Citation Nr: 18151433 Decision Date: 11/20/18 Archive Date: 11/19/18 DOCKET NO. 16-11 714 DATE: November 20, 2018 ORDER Whether new and material evidence has been received sufficient to reopen a claim of service connection for bilateral hearing loss is granted. Whether new and material evidence has been received sufficient to reopen a claim of service connection for tinnitus is granted. An increased rating for type 2 diabetes mellitus with diabetic retinopathy and erectile dysfunction is dismissed. An increased rating for left knee shrapnel wound scar is denied. An increased rating for posttraumatic stress disorder (PTSD) to 50 percent is granted. REMANDED Service connection for bilateral hearing loss is remanded. Service connection for tinnitus is remanded. A total disability rating based on individual unemployability due to service connected disability (TDIU) is remanded. FINDINGS OF FACT 1. In a September 2008 rating decision, the RO denied service connection for bilateral hearing loss and tinnitus; the Veteran did not timely initiate an appeal of that decision within one year of notification. 2. Evidence added to the record since the September 2008 rating decision denying service connection for bilateral hearing loss relates to an unestablished fact necessary to substantiate that claim and raises a reasonable possibility of substantiating that claim. 3. Evidence added to the record since the September 2008 rating decision denying service connection for tinnitus relates to an unestablished fact necessary to substantiate that claim and raises a reasonable possibility of substantiating that claim. 4. On February 4, 2017, prior to the promulgation of a decision in the appeal, the Board received notification from the appellant, through his authorized attorney representative, that a withdrawal of his appeal on the issue of increased rating for type 2 diabetes mellitus with diabetic retinopathy and erectile dysfunction is requested. 5. The Veteran’s left knee shrapnel wound scar manifests as a linear scar measuring 2.5 cm that is not painful or unstable and does not result in functional impairment of the left knee. 6. The Veteran’s PTSD results it occupational and social impairment with reduced reliability and productivity due to symptoms including depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, feelings of hopelessness and worthlessness, irritability, hypervigilance, concentration problems, and decreased motivation. CONCLUSIONS OF LAW 1. The September 2008 RO decision that denied service connection for bilateral hearing loss and tinnitus is final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §20.1103 (2018). 2. The criteria for reopening a claim of entitlement to service connection for bilateral hearing loss have all been met. 38 U.S.C. § 5108 (2012); 38 C.F.R. §3.156 (a) (2018). 3. The criteria for reopening a claim of entitlement to service connection for tinnitus have all been met. 38 U.S.C. § 5108 (2012); 38 C.F.R. §3.156 (a) (2018). 4. The criteria for withdrawal of an appeal on the issue of an increased rating for type 2 diabetes mellitus with diabetic retinopathy and erectile dysfunction by the Veteran have been met. 38 U.S.C. § 7105(b)(2), (d)(5) (2012); 38 C.F.R. § 20.204 (2018). 5. The criteria for an increased rating for left knee shrapnel wound scar have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.118, Diagnostic Code (DC) 7800-7802, 7804-7805 (2018). 6. The criteria for a 50 percent rating, but not higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code (DC) 9411 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1968 to December 1970. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from January 2015 and March 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. The January 2015 rating decision denied the Veteran’s claims for increased ratings for diabetic retinopathy, posttraumatic stress disorder, type 2 diabetes mellitus with diabetic retinopathy and erectile dysfunction, and left knee shrapnel scar and denied TDIU. The March 2015 rating decision denied the Veteran’s attempts to reopen his previously denied claims of service connection for bilateral hearing loss and tinnitus, denied service connection for emphysema, and denied the Veteran’s claim for additional special monthly compensation. Service Connection 1. Whether new and material evidence has been received sufficient to reopen a claim of service connection for bilateral hearing loss 2. Whether new and material evidence has been received sufficient to reopen a claim of service connection for tinnitus Prior to the filing of the current claim of entitlement to service connection for bilateral hearing loss and tinnitus, the AOJ previously denied claims of service connection for bilateral hearing loss and tinnitus in September 2008. Generally, a claim which has been denied in an unappealed AOJ decision is final and may not thereafter be reopened and allowed. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §20.1100 (2018). Once the AOJ makes a determination as to a claim, it must mail to the claimant, and his or her representative if there is one, proper notice of the decision, including notice of the claimant’s procedural due process and appellate rights. 38 U.S.C. § 7105 (b)(1) (2012); 38 C.F.R. §§ 3.103 (b)(1), 19.25, 20.1103 (2018). An appeal of an AOJ decision to the Board is initiated by the filing of a notice of disagreement (NOD) with the decision. 38 U.S.C. § 7105 (a) (2012); 38 C.F.R. § 20.200 (2008). An NOD is a statement, reduced to writing, which can reasonably be construed as expressing dissatisfaction with the AOJ’s decision and a desire to contest the result. 38 U.S.C. § 7105 (b); 38 C.F.R. § 20.201 (2008). Except in the case of simultaneously contested claims (which this is not) the NOD must be filed within one year from the date of mailing of result of the initial determination. See 38 U.S.C. § 7105 (b)(1); see also 38 C.F.R. §§ 20.200, 20.201, 20.302 (2008). If a timely NOD is not filed, the determination becomes final and the claim will not thereafter be reopened or allowed, except as may otherwise be provided by regulations not inconsistent with Title 38 of the U.S. Code. 38 U.S.C. § 7105 (c) (2012). If the claimant files a timely NOD and the disagreement is not resolved, the AOJ must provide the claimant and his or her representative, if there is one, with an SOC. 38 U.S.C. § 7105 (d) (2012); 38 C.F.R. § 19.30 (2018). As a general rule, the appellant must file a substantive appeal within 60 days of the mailing of the SOC or within one year of the notice of the decision being appealed, whichever is later. 38 U.S.C. § 7105 (d)(1); 38 C.F.R. § 20.302 (b) (2018). A substantive appeal consists of a properly completed VA Form 9 or a correspondence containing the necessary information. 38 C.F.R. § 20.200 (2008). If a claimant fails to respond after receipt of the SOC, the AOJ may close the case. 38 U.S.C. § 7105 (d)(3); 38 C.F.R. § 19.32 (2012). Once the AOJ closes the case for failure to complete the appeal to the Board, the AOJ decision is final. 38 U.S.C. § 7105 (c); 38 C.F.R. § 20.1103. The exception to this rule of not reviewing the merits of a finally denied claim is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. The regulation that implements 38 U.S.C. § 5108 defines “new and material evidence” as evidence not previously submitted to agency decision makers which is neither cumulative nor redundant of evidence previously of record, and which by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim, and which raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2018). New evidence means existing evidence not previously submitted to agency decision makers. 38 C.F.R. § 3.156(a). Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. New and material evidence can be neither cumulative nor redundant of the evidence already of record and must raise a reasonable possibility of substantiating the claim. Id. Of note, under 38 C.F.R. § 3.156(b), “new and material” evidence received prior to the expiration of the appeal period will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. If VA receives new evidence within the appeal period of an AOJ decision, it must make a determination as to whether the evidence is new and material and if it does not do so then the claim does not become final but rather it remains pending. See Beraud v. McDonald, 766 F.3d 1402, 1406-07 (Fed. Cir. 2014). In determining whether evidence is “new and material,” the credibility of the evidence in question must be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The September 2008 rating decision denied service connection for hearing loss because there was no evidence showing a current, chronic bilateral hearing loss that began during or was caused by military service and no evidence showing that chronic sensorineural hearing loss became manifest to a compensable degree within one year of the Veteran’s release from active duty, such as would be necessary to establish service connection on a presumptive basis. With regard to his tinnitus claim, this rating decision denied service connection because there was no evidence showing the Veteran’s tinnitus had begun during or was caused by military service. The evidence received since the September 2008 rating decision includes treatment records showing tinnitus, worsening hearing, and issuance of hearing aids and medical articles suggesting that noise-induced hearing loss and tinnitus can have a delayed onset, in direct contradiction to the August 2008 negative medical opinion. Thus, this new evidence relates to an unestablished fact necessary to substantiating the claim. See Shade v. Shinseki, 24 Vet. App. 110 (2010). Accordingly, the Board concludes that the criteria for reopening claims of service connection for bilateral hearing loss and tinnitus have been met. Increased Rating 3. An increased rating for type 2 diabetes mellitus with diabetic retinopathy and erectile dysfunction The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105 (20142). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2018). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, the appellant, through his authorized attorney representative, has withdrawn his appeal on the issue of an increased rating for diabetes in a January 2017 communication received February 4, 2017 and, hence, there remain no allegations of errors of fact or law for appellate consideration regarding this issue. Accordingly, the Board does not have jurisdiction to review the appeal on this issue and it is dismissed. 4. An increased rating for left knee shrapnel wound scar The Veteran was originally granted service connection for left knee shrapnel wound in a March 1973 rating decision, which rated this disability noncompensable (0 percent) effective December 10, 1970. In a June 2014 rating decision, the Veteran’s separate claims of service connection for bilateral knee conditions to include pain, stiffness, soreness, and loss of range of motion were denied. The Veteran did not appeal those denials and they are not before the Board. His current claim for an increased rating was received on August 22, 2014. Disability ratings are determined by applying the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran’s disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. 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. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as “staging the ratings.” See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). This disability is currently rated under Diagnostic Code (DC) 7805. This diagnostic code provides compensation under an appropriate diagnostic code for other effects of scars not considered in a rating provided under diagnostic codes 7800-04. See 38 C.F.R. 4.118. In a February 2014 statement, the Veteran reported worsening scar symptoms including general pain in the area. In May 2014, the Veteran underwent a VA examination in conjunction with this claim. At that time, he reported no current concern, noting that his left knee scar remained the same as in service. This scar was linear, measuring 1 cm. It was not painful or unstable. It was not due to burns. This scar did not result in limitation of function. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms associated with this scar. This scar did not impact his ability to work. In April 2016, the Veteran underwent a VA examination in conjunction with this claim. At that time, the examiner noted a faded, stable scar near medial middle section of left patella that was superficial and not adherent to underlying soft tissue. It was not painful or unstable. It was not due to burns. There was no edema or keloid. The Veteran’s gait was normal. This linear scar measured 2.5 cm. This scar did not result in limitation of function. With active range of motion of the left knee, there was no popping or crepitus and his range of motion appeared full. There was no left antalgia with ambulation. This scar did not impact his ability to work. In a January 2017 statement, the Veteran’s son reported noticing knee trouble with sitting and standing “always.” Eventually, the Veteran developed a limp. In a January 2017 statement, the Veteran’s wife reported noticing stiffness and pain in the Veteran’s knee. She would see him stand for a while and then sit, then stand and flex his leg, trying to get comfortable. While the lay evidence discussing mobility issues and pain in the Veteran’s knee, this has not been medically linked to the Veteran’s service connected left knee shrapnel scar. Again, the Board notes that the issue of a left knee joint disability is not before the Board because it was not appealed. Thus, only symptoms associated with the left knee shrapnel scar will be considered in assigning a rating. Based on the above, the Veteran’s left knee shrapnel wound scar does not warrant a compensable rating. The symptoms associated with this left knee shrapnel scar are a linear scar measuring no more than 2.5 cm, which is consistent with the current noncompensable rating. See 38 C.F.R. § 4.118. This scar is not located on the Veteran’s head, face, or neck, so a higher rating is not available under DC 7800. Id. There is no showing that this scar is deep or nonlinear or that it covers a total area greater than six square inches as required for a compensable rating under DC 7801. Id. Similarly, there is no evidence that this scar covers a total area greater than 144 square inches as required for a compensable rating under DC 7802. Id. This scar was not painful or unstable, which is required for compensation under DC 7804. Id. This scar is not noted to have any other effects for which compensation could be established under DC 7805. Id. Thus, the Board finds that the preponderance of the evidence is against a compensable rating for left knee shrapnel wound scar. Hence the appeal as to a compensable rating for this disability must be denied. There is no reasonable doubt to be resolved as to this issue. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. 5. An increased rating for posttraumatic stress disorder (PTSD) The Veteran was originally granted service connection for posttraumatic stress disorder (PTSD) in a July 1983 rating decision, which rated this disability noncompensable (0 percent) effective March 22, 1983. In a September 2005 rating decision, this rating was increased to 30 percent effective June 21, 2005. In a January 2014 rating decision, the Veteran was awarded a temporary total rating based on hospitalization effective September 9, 2013. His rating returned to 30 percent on November 1, 2013. The Veteran’s current claim for an increased rating was received on August 22, 2014. PTSD is evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Under that General Rating Formula, the current 30 percent rating is warranted for 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 for 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 for 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 worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation 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. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term “such as” in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002); see also Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013). In Vazquez-Claudio, the Federal Circuit stated: Entitlement to a 70 percent disability rating requires sufficient symptoms of the kind listed in the 70 percent requirements, or others of similar severity, frequency or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation. The 70 percent disability rating regulation contemplates initial assessment of the symptoms displayed by the veteran, and if they are of the kind enumerated in the regulation, an assessment of whether those symptoms result in occupational and social impairment with deficiencies in most areas. Language in Vasquez-Claudio indicates that symptoms other than those listed, which are “others of similar severity, frequency, and duration,” can be thought of as symptoms of like kind to those listed in the regulation for a given disability rating. Id. at 116. What this case makes clear is that first the Board must look at the symptoms suffered by the Veteran and if he has a symptom or symptoms listed in a given set of criteria, or a symptom or symptoms of similar severity, frequency, and duration to those listed, then the Board must assess of whether those symptoms or symptom result in the level of impairment corresponding to the criteria. This level of impairment is generally stated in the initial words of each set of criteria; for example, total occupational and social impairment for the 100 percent rating and occupational and social impairment with deficiencies in most areas or 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 for the 30 percent rating (although the 70 percent criteria does not strictly adhere to this description). VA treatment records show ongoing sleep complaints associated with the Veteran’s PTSD. In his February 2014 statement, the Veteran reported trouble sleeping, depression, anxiety, night sweats, nightmares, and survivor’s guilt. He stated that at night he heard the sounds of Vietnam. In May 2014 the Veteran underwent a VA PTSD examination. This examiner found that the Veteran’s PTSD resulted in 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, or; symptoms controlled by medication. The Veteran remarried three years earlier and reported having a good relationship with his wife. He also reported good relationships with his two children. He had good friends whom he visited often. He regularly attended alcoholics anonymous meetings. He stayed active and belonged to several veterans’ organizations. He reported that he had been forced to retire from his position as a drug and alcohol counselor at a job corps center in May 2013. He reported completion of a seven-week residential PTSD program in the Fall of 2013, noting that he had wanted to attend previously, but had not had the time because of work. After losing his job, he went through the program and found it helpful. The Veteran denied any legal problems since his 2005 examination and reported continued sobriety since 1984. His PTSD symptoms included depressed mood, anxiety, suspiciousness, and chronic sleep impairment. He was alert and oriented. His grooming and dress were appropriate. He had good eye contact. He was in no apparent pain or distress. He was friendly and cooperative and gave good effort. His social skills and insight were good. His speech and thought content were unremarkable. He described his mood as “peaks and valleys,” but he strove to be in a good mood around his wife. His affect was appropriate. He described his energy level as fair, noting ongoing sleep problems and afternoon naps. His self-esteem was good. He felt good about his future. He reported symptoms of depression a few times a week, lasting a day. He denied anxiety and panic attacks. He described his concentration and memory as good. He denied psychosis or current suicidal or homicidal ideation. The examiner found the Veteran’s PTSD symptoms were relatively unchanged since the prior examination in 2005. The Veteran continued to have some distress but was functioning well socially and had been functioning well occupationally until he was forced to retire for reasons unrelated to his mental health. A December 2014 employability opinion noted that the Veteran’s PTSD would lead to social and occupational impairment with intermittent periods of inability to perform occupational duties with occasional decrease in work efficiency. The Veteran would be capable of manual labor, skilled labor, or administrative assisting\clerical or higher-level duties. He had no functional restrictions due to his PTSD. In February 2016 the Veteran underwent a VA PTSD examination in conjunction with this claim. At that time, he reported mild working memory problems, which would reduce his productivity and efficiency to some extent. The examiner noted that the Veteran made no mention of mental health issues in the context of his May 2013 retirement. This examiner found that the Veteran’s PTSD resulted in occupational and social impairment with occasional decrease work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily. The Veteran continued to live with his wife of five years and described their marital relationship as “really good.” He also described his current relationship with his two adult children as good. His parents were deceased, but he maintained monthly contact with his older sister. He had a lot of acquaintances, but stated that he did not have any close friends. He spent his time watching television, going to the casino, and exercising three times a week. The Veteran had not worked since his May 2013 retirement, which he attributed to his pulmonary condition. The Veteran denied any legal problems and reported continued sobriety since 1984. His PTSD symptoms included depressed mood, anxiety, chronic sleep impairment, mild memory loss, passive suicidal ideation without intent, and feelings of hopelessness. He was adequately groomed in casual dress with an oxygen cannula in his nostrils. He was alert and well oriented. His affect was stable and relaxed. His thought and speech processes were logical and coherent. He described his typical mood as a little hypervigilant, he tried to maintain a good mood to get along with people, and his temper was not as good as it used to be. He reported depressed mood three times a week with trouble sleeping. He reported feeling hopeless and having passive suicidal ideation without intent or plan. His energy level was “pretty low” and he had gained twenty pounds in the prior four months without any changes in appetite. His self-esteem was no longer high. He reported anxiety, described as “impending doom.” He denied panic attacks. He was often irritable but tried to internalize it to keep it in check. He reported poor sleep quality, with trouble staying asleep. On average he slept four hours per night. His memory and concentration were somewhat reduced. He reported poor memory for names, but denied any memory-related problems. He was cooperative with the examiner. In a December 2016 PTSD disability benefits questionnaire (DBQ), a private psychologist diagnosed the Veteran with PTSD, major depressive disorder, panic disorder, and somatic symptom disorder persistent with predominant pain. This psychologist found it not possible to differentiate which psychiatric symptoms were attributable to which diagnosis. The Veteran’s PTSD symptoms included depressed mood, anxiety, irritation, anger outburst, emotional estrangement, restricted emotional range, social withdrawal, guilt, thoughts of death, less interest in sex, hopelessness, feelings of worthlessness, hypervigilance, recurrent trauma recollection, pain behaviors, suspiciousness, chronic sleep impairment, sleep disturbance, nightmares, poor problem solving, trauma-related avoidance, impairment of short and long term memory, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships, , and difficulty adapting to stressful circumstances. She found that the Veteran was totally socially and occupationally impaired due to his psychiatric symptoms. Despite this psychologist’s findings, this DBQ notes that the Veteran had an excellent relationship with his half-brother and great relationships with his adult children and his current wife. He had three grandchildren. The Veteran had a strong support system, including two friends that he could rely on. He felt closest to his wife. He felt less anxious around former military and enjoyed attending American Legion meetings if his symptoms allowed. He avoided social interaction outside of his small support group. He was able to go to significantly limited places in public where he engaged in minimal interactions. He was not currently receiving therapy for his PTSD, but was taking medication with low therapeutic effectiveness. He reported suicidal thoughts in the past without attempt. Currently he had significant thoughts of death. This DBQ reiterated that the Veteran retired in 2013 due to medical issues. The Veteran smoked a pack of cigarettes a day, but had retained his sobriety for more than three decades. As this psychologist’s finding of total social and occupational impairment is directly contradicted by the remainder of the evidence included in this DBQ, which show strong social ties with a small group of people, that finding itself is of no probative value. The enumerated symptoms, however, are probative. In a December 2016 DBQ addendum, this private psychologist found that all the Veteran’s psychiatric diagnoses were attributable to his active duty military service. The Veteran’s major depressive disorder was characterized by depressed mood most of the day nearly every day, loss of interest/pleasure, increase in appetite, hypersomnia, psychomotor agitation, fatigue, feelings of worthlessness and excessive guilt, problems thinking and concentrating, and recurrent thoughts of death. His panic disorder manifest as an abrupt surge of intense fear and discomfort with heart palpitations, sweating, feelings of choking, shaking, shortness of breath, chest pain, nausea, dizziness, chills, fear of dying, abdominal distress, paresthesias, derealization, depersonalization, fear of losing control; recurrent unexpected attacks; persistent concerns and worries about additional attacks or their consequences; and significant maladaptive change in behavior related to attacks. His somatic symptom disorder resulted in two or more somatic symptoms that were distressing and resulted in disruption of daily life, excessive time and/or energy directed to these symptoms, persistent high level of anxiety regarding symptoms. These somatic symptoms were persistent. Predominantly pain was present. His generalized anxiety disorder was characterized by excessive anxiety and worry, more days than not, about a number of events and activities; difficulty controlling the worry; feeling keyed up or on edge; mind going blank or difficulty concentrating; irritability; muscle tension; sleep disturbance; and anxiety. His agoraphobia manifest as marked fear or anxiety in unfamiliar places, enclosed places, crowds, social gatherings of more than five people, and traffic. The Veteran feared and avoided these situations because thoughts of escape might be difficult or symptoms might be incapacitating or embarrassing. The agoraphobic situation almost always provoked fear or anxiety and was actively avoided or endured with intense fear or anxiety. The fear or anxiety was disproportionate and persistent. These conditions caused clinically significant distress and impairment. The Veteran’s PTSD symptoms included intrusive memories, nightmares, flashbacks, intense or prolonged psychological distress and marked physiological reaction at exposure to internal or external cues that symbolize or resemble an aspect of his traumatic event, avoidance of internal and external stimuli associated with trauma, inability to remember an important aspect of the traumatic event, persistent and exaggerated negative beliefs or expectations, persistent negative emotional state, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, persistent inability to experience positive emotions, irritable behavior and angry outbursts, hypervigilance, exaggerated startle response, concentration problems, and sleep disturbance. In his January 2017 statement, the Veteran’s son stated that the Veteran got angry easily. They had had a strained relationship when he was growing up. The Veteran was always on edge and could associated only with other Vietnam veterans. In her January 2017 statement, the Veteran’s wife reported angry outburst at least once a week prior to achieving sobriety and less often since; anxiety; difficulty with crowds, darkness, loud noises, and having his back to a door; periods of social withdrawal; depression with feelings of worthlessness and lack of motivation to see people or leave the house; lack of emotion on his face; feelings of guilt; and sleep problems including nightmares and night terrors. He distrusted everyone except his wife. His PTSD made him tired, which had caused him to fall asleep at work. Attempts to accommodate him were unsuccessful. Based on the above, the Veteran’s current PTSD symptoms have resulted in occupational and social impairment with reduced reliability and productivity. His symptoms included depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, feelings of hopelessness and worthlessness, irritability, hypervigilance, concentration problems, and decreased motivation which is consistent with a 50 percent rating. See 38 C.F.R. § 4.130, DC 9411. A rating higher than the current 50 percent would require occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. See 38 C.F.R. § 4.130, DC 9411. Neither these symptoms nor other symptom of similar severity, frequency or duration are shown. The record does not show any impairment of family relations, work, judgement, or thinking. Indeed, the record shows that during this appeals period the Veteran has maintained strong relationships with his family and has at least some limited social interactions with other, described variously as acquaintances or close friends. While the lay evidence shows that the Veteran previously had strained relationships with family members, this was reported to have occurred outside of the current appeals period and is not relevant to the Veteran’s current evaluation. Occupationally, the Veteran has not worked during this appeals period. His wife attributes this to sleepiness caused by PTSD. This contention is not mentioned elsewhere in the record and contradicts the Veteran’s repeated reports that his non-service connected pulmonary condition led to the termination of his employment. Furthermore, the December 2014 employability opinion specifically found that the Veteran had no functional restrictions due to his PTSD. The record does not show impaired judgment and his thought processes were never found to impaired. Thus, the Board finds that the Veteran’s PTSD symptoms warrant an increased rating to 50 percent, but not more; to that extent the appeal is granted. In making this determination the Board has not ignored the reports of suicidal thoughts from the February 2016 VA examination report. That report also shows that the Veteran’s thoughts do not result in the level of impairment contemplated by the 70 percent or 100 percent criteria. As such, the presence of such thoughts does not make his disability picture more closely approximate the criteria for the 70 percent rating. Also considered are the reports of anger outbursts and difficulty with his anger. However, the record does not show impaired impulse control as described in the schedular criteria or any symptoms of like kind. Nor does the record show total social and occupational impairment, as is required for the 100 percent rating. Again, although the private psychologist indicated in her December 2016 DBQ that the Veteran had total social and occupational impairment, that finding was completely contradicted by the symptoms and history described within that document and throughout the remainder of the record. Thus, the Board finds that the Veteran’s PTSD symptoms do not warrant a rating higher than 50 percent. REASONS FOR REMAND 6. Service connection for bilateral hearing loss is remanded. 7. Service connection for tinnitus is remanded. The Board cannot make a fully-informed decision on the issues of service connection for bilateral hearing loss because no VA examiner has opined whether this conditions could be delayed onset reactions to in-service noise exposure as suggested in the medical articles submitted by the Veteran’s attorney. 8. A total disability rating based on individual unemployability due to service connected disability (TDIU) is remanded. Finally, because a decision on the remanded issues of service connection for bilateral hearing loss and tinnitus could significantly impact a decision on the issue of TDIU he issues are inextricably intertwined. A remand of the claims for TDIU is required. The matters are REMANDED for the following action: 1. Ensure that the Veteran is scheduled for an examination by an appropriate clinician to determine the nature and etiology of any bilateral hearing loss and/or tinnitus. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including noise exposure, to specifically include any such injury, event, or disease, including noise exposure, during a period of active duty for training injury to include noise exposure during a period of inactive duty for training. 2. After the above development, and any additionally indicated development, has been completed, readjudicate the issue on appeal, including the inextricably intertwined issue of TDIU. If the benefit sought is not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. JAMES G. REINHART Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Houbeck, Counsel