Citation Nr: 18158054 Decision Date: 12/14/18 Archive Date: 12/14/18 DOCKET NO. 15-08 038 DATE: December 14, 2018 ORDER The claim of entitlement to service connection for a back disability is withdrawn. The claim of entitlement to service connection for alcohol dependence in full remission is withdrawn. The claim of entitlement to service connection for a personality disorder is withdrawn. The claim of entitlement to a compensable disability rating for residuals of a left testicular contusion due to gunshot wound is withdrawn. The claim of entitlement to service connection for chronic sinusitis is denied. The claim of entitlement to service connection for an additional acquired psychiatric disability other than chronic adjustment disorder, specifically posttraumatic stress disorder (PTSD) or a mood disorder, is granted. The claim of entitlement to a disability rating in excess of 50 percent for chronic adjustment disorder is granted. REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a gastrointestinal disability, claimed as irritable bowel syndrome (IBS), is remanded. Entitlement to service connection for an additional acquired psychiatric disability, specifically bipolar disorder, is remanded. Entitlement to a compensable disability rating for residuals of a fracture and dislocation of the right middle finger is remanded. FINDINGS OF FACT 1. Prior to promulgation of a decision in the appeal, the Veteran withdrew his appeal with respect to the issues of entitlement to service connection for a back disability, alcohol dependence in full remission, and a personality disorder, and entitlement to a compensable disability rating for a left testicular disability. 2. The preponderance of the evidence is against finding that the Veteran has chronic sinusitis due to a disease or injury in service, to include his single diagnosis of frontal sinusitis during service. 3. The Veteran’s PTSD and major depressive disorder are causally related to service; the Veteran’s currently service-connected disability will now be known as an acquired psychiatric disability, to include a mood disorder, diagnosed as chronic adjustment disorder or major depression, and PTSD. 4. The Veteran’s acquired psychiatric disability manifested with total occupational and social impairment due to high suicide risk and ideation, severe anxiety, avoidance, isolation, loss of interest, and irritability. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a substantive appeal by the Veteran as to the issues of entitlement to service connection for a back disability, alcohol dependence in full remission, and a personality disorder, and entitlement to a compensable disability rating for a left testicular disability have been met. 38 U.S.C. § 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. §§ 20.202, 20.204 (2018). 2. The criteria for service connection for chronic sinusitis are not met. 38 U.S.C. §§ 1110, 1131, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303(a) (2018). 3. The criteria for service connection for PTSD and major depression are met. 38 U.S.C. §§ 1110, 1131, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303(a) (2018). 4. The criteria for a disability rating of 100 percent for an acquired psychiatric disability to include a mood disorder, diagnosed as chronic adjustment disorder or major depression, and PTSD have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9440 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service from July 1974 to July 1977 in the United States Army. The Veteran testified at a hearing before the Board in April 2018. A transcript of that hearing has been associated with the claims file. Withdrawal of Claims The Board may dismiss any appeal that fails to allege specific error of fact or law in the determination being appealed. A substantive appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.202, 20.204(b). Except for appeals withdrawn on the record at a hearing, appeal withdrawals must be in writing. 38 C.F.R. § 20.204(c). The Veteran perfected an appeal as to the issues of entitlement to service connection for a back disability, alcohol dependence in full remission, and a personality disorder, and entitlement to a compensable disability rating for a left testicular disability. In April 2018, the Veteran submitted a signed statement indicating that he wished to withdraw his current appeal regarding his left testicular condition and entitlement to service connection for organic personality disorder. At the hearing in April 2018, the Veteran formally withdrew his claims of entitlement to service connection for a back disability and alcohol dependence in full remission. As such, there remain no allegations of errors of fact or law for appellate consideration and the Board does not have jurisdiction to review the appeal regarding issues of entitlement to service connection for a back disability, alcohol dependence in full remission, and a personality disorder, and entitlement to a compensable disability rating for a left testicular disability. Therefore, the issues are dismissed. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed.Cir.2013) (holding that only conditions listed as chronic diseases in 38 C.F.R. § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b)). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Additionally, disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. The Board also notes that secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310, and compensation is payable for that degree of aggravation of a nonservice-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995); 38 C.F.R. § 3.310(b). In order to establish entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) competent evidence establishing a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for chronic sinusitis. The Veteran contends that he has a current diagnosis of chronic sinusitis that is causally related to his service. 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 a current diagnosis of chronic sinusitis, and evidence shows that he had a single diagnosis of frontal sinusitis during service, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of chronic sinusitis began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The Veteran had a single diagnosis of frontal sinusitis diagnosed in August 1975. He was treated and no further complaints were noted during service. VA treatment records show the Veteran was not diagnosed with chronic sinusitis until 2005, decades after his separation from service. While the Veteran is competent to report having experienced symptoms of intermittent facial pain since service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of chronic sinusitis. The issue is medically complex, as it requires knowledge of interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Further, the November 2012 VA examiner opined that the Veteran’s chronic sinusitis is not at least as likely as not related to an in-service injury, event, or disease, including the single diagnosis of frontal sinusitis during service. The examiner noted that he had a common upper respiratory infection when seen in the military in August 1975. The Veteran also was diagnosed with frontal sinusitis, which was a clinical judgment at the time with no radiologic studies being done. The examiner noted no sequelae to this episode. His current problem was first documented in 2005. At that time, he reported that his recurring facial and forehead pain started five years previous. The examiner noted no record of the Veteran having the present chronic sinusitis problem along with the deviated nasal septum prior to that time. The isolated incident of the Veteran being seen for an upper respiratory infection on one occasion was thus not related to his present chronic sinus problem that started around 2000 and first documented in 2005. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board finds that the Veteran’s more recently-reported history of continued symptoms of sinusitis since active service is inconsistent with the other lay and medical evidence of record. Indeed, while he now asserts that his disorder began in service, in the more contemporaneous medical history he gave at the service separation examination, he denied any history or complaints of symptoms of sinusitis. During the June 1977 separation report of medical examination, the Veteran examiner found clinically normal nose and sinuses. Also, he did not claim that symptoms of his disorder began in (or soon after) service until he filed his current VA disability compensation claim. Such statements made for VA disability compensation purposes are of lesser probative value than his previous more contemporaneous in-service histories and his previous statements made for treatment purposes. See Pond v. West, 12 Vet. App. 341 (1999) (although Board must take into consideration the veteran’s statements, it may consider whether self-interest may be a factor in making such statements); These inconsistencies in the record weigh against the Veteran’s credibility as to the assertion of continuity of symptomatology since service. See Madden v. Gober, 125 F.3d 1477, 1481 (Board entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Caluza v. Brown, 7 Vet. App. 498, 512 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996) (upholding Board’s finding that a veteran was not credible because lay evidence about a wound in service was internally inconsistent with other lay statements that he had not received any wounds in service). The Board has weighed the Veteran’s statements as to continuity of symptomatology and finds his current recollections and statements made in connection with a claim for VA compensation benefits to be of lesser probative value than his previous more contemporaneous in-service history and findings at service separation, his previous statements made for treatment purposes, and his own previous histories of onset of symptoms given after service. For these reasons, the Board finds that the weight of the lay and medical evidence is against a finding of service-connection for chronic sinusitis. Based on the evidence cited above, the Board finds that the preponderance of the evidence is against the claim of service connection for chronic sinusitis. As the preponderance of the evidence is against the claim for service connection for chronic sinusitis, the benefit of the doubt rule does not apply. 38 C.F.R. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for an additional acquired psychiatric disability other than chronic adjustment disorder, specifically PTSD or a mood disorder. The Veteran contends that he has additional psychiatric diagnoses that are causally related to service. Specifically, the Veteran is claiming entitlement to service connection for PTSD and a mood disorder. The Board concludes that the Veteran has a current diagnosis of PTSD and severe depression that is related to his in-service traumatic event and his service-connected diagnosis of chronic adjustment disorder. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). VA and private treatment records show a current diagnosis of PTSD and severe depression. The Veteran was afforded a private examination in August 2018. The examiner reviewed the claims file and the Veteran’s treatment records and performed a psychiatric examination. The examiner noted that records suggest a diagnosis of PTSD. He also noted a history of adjustment disorder, mood disorder, and possible personality disorder. The private examiner found that the prior VA examination, which determined that the Veteran’s PTSD diagnosis was erroneous, was based on inaccurate findings. The VA examiner found that the increased anger and decreased sadness was not indicative of PTSD. The August 2018 private examiner found that anger and irritability are typical features of PTSD. The examiner also noted that chronic adjustment disorder was a mood disorder in and of itself. The VA examiner also noted that the Veteran’s personality disorder caused his suicidal ideation, but indicated no other signs or symptoms that would warrant such a diagnosis. It is unclear why a personality disorder was opined at all when suicidal ideation is much more clearly explained by the Veteran’s depression and PTSD. The Veteran was given the PCL-M checklist, a standardized screening instrument for PTSD evaluation, which was significant for a diagnosis of severe PTSD. The examiner diagnosed PTSD and major depression. The examiner found that the Veteran clearly evidenced PTSD. He also had clear evidence of a long-standing mood disorder in the form of depression. He determined that it would be nonsensical to diagnose the Veteran with both an adjustment disorder and a separate diagnosis of depression as these overlap and would be fairly indistinguishable from each other at a chronic level. The Veteran likely had an initial adjustment difficulty after his traumatic event that evolved to become recurrent and severe major depression. Given the findings of the private examiner, the Board finds that the Veteran’s service-connected acquired psychiatric disability, which is currently addressed as chronic adjustment disorder, should be amended to include PTSD and major depression. The Board notes that although the decision above grants service-connection for PTSD and major depression, the Veteran’s psychiatric disabilities will not be rated separately, as to do so would constitute pyramiding. The evaluation of the same disability under various diagnoses is to be avoided. Disability from injuries to the muscles, nerves, and joints of an extremity may overlap to a great extent, so that special rules are included in the appropriate bodily system for their evaluation. Both the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation, and the evaluation of the same manifestation under different diagnoses are to be avoided. 38 C.F.R. § 4.14. In Amberman v. Shinseki, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) addressed the pyramiding question in the context of two psychiatric disabilities. 570 F.3d 1377 (Fed. Cir. 2009). In that case, service connection had been established for bipolar affective disorder and had been established for posttraumatic stress disorder (PTSD). VA rated the two disorders together assigning a 70 percent rating. The appellant contended that she should have separate ratings; i.e., a rating for PTSD and a rating for bipolar disorder. Her principle argument was that her separately diagnosed bipolar affective disorder and PTSD did not constitute the same disability as contemplated by 38 C.F.R. § 4.14 and therefore should be rated separately. The Federal Circuit affirmed the Court’s decision which had affirmed the Board decision. The Federal Circuit explained that although separately diagnosed injures are ordinarily rated individually, “VA regulations caution against making multiple awards for the same physical impairment simply because the impairment could be labeled in different ways.” Amberman, 570 F.3d at 1377. It further explained that it is the overall disability that is relevant, not the name of the causative disorder or disorders. When two ratings covering the same disability are combined, it is called pyramiding. Here, the Veteran’s psychiatric disabilities under the multiple diagnoses of PTSD, major depression, and chronic adjustment disorder constitute overlapping symptomatology that is covered under the General Rating Formula for Mental Disorders. Therefore, the Veteran’s current service-connected chronic adjustment disorder will now be considered as an acquired psychiatric disability to include a mood disorder, diagnosed as chronic adjustment disorder or major depression, and PTSD and will be rated as one single psychiatric disability. 3. Entitlement to a disability rating in excess of 50 percent for an acquired psychiatric disability to include a mood disorder, diagnosed as chronic adjustment disorder or major depression, and PTSD. Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person’s ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, 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); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran’s chronic adjustment disorder is current rated at 50 percent under Diagnostic Code 9440. Under that regulation, chronic adjustment disorder is rated under the General Rating Formula for Mental Disorders. Mental disorders are rated, in part, as follows: 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 warrants a 100 percent disability rating. 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 warrants a 70 percent disability rating. 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 warrants a 50 percent disability rating. 38 C.F.R. § 4.130. In July 2012, the Veteran was given an admission screen for a mental health residential rehabilitation treatment program. The Veteran did not have hallucinations or delusions. He had no history of violence or homicidal ideation. The Veteran had passive suicidal ideation. He noted multiple past suicide attempts. The Veteran attended a VA examination in December 2012. The examiner noted occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress or symptoms controlled by medication. The examiner noted that the Veteran’s symptoms increased when he ceased to work. The Veteran noted a positive relationship with his daughters. The Veteran had no activities. He occasionally meets a few friends. The Veteran noted that he mostly watches TV and goes to doctor’s appointments. The Veteran noted an increase in anxiety since he stopped drinking. He also noted an increase in suicidal ideation. He described symptoms of avoidance, anxiety, nervousness, and irritability. The examiner noted recurrent and distressing recollections and dreams, physiological reactivity to cues, avoidance, feelings of detachment, difficulty falling or staying asleep, irritability or outbursts of anger, and hypervigilance. The examiner also noted depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbance of motivation and mood, and suicidal ideation. The VA examiner provided an addendum opinion in March 2013. The examiner determined that 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 best summarized the Veteran’s level of impairment. The Veteran’s symptoms included suspiciousness, anxiety, chronic sleep impairment, disturbances of motivation and mood, depression, mild memory loss, and suicidal ideation. In November 2014, the Veteran reported spells of depression and a history of suicidal attempts. He reported depression but denied current suicidal or homicidal ideation. He has two daughters with whom he has a good relationship. He worked until 2002 when he suffered a severe back injury. He reported nightmares and intrusive thoughts. He also noted irritability and trust issues. He reported frequent anxiety and body tremors. The Veteran expressed feelings of anger. He denied suicidal or homicidal ideation during the session. He was alert and oriented to all spheres. He was casually dressed with adequate hygiene. He reported feelings of anger and depression. His speech was relevant, coherent, and normally modulated. The examiner found no evidence of psychosis. He did not appear to be responding to visual or auditory hallucinations. His insight and judgment were deemed fair. The Veteran was afforded a VA examination in January 2015. The examiner noted occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal behavior, self-care, and conversation. The Veteran’s symptoms included depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and suicidal ideation. The Veteran lost over 20 pounds in the prior three months due to depression and not eating properly. The examiner noted additional symptoms including anxiety, tremors, attempted suicide three times in the prior 15 years, and lack of trust. In March 2015, the Veteran was placed on the high risk for suicide list. He was alert and oriented to all spheres. He was dressed casually with good hygiene. He noted feelings of depression and anxiety as well as suicidal ideation. He did not appear to be responding to visual or auditory hallucinations. The examiner noted no evidence of psychosis. His insight and judgment were impaired. In December 2015, the Veteran had normal hygiene and was casually dressed. His mood was depressed and anxious. His speech was normal and his attention and concentration were unremarkable. He was able ot think abstractly and was oriented in all spheres. His thought patterns were coherent, linear, and organized. His thought content was free from evidence of psychosis, hallucinations, delusions, or paranoia. His insight and judgment were fair. He had suicidal ideation with plan to shoot himself, but denied intent. His most recent suicide attempt was in 2006 or 2007. During the April 2018 hearing, the Veteran noted symptoms of increased anxiety, crying, avoidance of people, paranoia, anger issues, trust issues, and suicidal thoughts on a daily basis. The Veteran was afforded a private examination in August 2018. The examiner reviewed the claims file and the Veteran’s treatment records and performed a psychiatric examination. The Veteran lived alone with no support. He reported that his psychiatric symptoms are managed with medication, and without counseling. Upon examination, the examiner noted that the Veteran was alert and oriented in all three spheres. His speech was notable for being dysphoric in content and tone. The Veteran endorsed considerable guilt and hopelessness. The Veteran experienced poor sleep and appetite. He had suicidal ideation with three prior suicide attempts, the most recent being three to four years prior. The Beck Depression Inventory indicated severe depression. The Veteran noted daily thoughts of suicide and feelings of uselessness. He lost interest in almost all people and hobbies. He had low energy and poor motivation. He reported severe anxiety symptoms. The Veteran had frequent episodes of hyperventilating and feeling short of breath when thinking about or discussing his previous traumatic experiences. He often stayed in his apartment for days and noted chronic feelings of being unsafe. The Veteran noted recurrent disturbing memories and thoughts of his traumatic event, including disturbing dreams. His distress was clearly observable to the examiner in the interview. He had severe physical reactions to these memories. He avoided talking about his experiences in much detail. He avoided social situations, community interactions, and any situation that had him in close proximity to others, due to his tendency to panic. He endorsed feelings of irritability and having angry outbursts. The Veteran noted that he did not trust anyone and exhibited mild paranoia that did not rise to the level of delusions. He had no signs and symptoms of psychosis or formal thought disorder. He denied any auditory or visual hallucinations. His thought processes were clear and linear. No short or long-term memory difficulties were seen. He had an average level of intelligence, fair insight, and moderate judgment. His impulsivity was moderately high. The examiner diagnosed PTSD and major depression. The examiner then went on to note that the Veteran was 100 percent disabled by virtue of his psychiatric conditions. His suicidal ideation was recurrent, chronic, and severe. He was at high risk of another attempt or completion. He had no ability to establish and maintain effective relationships with anyone due to the severity of his depression as well as his anxiety. His mood disorder and PTSD severely limited his daily activities and community involvement. The examiner recommended admission to a psychiatric facility for treatment. The Veteran was totally unemployable due to his psychiatric conditions. The Board finds that the evidence shows total occupational and social impairment due to the Veteran’s psychiatric symptoms. Although the Veteran did not experience all symptoms listed in the rating formula, the symptoms listed in Diagnostic Code 9411 are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). As such, the Board notes that the Veteran experiences other symptoms that are not listed in the criteria, but may reflect the severity of his psychiatric disabilities. These include, but are not limited to, nightmares, hypervigilance, severe anxiety, loss of interest, lowered energy, avoidance, isolation, and paranoia. Specifically, the Board has also considered many of the Veteran’s symptoms as “like or similar to” the schedular rating criteria of total occupational and social impairment due to such symptoms as persistent danger of hurting self or others and intermittent inability to perform activities of daily living. See Mauerhan, 16 Vet. App. 436. The Board acknowledges the Veteran’s high suicide risk and daily ideation with history of attempts, his multiple in-patient treatment periods, his extreme anxiety and avoidance, isolation, irritability, paranoia, and loss of interest. The Board finds that based upon the August 2018 examination findings that the Veteran experiences total occupational and social impairment due to his psychiatric issues and a 100 percent disability rating is warranted. REASONS FOR REMAND 1. Entitlement to service connection for hypertension is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for hypertension because no VA examiner has opined whether whether the Veteran’s hypertension is causally related to or aggravated by the Veteran’s serivce-connected psychiatric disability or his medication required to treat his service-connected disabilities. 2. Entitlement to service connection for a gastrointestinal disability, claimed as IBS, is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a gastrointestinal disability because no VA examiner has opined whether the Veteran’s diagnosed gastrointestinal disability, to include constipation, is causally related to or aggravated by the medication required to treat his service-connected disabilities. 3. Entitlement to service connection for an additional acquired psychiatric disability, specifically bipolar disorder. The Board notes that the record is unclear as to whether the Veteran has a diagnosis of bipolar disorder. The private examiner in August 2018 did not provide a diagnosis of bipolar disorder and did not address whether any previous diagnosis of bipolar disorder was causally related to the Veteran’s military service. The Veteran’s treatment records show a history of bipolar diagnosis, but in July 2015 the treating examiner noted that the Veteran did not have bipolar disorder, but rather appeared to have depression with significant symptoms of PTSD. Given the conflicting evidence regarding bipolar disorder, the Board finds that a VA examination is necessary to determine whether the Veteran had an accurate diagnosis of bipolar disorder at any time during the course of the appeal. 4. Entitlement to a compensable disability rating for residuals of a fracture and dislocation of the right middle finger is remanded. During the April 2018 hearing, the Veteran asserted that his right middle finger disability has increased in severity since the Veteran was last examined by VA in 2012, six years prior. The Veteran should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of his right middle finger disability. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination. The examiner should review the claims file, specifically the Veteran’s service treatment records, the Veteran’s lay statements, and his current treatment records. The examiner should then answer the following: a.) Is it at least as likely as not (50 percent probability or more) that the Veteran’s diagnosed hypertension began in service, was caused by service, or is otherwise related to the Veteran’s active service, to include active service? b.) Is it at least as likely as not (50 percent probability or more) that the Veteran’s diagnosed hypertension was caused or aggravated by the Veteran’s service-connected psychiatric disability or his medications used to treat any service-connected disabilities. The Veteran’s lay assertions must be considered and discussed when formulating an opinion. A complete rationale must be provided for all opinions offered. If any opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what, if any, additional evidence would potentially allow for a more definitive opinion. 2. Return the claims file to the November 2012 examiner for further comment. If the examiner is not available, ohprovide the claims file to an appropriate VA examiner for a nexus opinion. The examiner should review the claims file, specifically the Veteran’s service treatment records, his lay statements and history, and the November 2012 VA examinations and opinions. The examiner should then answer the following: Is it at least as likely as not (50 percent probability or more) that the Veteran’s diagnosed gastrointestinal disability, to include constipation, was caused or aggravated by the medications used to treat any service-connected disabilities. The Veteran’s lay assertions must be considered and discussed when formulating an opinion. A complete rationale must be provided for all opinions offered. If any opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what, if any, additional evidence would potentially allow for a more definitive opinion. If an additional examination is required for the examiner to sufficiently address the above questions, then a new examination should be afforded. 3. Obtain an opinion from an appropriate clinician regarding whether the Veteran had an accurate diagnosis of bipolar disorder at any time during the period on appeal. If the Veteran did have an accurate diagnosis of bipolar disorder, the examiner should determine whether is at least as likely as not causally related to service, or proximately due to or aggravated beyond its natural progression by a service-connected disability, to include his service-connected PTSD, chronic adjustment disorder, and major depression. A complete rationale must be provided for all opinions offered. If any opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what, if any, additional evidence would potentially allow for a more definitive opinion. If an additional examination is required for the examiner to sufficiently address the above questions, then a new examination should be afforded. 4. Schedule the Veteran for a VA orthopedic examination to address the current severity of his right middle finger disability. The examiner should review the claims file in conjunction with the examinations. Any tests deemed necessary should be accomplished and the results reported. Range of motion testing should be undertaken for both middle fingers for comparison purposes. The examiner is to report the range of motion measurements in degrees. Range of motion should be tested actively and passively and after repetitive use. The examiner should consider whether there is likely to be additional range of motion loss due to any of the following: (1) during flare-ups; and, (2) as a result of pain, weakness, fatigability, or incoordination. If so, the examiner is asked to describe the additional loss, in degrees, if possible. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. 5. After undertaking the development above and any additional development deemed necessary, the Veteran’s claims should be readjudicated. If the benefits sought on appeal remain denied, the appellant and his representative should be furnished a supplemental statement of the case and be given an appropriate period to respond thereto before the case is returned to the Board, if in order. B. MULLINS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Patricia Veresink