Citation Nr: 18159523 Decision Date: 12/20/18 Archive Date: 12/19/18 DOCKET NO. 16-55 905 DATE: December 20, 2018 ORDER As new and material evidence has not been received sufficient to reopen the claim of entitlement to service connection for hypertension, the claim is denied. As new and material evidence has not been received sufficient to reopen the claim of entitlement to service connection for prostate cancer, to include prostatitis, the claim is denied. Entitlement to service connection for tinnitus is denied. Entitlement to an effective date earlier than April 15, 2015, for the award of service connection for posttraumatic stress disorder (PTSD) is granted. Entitlement to a 70 percent disability rating, but no higher, for PTSD, to include depression, anxiety, and insomnia, is granted. REMANDED Entitlement to service connection for obstructive sleep apnea, to include as secondary to PTSD, is remanded. Entitlement to service connection for chronic headaches, to include as secondary to PTSD, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. A December 2010 rating decision denied service connection for hypertension. 2. The evidence received since the December 2010 rating decision is cumulative and redundant, and neither relates to an unestablished fact necessary to substantiate the claim, nor raises a reasonable possibility of substantiating the claim for service connection for hypertension. 3. An April 2005 rating decision denied service connection for prostate cancer. In March 2010, the Veteran petitioned to reopen the claim; in a December 2010 rating decision, the petition to reopen the claim for entitlement to service connection for prostate cancer, to include prostatitis was denied. 4. The evidence received since the December 2010 rating decision is cumulative and redundant, and neither relates to an unestablished fact necessary to substantiate the claim, nor raises a reasonable possibility of substantiating the claim for service connection for prostate cancer, to include prostatitis. 5. The Veteran does not have tinnitus. 6. For the year prior to April 15, 2015, the Veteran’s PTSD was manifested by occupational and social impairment with deficiencies in most areas. 7. For the period on appeal, the Veteran’s PTSD was manifested by occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. New and material evidence has not been received sufficient to reopen the claim of entitlement to service connection for hypertension. 38 U.S.C. § 5108 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 (2018). 2. New and material evidence has not been received sufficient to reopen the claim of entitlement to service connection for prostate cancer, to include prostatitis. 38 U.S.C. § 5108 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 (2018). 3. The criteria for service connection for tinnitus have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). 4. The criteria for an effective date of April 15, 2014, but no earlier, for the award of 70 percent for PTSD have been met. 38 U.S.C. §§ 5107, 5110 (2012); 38 C.F.R. §§ 3.102, 3.114(a), 3.400 (2018). 5. The criteria for a 70 percent rating for PTSD have been met. 38 U.S.C. § 1155, 5107(b) (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.21, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1968 to November 1972. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an October 2015 rating decision of the Department of Veterans Affairs (VA) Regional Offices (RO) in Winston-Salem, North Carolina. The Board notes that following issuance of the statement of the case (SOC) by the RO, the Veteran, through his attorney, submitted new evidence, accompanied by a waiver of Agency of Original Jurisdiction (AOJ) consideration of the new evidence pursuant to 38 C.F.R. § 20.1304 (2018). Under applicable law, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. The record reflects that VA’s duty to notify was satisfied by various correspondences. There is no indication in this record of a failure to notify. See 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2018); see also Scott v. McDonald, 789 F.3rd 1375 (Fed. Cir. 2015). Regarding the duty to assist, the Veteran’s service treatment records (STRs) are associated with the claims file, as are VA medical records and private treatment records. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. Green v. Derwinski, 1 Vet. App. 121 (1991). The Veteran has not had a VA examination for tinnitus. However, the Board finds that an examination is not necessary because there is no evidence of record indicating that the Veteran has tinnitus. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006); Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). Accordingly, VA’s duties to notify and assist are met. The issues of entitlement to service connection for sleep apnea and headaches as secondary to PTSD, and entitlement to a TDIU are addressed in the remand portion of the decision below. 1. New and Material Evidence A rating action from which an appeal is not perfected becomes final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. The governing regulations provide that an appeal consists of a timely filed notice of disagreement (NOD) in writing, and after a SOC has been furnished, a timely filed substantive appeal. 38 C.F.R. § 20.200. In order to reopen a claim which has been denied by a final decision, new and material evidence must be received. 38 U.S.C. § 5108. New and material evidence means evidence not previously submitted to agency decision makers; which relates, either by itself or when considered with previous evidence of record, to an unestablished fact necessary to substantiate the claim; which is neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and which raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. Shade v. Shinseki, 24 Vet. App. 110 (2010). Moreover, in determining whether that low threshold is met, consideration need not be limited to consideration of whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering VA’s duty to assist or through consideration of an alternative theory of entitlement. Hypertension In a December 2010 rating decision, the RO denied service connection for hypertension. The RO indicated that the evidence neither showed an in-service event, injury, or disease, nor was there a link between the Veteran’s hypertension and his active service. The pertinent evidence of record at the time was the Veteran’s service treatment records (STRs), post-service medical treatment records dated from August 2001 to February 2005, and a VA examination dated in September 2010. The Veteran was notified of the December 2010 rating decision, he filed a timely NOD in September 2011, and the RO issued a SOC in February 2014. However, the Veteran took no further action. Therefore, the December 2010 decision is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104 (a), 3.156(b), 3.160(d), 20.302, 20.1103 (2018). In April 2015, the Veteran submitted a request to reopen the previously denied claim for service connection for hypertension in the form of a fully developed claim, submitted via VA Form 21-526EZ. The only new evidence that the Veteran submitted related to hypertension were medical treatment records that note that the Veteran received a diagnosis of hypertension. The evidence added to the record is not new and material because it merely repeats evidence which was already of record at the time of the last final denial of the Veteran’s claim in December 2010. As the Veteran has not fulfilled the threshold burden of submitting new and material evidence to reopen the finally disallowed claim of service connection for hypertension, the benefit-of-the-doubt doctrine is not applicable. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993). Prostate cancer and prostatitis An April 2005 rating decision denied service connection for prostate cancer. The RO indicated that the evidence did not indicate that the Veteran had a current prostate disability. The Veteran was notified of the rating decision but took no further action at that time. The pertinent evidence of record at the time was the Veteran’s service treatment records (STRs) and post-service medical treatment records dated from August 2001 to February 2005. In March 2010, the Veteran petitioned to reopen his claim for entitlement to service connection for prostate cancer, to include prostatitis. The RO issued a rating decision in December 2010, denying the petition to reopen the claim because new and material evidence had not been received. The new evidence consisted of medical treatment records dated through October 2010. The Veteran was notified of the December 2010 rating decision, he filed a timely NOD in September 2011, and the RO issued a SOC in February 2014. However, the Veteran took no further action. Therefore, the December 2010 decision is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.104 (a), 3.156(b), 3.160(d), 20.302, 20.1103 (2018). In April 2015, the Veteran submitted a request to reopen the previously denied claim for service connection for prostate cancer, including prostatitis, to include as due to herbicide exposure, in the form of a fully developed claim, submitted via VA Form 21-526EZ. The only new evidence that the Veteran submitted related to a prostate disability were medical treatment records that note that the Veteran’s current medical conditions included chronic prostatitis. The Board notes that although this evidence appears to indicate that the Veteran received a diagnosis of prostatitis, which the RO indicated was not present at the time of the December 2010 rating decision, the evidence added to the record is not material and does not raise a reasonable possibility of substantiating a claim. Service connection based on herbicide exposure will be presumed for certain specified diseases that become manifest to a compensable degree within a specified period of time in the case of certain diseases. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307(a)(6), 3.309(e) (2018). Although chronic prostatitis is not one of the diseases for which service connection can be granted on a presumptive basis based on exposure to herbicides, the Veteran is not precluded from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039, 1041-42 (Fed. Cir. 1994). However, the Veteran’s new evidence does not include evidence, such as a medical opinion or documentation of additional in-service incurrences, purporting to make it likely that his current disability is related to a claimed in-service incurrence. As the Veteran has not fulfilled the threshold burden of submitting new and material evidence to reopen the finally disallowed claim of service connection for hypertension, the benefit-of-the-doubt doctrine is not applicable. See Annoni v. Brown, 5 Vet. App. 463, 467 (1993). 2. Service Connection Establishing service connection generally requires (1) evidence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 281 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established on a secondary basis. In this instance, the evidence must demonstrate an etiological relationship between a service-connected disability or disabilities on the one hand and the condition said to be proximately due to the service-connected disability or disabilities on the other. 38 C.F.R. § 3.310(a); Wallin v. West, 11 Vet. App. 509 (1998). Medical evidence is required to demonstrate a relationship between a current disability and the continuity of symptomatology demonstrated if the condition is not one where a lay person’s observations would be competent. Clyburn v. West, 12 Vet. App. 296 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was noted during service; (2) evidence of post-service continuity of the same symptomatology and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. Savage v. Gober, 10 Vet. App. 488 (1997). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Tinnitus The Veteran’s service treatment records (STRs) are silent for any complaints, treatment, or diagnosis of tinnitus. Although, there is a note dated in November 1970 which indicates that the Veteran reported an earache. Post-service medical treatment records do not reflect that the Veteran had tinnitus at any time during the period on appeal. In fact, the only records that mention tinnitus specifically note that the Veteran had denied having tinnitus. Additionally, the Veteran has not provided any lay evidence regarding tinnitus. Evidence of a current disability is a fundamental requirement for a grant of service connection. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). As there is no indication in the record of a current disability, the Board finds that the preponderance of the evidence is against the claim for service connection for tinnitus. Accordingly, the benefit-of-the-doubt rule does not apply, and the claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102; 4.3; Gilbert, 1 Vet. App. at 55. 3. Earlier effective date The Veteran contends that he is entitled to an earlier effective date and an increased rating for his service-connected PTSD. Generally, the effective date of an award of disability compensation is the day following separation from service or the date entitlement arose if the claim is received within one year of separation, otherwise the effective date is the date of claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(b); 38 C.F.R. § 3.400 (b)(2). The “date entitlement arose” has been interpreted to mean the date when the claimant met the requirements for the benefits sought; this is determined on a “facts found” basis. 38 U.S.C. § 5110(a); see also McGrath v. Gober, 14 Vet. App. 28, 35 (2000). Unless specifically provided otherwise, the effective date for an increased rating is to be the earliest date as of which it is factually ascertainable that an increase in disability occurred if a claim is received within one year from such date; otherwise, the effective date for increased rating is the date of receipt of the claim for increase. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2); Gaston v. Shinseki, 605 F.3d 979, 984 (Fed. Cir. 2010). Determining an appropriate effective date for an increased rating involves an analysis of the evidence to determine (1) when a claim for an increased rating was received and, if possible (2) when the increase in disability actually occurred. 38 C.F.R. §§ 3.155, 3.400(o)(2); see also Hazan v. Gober, 10 Vet. App. 511 (1997). The Veteran filed his increased rating claim on April 15, 2015. In this regard, this decision will consider whether an increased rating is warranted for any portion of the one-year period prior to the date of claim (i.e., April 15, 2014, to April 15, 2015). See Gaston, 603 F.3d at 984. Medical treatment records reflect that the Veteran attended support groups and counseling sessions and was compliant with his medications. The available records indicate that the Veteran reported experiencing sleep impairment, anxiety, depression, isolation, avoidance, irritability, and a lack of energy or motivation. Generally, the treatment notes indicate no impairment in the Veteran’s thought process and content, memory, or attention span. The treatment records note an absence of suicidal ideation or attempts to harm himself or others. In October 2015, the Veteran underwent a VA examination, which provided a diagnosis of PTSD. The examiner found that the Veteran had occupational and social impairment with reduced reliability and productivity. The examination notes that the Veteran experienced symptoms of depressed mood; anxiety; suspiciousness; chronic sleep impairment; flattened affect; disturbances of motivation or mood; difficulty establishing and maintaining effective relationships; and difficulty adapting to stressful circumstances, including work or a worklike setting. The examiner noted that depression, anxiety, and insomnia are symptoms of the Veteran’s PTSD and do not represent different or separate disorders. During the examination, the Veteran reported that he lived alone and was not in a relationship. He indicated that he had a friend that he spoke with regularly but they did not engage in social activities. He noted that he worked 3 to 4 hours a week watching children at school, and his last full-time job was five years prior working at a grocery store, noting that he was fired for working too slowly. The Veteran indicated that he was on medication and attended group therapy treatment. The Veteran submitted a private evaluation dated in April 2018, in which the provider noted a diagnosis of PTSD. After interviewing the Veteran, reviewing his VA records and claims file, she indicated that the Veteran had occupational and social impairment with deficiencies in most areas. The evaluation notes that the Veteran had symptoms of isolation, difficulty falling and staying asleep, chronic sleep impairment, irritability and angry outbursts, difficulty concentrating, hypervigilance, exaggerated startle response, depressed mood, anxiety, suspiciousness, panic attacks more than once a week, near continuous panic or depression, mild memory loss, impairment of short- and long-term memory, flattened affect, disturbances of motivation or mood, difficulty and inability establishing and maintaining effective relationships, difficulty adapting to stressful circumstances, suicidal ideation, persistent delusions or hallucinations, neglect of personal appearance and hygiene, intermittent inability to perform activities of daily living including maintenance of minimal personal hygiene. The provider indicated that the Veteran’s symptoms have been present since April 2015. The provider noted that the Veteran reported that he did not do household chores, and he showered “maybe” once a week. The Veteran reported that he had passive suicidal ideation, with suicidal thoughts occasionally. He also reported auditory and visual hallucinations in the form of hearing noises and seeing shadows when no one was present. The evaluation noted that the Veteran had psychological and physiological reactions to helicopters, the smell of burning flesh, fireworks, and unexpected loud noises. The Veteran also reported that he had lost every job he had due to his difficulty interacting with people and becoming angry with them. The provider indicated that the Veteran’s PTSD symptoms prevent him from maintaining substantially gainful employment. In March 2018, the VA received two lay statements, one from the Veteran’s friend and another from his neighbor. These statements indicate that the Veteran’s symptoms have worsened in the last 4 to 5 years and affect his daily ability to function. The lay evidence notes that the Veteran experienced memory loss, often repeating stories or conversations. The Veteran’s neighbor also reported that the Veteran told her that he had missed his appointments. The statements also reflect that the Veteran was isolated and not interested in socializing, often remaining at home. The lay evidence notes that the Veteran is easily frustrated. The Veteran’s neighbor additionally reported that the Veteran had poor hygiene and neglected his household chores, and as such, she noted that she occasionally went to the store for him and cleaned his house. She indicated that she never heard him say anything about hurting himself. Based on a review of the evidence, the Board finds the lay statements of record to be particularly probative because, as the Veteran’s friend and neighbor, these individuals are familiar with the Veteran and therefore, their reports of his symptoms carry substantial weight. Both lay statements note that the Veteran’s symptoms had worsened since approximately March 2013 to March 2014. Therefore, resolving reasonable doubt in favor of the Veteran, the Board finds that an effective date of April 15, 2014 for the Veteran’s PTSD rating is warranted. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2); Gaston, 605 F.3d at 984. 4. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher rating 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. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. The Court has held that separate ratings may be assigned for separate periods of time based on the facts found, a practice known as “staged” rating. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. When rating a mental disorder, VA must consider the frequency, severity, and duration of the psychiatric symptoms, the length of remissions, and the claimant’s capacity for adjustment during periods of remission. VA shall assign a rating based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). Under the General Rating Formula for Mental Disorders, a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9411. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. 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; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. Id. Effective August 4, 2014, VA amended the regulations regarding the evaluation of mental disorders by removing outdated references to DSM-IV. The amendments replace those references with references to the recently updated “DSM-5.” As the Veteran’s claim was certified to the Board after August 4, 2014, the DSM-5 is applicable to this case. According to the DSM-5, clinicians do not typically assess Global Assessment Functioning (GAF) scores. The DSM-5 introduction states that it was recommended that the GAF be dropped from DSM-5 for several reasons, including its conceptual lack of clarity (i.e., including symptoms, suicide risk, and disabilities in its descriptors) and questionable psychometrics in routine practice. In Golden v. Shulkin, 29 Vet. App. 221 (2018), the Court further addressed the value of GAF scores. The Court noted that although GAF scores were designed to help quantify and summarize the severity of symptoms associated with metal disorders, the DSM-5 eliminated GAF scores because of their “conceptual lack of clarity” and “questionable psychometrics in routine practice.” DSM-5 at 16. The Court further explained that although it is true that examiners no longer use these scores, an adjudicator is not permitted to rely on evidence that the American Psychiatric Association itself finds lacking in clarity and usefulness. Any reliance on evidence that expert consensus has determined to be unreliable would be impossible to justify with an adequate statement of reasons or bases. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran is currently assigned a 30 percent disability rating for PTSD, effective March 12, 2010, and a 50 percent disability rating for PTSD, which is now effective April 15, 2014, under DC 9411. 38 C.F.R. § 4.130. The Veteran claims that he is entitled to a higher disability rating for his PTSD because he experienced crying spells approximately 5 to 6 times a week, daily episodes of confusion, forgetfulness, panic, unhappiness, isolation, neglect of personal hygiene, and inability to maintain relationships with people. The Veteran also indicated that he had difficulty at work. Specifically, he reported that he had an angry outburst at work that his supervisor considered to be violent and threatening. At the time of filing his notice of disagreement (NOD), the Veteran indicated that he had been out of work two weeks due to his PTSD. After a review of the evidence, the Board finds that the Veteran’s PTSD symptoms more nearly approximate the symptoms considered by a 70 percent disability rating. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Specifically, due to the Veteran’s suicidal ideation; depressed mood; anxiety, chronic sleep impairment, impaired impulse control (such as anger and irritability), disturbances of motivation and mood, neglect of personal appearance and hygiene, inability to establish and maintain effective relationships, and difficulty in adapting to stressful circumstances, the Board finds that the Veteran’s symptoms result in occupational and social impairment, with deficiencies in most areas. See id. In so concluding, and as noted above, the Board finds particularly persuasive the lay statements of record. Moreover, the frequency and severity of the Veteran’s symptoms that are reported in the lay statements are supported by the private evaluation conducted in April 2018. The probative evidence of record notes symptoms of anxiety, depression, anger and irritability, intermittent inability to perform avidities of daily living, chronic sleep impairment, and impairment of short- and long-term memory. Therefore, the Board finds that a rating of 70 percent for the Veteran’s service-connected PTSD is warranted for the period on appeal. 38 C.F.R. § 4.130, DC 9411. A higher rating of 100 percent is not warranted for the period on appeal because the Veteran has not displayed symptoms of persistent delusions or hallucinations; persistent danger of hurting himself or others; disorientation to time or place; or memory loss of names of close relatives, own occupation, or own name. The Board notes that there is evidence in the record indicating that the Veteran experienced memory loss, delusions or hallucinations, and passive suicidal ideation. However, these occurrences do not rise to the level of frequency or severity warranting a higher disability rating. Therefore, the Veteran’s disability picture more closely reflects that of a 70 percent disability rating for the period on appeal. The record does not indicate that that the Veteran has experienced all of the symptoms associated with a 70 percent rating for his PTSD. However, the symptoms enumerated under the schedule for rating mental disorders are not intended to constitute an exhaustive list, but rather are intended to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular disability rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the Board finds that there is occupational and social impairment sufficient to warrant a 70 percent rating even though all of the specific symptoms listed for this evaluation are not manifested. REASONS FOR REMAND Sleep apnea and headaches VA’s duty to assist includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. 38 U.S.C. § 5103A(d) (2012). VA is obligated to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A(d) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran claims that he is entitled to service connection for sleep apnea and headaches as secondary to his PTSD. Post-service treatment records reflect that the Veteran received a diagnosis of obstructive sleep apnea and experienced difficulties sleeping. Regarding headaches, the Veteran’s post-service treatment records are silent for any complaints, treatment, or diagnosis. The Veteran submitted a private medical evaluation, conducted in April 2018, which provided a diagnosis of obstructive sleep apnea and noted that the Veteran required the use of a continuous positive airway pressure (CPAP) machine. The evaluation notes that the Veteran experienced persistent daytime hypersomnolence due to sleep apnea. During the evaluation, the Veteran reported that he frequently could not use his CPAP due to his anxiety disorder because the CPAP makes him feel trapped and claustrophobic, which aggravates the effects of his sleep apnea. The provider opined that the Veteran’s PTSD, and PTSD medication, more likely than not aided in the development of, and permanently aggravates, his obstructive sleep apnea. The opinion noted that antidepressants have been known to cause secondary effects on sleep. Specifically, the antidepressant prescribed to the Veteran for his PTSD is one of a group of drugs, shown in a study, to increase sleep onset latency and/or increase the number of awakenings and arousals, leading to an overall decrease in sleep efficiency. Another private medical evaluation, also conducted in April 2018, provided a diagnosis of tension headaches. The evaluation indicates that the Veteran reported that he experienced 2 to 3 headaches a week due to stress caused by his PTSD. The examination notes that the Veteran experienced pulsating or throbbing head pain on both sides of his head. The Veteran indicated that the only way to relieve the headaches was to lie down in a dark, quiet room for one and a half hours; he also noted that he took over-the-counter medication for relief. The evaluation also notes that the Veteran experienced non-headache symptoms associated with his headaches, such as nausea, vomiting, sensitivity to light and sound, changes in vision, sensory changes, disturbances in concentration, dizziness, and difficulty gripping objects. The provider noted that the Veteran experienced head pain for less than one day and he had frequent prostrating and prolonged attacks of non-migraine head pain more frequently than once per month. The provider opined that the Veteran’s headaches were more likely than not caused and permanently aggravated by his service-connected PTSD, relying on medical literature that indicated patients with mental health disorders were more likely to develop headaches because pain and mood are regulated by the same part of the brain. Additionally, the provider cited a medical study that determined mental health disorders, including PTSD, can cause or aggravate headaches. The private opinions of record are not adequate to render a decision. Medical opinions that are speculative, general, or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. at 33; Bloom v. West, 12 Vet. App. at 187. Although the opinions provided in the private evaluations are not sufficient to render a decision in this case, they are sufficient to trigger the VA’s duty to assist. As such, VA examinations and opinions are warranted to ascertain whether the Veteran’s obstructive sleep apnea and headaches are secondary to his service-connected PTSD. TDIU The Board notes that the evidence of record, with respect to the claim seeking an increased rating for PTSD, has raised the issue of entitlement to a TDIU. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In the above section, the Board found that a 70 percent rating for PTSD is warranted for the entire period involved in that appeal, and therefore, the Veteran is eligible for TDIU consideration under the scheduler percentage requirements contemplated by VA regulations. See 38 C.F.R. §§ 3.340, 3.341, 4.16(a). However, it is unclear based on the evidence of record, whether the Veteran is currently working and therefore, whether his service-connected disability prevents him from securing or following substantially gainful employment. A February 2015 medical treatment record reflects that the Veteran worked part-time as a teacher. Another treatment record, dated October 2015, indicates that the Veteran had recently started a job. An October 2015 VA examination notes that the Veteran worked 3 to 4 hours a week and his last full-time job was in 2010. An April 2018 private medical evaluation notes that the Veteran’s last job was in 2012, and indicates that the Veteran’s PTSD prevents him from maintaining substantially gainful employment. Accordingly, the matter should be remanded to the RO for further development and adjudication of the issue of TDIU, in accordance with the holding in Rice. These matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination regarding the nature and etiology of his sleep apnea and headaches. The electronic claims file must be made accessible to the examiner for review in conjunction with the examinations. (a.) The examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s sleep apnea was caused by or aggravated by his service-connected PTSD, or otherwise caused by or aggravated by the current medications used to treat his PTSD. (b.) The examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s headaches were caused by or aggravated by his service-connected PTSD. In rendering the requested opinions, the examiner should specifically consider the opinions provided in the April 2018 private medical evaluations. An explanation for all opinions expressed must be provided. 2. Send the Veteran a VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, in order to provide the information needed to substantiate the claim of TDIU. Upon receipt of the Veteran’s completed VA Form 21-8940, adjudicate the claim for TDIU. If the benefit is not granted, a supplemental statement of the case must be provided to the Veteran and his representative. THOMAS H. O'SHAY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Hite, Associate Counsel