Citation Nr: 18145184 Decision Date: 10/26/18 Archive Date: 10/26/18 DOCKET NO. 13-32 146 DATE: October 26, 2018 ORDER Entitlement to service connection for chronic fatigue syndrome is denied. Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. Entitlement to an increased rating in excess of 20 percent for lumbosacral strain is denied. Entitlement to an increased rating in excess of 10 percent for left hip strain is denied. Entitlement to an increased rating in excess of 10 percent for right hip strain is denied. Entitlement to an initial rating for panic disorder in excess of 10 percent effective July 22, 2010, in excess of 50 percent effective February 21, 2014, and in excess of 70 percent effective April 3, 2015 is denied. Entitlement to an effective date prior to September 14, 2010 for assignment of a 20 percent evaluation for lumbosacral strain is denied. Entitlement to an effective date prior to July 22, 2010 for the grant of service connection for panic disorder with sleep deprivation is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against a showing that the Veteran has a diagnosis of chronic fatigue syndrome. 2. The Veteran has not had a PTSD diagnosis at any period relevant to this appeal. 3. The Veteran’s lumbosacral strain is not manifested by a forward flexion limited to 30 degrees or less or ankylosis. 4. The Veteran is in receipt of the maximum schedular disability rating for left hip strain based on limited extension. 5. The Veteran is in receipt of the maximum schedular disability rating for right hip strain based on limited extension. 6. From July 22, 2010 to February 21, 2014, the Veteran’s panic disorder was not shown to cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 7. From February 21, 2014 to April 3, 2015, the Veteran’s panic disorder was not shown to cause occupational and social impairment with deficiencies in most areas. 8. From April 3, 2015, the Veteran’s panic disorder was not shown to cause total occupational and social impairment. 9. It is not factually ascertainable that the Veteran’s service-connected lumbosacral strain increased in severity within one year of September 14, 2010. 10. The Veteran’s claim for to service connection for anxiety disorder and sleep deprivation was received by the RO on July 22, 2010. CONCLUSIONS OF LAW 1. The criteria for service connection for chronic fatigue syndrome have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 4.88a. 2. The criteria for service connection for PTSD have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3.304(f), 4.125a. 3. The criteria for an increased rating in excess of 20 percent for lumbosacral strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237. 4. The criteria for an increased rating in excess of 10 percent for left hip strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5251. 5. The criteria for an increased rating in excess of 10 percent for right hip strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5251. 6. From July 22, 2010 to February 21, 2014, the criteria for an initial rating in excess of 10 percent for panic disorder have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.125, 4.126, 4.130, Diagnostic Code 9412. 7. From February 21, 2014 to April 3, 2015, the criteria for a rating in excess of 50 percent for panic disorder have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.125, 4.126, 4.130, Diagnostic Code 9412. 8. From April 3, 2015, the criteria for a rating in excess of 70 percent for panic disorder have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.125, 4.126, 4.130, Diagnostic Code 9412-9434. 9. The criteria for an effective date prior to September 14, 2010 for assignment of a 20 percent evaluation for lumbosacral strain have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 10. The criteria for an effective date prior to July 22, 2010 for the grant of service connection for panic disorder with sleep deprivation have not been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.400, 3.816. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from November 1989 to July 1993, including service in the Southwest Asia theater of operations. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Board notes that the Veteran has made general assertions of clear and unmistakable error (CUE) in prior decisions. A careful review of this contentions, however, fails to reveal an assertion of CUE plead with specificity regarding a final rating decision that affects any of the issues in appellate status. Service Connection To establish entitlement to service connection, there must be: (1) competent and credible evidence confirming the Veteran has the claimed disability or at least has since filing the claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or injury; and (3) competent and credible evidence of a nexus or link between the in-service injury or disease and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 1. Entitlement to service connection for chronic fatigue syndrome. The Veteran generally contends that her fatigue is related to service, to include as an undiagnosed Gulf War illness. At the outset, the Board acknowledges that the Veteran is a Persian Gulf veteran based on her Southwest Asia service. See 38 U.S.C. §§ 1117, 1118; 38 C.F.R. §§ 3.317(e)(1), 3.317(e)(2). Presumptive service connection is available to such veterans who demonstrate certain symptoms, to include joint pain and fatigue, which are not attributable to diagnosed illnesses. 38 C.F.R. § 3.317(b). However, the Board finds that the Veteran does not currently have and has never had any objective indications of an undiagnosed or medically unexplained chronic multisymptom illness manifested by chronic fatigue syndrome. See 38 U.S.C. §§ 1117, 1118; 38 C.F.R. §§ 3.317(a)(1), 3.317(a)(2)(i), 3.317(a)(2)(ii), 3.317(a)(3), 3.317(b). Further, the Board finds that the Veteran is not and has never been diagnosed with chronic fatigue syndrome. As such, the Veteran has not met the criteria for either presumptive or direct service connection for these claims. See 38 U.S.C. §§ 1110, 1117, 1118, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317; Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994); Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The Veteran complained of drowsiness and trouble staying awake in April 1990. Other than the April 1990 complaint, the Veteran’s service treatment records are silent for complaints of fatigue. On her July 1993 separation examination, she did not endorse frequent trouble sleeping. Post service treatment records reflect complaints and treatment of fatigue; however, these records do not indicate that the Veteran had any objective indications of an undiagnosed or medically unexplained chronic multisymptom illness. On a March 2011 compensation and pension examination, Dr. M.M. described insomnia as one of the Veteran’s psychiatric symptoms. The Veteran reported problems staying asleep and noted that her sleep problems started prior to her deployment in 1991. Dr. M.M. noted that the Veteran initially reported sleep impairment 5-7 nights weekly but admitted later in the examination that she only takes her sleep medication as needed. He described the Veteran’s sleep impairment as mild and causing increased fatigue. An April 2015 VA examination report shows that the Veteran’s sleep impairment symptoms were associated with her service-connected panic disorder with sleep deprivation. In this regard, the April 2015 VA examiner evaluated the Veteran and noted that the Veteran’s sleep impairment was attributable to the panic disorder. As the evidence does not reflect a diagnosis of chronic fatigue syndrome, presumptive service connection is not available in this case and service connection is not warranted. The Veteran has not been diagnosed with chronic fatigue syndrome or a disability manifested by fatigue at any time during the pendency of this appeal. See McClain v. Nicholson, 21 Vet. App. 319 (2007). Although the Veteran was treated for fatigue and tiredness at some point during the appeal period, the evidence does not reflect that the Veteran has been diagnosed with chronic fatigue syndrome at any time or other fatigue disability without a pathology. Service connection is in effect for psychiatric disability, and as noted, there is an indication that the fatigue is a symptom of this disability. As noted above, the Board has carefully and sympathetically considered the evidence of record but finds that the evidence weighs against a finding of a disability at any point in appellate period, to include when considering the special considerations outlined in 38 C.F.R. § 3.317. The Board’s own review of the record supports this finding. For VA purposes, the diagnosis of chronic fatigue syndrome requires: (1) new onset of debilitating fatigue severe enough to reduce daily activity to less than 50 percent of the usual level for at least six months; and (2) the exclusion, by history, physical examination, and laboratory tests, of all other clinical conditions that may produce similar symptoms; and (3) six or more of the following: acute onset of the condition, low grade fever, nonexudative pharyngitis, palpable or tender cervical or axillary lymph nodes, generalized muscle aches or weakness, fatigue lasting 24 hours or longer after exercise, headaches (of a type, severity, or pattern that is different from headaches in the pre-morbid state), migratory joint pains, neuropsychologic symptoms, sleep disturbance. See 38 C.F.R. § 4.88a. The record does not show that the Veteran meets these requirements. The evidence weighs against a finding of chronic fatigue syndrome; in addition, as noted, there is not otherwise a competent diagnosis of a disability manifested by fatigue. Further, while the Veteran is competent to report that she experiences fatigue, she does not have the required skill, knowledge or expertise to determine the likely etiology of such fatigue or to diagnose chronic fatigue syndrome. These issues are medically complex, as they require the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. For all the foregoing reasons, the claim for service connection for a disability manifested by chronic fatigue to include chronic fatigue syndrome must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 2. Entitlement to service connection for posttraumatic stress disorder (PTSD). The Veteran contends that service connection is warranted for PTSD. Service connection for PTSD requires a medical diagnosis; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). The Veteran was afforded a VA examination in March 2011. The examiner noted that the Veteran did not report stressors which met the criteria for a diagnosis of PTSD nor did she report symptoms of re-experiencing related to her reported stressors and thus did not fulfill the diagnostic criteria for PTSD. Additionally, Dr. M.M. noted that the Veteran’s reported stressors did not appear to rise to the level required for consideration as fear of hostile military or terrorist activity. The Board notes that the Veteran had positive PTSD screening tests in February 2014; however, a positive PTSD screening test is not a diagnosis in accordance with 38 C.F.R. § 4.125. Moreover, subsequent and prior mental health treatment notes include the results of thorough mental health evaluations, which did not result in a diagnosis of PTSD. The preponderance of the evidence of record weighs against a finding of a PTSD diagnosis at any time relevant to the appellate period. In the absence of proof of a current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) (service connection may not be granted unless a current disability exists). The Veteran has not had a confirmed diagnosis of PTSD during any period in appellate status or relevant to this appellate status period. The only suggestion of a diagnosis of PTSD comes from the Veteran’s lay statements. To the extent that the Veteran has contended that she has PTSD, she has not shown that she has specialized training sufficient to diagnose an acquired psychiatric disorder or determine its etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, while the Veteran is competent to report her observable symptoms, the diagnosis of PTSD is not capable of lay observation, and requires medical expertise to determine. Accordingly, her opinion as to whether a disability existed and the etiology of such is not competent medical evidence. In conclusion, the preponderance of the evidence is against finding that the Veteran has PTSD. As a preponderance of the evidence is against the claim for service connection, the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran’s service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). In Fenderson v. West, 12 Vet. App. 119, 125-26 (1999), the U.S. Court of Appeals for Veterans Claims (Court) distinguished appeals involving a Veteran’s disagreement with the initial rating assigned at the time a disability is service-connected. Accordingly, where the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection, and consideration of the appropriateness of further “staged ratings” (i.e., assignment of different ratings for distinct periods of time, based on the facts found) is required. Where an increase in an existing disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has thoroughly reviewed all the evidence in the Veteran’s claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the veteran or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). 3. Entitlement to an increased rating in excess of 20 percent for lumbosacral strain. The Veteran’s lumbosacral strain has been evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5237. Under the General Rating Formula for Diseases and Injuries of the Spine, with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply: A 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal curvature; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Note (1) to the General Rating Formula provides that associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be rated separately under an appropriate diagnostic code. In this case, the record reflects that the Veteran is separately service-connected for left lower extremity radiculopathy. The record is otherwise lacking evidence of bowel or bladder impairment; as such, the Board need not discuss such impairments. Note (5) explains that unfavorable ankylosis is a condition in which the entire thoracolumbar spine or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. The General Rating Formula also provides alternative rating criteria for Intervertebral Disc Syndrome (IVDS). Here, there is no evidence that the Veteran’s disability has resulted in IVDS requiring prescribed bed rest. On this basis, the Board finds that it need not further discuss these alternative rating criteria. In a November 2010 compensation and pension examination with Dr. M.M., the Veteran reported experiencing lower back pain since 1990. On physical examination, the Veteran’s gait and posture were normal and there was no ankylosis of the thoracolumbar spine. Range of motion testing showed forward flexion to 50 degrees, extension to 20 degrees, and right lateral flexion, left lateral flexion, right lateral rotation and left lateral rotation to 20 degrees. The Veteran was able to perform repetitive use testing with five repetitions and no additional loss of range of motion. Pain was present after the first range of motion, and pain and weakness were present after the fifth range of motion. The lower extremities were normal, as were diagnostic tests. The Veteran was afforded a VA back examination in December 2014. The Veteran reported chronic and constant low back pain that was worse with lifting, bending, and prolonged sitting. She reported flare-ups of moderate severity approximately twice a week that cause trouble walking, and described her functional loss as limiting prolonged sitting to about 2 hours, limiting driving to 1 hour, and avoiding repetitive bending and lifting. Range of motion testing showed forward flexion to 60 degrees, extension to 30 degrees, right lateral flexion to 20 degrees, left lateral flexion to 25 degrees, right lateral rotation to 20 degrees, and left lateral rotation to 20 degrees. The examiner noted pain as not causing functional loss. There was evidence of pain with weightbearing, but no pain or tenderness with palpation. The examiner noted that pain, weakness, fatiguability, or incoordination significantly limited functional ability with repeated use over a period of time, and resulted in range of motion measurements of forward flexion to 40 degrees, extension to 30 degrees, right lateral flexion to 25 degrees, left lateral flexion to 20 degrees, right lateral rotation to 0 degrees, and left lateral rotation to 10 degrees. The Veteran was not noted to have ankylosis of the spine. In a June 2017 VA back examination, the Veteran reported flare-ups that caused her to need to lie down and made her unable to do anything. She also reported functional loss of difficulty in prolonged sitting, prolonged standing, walking more than a few minutes, doing household chores, and an inability to lift. Range of motion testing showed forward flexion to 50 degrees, extension to 30 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 25 degrees. The examiner noted the Veteran had pain with all ranges of motion resulting in functional loss. There was evidence of pain with weightbearing and mild tenderness in the mid-lumbar and mid-thoracic spine pain. The Veteran was able to perform repetitive use testing with at least three repetitions and no additional loss of function or range of motion. The examiner noted, based on the Veteran’s reports, that pain, weakness, fatiguability, lack of endurance, and incoordination significantly limited functional ability with repeated use over a period of time. Muscle strength testing, reflex examination, and sensory examination were all normal. The Veteran was again not noted to have ankylosis of the spine. With respect to the Correia factors, the examiner noted that passive range of motion testing does not apply to a back condition, pain in non-weight bearing was not medically appropriate, and that there was no opposing joint for the spine. The Board has also considered the Veteran’s lay statements that her pain limits her daily activities. However, the objective medical evidence of record does not reflect impairment consistent with a rating higher than 20 percent, even when accounting for her pain during flare-ups that causes additional functional loss. Overall, the medical evidence does not reflect that the Veteran’s range of motion is limited to 30 degrees or less even when accounting for pain, weakness, and lack of endurance upon repetitive use. Nor does the evidence show favorable ankylosis. Therefore, the preponderance of the evidence of record weighs against a rating in excess of 20 percent. 4. Entitlement to an increased rating in excess of 10 percent for left hip strain. 5. Entitlement to an increased rating in excess of 10 percent for right hip strain. Regarding the bilateral hips, the RO granted service connection for right and left hip strain in an August 2009 rating decision and assigned 10 percent ratings under Diagnostic Code 5251. The Veteran requested an increased rating in September 2010, which was denied in the September 2011 rating decision currently on appeal. Limitation of motion of the hips is rated under Diagnostic Codes 5250-5253. Diagnostic Code 5250 addresses ankylosis of the hip. A rating of 90 percent is available for unfavorable ankylosis at an extremely unfavorable angle with the foot not reaching the ground and with crutches necessitated. A 70 percent rating is available for unfavorable ankylosis at an intermediate angle. A 60 percent rating is available for favorable ankylosis, in flexion, at an angle between 20 degrees and 40 degrees, and slight adduction or abduction. 38 C.F.R. § 4.71a, Diagnostic Code 5250. Diagnostic Code 5251 addresses limitation of extension of the thigh. A rating of 10 percent is available where extension is limited to 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5251. Diagnostic Code 5252 addresses limitation of flexion the thigh. A rating of 40 percent is available where flexion is limited to 10 degrees. A rating of 30 percent is available where flexion is limited to 20 degrees. A rating of 20 percent is available where flexion is limited to 30 degrees. A rating of 10 percent is available where flexion is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5252. Diagnostic Code 5253 addresses impaired abduction, adduction, and rotation of the thigh. A rating of 20 percent is available where abduction is limited such that motion is lost beyond 10 degrees. A rating of 10 percent is available where adduction is limited such that the individual cannot cross his/her legs; or, where rotation is limited such that the individual cannot toe-out more than 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5253. In a November 2010 compensation and pension examination, the Veteran reported that she suffered from pain, stiffness, fatigability, and lack of endurance. She also reported that her left hip popped at times depending on how she moves. Upon range of motion testing, the examiner noted left hip flexion to 100 degrees, extension to 30 degrees, adduction to 20 degrees, abduction to 30 degrees, external rotation to 60 degrees, and internal rotation to 30 degrees. Right hip flexion was to 100 degrees, extension was to 20 degrees, adduction was to 20 degrees, abduction was to 30 degrees, external rotation was to 40 degrees, and internal rotation was to 20 degrees. There was no additional loss of motion or functional loss after repetitive use. The Veteran was also afforded a VA examination in December 2014. She reported chronic hip pain that was present all the time and was worse with certain movements, walking, standing, and exercising. She also noted stiffness and pain with prolonged sitting. She reported painful popping and giving out of the left hip and that she had flare-ups 3-4 times per month that caused difficulty walking. On range of motion testing, the examiner noted left hip flexion to 75 degrees, extension to 30 degrees, abduction to 40 degrees, adduction to 20 degrees. Adduction was not limited such that the Veteran could not cross her legs. External rotation was to 50 degrees and internal rotation was to 10 degrees. The examiner noted right hip flexion to 95 degrees, extension to 30 degrees, abduction to 30 degrees, and adduction to 20 degrees. Adduction was not limited such that the Veteran could not cross her legs. External rotation was to 50 degrees and internal rotation was to 20 degrees. Pain was noted on examination but it did not result in functional loss bilaterally and the abnormal range of motion itself did not contribute to a functional loss bilaterally. There was evidence of pain with weight bearing bilaterally and no objective evidence of localized tenderness. There was no additional loss of function or range of motion after repetitive use testing. Functional ability was limited by pain during the flare-ups. No ankylosis was noted. At a December 2017 VA examination, the Veteran reported constant pain with flare-ups and described the flare-ups as difficulty walking, standing, and lifting more than 5-10 pounds. Upon range of motion testing, the examiner noted right hip flexion to 90 degrees, extension to 30 degrees, abduction to 45 degrees, adduction to 25 degrees, external rotation to 60 degrees, and internal rotation to 40 degrees. Pain was noted on examination causing functional loss, but the abnormal range of motion itself did not contribute to a functional loss. The examiner did not note pain on weight-bearing or objective evidence of localized tenderness. Range of motion testing of the left hip revealed left hip flexion to 75 degrees, extension to 30 degrees, abduction to 45 degrees, adduction to 25 degrees, external rotation to 60 degrees, and internal rotation to 40 degrees. Pain was noted on examination causing functional loss, but the abnormal range of motion itself did not contribute to a functional loss. The examiner did not note pain on weight-bearing or objective evidence of localized tenderness. There was no additional loss of function or range of motion after repetitive use testing. Per the Veteran’s report, functional ability was limited by pain, fatigue, weakness, lack of endurance, and incoordination during flare-ups. With respect to the Correia factors, the examiner noted that passive range of motion testing could not be performed and there was evidence of pain on non-weight bearing. The Veteran is in receipt of separate ratings for limitation of flexion of the right and left thighs under Diagnostic Code 5252 and impairment of the right and left thighs under Diagnostic Code 5253 associated with the back disability. The Veteran is not entitled to an increased rating under any of these Diagnostic Codes for the issue currently before the Board. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. Id. The ratings currently assigned under Diagnostic Codes 5251-5253 compensate the Veteran for limitations of motion in the relative motions and the record does not reflect that higher ratings are warranted. The record does not reflect that compensable ratings are warranted for additional loss of motion under DC 5252-5253. Other appropriate diagnostic codes for application have been considered. However, as the Veteran’s left hip disability does not reflect findings of ankylosis, hip flail joint, or impairment of the femur at any time during the pendency of the appeal, Diagnostic Codes 5250, 5254 and 5255 do not apply. 38 C.F.R. § 4.71a. The Board has considered the effects of the Veteran’s symptoms, including pain and functional loss, and the Board concludes that the preponderance of the evidence is against a finding that disability ratings in excess of 10 percent for right and left hip strains are warranted. As the preponderance of the evidence is against the claims for higher ratings, the benefit of the doubt doctrine is not for application, and the Veteran’s claims for increased ratings are denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 6. Entitlement to an initial rating for panic disorder in excess of 10 percent effective July 22, 2010, in excess of 50 percent effective February 21, 2014, and in excess of 70 percent effective April 3, 2015. Service connection for a panic disorder was granted in a November 2011 rating decision with a 10 percent evaluation effective July 22, 2010. The Veteran filed a notice of disagreement in October 2012. In March 2013, while her claim for an increased rating for panic disorders was on appeal, the Veteran filed a separate claim for depression. An April 2014 rating decision increased the evaluation for the Veteran’s service-connected panic disorder to 50 percent effective March 11, 2013. An April 2015 rating decision granted service connection for depressive disorder with panic disorder as a continuation of the evaluation for panic disorder and granted a 70 percent evaluation effective February 9, 2015. The effective dates of the 50 and 70 percent evaluations, respectively, were found clearly and unmistakably erroneous in an August 2018 rating decision and were changed to February 21, 2014 for the 50 percent evaluation and April 3, 2015 for the 70 percent evaluation. The RO has rated the Veteran’s panic disorder and depressive disorder with panic disorder under the General Rating Formula for Mental Disorders, which assigns ratings based on particular symptoms and the resulting functional impairment(s). See 38 C.F.R § 4.130, Diagnostic Codes 9412, 9434. The General Rating Formula is as follows: A 10 percent rating is warranted where there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and the ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. Id. A 30 percent rating is warranted where there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and 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). Id. A 50 percent rating 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. Id. A 70 percent rating is warranted where 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); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for 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. Id. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). However, 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, and that such symptoms have resulted in the type of occupational and social impairment associated with that percentage. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117-18 (Fed. Cir. 2013). In a March 2011 compensation and pension examination with Dr. M.M., the Veteran reported anxiety attacks with palpitations and chest tightening, insomnia, depressive symptoms, short-term memory problems, and panic attacks twice a month. On mental status examination, the Veteran did not have impairment of thought processes or communication, delusions, hallucinations, inappropriate behavior, suicidal or homicidal ideation, hygiene problems, obsessive or ritualistic behavior. The Veteran did, however, have panic attacks. The examiner stated that he considered the attacks mild in severity given that they were largely controlled through behavioral strategies suggested by the Veteran’s psychiatrist. The Veteran was diagnosed with panic disorder without agoraphobia and depressive disorder. Socially, the Veteran reported having been in 3 healthy long-term relationships since leaving the military and that she was currently in a dating relationship. She also reported a close relationship with her son and that she had many friends from church and friendships with people who had mentored her over the years. The Veteran also reported that she was attending a program in executive coaching. With respect to the Veteran’s occupational and social functioning, Dr. M.M. described her functioning as signs or symptoms that are transient or mild, which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, citing the twice monthly panic attacks. On VA examination in February 2014, the Veteran was diagnosed with dysthymia and panic disorder without agoraphobia. The examiner noted that it was not possible to differentiate which symptoms were attributable to which diagnosis. The Veteran’s symptoms included depressed mood, anxiety, panic attacks occurring weekly or less frequently, chronic sleep impairment, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances, including work or a worklike setting. The Veteran described her panic attacks as occurring approximately once a week and that they felt like a heart attack with shortness of breath, headaches, and palpitations. She stated that Zoloft helped reduce the severity of the panic attacks. The examiner described the Veteran’s occupational and social impairment as occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. The examiner noted that the Veteran’s panic disorder seemed to be at the same severity level as the previous rating examination and that dysthymia was a separate, nonservice-connected condition. The Veteran was afforded a VA mental disorders examination in April 2015. The diagnoses were panic disorder without agoraphobia and depressive disorder NOS. The examiner noted that only the Veteran’s panic attacks and sleep impairment were attributable to the panic disorder, while her depressed mood was attributable to the depressive disorder. Socially, the Veteran reported that she had not been in a relationship since 2010 and that she was close with her son, her parents, and her siblings. Outside of those immediate familial relationships, the Veteran described herself as socially isolated and reported that she had only attended 3 social events in the two years she had lived in Austin. Occupationally, the Veteran reported difficulty with one of her co-workers and a “loud verbal confrontation” with that co-worker that led the Veteran to go back to VA for help and increased medication. She reported that she had not had any problems interpersonally since then. The examiner described the Veteran’s occupational and social impairment as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily. The Veteran’s symptoms included panic attacks more than once a week, and she reported that she had recently missed 3 days at work due to lack of sleep related to a panic attack and that she had frequently missed time at work due to panic or lack of sleep in the past few years. From July 22, 2010 to February 21, 2014, the Board finds that the Veteran is adequately compensated by the assigned 10 percent evaluation. She reported healthy social relationships and that she was attending a certificate program. Further, her symptoms were controlled by behavioral interventions. The record does not establish that the Veteran’s panic disorder was manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks as required for a 30 percent disability rating. Therefore, an initial rating in excess of 10 percent from July 22, 2010 to February 21, 2014 is not warranted. From February 21, 2014 to April 3, 2015 the Board finds that a rating in excess of the 50 percent evaluation currently assigned is not warranted. The Board finds that the symptoms associated with the Veteran’s panic disorder did not meet the criteria for a 70 percent rating. The VA examiner observed the Veteran to be pleasant and cooperative, well-groomed with good eye contact, normal affect with coherent and logical thought processes, and good insight and judgment. The record does not show any episodes of neglect of personal hygiene, disorientation, irritability with periods of violence, which is indicative of impaired impulse control, contemplating a 70 percent rating. Nor does the record reflect that the Veteran has near continuous panic affecting the Veteran’s ability to function independently, appropriately and effectively. Considering all the symptoms of record, the Board finds that the 50 percent rating contemplates the Veteran for the level of overall social and occupational impairment caused by the psychiatric disability during this period of time. Further, the Board finds that the symptoms associated with the Veteran’s panic disorder do not meet the criteria for a 100 percent rating at any period of this appeal. A 100 percent rating requires total occupational and social impairment due to certain symptoms. The Board finds that neither the delineated symptoms nor comparable symptoms are shown to be characteristic of the Veteran’s panic disorder. The evidence of record does not indicate that the Veteran has exhibited persistent delusions; grossly inappropriate behavior; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. Throughout the record, the Veteran was consistently found to be oriented, and has never displayed grossly inappropriate behavior, any sort of delusions, or had the intermittent inability to perform activities of daily living. Therefore, the Board finds that total social and occupational impairment has not been shown. In sum, the Board finds psychiatric symptoms shown do not support the assignment of the maximum 100 percent schedular rating. The overall impact of the psychiatric symptoms was not total any period in appellate status. Effective Date 7. Entitlement to an effective date prior to September 14, 2010 for assignment of a 20 percent evaluation for lumbosacral strain. For an increase in disability compensation, the effective date will be the earliest date as of which it is factually ascertainable that an increase in disability had occurred if the claim is received within one year from such date, otherwise the date the claim was received. 38 U.S.C. § 5110; 38 C.F.R. § 3.400 (o)(2). If the increase became ascertainable more than one year prior to the date of receipt of the claim, then the proper effective date would be the date of the claim. See generally Harper v. Brown, 19 Vet. App. 125 (1997). The Veteran seeks an effective date earlier than September 14, 2010 for the 20 percent rating assigned for lumbosacral strain. Service connection for a disability manifested by recurrent low back pain with hip symptoms was granted in a February 1994 rating decision and a noncompensable rating was assigned. The Veteran filed for an increased evaluation and a September 2000 rating decision increased the evaluation to 10 percent effective June 1, 2000. The 10 percent evaluation was continued in a December 2000 rating decision. The Veteran again filed for an increased evaluation in May 2009. An August 2009 rating decision granted service connection and assigned separate 10 percent evaluations for right and left hip strains, effective May 13, 2009. The record does not indicate that the Veteran filed a notice of disagreement to the August 2009 rating decision or filed new and material evidence within a year of this decision. 38 C.F.R. §§ 3.156, 20.200, 20.201, 20.202. As such, those decisions are final, and an earlier effective date cannot be assigned based on this decision. 38 U.S.C. § 7105 (c); 38 C.F.R. §§ 3.104, 3.400(r), 20.302, 20.1103. Upon review of the record, the Board finds following the final August 2009 rating decision, the Veteran first filed a new claim for increased disability compensation on September 14, 2010. No other statements or VA treatment records from the period under consideration indicate an increase in the severity of her service-connected lumbosacral strain prior to then. Notably, no evidence or submissions pertaining to the Veteran’s lumbosacral strain were associated with the claims file in the interim between the last final decision and the claim for increase being received. Accordingly, the Board is unable to assign an effective any earlier than September 14, 2010 under 38 C.F.R. § 3.400(o)(2) because it only allows for an increased benefit to be awarded at the earliest date in which it is factually ascertainable that an increase in disability had occurred if the claim is received within one year of such date. 38 C.F.R. § 3.400(o)(2). There is no evidence the Veteran received medical treatment prior to that date that could be interpreted as an informal claim for increase. The record in the year prior to September 14, 2010 does not contain statements or other competent evidence that supports a finding that an increase was factually ascertainable prior to September 14, 2010. In summary, because it is not shown the Veteran filed a formal or informal claim for increase prior to September 14, 2010, and the evidence does not make the pertinent increase in disability factually ascertainable in the year prior to that date, an effective date prior to that date is not warranted. 8. Entitlement to an effective date prior to July 22, 2010 for the grant of service connection for panic disorder with sleep deprivation. In an October 2012 Notice of Disagreement, the Veteran stated she is seeking an earlier effective date for the grant of service connection for panic disorder with sleep deprivation. The Board notes that the Veteran initially filed a claim for an anxiety disorder and sleep deprivation on July 22, 2010 and that service connection was granted for panic disorder with sleep deprivation in the November 2011 rating decision on appeal. In general, the effective date of an award based on an original claim or a claim reopened after final adjudication of compensation shall be fixed in accordance with the facts found, but shall not be earlier than the date of the receipt of the application. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. However, if the claim is received within one year after separation from service, the effective date of an award of disability compensation shall be the day following separation from active service. 38 U.S.C. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2)(i). The essential elements for any claim, whether formal or informal, are “(1) an intent to apply for benefits, (2) an identification of the benefits sought, and (3) a communication in writing.” Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009). To determine when a claim was received, the Board must review all communications in the claims file that may be construed as an application or claim. See Quarles v. Derwinski, 3 Vet. App. 129 (1992). A review of the record indicates that the Veteran did not submit any written correspondence which could be construed as a formal or informal claim of entitlement to service connection for panic disorder with sleep deprivation prior to July 22, 2010. The Board has considered the applicable law and regulations, to include those that apply to informal claims (for the period in question) but cannot find a basis for establishing an earlier effective date under the facts of this appeal. In this regard, the Veteran did not file a formal claim or indicate a desire to file a claim for panic disorder with sleep deprivation (or for any acquired psychiatric disability) prior to the current effective date. As discussed above, an award of service connection is effective as of the date a claim is received or the date entitlement arose, whichever is later. See 38 C.F.R. § 3.400(b)(2). The Board finds that an effective date prior to July 22, 2010, is not warranted, as neither the Veteran nor any representative filed a claim for service connection for panic disorder with sleep deprivation or for any other acquired psychiatric disability prior to this date. Thus, the appeal must be denied. Id. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Thompson, Associate Counsel