Citation Nr: 18160896 Decision Date: 12/28/18 Archive Date: 12/28/18 DOCKET NO. 16-52 942 DATE: December 28, 2018 ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is granted. Entitlement to an initial 70 percent rating for posttraumatic stress disorder (PTSD) is granted. Entitlement to total disability individual unemployability (TDIU) due to service-connected PTSD is granted. FINDINGS OF FACT 1. A hearing disability was not present during the Veteran’s active service, sensorineural hearing loss is not shown to have been manifest to a compensable degree within one year of service separation, and the most probative evidence establishes that the Veteran’s current bilateral hearing loss disability is not related to his active service or any incident therein, including noise exposure. 2. The evidence is in equipoise as to whether the Veteran’s current tinnitus is causally related to noise exposure during his active service. 3. The Veteran’s PTSD is manifested by symptoms which caused occupational and social impairment with deficiencies in most areas; the symptoms do not cause total occupational and social impairment. 4. The Veteran is rendered unable to secure or follow a substantially gainful occupation as a result of his service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2017). 2. The criteria for entitlement to service connection for tinnitus have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for entitlement to an initial 70 percent rating for PTSD for the entire appeal period have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2018). 4. The criteria for TDIU based upon service-connected disabilities have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1966 to November 1968. He is the recipient of the Bronze Star Medal, the Silver Star Medal, and the Combat Infantryman Badge. This matter comes before the Board of Veterans' Appeals (Board) on appeal from February 2013 and July 2014 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which, denied service connection for bilateral hearing loss and tinnitus, granted service connection for PTSD and assigned an initial 50 percent rating, effective August 22, 2012, and denied entitlement to TDIU. The Board notes that the Veteran’s notice of disagreement (NOD) raised the issue of entitlement to an effective date earlier than August 22, 2012, for the award of service connection for PTSD and that issue was addressed by the RO in the October 2016 Statement of the Case. In an October 2016 letter, however, the Veteran’s attorney indicated that “the Veteran wishes to discontinue his appeal for an earlier effective date for his service-connected PTSD.” (emphasis in original). The Board finds that this written statement constitutes an explicit and unambiguous withdrawal of the issue of entitlement to an effective date earlier than August 22, 2012, for the award of service connection for PTSD. The Veteran is represented by experienced counsel and, thus, the Board finds that the withdrawal was done with a full understanding of the consequences of such action. DeLisio v. Shinseki, 25 Vet. App. 45, 57 (2011); 38 C.F.R. § 20.204 (2017); see also Acree v. O’Rourke, 891 F.3d 1009 (2018). Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). “To establish a right to compensation for a present disability, a Veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service”—the so-called “nexus” requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for certain chronic diseases, including an organic disease of the nervous system such as sensorineural hearing loss, may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a) (3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. Under 38 C.F.R. § 3.385, impaired hearing will be considered a disability for purposes of laws administered by VA when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107 (b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (b) (2012); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for bilateral hearing loss is denied. The Veteran seeks entitlement to service connection for bilateral hearing loss. The Board notes that in the Veteran’s VA Form 9, the Veteran’s representative clarified that the Veteran was seeking service connection for bilateral hearing loss and tinnitus as secondary to hazardous noise exposure while in service, as opposed to Agent Orange exposure as noted in the October 2016 statement of the case (SOC). The Veteran contends that his bilateral hearing loss is due to miliary noise exposure. He reports that he was exposed to artillery and mortar fire in addition to turbine and rotor noise from helicopters in-service. See Veteran’s December 2012 statement. He contends that his hearing was normal when he entered the military, however his hearing loss began during the second half of his tour. See Veteran’s February 2013 statement. Service treatment records (STRs) do not contain complaints or findings of hearing loss. At his October 1966 induction examination, pure tone thresholds, in dB, were recorded as follows: HERTZ 500 1000 2000 3000 4000 RIGHT -5 (10) -10 (0) 0 (10) 5 (10) LEFT 5 (20) 5 (15) 15 (25) 15 (20) (Note: as this audiometric testing was conducted prior to January 1, 1967, the results were presumably reported in American Standards Association (ASA) units. Where necessary to facilitate data comparison for VA purposes in the decision below, including under 38 C.F.R. § 3.385, audiometric data originally recorded using ASA standards will be converted to International Standards Organization-American National Standards Institute (ISO-ANSI) standard. The converted results are reported in parentheses above). The Veteran’s October 1968 separation examination recorded pure tone thresholds, in dB, were recorded as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 (15) 0 (10) 5 (15) 10 (15) LEFT 0 (15) 0 (10) 5 (15) 5 (10) (Note: Given the date of this test, it is unclear whether such thresholds were recorded in using ASA units or ISO-ANSI units; thus, Board will consider the recorded metrics under both standards, relying on the unit measurements most favorable to the Veteran’s appeal, if any.). Additionally, the Veteran denied having or ever having had hearing loss at separation. See October 1968 Report of Medical History. VA and private medical records do not contain evaluation or treatment for hearing loss until 2011. In November 2011, the Veteran was seen for a hearing evaluation due to complaints of hearing loss. The audiologist noted that the Veteran had in-service combat noise exposure. A hearing chart was not included in the report, however, the audiologist recorded that for pure tone thresholds, right and left ear hearing loss was mild to moderately severe from the frequencies of 2000 to 8000 Hertz (Hz). The audiologist diagnosed the Veteran with bilateral hearing loss and made the following assessment: Hearing loss is consistent with a normal progressive loss due to age (presbycusis) and a history of noise exposure with no indications of external, middle or retrocochlear pathology. Based on today’s findings and the patient’s reported history, it is possible that a component of the Veteran’s hearing loss is the result of acoustic trauma suffered while on active duty unless hearing evaluations performed at the time of and/or some date after his military discharge are available to document that the Veteran’s hearing was within normal limits or significantly better at that time. In February 2013, the Veteran underwent a VA examination for hearing loss. Pure tone thresholds, in dB, were recorded as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 15 30 50 50 LEFT 20 15 35 60 55 Speech recognition using the Maryland CNC word list was 94 percent in the right ear and 96 percent in the left. The audiologist concluded that the Veteran had bilateral sensorineural hearing loss; however, she determined that the Veteran’s hearing loss was less likely as not causally related to the Veteran’s in-service noise exposure. The audiologist noted, The induction and separation audiograms indicate normal hearing bilaterally with no threshold shift. All SMRs and STRs were silent for hearing loss and tinnitus complaints. The Institute of Medicine concluded that based on current knowledge of cochlear physiology there was no sufficient scientific basis for the existence of delayed onset hearing loss. The IOM did not rule out that delayed onset might exist, but because the requisite longitudinal animal and human studies have not been done and based on current knowledge of acoustic trauma and the instantaneous or rapid development of noise induced hearing loss, there was no reasonable basis for delayed onset hearing loss. After applying the facts in this case to the criteria set forth above, the Board finds that the preponderance of the evidence is against the claim of service connection for bilateral hearing loss. In addressing the first element of a service connection claim, the Board finds that the Veteran currently has bilateral hearing loss. As noted in the February 2013 VA examination, the Veteran’s pure tone thresholds for the 3000 and 4000 Hz frequencies for the right and left ear were greater than 40 dB. Therefore, the Veteran has bilateral hearing loss for VA purposes. See 38 C.F.R. § 3.385. With regard to the second element, the Board finds both in-service noise exposure and in-service hearing loss. The Veteran has reported that he was exposed to unprotected gunfire and helicopter noise and developed decreased hearing acuity during active service. The Board notes that the Veteran had combat service, as reflected by his multiple awards and decorations indicative of combat service, including the Silver Star Medal and the Combat Infantryman Badge. See Veteran’s DD-214. Thus, the Board has considered the provisions of 38 U.S.C. § 1154(b) and finds sufficient evidence to establish in-service acoustic trauma and symptoms of hearing loss. The provisions of section 1154(b) do not provide a substitute for evidence of a causal nexus between a combat service injury or disease and a current disability, or the continuation of symptoms subsequent to service. See Wade v. West, 11 Vet. App. 302, 305 (1999). In addressing the third element, the nexus requirement, the Board finds that the Veteran’s bilateral hearing loss is not causally related to his in-service noise exposure. Although the Veteran has reported experiencing hearing loss symptoms in service, it was not shown to be chronic, as he denied hearing loss on separation and audiometric testing showed normal hearing acuity at that time. Moreover, the record does not contain probative clinical or lay evidence of continuity of symptomatology since service. The first post-service evidence of a hearing loss disability was not until 2011 and the Veteran has not alleged continuity of symptomatology. The Board notes that the absence of evidence of a hearing disability during service is not in and of itself fatal to a service connection claim. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Rather, evidence of current hearing loss and a medically sound basis for attributing that disability to service may serve as a basis for a grant of service connection for hearing loss where there is credible evidence of acoustic trauma due to significant noise exposure in service, post-service audiometric findings meeting the regulatory requirements for hearing loss disability for VA purposes, and a medically sound basis upon which to attribute the post-service findings to the injury in service (as opposed to intercurrent causes). See Hensley v. Brown, 5 Vet. App. 155, 159 (1993). In this case, however, the most probative evidence establishes that the current hearing loss disability is not related to service. In the November 2011 evaluation, the audiologist determined that the Veteran’s hearing loss was consistent with a normal progressive loss in hearing due to age. Although she opined that it was possible that a component of the Veteran’s hearing loss could be attributable to in-service acoustic trauma, she clarified that this would be the case only if there was not a hearing evaluation performed either at separation or at some date after his discharge finding that his hearing was within normal limits or better. It does not appear that the audiologist had access to the Veteran’s STRs at the time of the November 2011 evaluation, as the separation examination, as noted above, reports hearing acuity within the normal range. There are no other post-discharge evaluations. Therefore, since the Veteran’s separation examination found the Veteran’s hearing within the normal limits, and there were no other hearing evaluations until 2011, the audiologist’s conclusion should reasonably be construed to mean that the Veteran’s hearing loss was not attributable to in-service acoustic trauma. In the February 2013 VA examination, the audiologist reviewed the Veteran’s claims file in its entirety and considered the Veteran’s reported history. After considering the record, the audiologist concluded that the Veteran’s hearing loss was not causally related to service. The audiologist provided a clear rationale, citing the nature of the Veteran’s current hearing pathology and current knowledge about acoustic trauma in her determination. There is no medical opinion evidence to the contrary and the Veteran’s assertions of causation are not competent given the nature of the medical question at issue. Questions of competency notwithstanding, the Board assigns more probative weight to the findings of the VA examiner, given her clinical expertise and the rationale she provided. Based on the foregoing, as the probative evidence is against the Veteran’s claim for service connection for bilateral hearing loss, the benefit-of the-doubt rule is not for application. See 38 U.S.C. § 5107, 38 C.F.R. § 3.102. Accordingly, the Board finds that the elements of service connection are not met, and the Veteran’s claim for bilateral hearing loss is denied. 2. Entitlement to service connection for tinnitus is granted. The Veteran contends that tinnitus began during the second half of his tour and that ringing in his ears has been almost constant ever since. See Veteran’s February 2013 statement. As noted above, in November 2011, the Veteran was seen for a hearing evaluation due to complaints of hearing loss and tinnitus. The audiologist noted that the Veteran reported the onset of tinnitus during his combat tour. The Veteran also reported that the tinnitus had continued to the present and was possibly louder than it had been in the past. The audiologist noted the Veteran’s medical history to be tinnitus, with onset during the Veteran’s Vietnam combat tour. In the February 2013 VA examination, detailed above, the audiologist diagnosed the Veteran with tinnitus and noted the Veteran’s subjective report of tinnitus being “present since the military.” The audiologist, however, determined that the Veteran’s tinnitus was less likely than not causally related to the Veteran’s in-service noise exposure. The audiologist noted, The induction and separation audiograms indicate normal hearing bilaterally with no threshold shift. All SMRs and STRs were silent for hearing loss and tinnitus complaints. The Institute of Medicine concluded that based on current knowledge of cochlear physiology there was no sufficient scientific basis for the existence of delayed onset hearing loss. The IOM did not rule out that delayed onset might exist, but because the requisite longitudinal animal and human studies have not been done and based on current knowledge of acoustic trauma and the instantaneous or rapid development of noise induced hearing loss, there was no reasonable basis for delayed onset hearing loss. After a review of the evidence, the Board finds that service connection is warranted for tinnitus. With regard to the first element of a service connection claim, the evidence shows a current diagnosis of tinnitus. The Veteran was diagnosed with tinnitus in both the November 2011 evaluation and the February 2013 VA examination. Moreover, when a condition may be diagnosed by its unique and readily identifiable features, as is the case with tinnitus, the presence of the disorder is not a determination medical in nature, and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 305 (2007). Thus, the Veteran’s reports of tinnitus are sufficient to establish the presence of a current disability. In addressing the second element, the evidence shows in-service noise exposure as well as in-service tinnitus, both during combat. With respect to the third element, as set forth above, certain chronic diseases may be presumed to have been incurred in or aggravated by service through a demonstration of continuity of symptomatology rather than through a finding of nexus. Tinnitus is a chronic disease subject to presumptive service connection. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In this case, the audiologist of the November 2011 evaluation noted the onset of the Veteran’s tinnitus to be during his combat tour. The Veteran has also credibly reported continuous tinnitus since service. The Board has considered the February 2013 VA medical opinion, but finds that in light of the evidence discussed above, the evidence is in relative equipoise. Weighing the positive and negative evidence of record, and taking into consideration the competent and credible statements of the Veteran that his tinnitus began during his combat tour and has been present on a continuous basis since that time, the Board will resolve the reasonable doubt in the Veteran’s favor and find that the evidence supports the grant of service connection for tinnitus. See 38 U.S.C. § 5107 (2012). Increased Rating 3. Entitlement to an initial rating in excess of 50 percent for PTSD. The Veteran seeks entitlement to an initial rating in excess of 50 percent for PTSD. Disability evaluations are determined by the application of a schedule of ratings, which is based on the Veteran’s average impairment of earning capacity resulting from such disabilities. 38 U.S.C. § 1155, 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. The basis of disability evaluations is the ability of the body to function under the ordinary conditions of daily life, including employment. Evaluations are based upon lack of usefulness of the part or system affected, especially in self-support. 38 C.F.R. § 4.10. Where a claimant appeals the initial rating assigned for a disability when a claim for service connection for that disability has been granted, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence “used to decide whether the [initial] rating on appeal was erroneous...” Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of the initial rating, “staged” ratings may be assigned for separate periods of time based on facts found. Id. 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the claimant. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). The Veteran’s PTSD has been rated under the criteria contained in the General Rating Formula for Mental Disorders. Under those criteria, a 70 percent rating is assigned when there is objective evidence demonstrating 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 100 percent rating is warranted when 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. In Mauerhan v. Principi, 16 Vet. App. 436 (2002), the U.S. Court of Appeals for Veterans Claims (Court) held that use of the term “such as” in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Accordingly, the evidence considered in determining the level of impairment under section 4.130 is not restricted to the symptoms provided in the diagnostic code. Rather, VA must consider all symptoms of a claimant’s condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. More recently, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) 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.” Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116 (Fed. Cir 2013). The Federal Circuit explained that in the context of a 70 percent rating, section 4.130 “requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas.” Id. at 118. The Federal Circuit indicated that “[a]lthough the veteran’s symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the veteran’s level of impairment in ‘most areas.’” Id. The Board notes that effective August 4, 2014, VA implemented rules replacing references to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) IV with the DSM-5. The DSM-5 applies to claims certified to the Board on and after August 4, 2014. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). The Veteran’s appeal was certified to the Board in November 2016. Consequently, the DSM-5 is for application to his appeal. The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b) (2012); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran contends that prior to his tour in Vietnam, he was an outgoing person with many friends and no anger issues. He also contends that since his return from Vietnam, he has been unable to maintain employment for more than a few months. He reports that he suffers from anxiety, panic, anger, and alcohol issues, has had 2 failed marriages, and has virtually no friends. He also reports that his current marriage is in jeopardy. See Veteran’s correspondence dated December 2012 VA medical records demonstrate a history of mental health symptomatology associated with the Veteran’s service in Vietnam. The Board notes that the Veteran has sought psychiatric treatment and counseling for his PTSD, which includes symptoms of depression, anxiety, anger, hyper-vigilance, grief, social isolation, and emotional numbing. The Board also notes that the Veteran has been treated for prior suicide attempts and suicidal ideations. See VA treatment records 2012-13. In correspondence dated November 2012, the Veteran’s spouse reported that she had known her husband for 10 years. She noted that it had gotten bad at home and that it was time for the Veteran to get some help. The Veteran was afforded a VA PTSD examination in February 2013. With regard to marital and family relationships, the Veteran reported that he had been married 3 times. He had been married to his first 2 spouses for approximately 4 ½ years each, and he reported being married to his current spouse for 10 years. The examiner noted that the Veteran identified his relationship as “tenuous” due to the Veteran’s unemployment, sarcasm, and lack of sexual intimacy. The Veteran stated that he has 2 adult sons who were adopted by their step-father in 1974. He reported weekly phone contact with 1 of his sons, who was currently incarcerated, and email contact “every now and then” with his other son who was in South Korea. The Veteran also reported 2 friends, although he noted that he did not have many friends since his return from Vietnam due to his fear of getting close to people. He also noted positive relationships with both his father and mother until their death. He stated that his oldest brother died 3 or 4 years before and that he had seen his other brother who lived in another state once since 1990. Occupationally, the Veteran reported that he has held approximately 100 jobs since he returned from Vietnam. He reported that after he worked somewhere for a short period of time, he was overcome with “this panic feeling that I gotta get out of there.” He stated that he felt like someone was grabbing him. He reported that his last job had been a year before as a travel nurse and that the longest nursing job he held was for 3 to 4 months. Prior to earning his nursing degree in 1994, the Veteran worked at welding jobs, built duplexes, and served on a volunteer rescue squad. His longest job had been a 3-year truck driving job. The Veteran also reported graduating in the top 10 percent of his high school class and completing 1 year of college as a civil engineering major before he enlisted. He reported spending most of his time doing things around his home and rental house and maintaining the vehicles. He enjoyed restoring an old car and occasionally watching television with his wife. With regard to alcohol and drug use, the Veteran reported that within 5 years of returning from Vietnam, he began drinking heavily on weekends. This continued until he became involved with his current spouse. The Veteran also reported using cocaine 3 or 4 times. He also reported being involved in several fights that typically occurred while he was drinking. He reported his last fight to be 10 years prior. The Veteran’s PTSD symptoms included depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or work-like setting. Additionally, the Veteran experienced intrusive memories, nightmares, distressing memories, physical reactions in response to triggers for trauma, avoidance in thinking and talking about trauma, avoidance of people, places, and activities that trigger trauma, anhedonia, detachment, restricted range of affect, sense of foreshortened future, irritability and anger, problems with concentration, hypervigilance, exaggerated startle response, and suicidal ideation in 1986 when the Veteran took pills while he was out drinking. With regard to effects of PTSD on occupational and social functioning, the examiner concluded that the Veteran’s symptoms caused reduced reliability and productivity. In April 2014, the Veteran was afforded another VA PTSD examination. With regard to marital and family relationships, the Veteran reported that he was married to his third wife for 11 years. He reported that he had 2 grown sons with whom he had some contact, mostly by text or email. He noted that 1 son had been recently released from prison in Michigan, and the other son lived in South Korea. The Veteran also reported that he had 1 close friend who had recently passed away and that he kept in contact with another friend from Vietnam. The Veteran reported spending most of his time fixing things around the house and watching basketball games on television. Occupationally, the Veteran reported that he has held many jobs. The Veteran worked as a truck driver for 3 years after returning from Vietnam. He reported working as a welder, building duplexes for a friend, and working as a paramedic for 2 years. After the Veteran became licensed as a registered nurse (RN) in 1995, the Veteran reported working as a travel and ER nurse. He worked as a travel nurse on short-term assignments, and his ER jobs lasted approximately 3 months. He estimated that the longest nursing job he held before quitting was for 6 months. The Veteran reported that he stopped working 1 ½ years before when he began receiving social security retirement. With regard to alcohol and drug use, the examiner noted a remote history of ethyl alcohol (ETOH) and cocaine abuse. The Veteran’s PTSD symptoms included depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or work-like setting. Additionally, the Veteran experienced recurrent distressing dreams related to traumatic Vietnam events, avoidance of distressing memories, thoughts, or feelings about traumatic events, persistent negative emotional state, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, irritable behavior and outbursts, and sleep disturbance nightmares. The examiner also noted that the Veteran was mildly dysphoric, with no anxiety, hypervigilance, or hyperstartle reaction noted. With regard to effects of PTSD on occupational and social functioning, the examiner concluded that the Veteran’s symptoms caused occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The examiner also noted that the Veteran’s PTSD did not impede the performance of sedentary or physical labor. In February 2015, the Veteran underwent a private PTSD examination. With regard to marital and family relationships, the Veteran reported that he had been married 3 times. He had been married to his first 2 spouses for approximately 4 ½ years each and reported excessive arguing as the reason the marriages ended. He reported being married to his current spouse for 11 years. The examiner noted concerns with the Veteran’s current marriage due to employment-related difficulties, lack of sexual intimacy, and the Veteran’s “outrageous issues with closeness and stuff.” The Veteran stated that he had 2 adult children. He noted that 1 son resided in Michigan, and the other son lived in Japan. He reported marked improvements in his relationships with his sons, however he did not characterize the relationships as close, due in part to his younger son’s drug use. He also noted a few instances of telephone contact with his second wife’s son. The Veteran also reported 2 close friendships during service. Since service, he reported that he had intermittent contact with 1 of those individuals and contact with the other individual twice. He also reported no close relationships, although he noted weekly telephone contact with a Vietnam Veteran who resided close to his home and the recent death of a friend. The Veteran also reported a “perfect” childhood family environment, noting a good relationship with his mother and normal relationship with his father. He noted that his brothers were significantly older than he was, which affected their relationship. Occupationally, the Veteran reported that he held approximately 50 jobs since he returned from Vietnam between 1968 and 1974. He reported that he worked as a truck driver, paramedic, and nurse. The Veteran reported working for several different employers and for varying periods of time, typically for not more than 3 months at a time. From 2003 to 2009, the Veteran noted that he worked as a travel nurse, however he reported his total time working to be approximately 1 year as he was frequently unemployed during that period. The Veteran noted that he had anxiety issues while he was working. He also stated that he had not worked since 2010 due to frustration with the impact sleeping difficulties had on his ability to work. He also described feeling debilitated by a sense of a foreshortened future. With regard to alcohol and drug use, the Veteran reported that he began drinking regularly after he returned from Vietnam. He noted drinking almost daily from 1969 to 2003. He reported that he hadn’t been drinking alcohol since 2003, noting that he only drank “like two beers or something” presently. The Veteran also reported cocaine use during the late 1970’s and into the early 1980’s. The Veteran’s PTSD symptoms included depression, symptoms of panic disorder, social isolation, distancing, estrangement, persistent reexperiencing of trauma, persistent avoidance or numbing, persistent arousal, anger, anhedonia, insomnia, concentration difficulties, fatigue, loss of energy, guilt, cognitive difficulties, recurrent thoughts of death, including suicidal ideation, and anxiety. On physical examination, the Veteran was found to be pleasant and easily engaged in the evaluation. His speech was normal, form of thought was remarkable for circumstantiality, and thought content was consistent with the presence of passive suicidal ideation although specific means, plans, time frames, and immediate intent were denied. The examiner opined that the Veteran’s impulse control appeared to fall below normal limits as demonstrated by his past substance abuse. The Veteran was found to be oriented to person, place, and time. The examiner found the Veteran’s attention capacities, as evidenced by his circumstantial speech, concentration abilities, and memory for recent events appeared to fall below normal limits. The examiner found that the Veteran’s immediate memory abilities and memory for recent past events appeared to fall within normal limits. Remote memory appeared to be intact, and intelligence and fund of information fell substantially above average. Judgment and insight were found to fall below normal limits. With regard to effects of PTSD on occupational and social functioning, the examiner concluded that the Veteran’s symptoms caused deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The Board also notes a March 2017 VA intake assessment, which noted the Veteran’s PTSD symptoms to include sleep disorder, nightmares, hypervigilance, avoidance, detachment, irritability, depression, and anxiety. The assessment also noted a history of 2 suicide gestures, both medication overdoses, for which the Veteran attended an inpatient program for depression and suicidal/homicidal ideation. It was noted that the Veteran reported the program to be completely successful. Progress notes from April 2017 noted on-going issues between the Veteran and his wife. The readjustment counselor also noted that the Veteran’s symptoms, including alterations in mood and cognition and alterations in arousal and reactivity, were consistent with a PTSD diagnosis. The counselor also noted that sensorium was otherwise clear; full range of affect was exhibited; speech and though processes appeared clear and organized; and no acute safety issues were noted. It was also noted that the Veteran met with his best surviving friend from Vietnam, and they reviewed pictures and memories of their year together in Vietnam. Applying the criteria set forth to the facts in this case, the Board finds that the record supports the assignment of an initial 70 percent rating for the Veteran’s service-connected PTSD. 38 C.F.R. § 4.3, 4.7. The record demonstrates that the Veteran’s overall disability picture is consistent with or more nearly approximates the criteria required for a 70 percent rating for the entire appeal period. In this regard, the Veteran’s symptoms caused deficiencies in most areas, specifically previous suicide attempts and suicidal ideation; impaired impulse control; difficulty in adapting to stressful circumstances, such as the Veteran’s inability to remain employed for long periods of time; and the inability to establish and maintain effective relationships, as evidenced by the Veteran’s lack of friends, with the exception of 1 Vietnam Veteran, intermittent contact with his 2 sons, and a failing relationship with his third wife. The Board has carefully considered the next higher rating of 100 percent, and the symptoms delineated in the rating criteria. After thorough review of the Veteran’s statement, the February 2013 and April 2014 VA PTSD examinations, the February 2015 private PTSD examination and the medical evidence of record, the Board finds that the 70 percent rating most closely approximates the Veteran’s current disability picture and that the preponderance of the evidence is against the assignment of a 100 percent schedular rating. The Board recognizes that the Veteran sincerely believes that he is entitled to higher ratings. However, the Veteran’s lay evidence and the lay evidence of his spouse regarding his symptoms is outweighed by the competent and credible medical evidence that evaluates the extent of impairment due to his PTSD based on objective data coupled with the lay complaints. In this regard, the Board notes that the VA examiners and treating medical professionals have the training and expertise necessary to administer the appropriate tests for a determination of the type and degree of the impairment associated with the Veteran’s complaints. For these reasons, greater evidentiary weight is placed on the examination findings and medical evidence of record in regard to the type and degree of impairment. After thorough review of all evidence of record, the Board finds that the evidence demonstrates that the Veteran’s psychological symptoms for the entire appeal period are, at most, indicative of occupational and social impairment with deficiencies in most areas. The Veteran’s PTSD was not shown to result in total occupational and social impairment at any time during the appeal period. As noted earlier, the Veteran did not suffer from gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living; disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Specifically, as set forth in more detail above, the medical evidence of record demonstrates that the Veteran had normal speech and consistent thought content. He was able to give a detailed personal, occupational, and mental health history, which included specific details about his childhood, family, employment, military experience, and mental health issues. The medical evidence of record does not contain reports of persistent delusions or hallucinations. Although the examiner of the February 2015 private examination concluded that impulse control fell below normal, the Veteran’s behavior was not determined to be grossly inappropriate. Intermittent inability to perform activities of daily living was not found. The Veteran was oriented to person, place, and time. The examiner found the Veteran’s memory for recent events appeared to fall below normal limits, however immediate memory abilities and memory for recent past events fell within normal limits. Remote memory was also intact. The evidence of record also indicates that the Veteran was not in persistent danger of hurting himself or others. Although the Board notes prior suicide attempts and suicidal ideations, the medical evidence of record does not indicate that the Veteran was in persistent danger of hurting himself or others. The February 2015 private examination noted the presence of passive suicidal ideation, however persistent danger of hurting self or others was not noted. In addition, the Veteran noted that an inpatient program for depression and suicidal/homicidal ideation had been completely successful. Suicidal ideation is contemplated in the 70 percent rating; as the Veteran’s suicidal ideation does not rise to the level of persistent danger of hurting oneself or others, a 100 percent rating is not appropriate based on this symptom. Additionally, although the Veteran noted being unable to maintain employment, the Veteran was able to engage in activities such as maintaining the vehicles, enjoying restoring an old car, and spending most of his time fixing things around the house. Furthermore, the Veteran reported having a relationship with his 2 sons, a Vietnam Veteran, with whom he spoke weekly on the phone, and another friend who had recently died. The Veteran also reported a relationship with his wife, although he noted that the marriage was in jeopardy. These relationships indicate that the Veteran did not suffer from total social impairment. In summary, the Board has considered all of the Veteran’s PTSD symptoms that affect the level of occupational and social impairment. After so doing, the Board concludes that the evidence is in favor of the assignment of an initial 70 percent rating but the preponderance of the evidence is against the assignment of an initial rating in excess of 70 percent, as the Veteran’s PTSD does not result in both occupational and social impairment. The Veteran and his attorney have not raised any other issues with respect to the increased rating claim, nor have any other assertions been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). TDIU 4. Entitlement to TDIU due to service-connected disabilities is granted. The Veteran seeks entitlement to TDIU. He contends that he is unable to maintain employment for more than a few months as a result of his service-connected PTSD. See correspondence received December 2012. Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Rating Schedule provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341(a). If the schedular rating is less than total, a total disability evaluation can be assigned based on individual unemployability if the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that the Veteran has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. The existence or degree of nonservice-connected disabilities will be disregarded if the above-stated percentage requirements are met and the evaluator determines that the Veteran’s service-connected disabilities render him incapable of substantial gainful employment. 38 C.F.R. § 4.16(a). The central inquiry is “whether th[e] veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19 (2018); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Applying the criteria set forth above to the facts in this case, the Board finds that the evidence is in favor of the assignment of a TDIU. A review of the record indicates that the Veteran is currently service-connected for PTSD rated at 70 percent disabling. Thus, the Veteran satisfies the threshold rating percentage requirements set forth in 38 C.F.R. § 4.16(a) for a TDIU. Furthermore, the Board finds that the evidence establishes that his service-connected PTSD has rendered him unable to secure or follow a substantially gainful occupation. As noted previously, the Veteran holds a nursing degree. The Veteran contends that he was employed in over 50 jobs since he returned from Vietnam. As noted earlier, the Veteran reports that he was employed as a truck driver, paramedic, and nurse, among other occupations. See February 2015 private examination. The Board notes that the Veteran was employed as a full time registered nurse for LMHS from January 1994 to February 1996; July 2009 to April 2010; and October 2011 to January 2012. See LMHS employment records. The Veteran was reported to have left employment with no notice. The Board also notes that the Veteran was employed as an RN at a hospital from June 2008 to November 2008. See FCH employment record. No other employment records are contained in the Veteran’s claims file. Available medical evidence, including VA medical examination reports, demonstrate limitation caused by the Veteran’s service-connected PTSD, notably the Veteran’s inability to hold a job for long periods of time; the evidence indicates that the Veteran’s service-connected disabilities render him unable to secure or follow a substantially gainful occupation. As detailed above, the February 2013 VA examination noted that the Veteran suffered from depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or work-like setting, among other symptoms, as a result of his service-connected PTSD. The examiner also noted that the Veteran reported holding approximately 100 jobs after returning from Vietnam, with the longest employment as a truck driver for approximately 3 years. The Veteran reported his longest nursing job lasting 3 to 4 months. The Veteran noted that after he had worked somewhere for a short period of time, he was overcome with “this panic feeling that I gotta get out of there.” He noted that it felt like someone was grabbing him. The examiner did not address whether the Veteran’s PTSD impacted his ability to work. As previously noted, the April 2014 VA examination found the Veteran’s PTSD symptoms to include depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or work-like setting. The examination noted that the Veteran had held many different nursing jobs and that the longest he held any nursing job before quitting was 6 months. The examiner noted that the Veteran’s PTSD did not impede the performance of sedentary or physical labor. As noted previously, the February 2015 private examination found the Veteran’s PTSD symptoms to include depression, symptoms of panic disorder, social isolation, distancing, estrangement, persistent reexperiencing of trauma, persistent avoidance or numbing, persistent arousal, anger, anhedonia, insomnia, concentration difficulties, fatigue, loss of energy, guilt, cognitive difficulties, recurrent thoughts of death, including suicidal ideation, and anxiety. As noted previously, the Veteran noted that he had anxiety issues while he was working. He also stated that he had not worked since 2010 due to frustration with the impact sleeping difficulties had on his ability to work. Additionally, the Veteran stated that he shifted jobs because he “had this feeling like this giant hand that reaches inside of me and squeezes my inside and I have to get out of here.” He also described feeling debilitated by a sense of a foreshortened future and reported that he was astounded that he was able to return to some of his places of employment. The examiner noted that the Veteran had been unable to follow substantially gainful employment as a result of his service-connected PTSD. Based on the foregoing, the Board finds that the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected PTSD. The Board notes inconsistencies between the Veteran’s reports of length and years of employment, as noted in PTSD examinations, his December 2012 statement, and employment records, which note periods of nursing jobs that lasted longer than a few months and the Veteran’s last nursing job to be in 2012. Despite these inconsistencies, the Board finds the Veteran to be competent to report the approximate number of jobs he has held and give an estimation as to the duration and years of his employment. The Board also finds that the Veteran has credibly reported his pattern of working for a period of time and then quitting due to PTSD symptomatology. Although the Veteran appears to have the physical ability to work, the Board finds that his mental symptoms prevent him from working. As noted previously, the Veteran has reported holding in excess of 50 jobs since returning from Vietnam. He noted a pattern of working in a job for a short time and then quitting due to panic associated with a feeling that a giant hand was pulling or squeezing him. The Board has carefully considered the Veteran’s statement that he is generally unable to maintain employment for more than a few months and that he has held more than 50 jobs, and the effects of the Veteran’s service-connected PTSD on his employability. More specifically, the Board has considered the Veteran’s anxiety, depression, suicidal ideation, social isolation, sense of a foreshortened future, and reports of feeling panic and like a giant hand is squeezing or grabbing him after he has been employed for a short time. Based on the foregoing, the Board finds that Veteran’s service-connected PTSD renders him incapable of substantial gainful employment. (Continued on the next page)   Accordingly, the Board has weighed the probative evidence of record and finds that the evidence is at least in equipoise as to whether the Veteran’s service connected PTSD renders him unable to secure or follow a substantially gainful occupation. The benefit-of-the-doubt rule is therefore for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Board will resolve the reasonable doubt in the Veteran’s favor and find that the evidence supports the grant of TDIU. See 38 U.S.C. § 5107. K. Conner Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Ruddy, Associate Counsel