Citation Nr: 18142500 Decision Date: 10/16/18 Archive Date: 10/16/18 DOCKET NO. 13-31 347A DATE: October 16, 2018 ORDER Entitlement to an effective date earlier than December 17, 2010, for an increased evaluation for PTSD is denied. Entitlement to a 100 percent rating for post-traumatic stress disorder (PTSD) is granted as of December 17, 2010. REMANDED Entitlement to a compensable rating for bilateral hearing loss is remanded. FINDINGS OF FACT 1. In an October 2008 decision, the Board of Veterans’ Appeals (Board) denied entitlement to an initial disability rating in excess of 50 percent for PTSD, and this decision was affirmed by the Court of Appeals for Veterans’ Claims (CAVC) in an October 2010 Memorandum Decision. 2. VA did not receive a new claim, formal or informal, for an increased rating for PTSD until December 17, 2010. 3. As of December 17, 2010, the evidence reflects that the Veteran’s PTSD has been manifested by symptoms that more nearly approximate total occupational and social impairment. 4. Within the one-year time period preceding the December 17, 2010 claim for benefits, at no time did the Veteran’s entitlement to a 100 percent rating for PTSD become factually ascertainable so as to warrant an effective date prior to December 17, 2010. CONCLUSIONS OF LAW 1. The criteria for entitlement to an effective date earlier than December 17, 2010, for an increased evaluation for PTSD have not been met. 38 U.S.C. § 5110 (2012); 38 C.F.R. §§ 3.114, 3.400, 3.816 (2017). 2. The criteria for entitlement to a 100 percent rating for PTSD as of December 17, 2010 have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130, DC 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran’s claim for an increased disability rating for PTSD comes to the Board on appeal from a November 2013 rating decision that assigned a 70 percent rating from December 17, 2010, the date that the Veteran filed a formal claim for an increased rating for PTSD. In a February 2014 Notice of Disagreement, the Veteran appealed the 70 percent rating, asserting that he is entitled to a higher rating for his PTSD, and he appealed the effective date of that rating. Both issues were addressed in a March 2014 Statement of the Case, and the Veteran perfected his appeal to the Board in March 2014. Meanwhile, the Veteran brought two claims for a temporary total disability rating for his PTSD for two separate periods of hospitalization. In a May 2014 rating decision, the Veteran was granted a total disability rating for his PTSD from March 4, 2014 until April 1, 2014; and, in a July 2015 rating decision, he was granted the same for the period from March 16, 2015 until May 1, 2015. The Veteran filed a claim for entitlement to a TDIU in December 2011 that was denied in a March 2012 rating decision. The Veteran did not file a timely Notice of Disagreement and that decision became final one year after the rating decision was issued. The Veteran filed a new claim for a TDIU in November 2016 that was denied in a March 2017 rating decision. The Veteran filed a Notice of Disagreement in March 2018 and the RO has acknowledged this filing. Earlier Effective Date The effective date for an award of an increased rating will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. If the increase is factually ascertainable within one year prior to the receipt of the claim for an increased rating, the rating will be effective as of the date of increase; however, if the increase occurred more than one year prior to receipt of the claim, the increase will be effective on the date of the claim. Further, if the increase occurred after the date of claim, the effective date will be the date of increase. 38 U.S.C. § 5110(b)(2), (b)(3); 38 C.F.R. § 3.400(o)(1), (o)(2); Harper v. Brown, 10 Vet. App. 125 (1997); VAOPGCPREC 12- 98 (1998). A “claim” is defined as a formal or informal communication, in writing, requesting a determination of entitlement, or evidencing a belief in entitlement to a benefit. 38 C.F.R. §§ 3.1(p), 3.151; see also Rodriguez v. West, 189 F.3d 1351 (Fed. Cir. 1999). Any communication or action indicating intent to apply for one or more VA benefits may be considered an informal claim; but an informal claim must identify the benefit sought. 38 C.F.R. § 3.155. VA must look to all communications from a claimant that may be interpreted as applications or claims for benefits, formal and informal; and it is required to identify and act on informal claims for benefits. Servello v. Derwinski, 3 Vet. App. 196, 198 (1992). In some cases, a report of examination or hospitalization may be accepted as an informal claim for benefits. 38 C.F.R. § 3.157(b). However, treatment records do not constitute informal claims when service connection has not yet been established for the condition. Sears v. Principi, 16 Vet. App. 244 (2002). While VA should broadly interpret submissions from a veteran, it is not required to conjure up claims not specifically raised. Brannon v. West, 12 Vet. App. 32 (1998) (the mere existence of medical records cannot be construed as an informal claim); Talbert v. Brown, 7 Vet. App. 352, 356-57 (1995). Importantly, the mere presence of a disability does not establish intent on the part of a veteran to seek service connection for that condition. See KL v. Brown, 5 Vet. App. 205, 208 (1993); Crawford v. Brown, 5 Vet. App. 33, 35 (1995). The Veteran brought his original claim for service connection for PTSD in May 2003. In a May 2005 rating decision, the claim was granted and a 30 percent rating was assigned. The Veteran filed a Notice of Disagreement, asserting that he was entitled to a higher rating and, in a January 2007 rating decision, he was granted a 50 percent rating from May 2003. He continued to appeal his disability rating and, in an October 2008 decision, the Board denied his claim and continued his rating at 50 percent. That decision became final on the date stamped on the face of the decision which, in this case, is October 22, 2008. 38 C.F.R. § 20.1100 (unless the Chairman of the Board ordered reconsideration, Board decisions are final on the date stamped on the face of the decision). This decision was affirmed by CAVC in an October 2010 Memorandum Decision. Following CAVC’s decision, VA received a November 2010 letter from the Veteran’s private attorney withdrawing power of attorney on behalf of the Veteran. The following month, on December 17, 2010, VA received the Veteran’s claim for an increased disability rating for PTSD, dated December 13, 2017. Prior to that, VA did not receive any other correspondence from the Veteran or any representative of the Veteran. Indeed, the Veteran has not asserted that he filed any other correspondence with VA that could be construed as a claim. Accordingly, the appropriate effective date for the Veteran’s increased rating for PTSD is December 17, 2010. The Board takes note that, in a February 2014 statement, the Veteran’s wife asserted that the Veteran had been appealing his PTSD rating since 2005, and that the evidence shows that the Veteran has been entitled to a 70 percent rating since back then. She argued that, on this basis, the effective date of the Veteran’s 70 percent rating should be much earlier. However, as stated above, the effective date of a claim is either the date entitlement arose or the date of claim, whichever is later. Even if the Veteran was entitled to a 70 percent rating earlier than 2010, the Veteran’s 50 percent rating became final in October 2008 when the Board issued its decision, and the Veteran did not file a new claim for an increased rating until December 2010. The Board further takes note of the Veteran’s assertion, in a July 2011 statement, that his 70 percent rating should date back to his prior PTSD claim because the exam upon which his 50 percent rating was based is inadequate. Similarly, the Veteran’s wife argued that, in reaching its decision on the Veteran’s prior claim, the Board overlooked that fact that her marriage to the Veteran was very unhappy as a result of the Veteran’s PTSD. These arguments that appear to challenge the weighing of facts in a prior decision do not amount to clear and unmistakable error and do not have any bearing of the effective date of the Veteran’s present claim. As stated above, effective dates are based on the date entitlement arose or the date of claim, whichever is later. The Board has considered whether it was factually ascertainable that the Veteran’s PTSD increased in severity in the year prior to December 17, 2010. See 38 C.F.R. § 3.400(o); see also Quarles v. Derwinski, 3 Vet. App. 129, 134 (1992). However, the evidence of record does not reflect treatment for psychiatric disorders during this period nor does it otherwise demonstrate that there was an ascertainable increase in the severity of the Veteran’s PTSD. As will be discussed below, prior to December 2010, the most recent medical evidence of record consists of treatment notes up to 2008. Accordingly, the evidence of record does not show that the Veteran suffered an increase in PTSD in the year prior to December 2010, and an earlier effective date on this basis is not warranted. For these reasons, the Board finds that an effective date prior to December 17, 2010, is not warranted. In making this determination, the Board has considered the provisions of 38 U.S.C. § 5107(b) regarding benefit of the doubt; however, as the preponderance of the evidence is against the Veteran’s appeal for an earlier effective date, the doctrine is inapplicable. See Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Increased Rating 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. In evaluating a disability, the Board considers current examination reports in light of the entire record 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); 38 C.F.R. §§ 4.1, 4.2, 4.10. 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. Reasonable doubt regarding the degree of disability will be resolved in the veteran’s favor. 38 C.F.R. § 4.3. Staged ratings are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In evaluating a claim, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a “competent” source. If the evidence is competent, the Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). Finally, the Board must weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995). 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. It may find that the 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. § 4.3. The Veteran’s PTSD is rated at 70 percent disabling pursuant to 38 C.F.R. § 4.130, DC 9411, for the entire period on appeal except those periods in 2014 and 2015 when his PTSD was rated at 100 percent. The regulation states that PTSD should be rated under the General Rating Formula for evaluating psychiatric disabilities other than eating disorders. Under the general formula, a 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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. A 100 percent rating is assigned for total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir. 2013), the Federal Circuit stated that “a veteran may only qualify for a given disability rating under 38 C.F.R. § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” It was further noted that 38 C.F.R. § 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 nomenclature employed in the rating formula is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, of the American Psychiatric Association (DSM-5). See 38 C.F.R. § 4.130. Prior editions of this manual referred to the Global Assessment of Functioning (GAF) scale, which is a scale from 0 to 100, reflecting the “psychological, social, and occupational functioning on a hypothetical continuum of mental health illness.” Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994) (DSM-IV) (100 representing superior functioning in a wide range of activities and no psychiatric symptoms). See also 38 C.F.R. §§ 4.125, 4.126, 4.130. In this regard, the Board acknowledges that effective August 4, 2014, VA amended the regulations regarding the evaluation of mental disorders by removing outdated references to the DSM-IV. The amendments replace those references with references to the recently updated DSM-5; and, notably, examinations conducted pursuant to the DSM-5 do not include GAF scores. Since the Veteran’s case was certified pre-DSM-5, many of his treatment visits and evaluations include a relevant GAF score. The Board will consider these GAF scores in adjudicating the claim, as doing so is most advantageous to the Veteran in this case. A GAF score of 31-40 indicates some impairment in reality testing or communications or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. A GAF of 41-50 denotes serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning. A GAF of 51-60 denotes moderate symptoms (e.g. flat affect, circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). A GAF of 61-70 denotes 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). It contemplates that an individual generally functions pretty well and has some meaningful interpersonal relationships. Entitlement to a disability rating in excess of 70 percent for PTSD As mentioned above, the Veteran brought his claim for an increased rating for PTSD in December 2010, and he was assigned a disability rating of 70 percent in November 2013. Accordingly, the appeal period is from December 2009, one year prior to VA’s receipt of the claim for increase. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010); 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o). After thorough consideration of all the evidence, the Board finds that a total disability rating as of the date of claim is warranted. At an August 2011 VA examination, the examiner diagnosed the Veteran with PTSD, depressive disorder and alcohol abuse. He noted that the Veteran’s PTSD was manifested by intrusive thoughts of combat trauma, frequent and persistent nightmares that disrupt sleep, avoidance behavior, hypervigilance and emotional numbing. His depression, noted as due to PTSD, was evidenced by persistent depressed mood, suicidal ideation without specific plan or intent, loss of interest, and feelings of worthlessness and helplessness. The examiner noted that the Veteran had a poor marital relationship and he lacked a social support network due to his anger problems that had alienated his friends, his wife, and his children. He explained that this impairment of social and marital functioning is due to the combined effects of PTSD and depression. The Veteran described his relationship with his wife as “hellish,” and he explained that he does not interact much with his wife due to problems with his temper. He explained also that his relationship with his children is “distant,” as his children are “afraid” of him; and he has a poor relationship with his siblings because “I am just kind of numb. It is hard to have feelings.” The Veteran noted that he had not seen his older sister in ten years after they got into an argument. He said, “I pretty much drove everyone away.” The examiner noted that the Veteran was going bankrupt. Regarding his daily life, the Veteran reported that he lost interest in golf a few years prior and that he has no hobbies. His typical day involves waking up around two-thirty in the morning due to nightmares, having approximately three alcoholic drinks in the morning (beginning at 7:00am), eating only snacks during the day, and sitting outside smoking and drinking until going to bed. The examiner noted that the Veteran attends continued psychotherapy and that his GAF score has declined overall from 60 in October 2006 to 50 in July 2011. The Board takes note that, although GAF scores are no longer considered probative by the Board, a significant drop from 60 (moderate symptoms) to 50 (severe symptoms) over the course of a few years is evidence of a marked changed for the worse in the Veteran’s functioning. As for work, the examiner noted that the Veteran was currently working as a machinist, although the Veteran explained that “the only reason he has this job is that he is the only one who can run one of the machines.” He reported having been “written up” at work numerous times and that he is often unfocused. Once every couple of days, he experiences anxiety at work when he hears loud noises. His heart races and he gets angry, and it can take up to ten minutes to calm down. The examiner noted that the Veteran’s anger issues create “conflictual relationships” at times with workmates. He opined that the Veteran’s difficulty focusing at work may be due to the combined effects of PTSD-related depression and the cumulative effects of daily and excessive use of alcohol. The examiner noted that the Veteran’s consistent use of high amounts of alcohol causes the Veteran to miss work due to hangovers and contributes to his poor marital relationship. It also likely makes his depression worse and exacerbates symptoms of PTSD. Overall, the examiner determined that the Veteran’s PTSD was manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking, or mood (which approximates 70 percent). However, a review of additional evidence indicates that the Veteran’s PTSD warrants a higher rating. Notably, in a September 2011 treatment note, the Veteran’s treating psychologist was emphatic that the Veteran’s drinking is due to his PTSD, stating in capital letters, “THE ALCOHOL ABUSE IS (MUCH MORE LIKELY THAN NOT) DIRECTLY RELATED TO HIS EXPOSURE TO COMBAT TRAUMA AND HIS SUBSEQUENT PTSD.” The VA examiner did not make this connection and, thus, his assessment of the severity of the Veteran’s PTSD is inaccurate. In addition, in a November 2011 statement, the Veteran’s wife took issue with the VA examiner’s finding that the Veteran can manage his finances, and she pointed out that the Veteran does not pay his bills on time and that, as a result, they were facing foreclosure. Indeed, the VA examiner did take note that the Veteran had gone bankrupt, and the Veteran submitted documents indicating he filed for bankruptcy in August 2011. The Veteran’s treatment notes throughout the Fall illustrate the difficulties the Veteran faced while working and the vast impact his PTSD had on his personal life. They also make clear that the Veteran began having increasing difficulties with PTSD years prior, after he was diagnosed with bladder cancer in 2009. In December 2010, the Veteran explained that he finds it difficult to go to work, it is extremely stressful being at work, and he experiences relationship difficulties when he gets home. He noted that he feels increasingly estranged from his children, and his wife talks about leaving him. In January 2011, the Veteran recognized that all of his problems at work, including a lack of adequate compensation and recognition from his boss, were due to problems created by his PTSD symptoms. These problems cause him to feel great anxiety, distress, and anger, and they result in panic attacks and anxiety attacks almost on a daily basis. The Veteran said that this makes him feel as if he is in combat again; and it takes a toll on his marriage and relationships. In May 2011, the Veteran reported that his symptoms were getting worse and that his coping strategies seem to be less effective. He commented: “I just go through the motions. It is like I dread one day after the other and simply drag myself through them hoping that nothing else goes wrong and knowing that it will.” In a July 2011 treatment note, the Veteran reported that the foreclosure on his home was imminent, that he was in the process of filing for bankruptcy, and that his wife was planning on leaving him once she found a suitable place to live. He stated that “his world is slowly crashing in around him.” The Veteran and his psychologist discussed the fact that “in most respects, this crash was started by [the Veteran’s] PTSD – from the difficulties it had created at work, in the home and socially.” A September 2011 treatment note states that the Veteran’s symptoms have continued to increase over time, and additional traumatic events created in large part by his PTSD have exacerbated his symptoms. The psychologist noted that the Veteran’s wife was planning to leave the Veteran when his cancer treatment was completed. He assigned a GAF score of 46 (representing “severe” symptoms). In an October 2011 treatment note, the Veteran’s psychologist noted that he and the Veteran agreed that “[the Veteran’s] PTSD and his continuing working is having a negative impact on his psychological life as well as having a detrimental effect on his marriage.” He noted that “these detrimental effects are now exacerbated by his bladder cancer treatment.” This is echoed in a December 2011 treatment note indicating that the Veteran’s bladder cancer surgery “has exacerbated his PTSD, depression, [and] feelings of hopelessness.” In October 2011, the psychologist explained that the Veteran felt his PTSD, along with related depression and panic, have “decimated important areas of [his] life.” His symptoms “have over the years grown worse as the psychosocial effects have created more problems.” The Veteran, he said, is experiencing anger and episodes of rage, as well as problems sleeping and frequent nightmares. Specifically, he noted that “[the Veteran’s] symptoms have exacerbated over the past few years.” In a December 2011 treatment note, the Veteran explained again that his employer wants to fire him, but he cannot do so because the Veteran is the only person that can operate one of the company’s complex machines. He said that the only reason he continues to work is for insurance and income. His psychologist noted that “in any job market, he would not be competitive and certainly would not last in any other job.” He noted also that “all this overwhelming stress with all that is happening, including his marriage falling apart, is really taking its toll on [the Veteran] physically and psychologically, and with the cancer and the treatments, [it is] likely to make it impossible.” In February 2012, the Veteran’s psychologist noted that the Veteran was experiencing serious impairment in psychosocial functioning “actually compounded by bladder surgery” that had taken place in September 2011. The Veteran was noted as experiencing symptoms indicative of PTSD at a serious level, including jumpiness, outbursts of anger, interrupted sleep, nightmares, estrangement from others, and hypervigilance. The symptoms were “creating a serious level of impairment in his psychosocial functioning as well as having a strong negative effect on his quality of life and continually creat[ing] inner feelings of emotional pain.” In May 2012, the Veteran noted that he returned to work after a few months off work due to his bladder surgery. His psychologist noted that the Veteran experiences passive suicidal ideation “most every day” and that the Veteran reported that he is getting worse. He said he would not kill himself, but at times he feels overwhelmed with little or no support outside of therapy. He has no friends and no hobbies, and he has panic attacks daily. The Veteran and his psychologist discussed a peculiar social work note that stated that the Veteran has a “very good support system” made up of his spouse and children, and that he has “many friends and coworkers who are also very supportive of the Veteran.” The psychologist noted that this is the opposite of what the Veteran reported to him and he and the Veteran agreed that the aforementioned statements are “totally inaccurate.” In July 2012, the Veteran indicated in a written statement that his house was repossessed, his house was resold, and he had to file for bankruptcy; all of which he attributed to his PTSD. He also indicated that his wife planned to leave him after the bankruptcy was finalized. In this regard, in a February 2014 statement, the Veteran’s wife explained that her life “has always been a lie, living with this man,” in that the Veteran has “verbally abused” her, “shoved” her, and broken her belongings “when he is at his worst.” She recounted that she “covered up for him so many times” when they were invited to places that he did not want to go, he has no friends, and she has been approached by some of the Veteran’s coworkers about “his moods.” Their children rarely visit because the Veteran is so distant, and they only phone her when the Veteran is not home. Notably, in March 2014, the Veteran was hospitalized for 22 days as a result of his PTSD. As mentioned above, the Veteran was assigned a total disability rating for this period. In a February 2014 written statement, the Veteran elaborated on the reasons why he believes he is entitled to a rating in excess of 70 percent. He explained that he has no hobbies and no friends, and that his wife’s friends do not like to visit her because he “won’t have anything to do with them because of [his] PTSD.” He said his wife complains often about his “unkept looks, shaving, showers, etc.,” and he noted that he and his wife do not sleep in the same bed. He said he missed several days of work and used up all four weeks of his vacation time because of his PTSD and his drinking. He said that he cannot get along with his boss and that he always argues with him. Furthermore, he works in a room away from the other employees, and he gets upset when someone comes near to him. In July 2014, the Social Security Administration (SSA) determined that, as of January 2014, the Veteran was unable to work due to his PTSD. The SSA noted that the Veteran experiences marked difficulties in maintaining social functioning, and that he is moderately limited in his ability to work with or near others, to complete a normal workday, and to interact appropriately with the general public. He was found markedly limited in his ability to get along with coworkers or peers without distracting them or exhibiting behavioral extremes, and he was found unable to do competitive work without special accommodations. In August 2014, the Veteran reported to VA that he is no longer able to work due to his PTSD, stating that “all that I have gone [through] this year has been so mentally stressful and emotionally stressful that I am not able to handle anything because of my PTSD.” The following year, in March and April 2015, the Veteran was hospitalized, once again, for his PTSD and, as mentioned above, he was assigned a total disability rating for that period. Afterward, in April 2015, the Veteran’s psychologist noted the Veteran’s extreme distrust toward “everyone,” created by the numerous and various betrayals of “what was right or proper by those with legitimate authority in combat” and how this affects all his interactions and creates many serious problems in his life, including exacerbating the effect of his PTSD. Into the Summer, the Veteran’s symptoms remained at a high level, as the Veteran continued to have a very strained relationship with his wife, sleep problems, nightmares, extreme jumpiness, and problems with focusing and concentration. The psychologist noted that the Veteran is “extraordinarily vigilant.” In October 2015, the Veteran told his psychologist that PTSD destroyed his marriage; and that, often times, he wishes “he would simply not wake up,” or he feels like wants to “just walk out and leave.” He reported having these thoughts two or more times per day. By May 2016, the Veteran’s psychologist discussed with the Veteran how his “rage” leaks out into his interactions, feelings, beliefs, and the way he looks at the world. The Veteran discussed his drinking habits and how he uses alcohol to “turn off [his] brain” and get to sleep; and he admitted that alcohol was the only way he found to deal with intrusive thoughts, memories, flashbacks and continuing distress from distrust and rejection. Finally, in March 2017, the Veteran underwent another VA examination at which the examiner affirmed the Veteran’s joint diagnoses of PTSD and depressive disorder and noted that the Veteran’s depression is likely due to his PTSD. The examiner explained that the Veteran and his wife minimally interact, although they still live together due to severe financial problems, and that the Veteran remains estranged from his adult children. The Veteran’s daily activities included only “pacing around and smoking in his garage.” The examiner noted that the Veteran reports thinking about suicide every day and that his sleep is impaired by nightmares 4 to 5 times weekly. The Veteran often “checks the perimeter,” and he feels tired during the day. In addition, the Veteran experiences panic symptoms at work and home at least twice daily, and he is startled easily by loud noises in the workplace. He avoids talking about combat, he lacks trust in everyone, and he has minimal contact with his wife and adult children. His irritable mood was noted as “persistently present.” Regarding work, specifically, the examiner noted that the Veteran continues to work part-time as a machinist, although, at times, he can only work for part of the day due to anxiety and panic attacks. He explained that the Veteran used to own that business, and that he has been afforded a job there only because of his history with the company. His actual work performance is so impaired by PTSD symptoms that he would not be retained from the job if he did not have such a profound history with the company. In this regard, the Veteran reported, in an April 2017 statement, that he worked an average of only 11 hours per week in 2016 “in an effort to do something to help pay my living expenses,” and he noted that he is unable to work a full time job specifically due to his PTSD. Indeed, this is corroborated by an April 2017 form provided by the Veteran’s employer indicating that he only works 12 hours per week. Overall, the examiner explained that PTSD and associated depressive disorder cause impairment in the Veteran’s ability to function in an occupational environment in that the Veteran has panic attacks while in the workplace which disrupt pace and persistence, he has problems with concentration when anxious, and he describes having impairment in motivation such that he does not even show up for work at times. The examiner concluded that the medical records and the Veteran’s current report of symptoms severity suggest he has severe impairment in his ability to work gainfully and consistently, and that this level of impairment is due to his PTSD and depression. Based on the foregoing, the Board finds that the Veteran is entitled to a total schedular rating for his PTSD as of his date of claim. The medical records and lay testimony consistently show the Veteran’s PTSD has been manifested by symptoms that more nearly approximate total occupational and social impairment. Specifically, the Veteran’s relationship with his wife has been severely strained consistently since December 2010 when he reported for the first time that his wife was planning to leave him. Although there is no evidence that his wife ever actually left him, it appears that she stayed with him only for financial reasons, and their relationship deteriorated to the point that they hardly spoke to one another and he described their relationship as “hellish.” The Veteran’s relationship with his children is similarly strained, as they avoid phoning their mother if the Veteran is around, and they have been “scared of him” for years. In addition, the Veteran experienced suicidal ideation persistently throughout the appeal period, and he consistently experienced very frequent nightmares and extreme anger. As for his daily life, the evidence makes clear that the Veteran has no friends and no hobbies, and he spends his days only sitting around his house, drinking and smoking until he goes to bed. Various notations in the record indicate that the severity of the Veteran symptoms increased drastically after his bladder cancer diagnosis in 2009. Although both VA examinations measure the severity of the Veteran’s symptoms as occupational and social impairment in most areas as opposed to total occupational and social impairment, neither examination report takes into account the fact that the Veteran’s persistent alcohol abuse is related to his PTSD. As for work, the Veteran’s 2017 VA examination highlighted the fact that the only reason the Veteran continues to maintain employment as a machinist is because of his history as the former owner of the company. Indeed, the Veteran maintained throughout the pendency of his appeal that his employer would likely fire him if not for the fact that he was the only person that could operate a particular machine. The Veteran’s psychologist specifically noted that continuing to work actually makes the Veteran’s symptoms worse; and the examiner in March 2017 noted that the Veteran would not be able to find and keep another job in a competitive setting. All of this, coupled with the fact that the SSA determined that the Veteran was disabled as of January 2014 due to his PTSD, indicates that the Veteran occupational impairment is extreme. Accordingly, the Board finds that the evidence of record reflects that the symptoms and overall impairment caused by the Veteran’s PTSD have more nearly approximated total social and occupational impairment as of the date of claim. A total disability rating is warranted. REASONS FOR REMAND Entitlement to a compensable rating for bilateral hearing loss is remanded. Although the Board sincerely regrets the additional delay, this claim must be remanded for a new examination. VA’s duty to assist includes obtaining a medical examination when it is necessary to decide a claim. See 38 U.S.C. § 5103A(d). Furthermore, when VA undertakes to provide an examination, it must ensure that it is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The most recent VA examination for this claim took place in May 2012. No additional evidence has been submitted with regard to the current state of the Veteran’s hearing loss. As the last VA examination was conducted over six years ago, the Board finds that a remand for a new VA examination is warranted. See 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also Caffrey v. Brown, 6 Vet. App. 377 (1994). The matter is REMANDED for the following action: Schedule the Veteran for an examination to determine the current severity of his bilateral hearing loss. All indicated tests should be conducted. In addition to objective test results, the examiner should fully describe the functional effects caused by the hearing disability in his or her final report. The examiner should set forth a complete rationale for all findings and conclusions in a legible report. K. PARAKKAL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Freda J. F. Carmack, Associate Counsel