has been awarded for the period beginning March 18, 2016 and throughout the remainder of the period (aside from the temporary total rating period). REASONS FOR REMAND 1. Entitlement to service connection for a back disability is remanded. 2. Entitlement to service connection for a right shoulder disability is remanded. The Veteran seeks service connection for a right shoulder disability and low back disability. Specifically, the Veteran reported that his back condition began in Iraq with physical training, and that he sustained injuries to his shoulder and back from a vehicle accident. Service treatment records (STRs) show that the Veteran complained of back pain from heavy lifting in April 2007, and was diagnosed with lumbago; however, there is no medical evidence pertaining to an injury, complaints, or treatment to his right shoulder. Post-service records show that after receiving a Disability Benefits Questionnaire (DBQ) for his back in January 2013, the examiner concluded that the Veteran’s current lumbar strain is less likely related to his diagnosed lumbago from 2007. The examiner explained that the Veteran’s lumbago was more likely an acute event without long term sequela and less likely to cause chronic joints of the spine or chronic lumbar strain; especially since there are no signs of progression or complaints of chronic back pain since 2007. Alternatively, in a June 2016 DBQ, the examiner diagnosed the Veteran with lumbago and muscle spasms of the lumbar spine, and concluded that more likely than not, a nexus existed between the Veteran’s military service and his lumbar spine pathology. In reviewing the afore-mentioned medical opinions, the Board finds that both opinions are inadequate for adjudicating the Veteran’s claim. With regard to the January 2013 DBQ, although the examiner provided a negative nexus, with supporting medical rationale, the examiner did not consider the lay statements of record. In particular, the Board notes an October 2012 statement in which a fellow service member attested to being involved in a vehicle accident with the Veteran in April 2008 where they both sustained injuries to their shoulders and back. Additionally, while the examiner noted that there were no signs of progression or complaints of back pain since 2007, the Veteran reported having continued pain since his April 2008 injury. The Board notes that in formulating medical opinions, lay statements must be considered by VA examiners; otherwise, their medical exams are inadequate. Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) and Dalton v. Nicholson, 21 Vet. App. 23 (2007). Here, the Board has no reason to doubt the competence and credibility of the soldier’s statement. Therefore, the examination and opinion is inadequate and a new examination is warranted. With regard to the June 2016 DBQ, the Board also finds the opinion inadequate as the examiner provided a positive nexus opinion; however, the examiner failed to include a medical rationale in support of his conclusion. Similarly, the same examiner provided a positive nexus for the Veteran’s right shoulder condition, but again failed to include medical rationale supporting his opinion. In light of the contrasting medical opinions of record, and given that the medical opinions are all inadequate for adjudicating the Veteran’s claims, new examinations and opinions are necessary to make a decision on the claims. Accordingly, the matters are REMANDED for the following action: 1. Obtain all of the Veteran’s outstanding VA treatment records from October 2017 to present. All efforts to obtain these records must be documented in the Veteran’s claim file. 2. Schedule the Veteran for a VA examination(s) to determine the nature and etiology of his right shoulder disability and back disability. The claims file must be made available to, and reviewed by the examiner. Any indicated studies should be performed. 3. The examiner should provide an opinion as to the following: a) Whether it is at least as likely as not (a 50% or greater probability) that the Veteran’s right shoulder disability is etiologically related to service? b) Whether it is at least as likely as not (a 50% or greater probability) that the Veteran’s back disability is etiologically related to service? The examiner(s) is advised that all lay statements of record should be considered in the rendered opinions. A clear explanation for all opinions based on specific facts for the case as well as relevant medical principles is needed. If the examiner determines that he or she is unable to provide the requested opinion without resort to speculation, the examiner must provide a reasoned explanation for such conclusion. 4. After completion of the above, readjudicate the claims. If any benefit requested on appeal is not granted to the Veteran’s satisfaction, the Veteran and his representative should be furnished a supplemental statement of the case and provided an opportunity to respond. The case should then be returned to the Board for further appellate consideration, if in order. GAYLE E. STROMMEN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Laffitte, Associate Counsel