Citation Nr: 18159438 Decision Date: 12/20/18 Archive Date: 12/19/18 DOCKET NO. 10-15 413 DATE: December 20, 2018 ORDER An initial rating of 70 percent, but no higher, for service-connected major depressive disorder (MDD) is granted, subject to the laws and regulations governing payment of monetary benefits. Entitlement to service connection for sleep apnea is denied. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected MDD is remanded. FINDING OF FACT 1. Throughout the appeal period, the Veteran’s service-connected MDD, at its worst, has been manifested by occupational and social impairment with deficiencies in most areas. 2. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of sleep apnea. CONCLUSIONS OF LAW 1. The criteria for an initial 70 percent disability rating, but no higher, for service-connected MDD are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9434 (2018). 2. The criteria for service connection for sleep apnea are not met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2018). REASONS AND BASES FOR FINDING AND CONCLUSIONS The Veteran served on active duty from May 1988 to June 2008. I. Initial Rating Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects her ability to function under the ordinary conditions of daily life, including employment, by comparing her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. A veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). However, where the question for consideration is entitlement to a higher initial rating assigned following the grant of service connection, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of “staged rating” (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). By way of background, the Veteran filed a claim for service connection for an acquired psychiatric disorder that was received on October 28, 2008, within one year from her June 30, 2008, discharge. In the April 2009 rating decision on appeal, the agency of original jurisdiction (AOJ) granted service connection for MDD, and assigned an initial 10 percent disability rating under Diagnostic Code 9434, effective July 1, 2008, the day after the Veteran was discharged. In a June 2017 decision, the Board awarded an initial 50 percent disability rating, but remanded the appeal for further development. MDD is evaluated under a general rating formula for mental disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9434. Under the formula, a 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory; 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 where 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; intermittently 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 and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Finally, a 100 percent rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. Id. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). On the other hand, if the evidence shows that a veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Id. at 443. The United States Court of Appeals for the Federal Circuit has embraced the Mauerhan Court’s interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Ultimately in Mauerhan, the Court upheld the Board’s decision noting that the Board had considered all of the veteran’s psychiatric symptoms, whether listed in the rating criteria or not, and had assigned a rating based on the level of occupational and social impairment. Mauerhan, supra at 444. In Vasquez-Claudio v. Shinseki, F.3d 112, 117 (Fed. Cir. 2013), the Court also held that 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. The Court further held that, in assessing whether a particular disability rating is warranted requires a two-part analysis, including (1) an initial assessment of the symptoms displayed by the veteran and, if they are of the kind enumerated in the regulation and (2) an assessment of whether those symptoms result in the occupational and social impairment contemplated by that particular rating. See id. at 118. Indeed, considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran’s capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). As this matter was certified to the Board in March 2017, which is after the August 4, 2014 implementation of the DSM-5, the DSM-5 applies to the claim. The Board notes that the DSM-5 eliminated the use of Global Assessment of Functioning (GAF) scores. In Golden v. Shulkin, 29 Vet. App. 221 (2018), the United States Court of Appeals for Veterans Claims found that “the Board errs when it uses GAF scores to assign a psychiatric rating in cases where the DSM-5 applies.” The Court explained that the DSM-5 eliminated GAF scores because of their “conceptual lack of clarity” and “questionable psychometrics in routine practice,” and stated that “an adjudicator is not permitted to rely on evidence that the American Psychiatric Association itself finds lacking in clarity and usefulness.” Id., *8-9. The Court explained that symptoms should be the primary focus when assigning a rating for a psychiatric disorder. Id. In accordance with Golden, the Board will not consider the Veteran’s GAF scores. An April 2008 private treatment record noted the Veteran’s complaint of nightmares and avoiding sleep. She stated that she was always paranoid, that she placed herself in rooms that allowed for an escape, and that she felt defensive thinking she was in harm’s way. She also noted that, when she felt suspicious at night, she would lock her doors and check things. A subsequent April 2008 private treatment record noted the Veteran’s long history of moderate and continuous depression symptoms, as well as decreased appetite, decreased sleep, depressed mood, apathy, and feelings of hopelessness. She also reported conflicts with others, feelings of suspiciousness, and hearing voices when she was sleeping. Testing revealed complaints of anxiety, feeling useless, at times feeling like smashing things, and very peculiar and strange experiences. She felt like she was being followed sometimes. The diagnostic impression was dysthymia. The treatment provider noted that testing revealed a high point triad which was often seen in individuals experiencing unusual or strange experiences, perhaps with a thought disorder; however, the treatment provider noted that the validity scales revealed a likely invalid profile. September 2008 and November 2008 VA treatment records note the Veteran’s report of a ten- to fifteen-year history of fearfulness, insomnia, paranoia, nightmares related to her in-service stressors, hearing voices in her dreams, poor motivation, depression, and not wanting to do anything. She indicated that she avoided being attractive so she dressed like a man. Upon examination, she was groomed; she had limited spontaneity in her speech; her mood and affect were flat and dysphoric; and her thoughts were organized. Her mood was congruent to paranoia; she denied suicidal and homicidal ideation; her insight and judgment were fair; and there were no gross deficits in cognition. A December 2008 VA treatment record noted the Veteran’s reports of sleep difficulties, including anxiety. She expressed problems concentrating at home and work. Upon examination, she was neatly dressed, focused, cooperative, and polite. Her speech was unremarkable, her mood with euthymic, and her affect was congruent with her mood. She was alert and oriented, her thought processes were within normal limits, and she denied both suicidal and homicidal ideation. At that time, she was working full time. She reported nightmares; avoidance behaviors; feeling constantly on guard, watchful, or easily startled; and feelings of numbness or detachment. Testing revealed a severe range of depressive symptoms, and the treatment provider noted that the testing was likely valid. Other reported symptoms included feeling depressed, restless, jumpy, unmotivated, anxious, fatigued, worried, self-critical, irritable, withdrawn, and impatient. In January 2009, the Veteran underwent a VA examination. She stated that she recently left her position as a cook with VA due to her medications. Although she reported combat participation, the examiner indicated that her credibility was questionable. The examiner noted that the Veteran brought copies of her April 2008 private treatment records; with regard to the findings, the examiner noted that the results showed possible signs of a thought disorder, but that they were of very questionable validity as the validity scaled were highly elevated. In the examiner’s opinion, based upon the results from current examination, the April 2008 results reflected an exaggeration of symptoms rather than an actual thought disorder. The Veteran reported the following symptoms: depression, withdrawing from others, having a hard time talking, and a lack of motivation. She reported suicidal thoughts, forgetfulness, and a lack of concentration and emotion. She stated that she was easily startled, that she was paranoid, and that she did not sleep very well. She reported anxiety and panic symptoms. She was divorced and was not involved in a relationship with anyone. She reported one friend who also served in the military, but no other friendships. She had a distant relationship with her daughter and her mother. She was able to care for herself independently. Upon examination, she was casually dressed and well groomed. She was hesitant, had slowed speech, and was apparently anxious. Her social skills were poor; her intelligence was estimated to be below average; and her thought process was logical, coherent, and relevant. She was oriented, and her reasoning and judgment were fair. She denied a history of suicide attempts and homicidal thoughts. While she reported psychotic symptoms, the examiner noted that these symptoms were questionable considering the test results and inconsistencies in her records. In terms of the level of occupation and social impairment, the examiner concluded that it was difficult to accurately assess due to problems with credibility. An April 2009 VA treatment record noted that the Veteran was experiencing less auditory hallucinations, but that she still was depressed. She denied suicidal and homicidal thoughts, manic symptoms, and anxiety. Upon examination, her mood and affect were flat and dysphoric; and her thoughts were organized. Her mood was congruent to paranoia; and there were no gross deficits in cognition. A January 2010 VA treatment record noted the Veteran’s reports of worsening attention, concentration, and increased forgetfulness, and that she had stopped driving as a result of those problems. She also reported increased social isolation, problems with auditory hallucinations, and she described her mood as primarily anxious and irritable. She described a startle response when touched. She denied suicidal and homicidal ideation, but indicated that before she sought treatment at VA, she had some homicidal ideation. She indicated that she slept off and on throughout the day. She worried about her safety and would check her doors and windows. She also reported nightmares and decreased appetite. She reported intrusive memories, flashbacks, and nightmares related to her in-service experiences. She stated that she saw her daughter every day, and that she spoke to her mother once or twice a month. She denied making any new friends since her discharge. She was not currently working. In May 2010, the Veteran underwent another VA examination. Her general appearance was clean; her speech was soft or whispered and coherent; her attitude was indifferent; her affect was normal; and her mood was anxious and depressed. She was easily distracted, but she was oriented; her thought process was unremarkable; and her thought content included delusions. She understood the outcome of her behavior; her intelligence was below average; and she understood that she had a problem. She suffered from a sleep impairment, including trouble falling and staying asleep, as well as nightmares. She did not display inappropriate or obsessive/ritualistic behavior. She experienced panic attacks three or four times a week, especially when in crowds. She denied homicidal and suicidal ideation; she had good impulse control; and there were no episodes of violence. She was able to maintain her personal hygiene, and she was able to perform activities of daily living. Other symptoms included the following: anhedonia; sadness; insomnia; feeling badly about herself; poor appetite; restlessness; fatigue; and poor concentration. Her remote memory was mildly impaired, her recent memory was moderately impaired, and her immediate memory was normal. Overall, the examiner concluded that the Veteran’s service-connected MDD resulted in occupational and social impairment with reduced reliability and productivity. An August 2010 VA treatment record noted the Veteran’s report of the following symptoms: recurrent/intrusive recollections; recurrent dreams; acting/feeling as if the event were recurring; intense psychological distress at exposure to internal/external cues; physiological reactivity on exposure to cues; avoidance behaviors; diminished interest in activities; detachment from others; restricted range of affect; difficulty falling or staying asleep; irritability/angry outbursts; difficulty concentrating; hypervigilance; and an exaggerated startle response. During a November 2010 Decision Review Officer (DRO) hearing, the Veteran reported social problems, trouble sleeping, panic attacks. She indicated that she had problems with memory, anger, and hallucinations. A January 2011 VA treatment record noted the following symptoms: anhedonia, depressed mood, change in sleep, decreased energy, change in appetite, poor self-worth, difficulty concentrating, and psychomotor change. Additionally, she reported auditory hallucinations, as well as delusional thoughts, thinking that others were watching her and against her. Other symptoms included nightmares, intrusive thoughts, feeling on guard, feeling ashamed, and avoidance behaviors. Upon examination, she was appropriately groomed and was cooperative; her speech was spontaneous and within normal limits; her mood was sad, and her affect was congruent and anxious; her thoughts were clear, logical, and goal directed; she denied suicidal and homicidal ideation; and her insight and judgment were fair. A May 2011 VA treatment record noted the Veteran’s report of the following: repeated memories, thoughts, or images related to her military service; repeated disturbing dreams; suddenly acting or feeling as though her stressful experiences were recurring; feeling very upset when reminded of her experiences; having physical reactions when reminded of her experiences; avoidance behaviors; memory problems; feeling distant or cut off from others; feeling emotionally numb; feeling as though her future would be cut short; sleep disturbances; irritability and angry outbursts; difficulty concentrating; being “superalert,” watchful, or on guard; and feeling jumpy or easily startled. She stated that these problems made it very difficult for her to work, take care of things at home, or get along with other people. A June 2011 VA treatment record noted the Veteran’s complaint of worsening attention, concentration, and forgetfulness which resulted in decreased driving and increased social isolation. Testing revealed intellectual functioning at borderline range for verbal abilities, and mildly impact for nonverbal or visual abilities. With regard to her memory, the treatment provider noted that she did not pass any validity measures, and that her performance was at near chance level, which would only be expected in individuals with dementia living in a nursing home. Visual memory could also not be measured due to her not copying stimuli that were present in front of her. Despite the lack of validity, her memory performance showed a pattern of limited learning and remembering the limited amount of information she did learn. Executive functioning was difficult to reliably interpret due to extremely slow performance and poorer performance than expected even than individuals with significant neurological dysfunction. Personality and psychosocial testing suggested a person with significant thinking and concentration problems, accompanied by prominent hostility, resentment, and suspiciousness which likely represented problems in the development of close friendships, and she was likely to be withdrawn and isolated. There were suggestions of psychotic processes with hallucinations and unusual ideas. She was likely hypervigilant to her surroundings, met the full criteria for a major depressive episode, and experienced anxiety with tension and apprehension. She was easily overwhelmed by her emotions and, with ruminative preoccupation with physical functioning and health matters, she was likely to be unable to meet even minimal role expectations. She also reported being prone to extreme displays of anger, including damage to property and threats to assault others, but she denied thoughts of self-harm. She was often hard on herself, was uncomfortable in social situations, and was passive when dealing with others. He had little to no support system, and her motivation was lower than others in treatment. In summary, the treatment provider concluded that the findings appeared to be an underestimate of her cognitive abilities, and were inconsistent with the pattern or strengths and weaknesses typical of neurological difficulties, likely reflecting the burden of her emotional distress. The overall profile suggested someone with significant thinking and concentration problems, accompanied by prominent hostility, resentment, and suspiciousness. The latter likely affected her ability to develop close friendships, and she was likely to be withdrawn and isolated. There were also suggestions that psychotic processes were present with hallucinations and unusual ideas, and that she was hypervigilant to her surroundings. Another June 2011 VA treatment record noted that the Veteran’s report an incident at a store when her temper got the better of her, and the police were called. In November 2011, the Veteran report an increase in her anxiety symptoms. Upon examination, she was alert, oriented, and groomed. Her attitude was cooperative and polite, her eye contact was good, her mood was anxious, and her affect was congruent to her mood and content. Her thought processes were grossly intact, and she denied suicidal and homicidal ideation, as well as hallucinations. She reported little interest or pleasure in doing things for several days, as well as feeling down, depressed, or hopeless nearly every day. A subsequent November 2011 VA treatment record noted that she was working part time as a security guard. In January 2012, the Veteran underwent another VA examination. Overall, the examiner concluded that the Veteran’s symptoms resulted in occupational and social impairment with reduced reliability and productivity. She described herself as a loner, noting that her military friends had all dispersed. She maintained periodic contact with her family and daughter, noting that “everyone has their own lives.” She indicated that she just started working part time. She stated that she did not like to be around people, and would typically go out during non-peak hours. When around crowds, she would sweat, shake, her heart rate would increase, and she would feel anxious and self-conscious. She continued to experience sleep disturbances, including waking up after a few hours, wandering the house, and checking the doors. She stated that she typically felt unsafe when home alone. She denied past and present suicidal ideation, as well as homicidal ideation. She stated that she was jittery, jumpy, and had trouble concentrating which caused her to stop driving. She described decreased motivation and drive, as well as feeling tired and drained. With regard to sleep, she indicated that she would wake up after only two to four hours, and had trouble falling back asleep, which she attributed to nightmares. Her symptoms included the following: depressed mood; suspiciousness; panic attacks more than once a week; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; flattened effect; disturbances in motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and obsessional rituals which interfere with routine activities. Other symptoms included the following: significant pessimism; anhedonia; feelings of guilt; self-critical thoughts; emotional numbing; loss of interest in activities or others; feelings of worthlessness; loss of energy; sleep disturbances; feelings of anger and irritability; decreased appetite; concentration problems; fatigue; and loss of interest in sexual interaction. Additionally, the examiner also noted her reports of auditory hallucinations during sleep. A November 2012 VA treatment record noted the Veteran’s report of depression, trouble sleeping due to nightmares, and a mild decrease in energy and concentration. She denied suicidal and homicidal ideation, as well as anxiety or mania symptoms. She reported hearing voices in her nightmares, as well as seeing shadows. She also reported flashbacks, intrusive thoughts, isolative behaviors, and suspiciousness. An April 2013 VA treatment record noted the Veteran’s reports of significant improvement in her mood symptoms. She also reported improved sleep, but occasional nightmares. She denied anhedonia, but reported improved energy, concentration, and a better mood. She denied any appetite change, as well as suicidal or homicidal ideation. She also denied anxiety or mania, but she still reported hearing voices in her nightmares. Other reported symptoms included flashbacks and intrusive thoughts. She was increasing her social activity, including trying to get out of her home on a daily basis. In November 2013, the Veteran stated that she was doing “so so,” and she expressed a desire to be calmer and not as easily startled. She indicated that she was hearing voices in her sleep, as well as when she was awake, and that the voices kept her from going places. She also reported seeing shadows, as well as problems with paranoia. She reported low energy, problems concentrating, and decreased appetite. She denied current homicidal or suicidal ideation, but she reported a past suicide attempt five or six years earlier. Other symptoms included difficulty sleeping, vivid nightmares, anhedonia, and self-isolation. She was reportedly unemployed. A March 2014 VA treatment record noted the Veteran’s report of auditory hallucinations at night, when she was driving, or when she was out, but that she heard them less frequently when taking her medication. She also reported improvement in her sleep, but was still isolative because her symptoms worsened when she went out. She denied current suicidal and homicidal ideation. Other symptoms included difficulty sleeping, vivid nightmares, anhedonia, and self-isolation, and her anxiety was about the same. She was determined to be a low risk to herself and others. Upon examination, she displayed good personal hygiene, was dressed appropriately, and was positively engaged. There was no remarkable psychomotor agitation, her speech was spontaneous, fluent, and of low volume. Her mood was anxious, and her affect was congruent with her mood. Her thought process was linear, her insight and judgement were good, and her cognition was grossly intact. A September 2014 VA treatment record noted that the Veteran was sleeping well with medication, but that she still experienced three to four nightmares a week. She stated that she had no interest in anything, that she isolated herself, and that she had difficulty being around people. She was hypervigilant and startled easily, experienced frequent intrusive memories, engaged in avoidance behaviors, and felt detached from others. Her energy and concentration were poor, she had a very little appetite, she endorsed occasional psychomotor retardation, and she has persistent negative belief about herself. She denied homicidal and suicidal ideation, as well as manic symptoms. She denied panic attacks. In March 2015, a VA treatment provider concluded that she was at a moderate risk of suicidal behavior and that she was judged to be at increased risk, but not acutely dangerous to herself. An April 2015 VA treatment record noted the Veteran’s report of anxiety, isolation, and suicidal ideation in the past. She stated that she slept off and on, and that she experienced nightmares. Her appetite was low, she had a lack of motivation, and she experienced low energy. She did not have a support system. She reported auditory and visual hallucinations. She denied current suicidal ideation, but stated that she previously experienced it. She had feelings of hopelessness and helplessness. She was well-groomed, but difficult to engage. Her speech was normal, her mood was depressed, and her affect was congruent with her mood. Her thought process was coherent and goal-directed, and her sensorium and cognition were grossly intact. She was oriented, her concentration and memory were intact, and her insight and judgment were good. An October 2015 VA treatment record noted that the Veteran’s sleep was steady, but interrupted. She was experiencing fewer nightmares, but she also reported suicidal ideation at times with no plan. She practiced gun safety, and thought about getting rid of it. Upon examination, she was casually dressed, her mood was “better than before,” and her affect was restricted. Her thought process was spontaneous and monotone with appropriate content. At that time, she denied homicidal and suicidal ideation, although there was a history of suicidal ideation without a plan. She was oriented, and her judgment and insight were “ok.” A June 2016 VA treatment record noted the Veteran’s reports of feeling depressed and anxious, but she denied feeling angry or irritable. She denied any major stresses or worries in her life, but she stated that she stayed home all day. She was feeling lonely, but she denied suicidal and homicidal ideation, and there was no evidence of psychosis and mania. Her symptoms included the following: difficulty falling asleep, and middle insomnia; okay energy; low interest; fair concentration; and okay appetite. Upon examination, she was neat and appeared her stated age. She was cooperative, maintained fair eye contact, and her speech with within normal limits. Her mood was depressed and anxious, and her affect was congruent to her mood. She was alert and oriented, and her memory was intact. Her thought process was organized and goal directed. She denied hallucinations, delusions, and suicidal and homicidal ideations, and her insight and judgment were fair. Similar findings were reported in December 2016 and April 2017. A September 2017 VA treatment record noted the Veteran’s reported struggles sleeping at night, as well as her reports of seeing shadows and spiders which caused her to jump. She dealt with her anxiety and triggers by avoiding and staying away from people. She felt “compressed,” as though she was going to snap if she was around too many people. She stated that she was detached from her daughter which hurt her a lot, and that she had felt this way for the past six years. The treatment provider noted that the Veteran had limited support, and that she did not have a positive support system. She was reportedly lonely and ashamed of her mental health issues, and she felt as though she was being judged by people around her. In December 2017, the Veteran underwent another VA examination, and was diagnosed with an unspecified depressive disorder with anxious stress, and unspecified personality disorder traits, and noted that it was not possible to differentiate which symptoms were attributable to each diagnosis because the symptoms overlapped with each diagnosis. Concerning the level of occupation and social impairment attributable to the Veteran’s diagnoses, the examiner concluded that the Veteran’s service-connected MDD resulted in occupational and social impairment with reduced reliability and productivity. The examiner noted that the Veteran lived alone and, although she had a daughter, they were not on good terms and did not see each other often. She reportedly did not have good relationships with her siblings or mother. She stated that she recently moved, but had not made friends. She stated that she felt detached and estranged from others, indicated that she spends all of her time alone. Her activities of daily living included taking care of her dog, sleeping most mornings, watching some television, and crying. She last worked as an unarmed security guard seven years ago, and stated that she did not miss working because crowds gave her anxiety. Upon examination, her symptoms included the following: depressed mood; anxiety; panic attacks that occur weekly or less often; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; and difficulty in establishing and maintaining effective work and social relationships. She described her mood as “all over the place,” and she indicated that she did not sleep. Her affect was appropriate to the content of the discussion in both intensity and direction. Her thought processes were clear, logical, linear, coherent, and goal directed. There was no impairment of thought processes or communication, and she was able to attend to her personal hygiene and other activities of daily living. Her memory was characterized as fair to poor, and she had very low concentration. She denied any obsessive or ritualistic behavior. There was no impairment of impulse control. She rated her depression as a nine out of ten, and her anxiety as a ten out of ten. With regard to delusions and hallucinations, she stated that she saw “shadows” when she would wake. She had a prior history of two suicide attempts in 2008 and 2009; however, she denied any current suicidal or homicidal ideation. The examiner indicated that psychopathology and personality testing was consistent with the invalid results of the January 2009 VA examination, in that it revealed an overreporting of a large number of symptoms. Based on the above evidence, the Board concludes that the evidence of record demonstrates that the symptomatology associated her service-connected MDD more nearly approximates occupational and social impairment in most areas, warranting the assignment of a 70 percent disability rating for the entire appellate period. See 38 C.F.R. § 4.7. In reaching this conclusion, the Board notes that the Veteran’s symptoms included the following: chronic sleep disturbances, including nightmares and interrupted sleep; paranoia and hypervigilance; depression, including feelings of hopelessness and apathy; anxiety; anger and irritability, including conflicts with others; intermittent suicidal ideation and low self-worth; difficulty in establishing and maintaining relationships; difficulty concentrating; problems with memory; and avoidance behaviors and self-isolation. The Board finds that while these symptoms were not always present together, they were of sufficient persistence to result in occupational and social impairment with deficiencies in most areas throughout the entire appellate period. For this reason, staged ratings are not applicable. See Fenderson, 12 Vet. App. at 119. Therefore, as explained above, the medical evidence supports the Board’s conclusion that an initial 70 percent rating is warranted. The Board adds that while a 70 percent disability is granted, the Veteran’s symptoms are not so severe as to cause total occupational and social impairment, warranting a 100 percent rating at any time during the period under review. Indeed, none of the VA examiners who have assessed the nature and severity of the Veteran’s MDD found that it resulted in total occupational and social impairment. Furthermore, insofar as testing has revealed some level of thought impairment, multiple medical professionals have indicated that those results were likely invalid, and her VA treatment record consistently note that she was oriented, that her thought process was lineal and logical, and that her judgment and insight were at least fair. Furthermore, although the Veteran has consistently reported auditory and visual hallucinations, there is nothing in the record to indicate that those hallucinations manifest in impairment that is total. Indeed, with regard to relationships, although she has largely isolated herself, she nevertheless maintained some contact with her daughter and her mother. Furthermore, while the Veteran has described intermittent suicidal ideation, there is nothing in the record to suggest that she was a threat to herself or to others. To the contrary, as noted above, in March 2014, she was found to be a low risk to herself and others, and in March 2015, she was determined be not acutely dangerous. Furthermore, there is no indication that the Veteran was unable to care for herself; rather, she was consistently noted to be appropriately groomed, and she was able to perform activities of daily living. Therefore, the Board finds that total social impairment is not shown by the record, and a 100 percent disability rating is not warranted. For the foregoing reasons, the Board finds that the Veteran’s service-connected MDD more nearly approximated the criteria for an initial 70 percent disability rating, but no higher, throughout the appeal period. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). II. Service Connection The Veteran claims entitlement to service connection for sleep apnea. Specifically, she contends that she experienced sleep apnea symptoms during her active duty service, and that they have continued to the present. 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 the Veteran does not have a current diagnosis of sleep apnea and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). A September 2008 VA treatment record noted the Veteran’s complaint of disturbed sleep for many years, including her reported of snoring without apneas, and sleep talking. The treatment provider noted her long history of sleep disturbances which were suggestive of insomnia. The treatment provider also noted that, while the clinical features were highly suggestive of insomnia, her complaints of snoring and the evidence of an overbite on examination were suggestive of a sleep-related breathing disorder, which could also contribute to her sleep disturbances. The treatment provider requested a nocturnal polysomnogram to see if she experienced problems such as obstructive sleep apnea. In December 2008, the Veteran underwent a home-based sleep study. Testing revealed an apnea hypopnea index (AHI) of 2.9 and an average oxygen saturation of 96 percent with a nadir of 93 percent. The study was consistent with mild REM-related sleep-disordered breathing, and a trial of an auto-CPAP was recommended. A June 2009 VA treatment record noted the Veteran’s ongoing complaints of excessive daytime sleepiness. The treatment provider documented an impression of obstructive sleep apnea. In January 2012, the Veteran underwent a VA examination, and the only diagnosis rendered was insomnia. The examiner noted the Veteran’s reports of trouble falling and staying asleep which on active duty, as well as a lot of daytime sleeping. Her current symptoms included persistent daytime hypersomnolence, snoring, and frequent nighttime awakenings. The examiner concluded that the Veteran did not have sleep apnea. The examiner then discussed the results of the December 2008 home-based sleep study, including the fact that no apneas were reported during the study, and that there were no periods of desaturation below 93 percent. The examiner then noted the June 2009 diagnosis of obstructive sleep apnea; however, she also noted that no split sleep study had been repeated. In December 2017, the Veteran underwent another VA examination, and once again, the only diagnosis reported was insomnia. The examiner noted the Veteran’s reports of trouble falling and staying asleep due to nightmares. She indicated that sounds wake her up, that she snored a little, and that she stayed up all day and was irritable. She stated that she slept sitting up, and that she still snored in this position. Ultimately, the examiner concluded that she did not have obstructive sleep apnea. The examiner quoted a medical article which stated that “hypopneas that occur in associated with phasic eye movements during REM sleep often meet scoring criteria, and contribute to AHI. However, in the absence of associated arousals or substantial oxygen desaturation, they are thought to be normal physiologic events that must be discounted in assessment to the overall AHI.” With regard to the December 2008 study, the examiner noted that the results did not show arousal or substantial oxygen desaturation associated with apneic episodes; therefore, the examiner concluded that the REM-related sleep disturbances were considered normal physiological events. With regard to the Veteran’s current report of daytime sleepiness, the examiner noted that such was not specific to sleep apnea, and could result from insomnia or a lack of sleep. Furthermore, the examiner noted that the Veteran’s reported symptoms were not consistent with sleep apnea. Finally, the examiner noted that she declined a sleep study. Based on the foregoing, the Board finds that the preponderance of the evidence is against finding that the Veteran has a current diagnosis of sleep apnea. While the December 2008 home-based sleep study indicated that the Veteran’s had mild REM-related sleep-disordered breathing, the December 2017 VA examiner explained that mild REM-related sleep-disordered breathing was a normal physiological event without evidence of either associated arousals or substantial oxygen desaturation, which were not shown at that time. While the June 2009 VA treatment record noted an assessment of obstructive sleep apnea, it is unclear as to how that diagnosis was derived given that no follow-up sleep study was performed. Additionally, the December 2017 VA examiner indicated that the Veteran declined to undergo a sleep study. The Board finds that the December 2017 VA examination report is the most probative evidence of record as to whether the Veteran has a current diagnosis of sleep apnea, as it reflects consideration of all pertinent evidence of record, to include the December 2008 home-based sleep study and the June 2009 VA treatment record, and it provides a clear conclusion with a supporting rationale that addresses the issues and questions raised. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.”). While the Veteran believes she has a current diagnosis of sleep apnea, she is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education and the ability to interpret complicated diagnostic medical testing, which she is not shown to have. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Finally, the Board notes that the Veteran’s sleep-related complaints, including chronic sleep disturbances and insomnia, have been attributed to her service-connected MDD, and those symptoms are contemplated in her current-assigned disability rating. See, e.g., December 2017 Mental Disorders VA Examination Report. Therefore, in the absence of competent evidence demonstrating a current diagnosis of sleep apnea, the Board finds that preponderance of the evidence is against her claim. As such, reasonable doubt does not arise, and her claim for service connection for sleep apnea must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). REASONS FOR REMAND Pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009), a claim for a TDIU is part of an initial rating claim when such claim is expressly raised by the veteran or reasonably raised by the record. Here, a claim of entitlement to a TDIU has been raised by the record. For example, at a November 8, 2017 VA Primary Care Note, the veteran indicated that she was unable to work due to her anxiety. Thus, the Board has jurisdiction over this issue as part and parcel of her claim for a higher initial rating and has listed such on the title page. On remand, the AOJ should send the Veteran notice of the evidence required to establish a TDIU. In addition, the AOJ should request that she complete an updated VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, and then adjudicate this matter in the first instance. The matter is REMANDED for the following action: 1. Send the Veteran the proper notice that advises her about what is needed to substantiate a claim for a TDIU. In addition, request that she complete and return a VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability. (Continued on Next Page) 2. Thereafter, and after any further development deemed necessary, adjudicate the issue of entitlement to a TDIU. If the benefit sought on appeal is not granted, the Veteran and her representative should be provided with a Supplemental Statement of the Case and afforded the appropriate opportunity to respond. The case should then be returned to the Board for further appellate consideration, if otherwise in order. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD James R. Springer, Associate Counsel