Citation Nr: 18145960 Decision Date: 10/30/18 Archive Date: 10/30/18 DOCKET NO. 16-17 472 DATE: October 30, 2018 ORDER Entitlement to service connection for lung disease is denied. Entitlement to an increased rating for posttraumatic stress disorder (PTSD), rated 30 percent prior to December 12, 2017, and 70 percent thereafter is denied. FINDINGS OF FACT 1. The Veteran has a current diagnosis of idiopathic pulmonary fibrosis and he is presumed to have been exposed to herbicide agents, to include Agent Orange, during his service in the Republic of Vietnam; however, the evidence does not support a nexus between his current disease and active service, to include exposure to herbicide agents. Moreover, idiopathic pulmonary fibrosis is not eligible for presumptive service connection based on exposure to herbicide agents. 2. Prior to December 12, 2017, the Veteran’s PTSD more nearly approximated 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 normal conversation. 3. From December 12, 2017, the Veteran’s PTSD more nearly approximated occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. 4. The Veteran’s service-connected disabilities do not preclude the ability to secure and maintain substantially gainful employment consistent with his education and work history. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a lung disease have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for an increased rating for PTSD, rated 30 percent prior to December 12, 2017 and 70 percent thereafter have not been met. 38 U.S.C. §§ 1114, 1155, 5107; 38 C.F.R. §§ 3.102, 3.350-3.352, 4.1-4.16, 4.125-4.129, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from October 1966 to September 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from October 2013 and July 2015 rating decisions issued by the Department of Veterans Affairs (VA). The issue of entitlement to service connection for chronic obstructive pulmonary disorder has been recharacterized as a claim for service connection for lung disease in accordance with Clemons v. Shinseki, 23 Vet. App. 1 (2009). In a January 2018 rating decision, the Regional Office (RO) awarded an increased 70 percent rating for posttraumatic stress disorder (PTSD), effective December 12, 2017. As this was less than the maximum benefit allowed under VA law and regulations, the claim for increase remained on appeal. AB v. Brown, 6 Vet. App. 35, 38 (1993). In October 2018, the Veteran waived initial consideration of all evidence associated with the claims file subsequent to an April 2016 statement of the case (SOC). 38 U.S.C. § 7105(e); 38 C.F.R. § 20.1304(c). It is noted that the appeal of both issues was filed subsequent to February 2013 and the Veteran did not request initial consideration of new evidence he submitted; therefore, the automatic waiver exception under 38 U.S.C. § 7105(e) is also applicable to evidence he submitted. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. 1. Entitlement to service connection for lung disease The Veteran seeks service connection for a lung disease. He asserts that it is related to exposure to Agent Orange. For the reasons that follow, the Board finds that service connection is not warranted. The Veteran is diagnosed with idiopathic pulmonary fibrosis. This was first confirmed with a computerized tomography (CT) scan of the chest in 2010. The diagnosis was reaffirmed with subsequent CT scans. See, e.g., VA treatment record (10/1/2015). The Board acknowledges that both the Veteran and his medical records include references to chronic obstructive pulmonary disorder (COPD). See, e.g., VA treatment record (5/10/2017) (showing an assessment of COPD instead of pulmonary fibrosis). The Veteran is not competent to diagnose this condition as it is medically complex and he does not have the requisite medical training or expertise. 38 C.F.R. § 3.159(a)(1), (2); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2009). Insofar as the diagnoses were provided by medical treatment providers, they were in error. A diagnosis was not supported by testing, which actually indicated the opposite. E.g., VA treatment record (5/29/2012) (pulmonary function test is not suggestive of COPD). Accordingly, the Board finds the Veteran does not have a diagnosis of COPD. Nonetheless, as noted above, he does have a current disability: idiopathic pulmonary fibrosis. The Veteran asserts that his current disability is related to exposure to Agent Orange during service in the Republic of Vietnam. The Veteran’s military personnel records show service in the Republic of Vietnam during the presumptive period. Exposure to herbicide agents, to include Agent Orange, is presumed. 38 C.F.R. § 3.307(a)(6). The Veteran’s STRs do not reveal any complaints, injury, treatment, or diagnoses related to a lung problem. His September 1968 separation examination report showed a normal clinical evaluation of the lungs and chest. The Report of Medical History, which the Veteran completed in conjunction with that examination, shows he marked “no” to asthma, shortness of breath, pain or pressure in chest, and chronic cough. The Veteran’s medical records reveal that he reported chest pains in 1991; contemporaneous to when he quit smoking tobacco. VA treatment record (7/10/2007). He reported that he had a stress test conducted then and the results were normal. He reported no problems after that time. He sought VA treatment for his lung problems in 2007. In 2010, he reported a five to six-year history of chronic dyspnea with a more recent decline in pulmonary capacity in the last year to year and a half. He felt that his alcoholism may have caused him to disregard his symptomology at the time. Given the forgoing, the Board finds that the only in-service incurrence is the Veteran’s presumed exposure to herbicide agents. The Veteran is not competent to provide a nexus between his current disability and his exposure to herbicide agents because it is a medically complex determination and he does not possess the requisite medical training or expertise. 38 C.F.R. § 3.159(a)(1), (2); see Jandreau, 492 F.3d at 1377. There is no competent evidence of record supporting such a link. The evidence shows the Veteran has a current diagnosis of idiopathic pulmonary fibrosis and an in-service incurrence of exposure to herbicide agents, to include Agent Orange. There is no competent evidence indicating a nexus between the two. Accordingly, VA does not have a duty to provide an examination or medical opinion to address this issue. 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) (explaining that something more than an appellant’s conclusory, generalized statement is needed to trigger VA’s duty to assist by providing a medical examination). In sum, the competent evidence does not establish a nexus between the Veteran’s current idiopathic pulmonary fibrosis and his active service, to include exposure to herbicide agents. Accordingly, service connection is not warranted on a direct basis. Idiopathic pulmonary fibrosis is not listed under § 3.309(e); therefore, service connection is also not warranted on a presumptive basis. Increased Rating Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 2. Entitlement to an increased rating for posttraumatic stress disorder, rated 30 percent prior to December 12, 2017 and 70 percent thereafter The Veteran seeks an increased rating for posttraumatic stress disorder (PTSD), rated 30 percent prior to December 12, 2017 and 70 percent thereafter. The appeal period before the Board begins on October 25, 2011, one year prior to the date VA received the claim for an increased rating. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). For the reasons that follow, the Board finds that an increased rating is not warranted. The Veteran’s PTSD has been evaluated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. Under the General Rating Formula for Mental Disorders, a 30 percent rating is warranted when 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; and mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted when 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 often 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 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); inability to establish and maintain effective relationships. Id. A 100 percent rating 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; memory loss for names of close relatives, own occupation, or own name. Id. The rating of psychiatric disorders is ultimately based upon their resultant level of occupational and social impairment. 38 C.F.R. § 4.130; Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117-18 (2013). The evaluation, however, is symptom-driven, meaning that the symptomatology should be the fact-finder’s primary focus in determining the level of occupational and social impairment. Vazquez-Claudio, 713 F.3d at 116-17. This includes consideration of the frequency, severity, and duration of those symptoms. 38 C.F.R. § 4.126(a); Vazquez-Claudio, 713 F.3d at 117. Significantly, however, the symptoms enumerated in the rating criteria are merely examples of those that would produce such level of impairment; they are not exhaustive, and 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, 713 F.3d at 115; Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). If the Board finds that the Veteran suffers from symptoms of similar severity, frequency, and duration that cause occupational and social impairment equivalent to that which would be produced by the specific symptoms enumerated in the rating criteria, then the appropriate equivalent rating will be assigned. 38 C.F.R. 4.21; Mauerhan, 16 Vet. App. at 443; see also Vazquez-Claudio, 713 F.3d at 117. VA intends the General Rating Formula to provide a regulatory framework for placing veterans on a disability spectrum based on their objectively observable symptoms. Vazquez-Claudio, 713 F.3d at 117 (emphasis added). Accordingly, in evaluating the Veteran’s disability the Board will place great probative value on the Veteran’s observable symptoms as demonstrated in clinical treatment notes and mental status evaluation. As the claim on appeal was pending before the Agency of Original Jurisdiction (AOJ) on or after August 4, 2014, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013) (DSM-5) is for application. 79 Fed. Reg. 45093, 45094 (Aug. 4, 2014). Consequently, Global Assessment of Functioning (GAF) scores may not be considered. Golden v. Shulkin, 29 Vet. App. 221 (2018). A. Factual Background A mental status examination was conducted in February 2012. The Veteran was alert and oriented in all three spheres. He presented neatly dressed and groomed. His behavior was withdrawn. His motor activity showed dizziness (relating to a separate diagnosis of vertigo). Speech and flow of thought were normal. Memory was normal. Concentration was normal. He had no harmful thoughts. His perceptions were normal and he had no delusions. His mood was depressed and anxious. Affect was congruent to mood and with normal range. Judgment was normal. Insight was fair. In November 2012, the Veteran reported an increase in anxiety since his prior March 2011 VA examination. In January 2013, the Veteran reported he was sleeping better on his increased Klonopin medication and also having less nightmares. He reported ongoing fatigue during the day and a decrease of interest in activities. He noted frustration with multiple medical problems preventing him from doing certain activities. In April 2013, the Veteran reported that he was less depressed on his increased Zoloft medication. He reported an increase in flashbacks and nightmares several weeks ago but less during the current week. In August 2013, the Veteran reported that he was able to go to West Virginia with his daughter; he noted she has some property they are hoping to build a home on. During the contemporaneous mental status examinations, the Veteran was alert and oriented in all three spheres. He presented neatly dressed and groomed. His behavior was withdrawn. Speech and flow of thought was normal. Memory and concentration were normal. He had no harmful thoughts. He had normal perceptions and no delusions. His mood was depressed and/or anxious. Affect was congruent to mood and with normal range. Judgement was normal. Insight was fair. In August 2013, the Veteran underwent a VA examination. The examiner diagnosed anxiety disorder, NOS. The Veteran reported anger/irritability and nightmares. He reported thoughts related to Vietnam experiences and being reminded of them by hearing loud noises and being surprised or startled by something. He reported avoiding watching action movies, especially those pertaining to Vietnam. He reported avoiding fireworks, fairs, and concerts. He described himself as suspicious and frequently looking around when in an unfamiliar place to try and keep up with everyone near him. He described the frequency of his symptomology as occurring every three to four days and to be of moderate severity. He reported the symptomology had continued since service. Regarding social functioning, the Veteran reported two prior marriages, the most recent one ending in divorce in 2005. He reported residing with his eldest daughter and her son at their home in Florida. He reported his relationship with his two daughters is very good. He described them as great girls and very supportive. He reported having three grandchildren with a great grandchild on the way in November. He denied having many friends or a social support network other than family and his weekly substance abuse treatment group. Regarding occupational functioning, the Veteran reported he retired in 2005. He had owned a home maintenance business. He noted that he last held a job approximately five years ago. The Veteran described his neurocognitive symptoms from the prior two-week period. He reported that he sleeps well five nights per week but wakes due to nightmares; with medication, the intensity of nightmares is decreased. He reported he sometimes wakes up sweating. He reported averaging approximately six hours of uninterrupted sleep per night but would awake feeling groggy due to his medication. He described his day-time interests as going outside and walking or working. He reported feelings of uselessness related to macular degeneration (this disease had a sudden onset and was causing him to go blind quickly) and having others assist him in things like driving. He described his energy as good, and noted he walks half a mile per day. He reported his concentration was decreased with respect to learning new material. He reported his sexual interest is completely gone and he had sexual dysfunction. He reported that he is able to perform activities of daily living independently. On mental status examination, the Veteran presented as casually dressed and adequately groomed. His interpersonal style was cooperative and responsive. His reporting was considered reliable and congruent with history. He was alert and oriented in all spheres. His responses to questions were logical, linear, and goal directed. Speech was normal. Eye contact was good. Mood was euthymic, and affect was congruent with mood. There was no evidence of a formal thought disorder. The Veteran denied psychosis, including auditory/visual hallucinations. Insight and judgment appeared to be intact. Memory appeared to be within normal limits, as well. The examination report identified symptoms of depressed mood, anxiety, and chronic sleep impairment. The examiner remarked that the Veteran had good functioning in the domain of family relationships and maintaining his chronic health conditions. The examiner opined that his mental health problems were not of such intensity so as to preclude occupational functioning. The examiner opined that the mental health problems cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care, and conversation. In November 2013, the Veteran reported that he had a long history of alcohol abuse but was now sober (since approximately 2009). He was unable to handle crowds and had problems with sleep and anxiety. He could not watch any war-related TV or movies. The examiner described the Veteran as grossly impaired socially and occupationally with no future outlook for employment secondary to PTSD. The examiner noted he continues with symptoms of emotional liability, sleep fragmentation, social isolation, nightmares, hypervigilance, exaggerated startle response, avoidance of war-related stimuli, persistence of ego-dystonic intrusive thoughts that lead to social isolation, chronic anxiety, and feelings of worthlessness. The examiner opined that these cluster of symptoms manifest in an inability to function in the norms of society. On mental status examination, the Veteran presented as neatly dressed and groomed but unshaven. He was alert and oriented in all three spheres. Behavior was fearful and withdrawn. Speech and flow of thought were normal. Memory was normal. Concentration was normal. He had no harmful thoughts. He had normal perceptions and no delusions. His mood was depressed and anxious. Affect was constricted. Judgment was normal and insight was fair. In February 2014, the Veteran reported difficulty with acceptance of losing his eyesight, which was impacting his independence, self-esteem, and activity levels. He reported episodic nightmares. He also reported that he was now a great grandfather. The mental status examination revealed similar findings as in November 2013 except that his affect was normal, congruent with mood. Also, his insight was intact. In July 2014, the Veteran reported problems with insomnia since discontinuance of Klonopin. He reported being less depressed on Zoloft. He denied suicidal ideation. The mental status examination findings were nearly identical to those in February 2014. In August 2014, the Veteran was evaluated in conjunction with the Blind Rehabilitation Center (BRC) program. His goals were to lean to use a computer and develop manual and orientation and mobility skills. He reported that he had lived with his daughter and her 13-year-old son in their house in Florida since 2007. He said he was comfortable with this living situation. His family was emotionally supportive. He said he also had other relationships and friends who are close and dependable. He reported that he does chores and sorts the mail at home. His daughter pays the bills. He reported that he enjoys walking, sports, TV, radio, reading, household chores, gardening, and family. A cognitive screen showed no obvious learning problems. Concentration and mental calculation abilities were grossly intact. Immediate memory was grossly intact. On mental status examination, he was oriented in all spheres. Speech was spontaneous and fluid. Mental processing speed was within normal limits. Thought process was goal oriented, and thought content showed no overt or reported signs of psychosis, delusion, or hallucination. There was no suicidal or homicidal ideation evidenced or reported. Mood was described as good, and affect was appropriate to content of discussion. His behavior was socially appropriate and he was cooperative with this evaluation. Attention, concentration, and mental calculation abilities were grossly intact. Immediate memory was grossly intact. In November 2014, the Veteran reported he went to the blind school (BRC program) at the West Palm Beach VA Medical Center (VAMC). He stayed for seven weeks. He reported that he learned a lot and it helped him become more confident. He reported he now has a computer. He reported he is going to the Tee Olympics (blind golf tournament). He reported some episodic sleep problems with nightmares. He reported he was less depressed on Zoloft. On mental status examination, he presented as neatly dressed and groomed. He was alert and oriented in all spheres. His behavior was normal. Motor activity was normal. Speech and flow of thought were normal. Memory and concentration were normal. He had no harmful thoughts. He had normal perceptions and no delusions. His mood was euthymic, and affect was congruent with mood. Judgment was normal. Insight was intact. In February 2015, the Veteran reported he was still able to walk one-to-two miles per day. In May 2015, the Veteran reported that he recently got a seeing eye dog. He reported that he and his daughter have been discussing him getting his own house. He stated that he would like a 2-bedroom house with a garage for his tools. He reported that he wants to continue on Zoloft as he is less depressed. He also noted that he is sleeping better. On mental status examination, he presented neatly dressed and groomed. He was alert and oriented in all spheres. His behavior was normal. Motor activity was normal. Speech and flow of thought were normal. Memory was normal. Concentration was normal. He had no harmful thoughts. He had normal perceptions and no delusions. His mood was anxious and affect was congruent to mood. Judgment was normal. Insight was intact. In December 2016, the Veteran reported that he was going to his granddaughter’s house for Christmas. He reported that he struggles and gets depressed over his multiple medical problems: blind, pulmonary fibrosis, tremors. He reported that he has a home health nurse who comes once a week to plan his medications. He reported he is independent with cooking in a microwave. He admitted having less energy and motivation. He reported episodic nightmares. On mental status examination, it was noted that he required the aid of a seeing eye dog. His mood was depressed with affect congruent to mood. Judgment was normal. Insight was intact. In April 2017, the Veteran reported he is moving to West Virginia to live with his youngest daughter as he needs more support. The mental status examination findings were similar to those in December 2016. In May 2017, the Veteran reported that, for the most part, he has found ways to help himself. He reported he still goes through spells where he gets depressed. He reported that he lives on a 90-acre farm with his daughter and her 18-year-old son in separate RVs. The son stays in the same RV as him. On mental status examination, he presented appropriately groomed and was cooperative. He was alert and oriented. Affect was appropriate. Speech was normal. He was pleasant and kindly. There was no evidence of hallucinations, delusions, or psychotic thought process. There was no overt evidence of cognitive dysfunction. In June 2017, the Veteran scored a 17 on a Patient Health Questionnaire (PHQ-9), indicative of at least moderately severe depressive symptoms. He reported sleeping eight hours per night. Nightmares are occasional. Appetite is decreased. Energy level is low. There were no hallucination, and he denied suicidal and homicidal ideation. He reported no active hobbies at this time; it was noted that he has been diagnosed legally blind for three years. On mental status examination, he presented casually dressed with good hygiene and grooming. He was cooperative, alert, and oriented in all spheres. He ambulated with the aid of a service dog. His mood was depressed, but still cooperative, and affect was congruent with mood. He answered questions appropriately. Speech was normal. Fund of information was adequate. Thought content was not delusional, psychotic, or dangerous. Sensorium and perception appeared clear. Insight and judgment into illness was adequate. Immediate, recent, and remote memory all appeared intact. In July 2017, the Veteran underwent another mental status examination. He presented casually dressed in shorts with good hygiene and grooming. He was cooperative, alert, and oriented in all spheres. He ambulated with the aid of a service dog. His mood was talkative, friendly, and cooperative. Affect was congruent with mood. He answered questions appropriately. Speech was clear, logical, and goal directed. Fund of information was adequate. Thought content did not appear to be delusional, psychotic, or dangerous. He denied hallucinations or suicidal or homicidal ideation. Sensorium and perception appeared clear. Insight and judgment into illness was adequate. Immediate, recent, and remote memory appeared intact. In November 2017, the Veteran reported nightmares at least two months ago where he woke up in a sweat. He reported such experiences since he became sober (in 2009). He reported dreams dealing with killing and being lost. He reported having flashbacks of events in Vietnam several months ago. He reported avoiding, as much as possible, war-related events. He reported he cannot tolerate the smell of dead animals (it is a trigger). He reported negative beliefs about himself and that he felt detached and estranged from others. He reported irritable behavior and anger outbursts, as well as reckless/self-destructive behavior (the prior alcoholism). The examiner noted the disturbance caused clinically significant distress and impairment in social life (he has avoided social interactions, especially with crowds). On mental status examination, his affect was blunted and eye contact was poor. He reported seeing images of things he cannot discern secondary to blindness. He denied delusions. There was no looseness of associations. No flight of ideas. No tangentiality or circumstantiality. He denied suicidal or homicidal intent, plan, or ideation. Judgment and insight were fair. In December 2017, the Veteran reported nightmares more than three times per week with increased anxiety. In January 2018, the Veteran underwent a VA examination. The examiner diagnosed PTSD; the diagnosis was indicated to be a progression of his service-connected psychiatric disorder. The Veteran reported intrusive memories several times per week that he addresses by redirecting himself. He reported nightmares occurring monthly. He reported avoiding war- or conflict-themed material, fireworks, crowds, and being overwhelmed by the smell of dead animals. He reported that in stores he feels trapped in the aisles if it is busy and he will run into people or knock things over to get out. He reported a long history of anger and aggression that is reduced by medication. He reported his sleep is also improved by medication. The examination report identified symptoms of depressed mood, difficulty establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances, including work or a work-like setting. Additional symptomology was noted in the subsection evaluating PTSD criterion. The Veteran was found to have recurrent, involuntary, and intrusive distressing memories of a traumatic event; recurrent distressing dreams; avoidance, or efforts to avoid, external reminders that arouse distressing memories, thoughts, or feelings associate with the trauma; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; irritable behavior and anger outbursts; hypervigilance; and exaggerated started response. On behavioral observation, the Veteran presented early for the appointment with his service dog, daughter, and grandson. He was fully alert and oriented. Eye contact was attempted throughout but difficult with blindness. Psychomotor activity was normal. Speech was clear but soft. Thought process was logical and linear. Attention and concentration were good. Memory was grossly intact. Fund of knowledge was good for education. Judgment and impulse control were noted to be historically poor but had limited access to options now. There was no evidence of suicidal ideation. The Veteran remarked that he became sober (in 2009) after becoming spiritual. He reported being relieved to be away from people who were merely acquaintances but not friends. He reported his irritability remains. He reported he left his eldest daughter’s home in Florida seven months ago because they were not seeing eye-to-eye. He reported that he is doing better at his other daughter’s home in West Virginia. He reported being uninterested in doing things away from home or in spending time with people. The examiner opined that the Veteran has occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. In February 2018, the Veteran reported sleep approximately eight hours per day with nightmares zero out of seven days per week. He reported audio and visual hallucinations. He reported energy level below average. On mental status examination, he presented casually dressed with good hygiene and grooming. He was cooperative, alert, and oriented in all spheres. He ambulated with the aid of a service dog. Mood was talkative, friendly, and cooperative. Affect was appropriate and congruent to mood. He answered questions appropriately. Speech was clear, logical, and goal directed. Fund of information was adequate. Thought content did not appear to be delusional, psychotic, or dangerous. He denied auditory or visual hallucinations or suicidal or homicidal ideation. Sensorium and perception appeared clear. Insight and judgment into illness was improved. Immediate, recent, and remote memory appeared intact. The examiner noted he appeared and presented as stable. In May 2018, he reported to a nurse that he was a little more depressed lately. He reported that he is trying to get his trailer set up, power turned on, and well dug; he described it as stressful. Later at the same appointment, he told the examining physician that he was doing pretty good. He reported that he just got a good report from his oncology doctor so he was happy about that. On mental status examination, he presented casually dressed with good hygiene and grooming. He was cooperative, alert, and oriented in all spheres. He ambulated with the aid of a service dog. His affect was appropriate and congruent with mood. He answered questions appropriately. Speech was clear, logical, and goal directed. Fund of information was adequate. Thought content did not appear to be delusion, psychotic, or dangerous. He denied hallucinations or suicidal or homicidal ideation. Sensorium and perception appeared clear. Insight and judgment into illness was improved. Immediate, recent, and remote memory were intact. The examiner noted he appeared and presented as stable. The Board notes the Veteran’s VA treatment records also show that he attended group therapy for his substance abuse for multiple years. It does not appear this continued after he moved from Florida to West Virginia. B. Analysis The Veteran’s PTSD is rated as 30 percent disabling prior to December 12, 2017 and 70 percent thereafter. The Board will address the two periods separately. For the reasons that follow, an increased rating is not warranted. Further the Board acknowledges that in a December 2013 notice of disagreement, the Veteran asserted that the August 2013 VA examination was incomplete because he was unable to accomplish the computerized portion of the examination due to his blindness and there was no alternative for that portion. A medical examination or opinion is adequate where it is based upon consideration of the veteran’s prior medical history and examinations and also describes the disability in sufficient detail so that the Board’s evaluation of the disability is a fully informed one. D’Aries v. Peake, 22 Vet. App. 97, 104 (2008). There is no specific requirement from testing; it is expected that examiner’s will conduct such testing as they require to provide an informed opinion. A review of the examination report shows that such an opinion was provided. It clearly identified the Veteran’s symptomology and associated occupational and functional affects. The Veteran’s lay statements were considered, and his medical history was reviewed. It does allow the Board to make a fully informed decision regarding his claim for increase. Remand for a new examination is not required. Prior to December 12, 2017 With regard to the enumerated symptomology under DC 9411, the evidence does not support the criteria for a 50 percent rating. There is no evidence of flattened affect. The Veteran’s affect was typically described as normal and congruent with mood, though there were a couple occasions where it was described as constricted or blunted. There is no evidence of circumstantial, circumlocutory, or stereotyped speech; panic attacks; difficulty in understanding complex commands, or impairment of short- and long-term memory. It is noted that panic attacks and mild memory impairment were reported by the Veteran during a March 2011 VA examination; however, this examination was prior to the appeal period. During the appeal period, there was no evidence of panic attacks and the Veteran’s recent, remote, and immediate memory was described as normal or grossly intact on all mental status examinations. The evidence did not support impaired judgment. All mental status examinations conducted during the appeal period described judgment as intact or normal. The Board acknowledges that the January 2018 VA examination report described judgment as historically poor but the Veteran had limited options now. While this evidence is from after December 12, 2017, the underlying rationale from the opinion is relevant to the entire appeal period so it will be addressed. Read as a whole, the examination report indicated that historical impairment of judgment related to the Veteran’s history of alcoholism and anger outbursts and misdemeanor crimes. The Veteran having limited options now was in reference to his physical limitations due to blindness, pulmonary fibrosis, and other illnesses. The Board finds the Veteran did not have impaired judgment during the appeal period because numerous mental status examinations described his judgment as normal. It is also noted that the Veteran was physically active and not blind during the early part of the appeal period and mental status examinations from that time period evidenced normal judgment, as well. The frequency and consistency of those findings outweighs the implication that the Veteran has impaired judgment that is muted by his physical limitations. There was no evidence of impaired abstract thinking. There was evidence of disturbance of motivation and mood. The Veteran frequently described himself as lacking energy and motivation for activities. He reported feelings of uselessness and worthlessness. On mental status examinations, his mood was often described as depressed and/or anxious. In June 2017, he scored a 17 on a PHQ-9, indicative of moderately severe depressive symptoms. It is noted that impairment in this area bared some association with his other medical problems, notably his macular degeneration and forthcoming blindness. As he learned to cope with that condition his motivation and mood improved. To that end, during a May 2017 VA appointment, he reported that he had found ways to help himself but he still goes through spells where he gets depressed; this indicated a decrease in severity and frequency of this symptom. The record also contains additional lay statements by the Veteran that indicate this symptom occurred less frequently. To that end, he reported enjoying spending time outdoors and going on walks. He had good family support and loved his grandson, with whom he lived. He reported helping do chores around the house and sorting mail. An August 2013 VA examiner remarked that he had good functioning in the domains of familial relations and maintenance of his chronic health conditions. Given the forgoing, the Board finds that there is evidence of disturbance of motivation and mood of moderate to severe severity but decreasing frequency throughout the appeal period. There was evidence of difficulty in establishing and maintaining effective work and social relationships. The Veteran reported that he lacked a desire for social interaction. His responses regarding friendships were mixed. At times he reported no friends outside of his family and members of his substance abuse group. On another occasion, he reported having non-familial relationships and friends who were close and dependable. On some mental status examinations, his behavior was described as withdrawn. Other mental status examinations described him as talkative and friendly. Given the forgoing, the Board finds that this symptom was present but its severity was muted. It appears its presence stemmed from his desire to isolate rather than an inability to effectively interact with others. The Board acknowledges that there could be some interplay with his irritability and anger outbursts; however, during this portion of the appeal period the evidence does not suggest that was a problem. Regarding the symptomology listed under enumerated under the criteria for a 70 percent rating, the evidence does not support suicidal ideation, obsessional rituals, impaired speech, near-continuous panic or depression affecting an ability to function independently, appropriately, and effectively; spatial disorientation, neglect of personal appearance and hygiene, or an inability to establish and maintain effective relationships. There is evidence of impaired impulse control, manifesting in irritability and anger outbursts. The severity of this symptom is muted by a lack of associated violence during the appeal period. The Veteran reported that he moved from Florida to West Virginia because he and his eldest daughter did not see eye-to-eye. The Board interprets this in the context of prior statements in which he indicated he planned to move to West Virginia for greater support; it is noted that his plans occurred while his blindness was worsening and, in general, he required greater assistance. The Board also finds this symptom to be of lesser severity based on a lack of related occupational impairment during the appeal period. While the Veteran has been retired for a number of years due to advanced age, he did participate in blindness rehabilitation classes via VA; the Veteran views that school work as a valid approximation. He was able to complete that coursework and improve his life without indication that his irritability or anger outbursts were a hinderance. There is also evidence of difficulty adapting to stressful circumstances, most notably adapting to progressive impairment from unrelated medical conditions like macular degeneration. He frequently described depression related to those conditions. He described episodic anxiety to new experiences. Weighing against the frequency and severity of this problem is that the evidence shows the Veteran actively worked to improve his ability to cope with these problems and was successful as the appeal period continued. The evidence does not support the presence of any symptomology enumerated under a 100 percent rating. Based on the forgoing, the Board finds that, prior to December 17, 2012, the Veteran’s symptomology largely corresponded to that of a 30 percent rating or less. This included symptoms such as depressed mood, anxiety, suspiciousness, chronic sleep impairment, hypervigilance, exaggerated startle response, and nightmares. The use of medication was effective in limiting the frequency and severity of these symptoms. The evidence showed subjective reports of flashbacks, which are not listed in the rating criteria. These were not objectively observed on examination or mental status examination. The Veteran’s report of their occurrence was also infrequent, which leads the Board to find that if they were of limited frequency. There was also no evidence they were productive of social or occupational impairment. Accordingly, they would more nearly approximate the criteria for a 30 percent rating or less. The Veteran’s PTSD did present with more severe symptoms, corresponding to the criteria for 50 and 70 percent ratings as noted above; however, limited number of such symptoms combined with their lesser severity and frequency has lead the Board to conclude they did not raise the overall level of impairment to more nearly approximate a higher rating. 38 C.F.R. § 4.7. Regarding occupational and social functioning, the August 2013 VA examiner described it as occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with routine behavior, self-care, and normal conversation. The Board agrees with this characterization. It is consistent with the ameliorative effects of his medications on the frequency and severity of his symptomology and the relative consistency of his mental status examinations, which portrayed his condition as less impactful. The Board also considers the blind rehabilitation program he completed in seven weeks in 2014 as a good approximation for occupational functioning because he was retired and had no other work experience during the appeal period. Through that program, he learned how to use a computer and learned other orientation and mobility skills helpful for those with blindness. He reported that he learned a lot from the program. He showed no learning problems or cognitive impairment. The Board acknowledges a November 2013 VA treatment record wherein the examiner opined the Veteran was grossly impaired socially and occupationally and had no future outlook for employment secondary to his PTSD. The Board disagrees with this opinion as it is inconsistent with the remainder of the evidence of record, and largely inconsistent with the mental status examination conducted at that appointment. That mental status examination showed the Veteran appeared neatly dressed and groomed but unshaven; behavior was fearful and withdrawn; mood was depressed and anxious; and affect was constricted. On the other hand, his orientation, speech, memory, concentration, perceptions, judgment, and insight were all normal. Regarding the other evidence of record, the Veteran showed an ability and willingness to help care for his eldest daughter’s son and do chores around the house. He also managed his chronic medical problems, to include keeping appointments to attend frequent substance abuse classes. The Board also cites to completion of the blindness rehabilitation classes approximately half a year after this opinion was given. While the Veteran’s symptomology clearly improved as he learned to cope with his numerous medical problems, there was not a substantial improvement in functional status so as to warrant a higher rating for the earlier part of the appeal period. This is further borne out by the consistency and frequency of mental status examinations throughout the appeal period that were indicative of lesser levels of impairment. In sum, the Veteran’s symptomology and related occupational and social impairment more nearly approximate the criteria corresponding to his current 30 percent rating. There is no doubt to be resolved. A rating in excess of 30 percent prior to December 12, 2017 is not warranted. From December 12, 2017 onward During this portion of the appeal period, the Veteran is currently rated 70 percent. With regard to the enumerated symptomology under DC 9411, the evidence does not support the criteria for a 100 percent rating. The evidence does not suggest gross impairment in thought processes or communication; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (due to the service-connected psychiatric disorder under consideration), disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. At a February 2018 VA appointment, the Veteran reported experiencing audio and visual hallucinations. Further details regarding the nature of these symptoms or their frequency, duration, or severity were not reported. They were not found on mental status examination at the appointment. Relative to the remainder of evidence of record, there is no indication that the Veteran’s service-connected condition was productive of such symptomology and there are no mental status examinations or evaluations of record during the appeal period where it was objectively observable. Vazquez-Claudio, 713 F.3d at 117. To the contrary, all such evidence showed him to have normal perceptions with no delusions or hallucinations or evidence of psychotic symptomology. Accordingly, the Board finds the Veteran’s report of such symptomology is outweighed by the abundance of evidence to the contrary. The Veteran’s PTSD does not manifest in other non-enumerated symptoms that more nearly approximate those corresponding to a 100 percent rating. The Veteran’s PTSD does manifest in other symptoms as described above in the section evaluating his disability prior to December 12, 2017. There was not a significant change in symptomology after December 12, 2017. Accordingly, that discussion is incorporated herein by reference. Regarding occupational and social functioning, the January 2018 VA examiner described it as productive of deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. This is consistent with the current 70 percent rating. The evidence does not suggest total social impairment because the Veteran maintains good familial relationships, although he does remain uninterested in doing things away from home or spending time with people. The evidence also does not suggest total occupational impairment. While the Veteran has not worked at any point during the appeal period, his completion of blindness rehabilitation classes was considered evidence of continuing occupational functioning. During this portion of the appeal period, the Veteran also described that he was continuing to attend counseling at VA, setting up his trailer, getting power, and getting a well dug. All these actions weigh against total industrial impairment. In sum, neither the Veteran’s symptomology nor his occupational and social functioning more nearly approximate the criteria corresponding to a higher 100 percent rating. There is no doubt to be resolved. A rating in excess of 70 percent from December 12, 2017 is not warranted. The Board has considered whether the Veteran’s PTSD merits further staging of his rating. He is rated 30 percent prior to December 12, 2017 and 70 percent thereafter. As discussed above, the evidence does not more nearly approximate the criteria corresponding to higher ratings in either delineated period. Similarly, the evidence does not warrant an earlier effective date of increase to 70 percent. That date was chosen by the agency of original jurisdiction (AOJ) and will not be disturbed. The evidence does not support a higher rating prior to that date. In sum, further staging of the rating is not warranted. Hart v. Mansfield, 21 Vet. App. 505 (2007); Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994).   C. Additional Considerations TDIU The record has reasonably raised the issue of entitlement to a total disability rating based on individual unemployability (TDIU). Rice v. Shinseki, 22 Vet. App. 447 (2009). It is considered part-and-parcel of the claim for increase. Id. The Veteran did receive notice of how to substantiate such a claim, and he was asked to submit a VA Form 21-8940 in connection with the application for this benefit. While he did not submit such a form, the information that would have been provided in that record is found elsewhere in the file. Thus, the Board will proceed with consideration of this issue. Total disability ratings for compensation may be assigned when a veteran is unable to secure and follow a substantially gainful occupation. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is “whether the veteran’s service connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993); see Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment). Consideration may be given to the veteran’s level of education, special training, and previous work experience when arriving at this conclusion; factors such as age or impairment caused by non-service connected disabilities are not to be considered. 38 C.F.R. §§ 3.341, 4.16, 4.19. The Veteran is service connected for PTSD (rated 30 percent prior to December 12, 2017 and 70 percent thereafter), tinnitus (rated 10 percent), bilateral hearing loss (rated noncompensable), and ischemic heart with valvular heart disease (rated 10 percent from May 23, 2017). Given his compensation record, he qualifies for schedular consideration of a TDIU from December 12, 2017. Prior to that date, he does not meet the percentage threshold enumerated in § 4.16(a). Nonetheless, the Board will consider that period as well to determine whether referral for extraschedular consideration may be warranted. The Veteran has a 10th grade education. He did not complete high school, and he has reported that he lost interest in academics. He worked for 10 years prior to military service, part of that time for the company Magnavox. During service, he held a military occupational specialty (MOS) of supply specialist. In civilian life, he worked in construction for approximately 37 years. He worked as a maintenance mechanic for the Florida Department of Agriculture from March 1997 to July 2005. He subsequently worked as a handyman in his own business. The exact date he stopped working is unclear, but the record, to include his own statements, indicate it was in approximately 2007, well before the appeal period under consideration. The Veteran’s PTSD was evaluated above. That discussion is incorporated herein by reference. Generally, the Veteran’s psychiatric disorder did not manifest in cognitive impairment, memory loss, difficulty understanding complex commands, or any impairment of physical functioning. The disorder most notably caused difficulty in establishing and maintaining effective work and social relationships. This stemmed from a tendency to isolate and a general lack of interest in engaging in non-familial relationships. Mental status examinations showed him to be capable of having such relationships, as he had normal speech, appearance, hygiene, and behavior. The record also showed he made friends with people when put into social situations, evidenced by having friends in his substance abuse therapy groups. Some mental status examinations noted him to be talkative and friendly. This disorder also impaired his motivation and mood, as he had moderate to severe depression, low energy, fatigue, and feelings of uselessness and worthlessness. The disorder caused impaired impulse control manifesting in irritability and anger outbursts. This symptom was reduced by medication, and the Board found it to be of lesser severity. The disorder also produced difficulty in adapting to stressful situations, as evidenced by his problems adjusting to macular degeneration. Weighing against such impairments were the fact that the Veteran completed seven weeks of a blindness rehabilitation program through VA where he learned how to use a computer and also motor and orientation skills helpful to those with blindness. Moreover, the Veteran regularly attended frequent substance abuse group therapy sessions. One VA examiner commented that he had good functioning in the maintenance of his chronic medical conditions; this further supports his industrial capacity. More recently, he reported that he was working on getting his trailer set up, power turned on, and a well dug, though he did characterize this work as stressful. The Veteran’s ischemic heart with valvular heart disease was described as causing difficulty with walking, daily activities, lifting, and even minimal physical activity. Regarding hearing loss and tinnitus, the Veteran reported difficulties with hearing speech and other noises in various environments. Based on the forgoing, the Board finds that a TDIU is not warranted. His psychiatric and heart problems cause the greatest occupational impact. The ischemic heart with valvular heart disease provides such physical impairment that he would be unable to perform any of the work he historically did, which was primarily physical labor such as construction and maintenance. The Veteran has, however, shown a continued ability to learn. In October 2014, he completed the blindness rehabilitation program through VA and learned how to use a computer. This aided in expanding his range of employment possibilities. It is noted the completion of this program occurred prior to service connection for the heart problems. Moreover, the evidence does not suggest he experiences cognitive impairment, memory problems, an inability to follow directions or understand complex directions, or that his service-connected disabilities would cause absenteeism. His most prominent occupational difficulties would revolve around interacting with co-workers and/or customers and handling stressful situations. As discussed above, and in the evaluation of PTSD, these functional impairments would not be prohibitive and there is some evidence weighing against their severity, such as making friends in his substance abuse group when placed in such a setting, doing chores and helping care for his eldest daughter’s son when he still lived with her, and completing the blindness rehabilitation program through VA. In sum, the Board does not find that the Veteran’s service-connected disabilities, either alone or in the aggregate, would preclude the ability to secure or maintain substantially gainful employment consistent with his education and work history. 38 C.F.R. § 4.16. There is no doubt to be resolved in this regard. The Board is aware that the Veteran experiences considerable difficulty from non-service-connected disabilities including his legal blindness and tremors. Those problems and associated impairments could not be considered in this analysis. Special Monthly Compensation The Board has considered whether special monthly compensation (SMC) under 38 U.S.C. § 1114(s) is warranted. Akles v. Derwinski, 1 Vet. App. 118, 121 (1991) (noting VA’s policy to consider SMC where applicable); see Bradley v. Peake, 22 Vet. App. 280, 294 (2008) (finding that SMC “benefits are to be accorded when a veteran becomes eligible without need for a separate claim”). Several separately rated disabilities cannot be combined to achieve a single 100 percent rating in order to qualify for SMC. VAOGCPREC 66-91 (Aug. 15, 1991). A total disability rating for individual unemployability (TDIU) based on a single disability does, however, qualify as a single 100 percent rating for the purposes of § 3.350. Bradley, 22 Vet. App. at 293. The Veteran does not have a single service-connected disability rated as total, along with additional service-connected disabilities rated at 60 percent or higher. As a result, he does not meet the criteria for statutory housebound benefits. 38 C.F.R. § 3.350(i). Accordingly, SMC based on being permanently housebound is not warranted. (Continued on the next page)   There are no additional issues expressly or reasonably raised related to the claim on appeal. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Mike A. Sobiecki, Associate Counsel