Citation Nr: 18154341 Decision Date: 11/29/18 Archive Date: 11/29/18 DOCKET NO. 16-27 519 DATE: November 29, 2018 ORDER Entitlement to service connection for a back disability is denied. Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for sleep apnea, to include as secondary to service connected disease or injury is granted. Entitlement to service connection for liver damage is denied. Entitlement to service connection for hepatitis C is denied. Entitlement to service connection for a disability affecting the vocal chords is denied. Entitlement to service connection for left leg Achilles tendonitis is denied. Entitlement to an initial rating greater than 50 percent for Posttraumatic Stress Disorder (PTSD) with Depression and Anxiety Disorder is denied. FINDINGS OF FACT 1. A back condition was not manifest in service and was not caused by any aspect of active service. 2. A left knee disability was not manifest in service, arthritis was not manifest within one year of service, and was not caused by any aspect of active service. 3. A right knee disability was not manifest in service, arthritis was not manifest within one year of service, and was not caused by any aspect of active service. 4. The Veteran’s obstructive sleep apnea is proximately due to or aggravated by her service-connected PTSD. 5. The Veteran does not have a liver disability. 6. The Veteran does not have hepatitis or residuals of hepatitis. 7. A disability affecting the vocal cords was not manifest in service and was not caused by any aspect of active service. 8. Left leg Achilles tendonitis was not manifest in service and was not caused by any aspect of active service. 9. The Veteran’s PTSD with depression and anxiety disorder manifested as occupational and social impairment with reduced reliability and productivity. Neither occupational and social impairment with deficiencies in most areas, nor total occupational and social impairment are shown during this period or symptoms on par with the level of this severity contemplated by the 70 or 100 percent ratings are shown. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a back disability are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for entitlement to service connection for a left knee disability are not met. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309. 3. The criteria for entitlement to service connection for a right knee disability are not met. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309. 4. The criteria for entitlement to service connection for sleep apnea are met. 38 U.S.C. § 1131; 38 C.F.R. § 3.310. 5. The criteria for entitlement to service connection for liver damage are not met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 6. The criteria for entitlement to service connection for hepatitis C are not met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 7. The criteria for entitlement to service connection for a disability affecting the vocal chords are not met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 8. The criteria for entitlement to service connection for left leg Achilles tendonitis are not met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 9. The criteria for an evaluation in excess of 50 percent for PTSD with depression and anxiety disorder are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.130 Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty as a U.S. Army administrative specialist from August 1979 to July 1982. Service Connection A veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active service. 38 U.S.C. §§ 1131. To establish a right to compensation for a present disability, a Veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service” - the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for a disease shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in-service. 38 C.F.R. § 3.303(d). Service connection for chronic disease may be granted if manifest to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “Chronic.” When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. 3.303(b). With respect to the current appeal, the list of current diseases includes arthritis. Service connection for a recognized chronic disease can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309. For secondary service connection, it must be shown that the disability for which the claim is made is proximately due to or the result of service-connected disease or injury, or that service-connected disease or injury has aggravated (increased in severity) the nonservice-connected disability for which service connection is sought. See 38 C.F.R. § 3.310 In evaluating a claim, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a “competent” source. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159 (a); Layno v. Brown, 6 Vet. App. 465, 470 (1994) (providing that a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis if (1) the medical issue is within the competence of a layperson, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Under applicable criteria, VA shall consider all lay and medical evidence of record in a case with respect to benefits under laws administered by VA. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to Service Connection for a Back Disability 2. Entitlement to Service Connection for a Left Knee Disability 3. Entitlement to Service Connection for a Right Knee Disability 4. Entitlement to Service Connection for a Disability Affecting the Vocal Chords The Veteran contends that she is entitled to service connection for bilateral knee disabilities, a back disability, and a disability affecting her vocal cords. She has not provided any rationale as to why she believes these conditions are caused by her service. The Veteran’s service treatment records (STRs) are associated with the claims file. There is no evidence that the Veteran sought treatment for her knees, back, or vocal cords at any time. At separation on the report of medical examination, the clinical examination of the lower extremities, spine, and musculoskeletal system was normal. See May 1982 separation examination. Her mouth and throat were also determined to be normal. At separation, the Veteran denied swollen or painful joints, bone, joint or other deformities, a “trick” or locked knee, or back pain. She marked that she had ear, nose or throat trouble, but did not elaborate. VA treatment records reflect that the Veteran was diagnosed with moderate lumbar stenosis and bilateral knee arthritis in May 2009, and a vocal polyp in November 2009. There is no evidence of manifestations of any of these conditions prior to 2009. The Board recognizes that the Veteran has not been afforded VA compensation and pension examination for knee, back, or vocal cords disabilities. A medical examination or medical opinion is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but: (1) contains competent evidence of a current diagnosed disability or persistent or recurrent symptoms of a disability; (2) establishes that an event, injury, or disease occurred in service or certain diseases manifested during an applicable presumptive period for which the claimant qualifies; and (3) indicates that the disability or symptoms may be associated with the established event, injury or disease in service or with another service-connected disability. McClendon v. Nicholson, 20 Vet. App. 79 (2006). VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to and mere conclusory generalized lay statement that service event or illness caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). The Board finds that the standards of McClendon are not met in this case. The evidence of record fails to show that any knee, back, or vocal cord conditions manifested during or were caused by service. VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to” and mere conclusory generalized lay statement that service event or illness caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Thus, the Board finds that VA examinations for knee, back, or a vocal cord conditions are not warranted. After a review of the evidence, the Board finds that any knee, back, or vocal cord disabilities are unrelated to service. There is no medical opinion that purports to relate a knee, back, or vocal cord disability to service or to a service-connected disability and there is no theory of entitlement provided by the Veteran. In summary, there is no evidence to support that the Veteran’s knee, back, or vocal cord disabilities are related to service. Because there is no evidence that a knee, back, or vocal cord disability is related to service, the weight of the evidence is against the claim; and the doctrine of reasonable doubt is not applicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 5. Entitlement to Service Connection for Sleep Apnea, to Include as Secondary to Service Connected Disease or Injury The Veteran contends that she is entitled to service connection for sleep apnea, secondary to her service-connected PTSD. STR’s do not reflect any manifestations of or treatment for a sleeping disorder, and the Veteran does not contend that a sleeping disorder began in service. The Veteran is currently diagnosed with obstructive sleep apnea. See February 2010 VA treatment records. The Veteran submitted a Disability Benefits Questionnaire (DBQ) and a corresponding opinion completed by Dr. H.S., a private physician in November 2016. On the opinion, Dr. H.S. stated that “[b]ased on my experience, interview with the Veteran, review of the medical records, and supporting medical literature, I feel it is as likely as not the Veteran’s service connected PTSD aided in the development and permanently aggravates her [obstructive sleep apnea].” As the physician’s address is listed in a state distant from the Veteran’s residence, any interview was likely electronic. The physician did not provide an adequate discussion of this Veteran’s medical history or physical presentation. Dr. H.S. also stated, with a footnote citation to a submitted 2005 medical journal article, that: A recent study found an arousal-based mechanism initiated by posttraumatic stress that promotes the development of [obstructive sleep apnea] in trauma survivors. The study also found that with CPAP treatment, both [obstructive sleep apnea] and PTSD symptoms decreased providing further evidence of the co-morbidity of these conditions. Based on my experience, interview with the Veteran, review of the medical records, and supporting literature, I feel it is as likely as not the Veteran’s anxiety aided in the development and permanently aggravates her [obstructive sleep apnea]. Upon review, the Board finds that the Veteran’s obstructive sleep apnea is proximately aggravated by her service-connected PTSD. The only competent opinion of record as to this issue is the November 2016 opinion from Dr. H.S. This opinion was provided by a doctor following interview with the Veteran but no physical examination. The opinion was supported by a rationale and citation to medical literature. The opinion is based entirely on the findings of the researchers who, based on their study of VHA data, find evidence of co-morbidity between patients with OSA and several mental health disorders. Except for the quotation above, most of the research addresses those patients with OSA and the coincidence of mental health disorders and not the reverse. There is no discussion of the physiological factors including the Veteran’s near 50-pound weight gain during service. Moreover, the opinion regarding the effect of treatment shows that treatment for OSA reduces the severity of anxiety but not the reverse as would be relevant to aggravation of OSA by mental health symptoms. Even though the Board finds that this opinion and research would warrant low probative weight, there is no competent opinion contrary to the conclusion provided by Dr. H.S. As such, the Board concludes that the criteria for entitlement to service connection for obstructive sleep apnea have been met and, in this regard, the Veteran’s claim is therefore granted. 38 U.S.C. § 1131; 38 C.F.R. § 3.310. 6. Entitlement to Service Connection for Liver Damage 7. Entitlement to Service Connection for Hepatitis C The Veteran contends that she is entitled to service connection for Hepatitis C and a liver condition. She has not provided any rationale as to why she believes these conditions are related to her service. The Veteran’s STRs are associated with the claims file. There is no evidence that the Veteran sought treatment for hepatitis C or a liver condition at any time. Hepatitis C or a liver condition were not noted in her May 1982 separation examination. At separation the Veteran explicitly denied jaundice or hepatitis. The Veteran was successfully treated for hepatitis C in 2004 and 2005. See May 2009 VA treatment records. In December 2007, diagnostic testing revealed that the Veteran was negative for hepatitis. Id. Hepatitis was also not detected in April 2015. Several diagnostic tests revealed that the Veteran’s liver was normal. See July 2013, March 2014, April 2015, and August 2015 VA treatment records. “Congress specifically limits entitlement to service-connected disease or injury where such cases have resulted in a disability... in the absence of a proof of present disability there can be no claim.” Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Court has held that the requirement for service connection that a current disability be present is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim even though the disability resolves prior to the Secretary’s adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Board recognizes that the Veteran has not been afforded VA compensation and pension examination for Hepatitis C or a liver condition. A medical examination or medical opinion is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but: (1) contains competent evidence of a current diagnosed disability or persistent or recurrent symptoms of a disability; (2) establishes that an event, injury, or disease occurred in service or certain diseases manifested during an applicable presumptive period for which the claimant qualifies; and (3) indicates that the disability or symptoms may be associated with the established event, injury or disease in service or with another service-connected disability. McClendon v. Nicholson, 20 Vet. App. 79 (2006). VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to and mere conclusory generalized lay statement that service event or illness caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). The Board finds that the standards of McClendon are not met in this case. The evidence of record fails to show that the Veteran has suffered from Hepatitis C or a liver condition at any time during the period of the appeal. VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to” and mere conclusory generalized lay statement that service event or illness caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Thus, the Board finds that a VA examination for Hepatitis C or a liver condition is not warranted. Having reviewed the medical evidence of record, the Board finds that the Veteran does not have hepatitis or a liver condition, and has not had such a diagnosis or disability at any time during the claims period. McClain, supra. In the absence of a disability, compensation may not be awarded. In the absence of evidence of a current disability, there can be no grant of service connection under the law. See Brammer, supra. The preponderance of the evidence establishes that the Veteran does not have hepatitis or a liver condition, and has not had such a disorder at any time during the pendency of this appeal. As the preponderance of the evidence is against the claims for service connection, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 8. Entitlement to Service Connection for Left Leg Achilles Tendonitis The Veteran contends that she is entitled to service connection for left leg achilles tendonitis. She has not provided any rationale as to why she believes this condition is related to her service. The Veteran’s STR’s reflect that she sought treatment for a painful left ankle in August 1980. Diagnostic testing revealed that there was no fracture. At separation on the report of medical examination in May 1982, the clinical examination of the lower extremities was normal. On a May 1982 Report of Medical History, she explicitly denied swollen or painful joints, or bone, joint or other deformities. A July 1982 Medical History Questionnaire reflects that the Veteran denied ever having swollen or painful ankles or joints. The Veteran was diagnosed with left achilles insertional tendinopathy in September 2008, more than 25 years following separation from service. The Veteran was afforded a VA examination in December 2015. She stated that she was unable to recall how she injured her left ankle. Following an examination of the Veteran and a review of the claims file, the examiner determined that the Veteran’s left ankle disability was less likely than not caused by her service. The examiner stated that the Veteran required surgery on her ankle in 2012 due to Haglund’s deformity and insertional Achilles tendinopathy. She explained that Haglund’s deformity is a bony enlargement of the back heel, which is sometimes impacted by an individual’s bone structure if high arches are present. In this case however, the Veteran has pes planus, making it less likely than not that her bone structure contributed to the development of an achilles condition. There is no probative medical or lay evidence in the record which suggests a causal relationship between the Veteran’s service and any left ankle disability. In short, the credible and probative evidence establishes that the Veteran’s left ankle disability was not manifest during service and is not caused by service. The Board concludes that the preponderance of the evidence is against the claim for entitlement for service connection for left leg Achilles tendonitis. As the preponderance of the evidence is against the claim for service connection, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Disability Ratings 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 resulting from disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Board has been directed to consider only those factors contained wholly in the rating criteria. Massey v. Brown, 7 Vet. App. 204 (1994). However, the Board has been advised to consider factors outside the specific rating criteria in determining the level of occupational and social impairment. Mauerhan v. Principi, 16 Vet. App. 436 (2002). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as “staged” ratings.” Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here uniform evaluations are warranted. The Board has reviewed all of the evidence of record, with an emphasis on the evidence relevant to this appeal. Although there is an obligation to provide reasons and bases supporting the Board’s decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board has summarized the relevant evidence where appropriate; and the analysis below focuses specifically on what the evidence shows, or fails to show, as to the claims on appeal. 9. Entitlement to an Initial Rating in Excess of 50 Percent for Posttraumatic Stress Disorder (PTSD) with Depression and Anxiety Disorder. The Veteran’s PTSD is assigned a 50 percent rating under Diagnostic Code 9411. 38 C.F.R. § 4.130. The Veteran’s military trauma involves sexual assault. The actual criteria for rating psychiatric disabilities other than eating disorders are contained in a General Rating Formula. Under that formula, a 50 percent rating is assigned 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 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; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted for occupational and social impairment with deficiencies in most areas-such as work, school, family relationships, judgment, thinking or mood-due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. The “such symptoms as” language means “for example,” and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The list of examples provides guidance as to the severity of symptoms contemplated for each rating. Id. However, this fact does not make the provided list of symptoms irrelevant. See Vasquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). The Veteran must still demonstrate either the particular symptoms associated with the rating sought or other symptoms of similar severity, frequency, and duration. Id. at 117. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission. 38 C.F.R. § 4.126. The rating agency shall assign an evaluation based upon all the evidence of record that bears on occupational and social impairment, rather than solely upon the examiner’s assessment of the level of disability at the moment of the examination. Id. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. Id. The records reflect that the Veteran has not been employed since August 2007. See Social Security Administration (SSA) medical records. A buddy statement reported that the Veteran had difficulty working because of her knees, ankles and back. See November 2007 SSA records. When asked how her illnesses, injuries or conditions limited her ability to work, the Veteran responded that she was limited by pain caused by her back and knees. She reported that she stopped working because of pain and disability. The SSA adjudicator also considered the results of a Mental Residual Functional Capacity Questionnaire dated in September 2008 in which a physician found the Veteran unable to meet competitive work standards or had no useful ability to function in several work abilities and aptitudes. The SSA determined that the Veteran was disabled due to her back disorder and other disorders of the gastrointestinal system. However, the adjudicator also attributed some dysfunction to anxiety and depression. VA treatment records reflect that the Veteran’s mental health was well managed and stable. In October 2010, clinicians noted that her participation in therapy for those who experienced military sexual trauma was positive with supportive family and denial of suicidal or homicidal ideations. Her depression was noted as partially in remission until November 26, 2012, when she called the VA suicide hotline. From this point forward, VA treatment records reflect that the Veteran periodically called the VA suicide prevention hotline, sometimes voicing suicidal ideation, or increased depressed mood. However, in December 2012, the Veteran reported that she had strong protective factors and would never consider suicide because it would hurt her mother. She reported attending church services twice per week. February 2013 VA treatment records reflect that the Veteran sought medical attention due to increased worry, feelings of loneliness, self-doubting, and increased reflection on past traumatic experiences. The Veteran reported that church attendance and communication with a friend improved her mood. May 2013 VA treatment records reflect a clinician’s opinion that the Veteran had was a high suicide risk, demonstrating desire, intent and capability. It was noted that the absence or presence of buffers may increase or decrease the Veteran’s risk. See June 2013 VA treatment records. September 2013 VA treatment records reflect that the Veteran was tearful and dysphoric. In October 2013, the Veteran was invited to participate in a therapy group that met in the evenings. She declined because of financial constraints and stated that she was unable to travel at night alone. See October 2013 VA treatment records. A July 2014 statement by the Veteran’s mother and sister are of record. The Veteran’s mother stated that the Veteran frequently called her at night, in tears, worried that someone was in her home. She said that the Veteran appears very sad most of the time and stays in bed six day a week. The Veteran’s mother also said that the Veteran would not go anywhere in the dark and was “jumpy.” The Veteran’s sister reported that the Veteran attended family events but isolated herself. The Veteran’s sister said that the Veteran attended church, but was unable to focus. October 2014 VA treatment records reflect that the Veteran continued to have a strong support system of family, friends, and members from her hall. She also stated that she intended to attend her high school reunion. September 2015 VA treatment records reflect that the Veteran believed that her past two marriages were with emotionally abusive partners, and that she would continue to make poor choices selecting partners because of her past trauma. She stated that while she did want to be in a healthy relationship, she thought it was an impossibility. The Veteran submitted a Disability Benefits Questionnaire (DBQ), completed by a private psychologist in January 2015, who determined that the Veteran’s mental health disabilities were manifested by depressed mood, anxiety, suspiciousness, more than weekly panic attacks, near-continuous panic or depression, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty establishing and maintaining effective relationships, suicidal ideation, persistent delusions or hallucinations, neglect of personal hygiene and intermittent inability to perform activities of daily living. The private psychologist noted that the Veteran had been married and divorced twice, and struggled to enter into new relationships. The psychologist provided a one-sided summary of selected observations by others while failing to mention any of the Veteran’s positive functional capabilities. The private psychologist commented on occupational function without any mention of the Veteran’s education, skills, experience, cognitive, and communications capabilities or that she was able to live alone and leave the home when so desired. The private psychologist ultimately concluded that the Veteran’s mental health disabilities caused occupational and social impairment with deficiencies in most areas-such as work, school, family relationships, judgment, thinking or mood. The Veteran has not been afforded a VA examination. In many of the mental health reports the Veteran has reported and the treating physician has noted sleep impairment; recurrent, involuntary, and intrusive distressing memories; avoidance behavior; isolative behaviors; and depressed mood. The Veteran has reported periodic suicidal ideation. The Veteran has never exhibited illogical, obscure, or irrelevant speech, reports of panic attacks, obsessive rituals, or neglect of personal hygiene. VA treatment records reflect regular, continued care for mental health, where the Veteran denied experiencing hallucinations or delusions, appeared well-groomed, organized and logical, and alert and attentive. She regularly discussed her church attendance and relationships with family and friends, and as noted above, discussed plans to go to large social gatherings. While the Board accepts that the Veteran’s PTSD traits moderately affect her functioning, with some episodic evidence of suicidal ideation, intimate relationship difficulties, and isolative behaviors, a higher rating is not warranted because the impairment does not more nearly approximate deficiencies in most areas. The Board considered the detailed documentation of the crisis line calls and finds that the Veteran expressed loneliness, intrusive thoughts, and depressed mood but that the ideations were always mitigated by an admission that she would never carry it out because it would hurt her family and because she did not want outside intervention. During most in person clinical evaluations, the Veteran denied any suicidal ideations. Throughout the period of the claim, there is no evidence that the Veteran exhibited symptoms of obsessional rituals that interfere with routine activities, illogical, obscure, or irrelevant speech, 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 or hygiene, difficulty in adapting to stressful circumstances, or inability to establish and maintain effective relationships. Rather, the Veteran exhibited clear, linear thought, was fully oriented, exhibited no periods of violence, maintained good hygiene, maintained relationships with her family, friends and church community, and exhibited no delusions, obsessive rituals, or hallucinations. Even though her mother reported that the Veteran was afraid of leaving the home at night and stayed in bed often, the Veteran was able to participate in therapy sessions with others and attend church and reunion functions. As noted, a 70 percent rating requires a level of occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near -continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish effective relationships. The Board notes that the Court of Appeals for the Federal Circuit (Federal Circuit) held in Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013) that “in the context of a 70 percent rating, § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas.” The Board has considered the September 2009 SSA mental health observations and the January 2015 private opinion which determined that the Veteran’s PTSD caused occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, however this opinion is considered less probative than the extensive VA treatment records. The Veteran has explicitly and routinely denied hallucinations. She has always appeared well groomed with good hygiene and did not report panic attacks. She has not reported that her mental health disability infringed on her ability to perform activities of daily living, and maintains relationships with friends and family. Although she reported suicidal ideations with calls to a prevention hot-line, there is no evidence of attempts or any situations requiring immediate medical intervention or that the reported ideations caused some form of functional impairment. Rather, the Veteran reported that suicide was not contemplated because of her family relationships. Additionally, as the psychologist’s address is listed in a state distant from the Veteran’s residence, any interview was likely electronic. In short, the Board finds that the overall severity, frequency, and duration of the Veteran’s symptoms are on par with the level of severity contemplated by the 50 percent rating criteria. The Veteran regularly engages with friends, family, and her church. Additionally, as reflected in SSA records, her unemployment is caused primarily by nonservice-connected disabilities but with some contribution from her mental health disability. Even affording the Veteran full competence and credibility, the evidence in aggregate is best assessed as occupational and social impairment at the 50 percent level under the schedular criteria. In summary, for the reasons and bases set forth above, the Board concludes that an initial increased rating greater than 50 percent is not warranted. In a January 2015 record review and opinion but no in person examination, the consulting psychologist included a comment that the Veteran could not sustain stress in or adapt to a competitive work environment or be expected to engage in gainful activity. The psychologist noted that the Veteran left a manufacturing job in 2007 but left because of the way she was treated by coworkers. There was no discussion of the Veteran’s education, job skills, participation in and responsiveness to therapy, or how accommodations are required to be provided by many employers by law. The Board finds that there is insufficient foundation for this opinion to raise an issue of unemployability on an extraschedular basis solely because of the mental health disorder. (Continued on the next page)   Additionally, the Board notes that neither the Veteran nor her representative has raised any other issues, nor have any other issues been raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of records). J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Fitzgerald, Associate Counsel