Citation Nr: 18156026 Decision Date: 12/06/18 Archive Date: 12/06/18 DOCKET NO. 13-23 512 DATE: December 6, 2018 ORDER The claim of entitlement to service connection for a liver disability is denied. The claim of entitlement to an evaluation in excess of 70 percent for posttraumatic stress disorder (PTSD) since December 5, 2013 is denied. REMANDED The claim of entitlement to an evaluation in excess of 30 percent for PTSD prior to December 5, 2013, is remanded. The claim of entitlement to an effective date earlier than December 5, 2013, for the grant of total disability based on individual unemployability due to service-connected disabilities (TDIU) is remanded. The claim of entitlement to an effective date earlier than December 5, 2013, for the grant of Dependents’ Educational Assistance (DEA) is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran has a liver disability due to a disease or injury in service or caused by or aggravated by a service-connected disability. 2. Since December 2013, the Veteran’s PTSD manifested with symptoms most closely analogous to occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, but did not rise to the level of a total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for service connection for a liver disability are not met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.310(a) (2018). 2. The criteria for an evaluation in excess of 70 percent for PTSD since December 5, 2013, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service with the United States Army from May 1968 to May 1970, to include service in the Republic of Vietnam. Service Connection Generally, service connection will be granted for a disability resulting from an injury or disease caused or aggravated by service. 38 U.S.C. §§ 1110 (2012). A grant of service connection for a disability requires: (1) a present disability or persistent or recurrent symptoms of a disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship (“nexus”) between the present disability and the in-service event, injury, or disease. 38 C.F.R. § 3.303; see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In order to prevail under a theory of secondary service connection, there must be: (1) evidence of a current disorder; (2) evidence of a service-connected disability; and, (3) medical nexus evidence establishing a connection between the service-connected disability and the current disorder. See Wallin v. West, 11 Vet. App. 509, 512 (1998). In addition, the regulations provide that service connection is warranted for a disorder that is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected disability, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected disability, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary disorder, the secondary disorder shall be considered a part of the original disability. When determining service connection, a presumption of soundness applies. 38 U.S.C. § 1111; 38 C.F.R. § 3.304 (b). Pursuant to such presumption, a Veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by such service. Only such conditions as are recorded in examination reports are to be considered as noted. The presumption of soundness also applies to congenital diseases that are not noted upon entry into service. Quirin v. Shinseki, 22 Vet. App. 390 (2009). Accordingly, service connection may be granted for congenital hereditary diseases that either first manifest during service, or which preexist service and progressed at an abnormally high rate during service. VAOPGCPREC 67-90; 55 Fed. Reg. 43, 253 (1990). “Only when symptomatology and/or pathology exist can he or she be said to have developed the disease.” Id. At what point the individual starts to manifest the symptoms of, or have pathological changes associated with the disease is a factual, not a legal issue. This must be determined in each case based on all the medical evidence of record. Id. The presumption of soundness does not apply to congenital defects because such defects “are not diseases or injuries” within the meaning of 38 U.S.C. §§ 1110 and 1111. See 38 C.F.R. § 3.303 (c); see also Quirin v. Shinseki, 22 Vet. App. 390 (2009) (holding that the presumption of soundness does not apply to congenital defects). Congenital defects are by definition static in nature, and thus the litmus test for distinguishing a congenital defect from a congenital disease is whether the disorder in question is subject to change. See VAOPGCPREC 67-90. As explained in the precedential General Counsel opinion, “congenital or developmental defects are normally static conditions which are incapable of improvement or deterioration.” Id. The opinion states further: “A disease, on the other hand, even one which is hereditary in origin, is usually capable of improvement or deterioration.” Id.; see also Quirin, 22 Vet. App. at 395 (observing that “[u]nder the framework set forth in the General Counsel opinion, any worsening - any change at all - might demonstrate that the condition is a disease, in that VA considers defects to be ‘more or less’ static and immutable”). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the veteran. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno, 6 Vet. App. at 465. Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 C.F.R. § 3.159; see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim on appeal. 1. The claim of entitlement to service connection for a liver disability The Veteran contends that he is entitled to service connection for a liver disability. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has current diagnoses of nonalcoholic fatty liver disease and hereditary hemochromatosis, the preponderance of the evidence weighs against finding that the Veteran’s diagnosed liver disorders began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The Veteran’s February 1968 entrance examination was silent with respect to preexisting liver conditions. The Veteran’s April 1970 separation examination reported no ongoing liver disabilities. The Veteran served in the Republic of Vietnam where he believes he was exposed to a parasite that caused his liver disorders. In February 2008, private treatment records reflect that parasitic exposure from Vietnam was not likely as his computer tomography scan (CAT scan) in 2007 was normal. The Veteran underwent a liver biopsy following elevated liver function tests in December 2008. He was subsequently diagnosed with nonalcoholic fatty liver disease and hereditary hemochromatosis, a gene mutation. In April 2011, his treating clinician noted that a definitive etiology for the nonalcoholic fatty liver disease could not be provided, but a parasitic infection could not be excluded from consideration. In June 2012, the Veteran underwent a VA examination to assess the nature and etiology of his liver disability. The examiner noted his diagnosis of nonalcoholic fatty liver disease. The Veteran reported that he contracted malaria in service, and suffered from liver problems ever since. He reported a history of alcohol abuse, but stated that he had cut back to three drinks per day. The examiner concluded that the Veteran’s liver disability was less likely than not related to active duty service. There was no indication of malaria in his service treatment records. Even if he did have the illness in service, his fatty liver disease with hereditary iron condition were not caused by parasites. Hereditary hemochromatosis is an inherited condition that causes the body to absorb too much iron. Signs and symptoms of this hereditary condition typically manifest in midlife. Nonalcoholic fatty liver disease was also noted to be a common condition that resembled alcoholic liver disease, but occurred in people who drank little to no alcohol. In April 2018, the Veteran underwent a second VA examination to assess the etiology of his liver disability. The examiner noted the ongoing diagnoses of hereditary hemochromatosis and nonalcoholic fatty liver disease. The examiner also reviewed the article provided by the Veteran regarding parasite exposure in Vietnam. The examiner concluded that the Veteran’s liver disability was less likely as not related to exposure to parasites. Based upon the Veteran’s symptomatology since service, the examiner found that he did not exhibit symptoms or signs of Liver Fluke infection or parasitic infection. Typical symptoms include: fever, chills, epigastric pain, tender hepatomegaly, diarrhea and mild jaundice. Longstanding inflammation or reinfection of bile ducts caused by Liver Fluke infection would also cause scarring of the bile ducts, which was not present in the Veteran’s case. The Veteran additionally did not have gallstone formation, hepatitis, or cholangiocarcinoma, which would indicate a parasitic infection. Accordingly, as the Veteran did not demonstrate signs or symptoms of a parasitic infection following his service in Vietnam, the examiner concluded that his present disability was less likely as not incurred during active duty service. The examiner also concluded that his liver problems were not caused by or aggravated by his alcohol consumption, which is secondary to his service-connected PTSD. Hereditary hemochromatosis is most commonly due to mutations in the HFE gene, and is an autosomal recessive disorder in which there is increased intestinal iron absorption. In March 2006, the Veteran’s private clinician opined that the Veteran’s elevated liver function test was probably secondary to alcohol abuse, and referred the Veteran to a specialist. The specialist, however, determined that the elevated function tests were not due to alcoholic liver disease. A subsequent biopsy diagnosed nonalcoholic fatty liver disease and hereditary hemochromatosis. While the Veteran drank alcohol over the years, his liver function tests did not worsen with his consumption. In fact, as the examiner noted, his 2017 liver function test was better than his 2007 test. As the liver function tests have shown improvement even with the Veteran’s drinking patterns, the examiner concluded that the liver disability was not caused by or aggravated by his alcohol use. As a preliminary matter, the Board finds that the Veteran’s hereditary hemochromatosis is a disease, not a defect, under the applicable provisions mentioned above. The April 2018 VA examiner noted that hereditary hemochromatosis generally does not manifest with symptoms until later in life. This indicates that it is not a static condition and is capable of getting worse. Thus, it is a disease and may be subject to service connection. It is necessary to consider the hereditary nature of the Veteran’s disease. Upon review of the medical and lay evidence of record, the Board finds that the preponderance of the evidence supports the classification of the Veteran’s disease as hereditary. There are repeated diagnoses of hereditary hemochromatosis throughout the Veteran’s treatment records, including the original diagnosis in January 2009, and the June 2012 and April 2018 VA examination reports. These diagnoses are made by medical professionals with experience and expertise in the field of medicine, and are thus competent to draw such conclusions. Thus, all credible and competent evidence supports that the Veteran’s hemochromatosis is hereditary. The Veteran’s hereditary hemochromatosis was not noted at his entry examination. Thus, even though the disease is hereditary, he is entitled to a presumption of soundness. This means that absent clear and convincing evidence, the Veteran’s condition is not considered to have preexisted his active service. Here there is no evidence that indicates that the symptomatology or pathology of hereditary hemochromatosis existed prior to the Veteran’s enlistment. Therefore, for the purposes of establishing service connection, the Veteran’s hereditary hemochromatosis did not preexist service. As the Veteran’s hereditary hemochromatosis is not considered to have preexisted service, it is necessary to consider whether the disease was incurred in, caused, or related to the Veteran’s active duty service. Here, the preponderance of the evidence is against finding the Veteran’s hereditary hemochromatosis was incurred during active service. In accordance with VAOPGCPREC 67-90, the disease will not be considered to have existed unless there is symptomatology or pathology of the disease. 55 Fed. Reg. 43,253 (1990). The June 2012 and April 2018 VA examiners noted that the Veteran’s service treatment records did not show any evidence of hereditary hemochromatosis symptoms during active service. The VA examiners are trained in the field of healthcare and are competent to render such an opinion. Further, the record supports the VA examiners’ opinions. The Veteran’s service treatment records do not contain a diagnosis of hereditary hemochromatosis. The Veteran was not formally diagnosed until January 2009. It is also notable that the Veteran’s medical treatment records from April 2006 and November 2008 prior to his diagnosis indicate that he was “practically asymptomatic,” and experienced no identifiable symptoms of hereditary hemochromatosis other than the elevated liver function tests. In sum, the medical evidence of record reflects that the Veteran was essentially asymptomatic for decades following discharge from service, and that the condition manifested later in life, as typical of its presentation. Thus, a preponderance of the evidence is against finding the Veteran’s hereditary hemochromatosis was incurred during active service. Furthermore, the preponderance of the evidence is also against finding that the Veteran’s nonalcoholic fatty liver disease was incurred in active duty service. Nonalcoholic fatty liver disease is a common condition, affecting 2 to 5 percent of Americans. The Veteran’s condition manifested decades after service, and he did not exhibit symptoms typically reflective of nonalcoholic fatty liver disease during active duty or within a year after discharge. The Veteran’s own private treatment records ruled out involvement of a parasitic infection as the cause of the condition, citing a normal 2007 CAT scan. Furthermore, the VA examination reports of record determine that, based upon the Veteran’s symptomatology since service, he did not exhibit symptoms or signs of Liver Fluke infection or parasitic infection. Finally, the preponderance of the evidence is against a finding that the Veteran’s liver disability was caused by or aggravated by his alcohol use as secondary to his service-connected PTSD. The Veteran’s private treatment records consistently reflect a diagnosis of nonalcoholic fatty liver disease, and a biopsy ruled out alcoholic liver disease. Based upon the multiple liver function tests of record, the April 2018 VA examiner determined that the Veteran’s alcohol usage, which appeared to be consistent or increasing since his liver diagnoses, did not additionally aggravate his liver disability. In fact, his liver function tests improved since the liver function test taken in 2007. Consequently, the Board gives more probative weight to the June 2012 and April 2018 VA examination reports of record. While the Veteran believes his liver disability is related to an in-service injury, event, or disease, he is not competent to provide a nexus opinion in this case. This issue is also medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the June 2012 and April 2018 VA examination reports of record which were rendered by medical professionals. Based on the foregoing, the claim of entitlement to service connection for a liver disability is denied. The preponderance of the evidence is against the Veteran’s claim; thus, the benefit-of-the-doubt rule is not for application. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). Increased Rating Disability ratings are determined by application of a ratings schedule which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. However, pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran’s service-connected disability. 38 C.F.R. § 4.14; see Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In a claim for a greater original rating after an initial award of service connection, all of the evidence submitted in support of the Veteran’s claim is to be considered. In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2. VA’s determination of the “present level” of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending and, consequently, staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the veteran. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno, 6 Vet. App. at 465. Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 C.F.R. § 3.159; see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim on appeal. 2. The claim of entitlement to an evaluation in excess of 70 percent for PTSD since December 5, 2013 The Veteran contends that he is entitled to an evaluation in excess of 70 percent for PTSD since December 5, 2013. The Veteran’s PTSD is rated under Diagnostic Code 9411, 38 C.F.R. § 4.130. Mental disorders are rated under the General Rating Formula for Mental Disorders pursuant to 38 C.F.R. § 4.130. A 70 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); and an inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions 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. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). However, a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration, and that those symptoms have resulted in the type of occupational and social impairment associated with that percentage. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117-18 (Fed. Cir. 2013). The Veteran contends that he is entitled to a 100 percent evaluation for his PTSD beginning December 5, 2013. After a thorough review of the medical and lay evidence of record, the Board finds that the Veteran is not entitled to a total disability rating for his PTSD. In the December 2013 VA examination, the Veteran’s diagnoses of PTSD and alcohol use disorder secondary to PTSD were confirmed. The examiner concluded that his PTSD caused occupational and social impairment with deficiencies in most areas. He continued to be married to his wife of nearly 35 years, but the relationship remained strained. They did not travel together, preferring to arrange separate trips to “maximize their time apart.” They remained together primarily for financial reasons. The Veteran reported growing increasingly anxious and paranoid. When outside of the house, he carried pepper spray. While at home, he had a weapon on his person or within reach at all times. He typically consumed alcohol every night, but could go without while on trips with his friends. He continued to report chronic sleep impairments and anger issues. The examiner noted symptoms of: depressed mood, anxiety, suspiciousness, panic attacks that occurred weekly or less often, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. The Veteran presented appropriately groomed and casually dressed. He was alert and oriented in all spheres with some mild memory impairments on examination. He was cooperative throughout the examination. His mood was dysphoric with an irritable affect. He displayed good eye contact and mild psychomotor agitation. The Veteran’s speech was normal. Thought processes were generally organized with no evidence of a formal thought disorder. He denied hallucinations, delusions, mania, or obsessive-compulsive features. The Veteran also denied suicidal and homicidal ideation. He displayed no difficulties with the activities of daily living due to his mental health. In March 2018, the Veteran underwent a second VA examination to assess the nature and severity of his PTSD. His diagnoses remained unchanged, and were again assessed to cause occupational and social impairment with deficiencies in most areas. His relationship with his wife remained the same. He had a good relationship with his stepdaughters and granddaughter. The Veteran reported having two close friends. More recently, he became “burned out” on riding his motorcycle, particularly after a near accident, and he sold it. He endorsed feelings of paranoia in crowded environments, and he avoided some family gatherings due to his anxiety. The Veteran also reported panic attacks triggered by loud, unexpected noises, as well as flashbacks. He denied suicidal and homicidal ideation. The examiner noted symptoms of: depressed mood, anxiety, suspiciousness, panic attacks that occurred weekly or less often, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty and establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. The Veteran presented for the examination casually dressed and appropriately groomed, and was fully oriented throughout. His mood and affect were anxious with an underlying flatness. He displayed good eye contact, and his speech was within normal limits. Thought processes were generally organized with no evidence of formal thought disorder, hallucinations, delusions, mania or obsessive-compulsive features. After a thorough review of the medical and lay evidence of record, the Board finds that the Veteran is not entitled to a 100 percent evaluation for his PTSD. The Board recognizes that the Veteran suffered from deficiencies attributable or exacerbated by his PTSD. The Board’s determination of the appropriate degree of disability is a finding of fact. In applying the ratings schedule, the Board considers the severity, frequency, and duration of psychiatric symptoms to determine the appropriate disability evaluation. See, e.g., Brewer v. Snyder, No. 15-2800, 2017 U.S. App. Vet. Claims LEXIS 90, at 13 (Vet. App. Jan. 31, 2017); citing Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). While symptoms are listed under each category for evaluation, the particular symptoms are to be demonstrative of that overall level of severity, frequency and duration. Mauerhan v. Principi, 16 Vet. App. 436, 442 (U.S. 2002). As such, the Board has considered the symptoms specific to the Veteran throughout the period on appeal, and determined the analogous evaluation pursuant to the ratings schedule in 38 C.F.R. § 4.130. When considering the severity, frequency and duration of the impairments as delineated in the 70 percent evaluation, the Board notes that the symptoms listed present a significant impediment to daily life. Symptoms such as obsessional rituals which interfere with routine activities, near-continuous panic or depression, and the inability to establish and maintain effective relationships, present obstacles to routine functioning on a daily basis. Personal hygiene and grooming are not limited to one particular sphere, but affect work, school, and family relations. Spatial disorientation and intermittently illogical speech are markedly severe symptoms associated with basic cognitive function and the ability to interact with the world. Suicidal ideation, in of itself, represents the impulse or desire to remove oneself from the world entirely. As exemplified by the symptoms listed in this category, the 70 percent evaluation is appropriate for deficiencies that harm most areas of life. Either symptoms are continuous, or near-continuous, or represent such a severity that routine daily functions are chronically impeded. In contrast, the evaluation for a 100 percent impairment includes symptomatology that presents a total impairment to daily functioning. Not only are the representative symptoms of the most severe possible from a psychiatric disorder, but they interfere with the ability to independently engage in activities of daily life. Persistent delusions or hallucinations, disorientation to time or place, and significant memory loss all prevent the person from routine engagement with the world. The ability to even maintain the most basic hygiene standards has been harmed by the severity or frequency of the associated symptomatology. When symptoms of a psychiatric disorder are so severe as to present a total impairment to occupational and social activity, then a 100 percent evaluation should be afforded. Throughout the period on appeal, the Veteran regularly endorsed symptoms of anxiety, depressed mood, suspiciousness, and paranoia. He reported difficulty interacting with others, and only had a few friends. His relationship with his wife remained poor throughout this period on appeal. He lost interest in riding his motorcycle, but only sold the bike following a near accident while traveling. The Veteran reported panic attacks triggered by unexpected noises. He also reported mood swings and bouts of anger, as well as flashbacks to Vietnam. While certainly severe, the manifestations of the Veteran’s service-connected PTSD in this timeframe do not rise to the level of a total occupational and social impairment for the purposes of 38 C.F.R. § 4.130. His impairments, while touching on many areas of his life, are not of such severity to interfere with routine functions necessary for daily life. The Veteran was consistently alert and oriented in all spheres, and maintained his grooming and hygiene. While he experienced outbursts of anger, he relied on his previous therapeutic treatments to identify these triggers and analyze whether he was overreacting after the initial anger passed. While he avoided some family gatherings due to his anxiety, he admitted to feeling “ok” when he would force himself to attend. In sum, the Veteran’s symptoms do not mirror the severity, frequency and duration of ones such as persistent delusions or hallucinations, or inability to attend to basic hygiene. He continues to perform the activities of daily living, including maintaining his hygiene and grooming. While the Veteran certainly continues to cope with serious manifestations of his PTSD, they do not rise to the level of a total occupational and social impairment as contemplated by the rating schedule. As the preponderance of the evidence weighs against the claim for an evaluation in excess of 70 percent, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran’s claim of entitlement to an evaluation in excess of 70 percent must be denied. REASONS FOR REMAND 1. The claim of entitlement to an evaluation in excess of 30 percent for PTSD prior to December 5, 2013 is remanded. The Board cannot make a fully informed decision regarding the Veteran’s claim of entitlement to an evaluation in excess of 30 percent for PTSD prior to December 5, 2013, as a clarifying medical opinion is needed for this period of time. In June 2008, the Veteran’s VA treatment records note treatment for anger, nightmares, and sleep difficulties stemming from his PTSD. He reported that his PTSD “kicked in” approximately five years earlier when his wife cheated on him. He reported that the marriage was “so-so,” and it was cheaper to stay together. He enjoyed riding motorcycles with his friends and fishing. He also spent time with his grandchildren and had good relationships with his family. The Veteran was well-groomed and fully oriented. His memory was grossly intact, and his speech was clear and coherent with appropriate affect. His mood was depressed. He denied hallucinations, paranoia, psychotic symptoms, and suicidal and homicidal ideation. Concurrent VA treatment records note that the Veteran enjoyed beer and consumed a couple per day. In November 2008, VA treatment records reflect moderate alcohol usage, approximately 2 beers per day, with a history of alcohol abuse in his 30’s and 40’s. In June 2009, the Veteran reported that he consumed 3 to 4 ounces of beer per day, maybe more. In December 2009, a VA examination assessed the nature and severity of his PTSD. The examiner noted that he underwent previous treatment in 1984, which helped his temper and nightmares. The Veteran’s marriage remained strained, and he exhibited difficulty relating to other people outside of a few friends. His temper and drinking in the 1980’s led him to seek treatment, and he cut down significantly on his alcohol consumption as a result. There were reportedly no problems working except some issues with temper and socialization. He reported flashbacks, sleep disturbances, some hypervigilance, social dysfunction, and temper problems that had improved since the 1980’s. He also endorsed occasional anxiety attacks and mood problems. The Veteran denied suicidal and homicidal ideation. The examiner noted that the Veteran did abuse alcohol in the past, but his alcohol abuse was in remission at the time of examination. In August 2010, the Veteran’s wife submitted a statement regarding the severity of her husband’s symptoms. She reported that his PTSD grew progressively worse over the previous four years, causing him to drink excessively and exhibit a violent temper. She felt as though she was “walking on eggshells” around him due to his explosive temper. He reportedly did not trust anyone else, and would seldom leave the house. When he did go out with her, he became angry over something trivial and insisted that they go home. She reported that the Veteran’s anger and drinking issues were much more severe than reported. Unfortunately, the Veteran did not engage in regular mental health treatment throughout this period on appeal. The wife’s statements appear to contradict the Veteran’s VA treatment records and the findings of the December 2009 VA examination report. Clarification is thus required regarding the period prior to December 5, 2013, before the Board can make a final determination as to the severity of the Veteran’s PTSD during this period. As such, an addendum opinion is necessary in order to reconcile these varying symptoms on remand. 2. The claim of entitlement to an effective date earlier than December 5, 2013, for the grant of TDIU is remanded. Regarding the claim of entitlement to an effective date earlier than December 5, 2013, for the grant of TDIU, the Veteran submitted a timely notice of disagreement with an August 2015 rating decision, but a statement of the case has not yet been issued. A remand is required for the AOJ to issue a statement of the case. 38 C.F.R. § 20.200; Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). 3. The claim of entitlement to an effective date earlier than December 5, 2013, for the grant of DEA is remanded. Regarding the claim of entitlement to an effective date earlier than December 5, 2013, for the grant of DEA, the Veteran submitted a timely notice of disagreement with an August 2015 rating decision, but a statement of the case has not yet been issued. A remand is required for the AOJ to issue a statement of the case. 38 C.F.R. § 20.200; Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). The matters are REMANDED for the following actions: 1. Contact the Veteran and the representative of record in order to identify any outstanding non-VA treatment records regarding the issues on appeal. If non-VA providers are identified, obtain releases for those records. Make all reasonable attempts to obtain the non-VA treatment records and associate them with the claims file. If such records cannot be obtained, inform the Veteran and the representative of record, and afford an opportunity to provide these outstanding records. 2. Obtain any relevant, outstanding VA treatment records that are not already associated with the claims file. If no records are available, the claims folder must indicate this fact and the Veteran should be notified in accordance with 38 C.F.R. § 3.159 (e). All attempts to contact the Veteran should be documented in the record. 3. After the aforementioned evidentiary development is complete, obtain an addendum opinion regarding the severity of the Veteran’s PTSD prior to December 5, 2013. An examination may be ordered if the clinician deems it necessary. A complete copy of the claims file must be made available to the examiner. After a thorough review of the medical and lay evidence of record, the examiner should discuss the following: (a.) Provide a retrospective opinion of the severity of the Veteran’s PTSD from November 17, 2008, to December 5, 2013. The examiner should also provide an assessment of the Veteran’s occupational impairment in this period of time. Please address the wife’s lay statements regarding manifestations of PTSD during this period of time. The examination report should specifically state that a review of the record was conducted. The examiner should provide a complete rationale for all opinions provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. 4. Send the Veteran and his representative a statement of the case (SOC) that addresses the issues of entitlement to earlier effective dates for the grants of TDIU and DEA. If the Veteran perfects an appeal by submitting a timely VA Form 9, the issues should be returned to the Board for further appellate consideration. (Continued on the next page)   5. Following completion of the foregoing, the Agency of Original Jurisdiction should review the record and readjudicate the claim on appeal. If it remains denied, the AOJ should issue an appropriate supplemental SOC, afford the Veteran and his representative an opportunity to respond, and return the case to the Board. L. Chu Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD H. Fisher, Associate Counsel