Citation Nr: 1806889 Decision Date: 02/02/18 Archive Date: 02/14/18 DOCKET NO. 14-16 724 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to service connection for sleep apnea, to include as secondary to service-connected PTSD. 2. Entitlement to service connection for chronic obstructive pulmonary disease (COPD). 3. Entitlement to an initial rating in excess of 50 percent disabling from July 29, 2010, to February 8, 2014, for service-connected post-traumatic stress disorder (PTSD). 4. Entitlement to service connection for fibromyalgia to include as secondary to service-connected PTSD. REPRESENTATION Veteran represented by: California Department of Veterans Affairs ATTORNEY FOR THE BOARD Rachel E. Jensen, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Air Force from July 1980 to July 1984. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. That decision granted service connection for PTSD at 50 percent disabling, effective July 29, 2010, and denied service connection for sleep apnea, fibromyalgia, and COPD. In a March 2014 rating decision, the Veteran's PTSD rating was increased to 100 percent disabling, effective February 8, 2014. In May 2014, the Veteran claimed an increased initial rating for the period prior to February 8, 2014. In his May 2014 substantive appeal, the Veteran requested a hearing. In an October 2017 statement, the Veteran requested that his scheduled hearing be cancelled and his appeal be forwarded to the Board. The Board finds that the request has been withdrawn. 38 C.F.R. § 20.704 (2017). The Veteran is receiving 100 percent schedular disability benefits for his service-connected PTSD. Accordingly, the Board need not consider whether the issue of unemployability has been raised. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The issue of service connection for fibromyalgia is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The most probative evidence of record indicates that the Veteran's sleep apnea is not caused or aggravated by his PTSD. 2. The Veteran does not have a diagnosis of COPD. 3. From July 29, 2010, to February 8, 2014, the Veteran's PTSD manifested in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as passive suicidal ideation; near-continuous depression affecting the ability to function independently, appropriately and effectively; impaired impulse control, including unprovoked irritability with periods of violence; difficulty in adapting to stressful circumstances; and inability to establish and maintain effective relationships. CONCLUSIONS OF LAW 1. The criteria for service connection for sleep apnea, to include as due to PTSD, have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5103, 5103a, 5107 (2012); 38 C.F.R. §§ 3.102, 3.103, 3.159, 3.303, 3.310 (2017). 2. The criteria for service connection for COPD have not been met. 38 C.F.R. §§ 1101, 1110, 1131, 5103, 5103a, 5107; 38 C.F.R. §§ 3.102, 3.103, 3.159, 3.303, 3.304 (2017). 3. The criteria for a 70 percent disability rating, but no higher, from July 29, 2010, to February 8, 2014, for PTSD have been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code (DC) 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). I. Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167(Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Pertinent to a claim for service connection, such a determination requires a finding of disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). Under applicable regulation, the term "disability" means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1 (2017). See also Hunt v. Derwinski, 1 Vet. App. 292, 296 (1991); Allen v. Brown, 7 Vet. App. 439 (1995). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To do so, the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. See Masors v. Derwinski, 2 Vet. App. 181 (1992). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b). A. Sleep Apnea The Veteran contends that his sleep apnea is caused or aggravated by his service-connected PTSD. The Veteran's service treatment records (STRs) are silent for any symptoms, diagnosis, or treatment of sleep apnea. The Veteran first sought treatment for daytime fatigue and snoring during sleep in 2010. Following a private sleep study conducted in February 2010, he was diagnosed with severe obstructive sleep apnea and prescribed use of a continuous positive airway pressure (CPAP) machine. Due to the fact that there was no indication of sleep apnea or any other sleep disorder in service, and to the large gap in time until the Veteran sought treatment for his symptoms, the Board finds that direct service connection is not warranted. As such, only service connection on a secondary basis will be considered. The Veteran completed a sleep disorder questionnaire in October 2013 in which he reported complaints of excessive daytime sleepiness; pauses in breathing during sleep; snoring; dry mouth in the morning; awakening with headaches; gaining ten pounds in the last year; restlessness or tingling in the legs before sleep; leg-kicking during sleep; vivid dreams; dreams or hallucinations while awake; sudden sensations of weakness in neck, arms, or legs; paralysis or inability to move on awakening; grinding teeth during sleep; bedwetting as an adult; awakening with choking or gasping; bitter or sour taste in mouth in the morning; sudden awakening with anxiety or fear; wheezing during the night; and seizures during the night. In February 2014, the Veteran underwent a VA examination. He reported persistent daytime hypersomnolence. The examiner found that continuous/frequent activities requiring prolonged walking, running, heavy-lifting, or carrying were impacted due to daytime hypersomnolence. It was noted that the Veteran is morbidly obese. The examiner found that the Veteran's sleep apnea was less likely as not (less than 50 percent possibility) proximately due to or the result of his service-connected PTSD. He noted that the Veteran's sleep apnea is more likely related to being morbidly obese and stated that "there is no known pathophysiology to ascribe sleep apnea to PTSD." An addendum VA opinion was obtained in May 2014. The clinician found that it was less likely than not (less than 50 percent probability) that the Veteran's PTSD aggravated his sleep apnea. He stated that there is no scientifically proven causative nexus between PTSD and sleep apnea, with no known peer-reviewed scientific literature supporting the hypothesis that PTSD causes or aggravates or contributes to sleep apnea. The Veteran's VA social worker submitted a letter in June 2014 which stated that sleep apnea was a symptom of the Veteran's PTSD and that it was more likely than not that his sleep apnea resulted from the traumas suffered during his military service, or that it was caused or aggravated by PTSD. No rationale for this opinion was given. The Veteran's private medical provider submitted the same opinion in June 2014, as well. Again, no rationale for the opinion was given. The Board understands that the Veteran believes his sleep difficulties are related to his PTSD. Although the Veteran's statements are competent to describe his history of snoring and sleeping difficulties, as the cause of any respiratory dysfunction involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and effect relationship, he is not competent to render such a complex medical opinion regarding etiology of a sleep apnea disorder. As such, the question of etiology in this case may not be competently addressed by lay evidence. See Layno v. Brown, 6 Vet. App. 465, 469 - 470 (1994); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Obstructive sleep apnea is a clinical diagnosis of sleep apnea resulting from collapse or obstruction of the airway with the inhibition of muscle tone that occurs during REM sleep. See Dorland's Illustrated Medical Dictionary 118 (31st ed. 2007). "Sleep apnea" does not encompass all of the observable symptoms identified by the Veteran as disturbing of his sleep, but is a specific diagnosis regarding the Veteran's ability to breathe during sleep. As such, the medical opinions of record are the most competent and credible evidence upon which to determine the claim. The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, his knowledge and skill in analyzing the data, and his medical conclusion. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The Court has expressly declined to adopt a 'treating physician rule' which would afford greater weight to the opinion of a veteran's treating physician over the opinion of a VA or other physician. See Guerrieri, supra. The Board finds that the examining VA physicians possess the necessary education, training, and expertise to provide competent medical opinions. 38 C.F.R. § 3.159(a)(1) (2016); Sickels v. Shinseki, 643 F.3d 1362, 1366 (Fed. Cir. 2011). Further, there is no reason to question the credibility of the opinions. The examiners have provided a clear rationale based on an accurate medical and factual history for the opinions provided. They not only found that there was no scientifically proven causative nexus or pathophysiology to ascribe sleep apnea to PTSD, but also provided a medically plausible etiology of the Veteran's sleep apnea: obesity. The opinion from the Veteran's social worker and private physician state a relationship between the Veteran's PTSD and sleep apnea, but provide no rationale to support the opinion whatsoever. As such, the Board finds that the opinions by the VA examiners are the most probative medical evidence of record. As such, the evidence weighs against the Veteran's claim that his PTSD causes or aggravates his sleep apnea. The Board also notes that that the observable symptoms the Veteran has consistently reported (i.e., broken sleep, sleep of four to five hours per night, getting up to check his house in the middle of the night, etc.) have been recognized by his clinicians as aspects of his PTSD which are compensated in his 100 percent disability rating. The Veteran cannot be compensated twice for the same symptomatology. See 38 U.S.C. § 1155; 38 C.F.R. § 4.14. Therefore, the Board finds that the preponderance of the evidence is against granting service connection. See 38 C.F.R. 3.303(a). The benefit of the doubt doctrine is not applicable in this case as there is no doubt to be resolved. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. at 57. B. COPD The Veteran's STRs indicate that he sought treatment in February 1983 and was diagnosed with bronchitis and sinusitis. A chest x-ray examination resulted in findings within normal limits, although allowing for a mild degree of hilar and lower medial bronchovascular congestion. Bronchitis was again diagnosed in March 1983. In November 1983, the Veteran sought treatment and the primary admission diagnosis was a respiratory infection and the secondary diagnosis was bronchitis. The final diagnosis was a viral syndrome. In January 1984, he was diagnosed with hay fever. In late March/early April 1984, he was diagnosed with bronchitis and put on quarters for 72 hours. The Veteran's separation examination report listed a history beginning in 1981 of nose and throat trouble associated with sinusitis and hay fever that was monthly, moderate, and treated with Actifed. His clinical evaluation was normal and no respiratory conditions were noted. In November 2010, the Veteran reported to a private provider that he had a thirty-year history of a chronic cough and "recurrent bronchitis." He also reported being a smoker from 1980 to 1982. He stated that cold air in the morning made him cough and that he used an Albuterol inhaler a few times per week which improved his cough. The Veteran has indicated that at some point, he was told by his private provider that he had COPD. VA records indicated COPD on the Veteran's medical problems list, however, no diagnosis was ever made. In October 2012, he reported to VA clinicians that he was mistaken about the COPD diagnosis. He had spoken to his private provider who told him he did not have COPD, but instead had allergy-related symptoms. In February 2014, the Veteran underwent a VA examination. A chest x-ray resulted in normal results with clear lungs, no pleural effusions, and unremarkable osseous structures. A pulmonary function test indicated restricted breathing. The examiner determined that the Veteran's records did not support a history of COPD or chronic bronchitis. He found that the Veteran's COPD was less likely as not (less than 50 percent probability) incurred in or caused by bronchitis in service that occurred in 1983 and 1984. He continued that the Veteran was shown to have recurrent bronchitis while in service, rather than chronic bronchitis. The Veteran's normal chest x-ray did not support a diagnosis of COPD. The pulmonary function test results were not consistent with the chest x-ray. As such, a diagnosis of recurrent bronchitis was given. The Veteran's most recent treatment records indicate that he continues to use an Albuterol inhaler as needed. The Veteran has no current respiratory medical problems or diagnoses listed. The Board finds that the first prong of service connection is not satisfied. There is no evidence of a diagnosis of COPD throughout the appeal period and the Veteran himself has said that he was mistaken about maintaining that he had the condition. As such, service connection for COPD is not warranted. Although the Veteran did have several bouts of bronchitis in service, the only medical evidence of record indicates that it was not a chronic condition. There is no indication of a current diagnosis of bronchitis throughout the appeal period. As such, service connection is not merited for any other respiratory condition, as well. The Board finds that the preponderance of the evidence is against granting service connection. See 38 C.F.R. 3.303(a). The benefit of the doubt doctrine is not applicable in this case as there is no doubt to be resolved. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. at 57. II. Increased Rating As noted above, the Veteran seeks a rating in excess of 50 percent for PTSD from July 29, 2010, to February 8, 2014. Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where, as here, the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. 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 required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. By way of history, the Veteran was service-connected for PTSD at 50 percent disabling, effective July 29, 2010, under 38 C.F.R. § 4.130, DC 9411, the General Rating Formula for Mental Disorders. This initial rating was increased in March 2014 and is currently evaluated at 100 percent disabling, effective February 8, 2014. A 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent evaluation is assignable where 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); and disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation 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. See 38 C.F.R. § 4.126(a). Furthermore, when evaluating the level of disability arising from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2 (2016). The symptoms associated with the psychiatric rating criteria are not intended to constitute exhaustive lists, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002). Thus, the Board will consider whether "the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code," and, if so, the "equivalent rating will be assigned." Id. In Vazquez-Claudio v. Shinseki, the Federal Circuit held that a Veteran may only qualify for a given disability rating "by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." 713 F.3d 112, 117 (Fed. Cir. 2013) ("Reading [38 C.F.R. §§ 4.126 and 4.130] together, it is evident that the 'frequency, severity, and duration' of a Veteran's symptoms must play an important role in determining his disability level."). It should be noted that prior to August 4, 2014, VA's Rating Schedule that addresses service connected psychiatric disabilities was based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "DSM-IV"). 38 C.F.R. § 4.130. Diagnoses many times included an Axis V diagnosis, or a Global Assessment of Functioning ("GAF") score (explained in more detail below). The DSM was updated with a 5th Edition ("DSM-5"), and VA issued an interim final rule amending certain provisions in the regulations to reflect this update, including the Schedule for Rating Disabilities. 70 Fed. Reg. 45093 (Aug. 4, 2014). This updated medical text recommends that GAF scores be dropped due to their "conceptual lack of clarity." See DSM-V, at 16. Because the Veteran's PTSD claim was originally certified to the Board before the adoption of the DSM-5, the DMS-IV criteria will be utilized in the analysis set forth below. Under DSM-IV, GAF scores ranging between 61 and 70 are assigned when there are some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but when the individual is functioning pretty well and has some meaningful interpersonal relationships. Scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging between 41 and 50 are assigned when there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). GAF scores ranging between 31 and 40 are assigned when there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family and is unable to work). According to the DSM-IV, GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. A GAF score is highly probative as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). There is no question that the GAF score and interpretations of the score are important considerations in evaluating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, an assigned GAF score, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). In July 2010, the Veteran began attending individual and group therapy sessions for PTSD and was prescribed several medications to treat his symptoms. In August 2010, he complained of heart racing, panic attacks, quick temper, hypervigilance, hyperarousal, intrusive thoughts, nightmares of killing a superior officer, problems sleeping, depressed mood, low energy level, and stated "I wonder if everyone will be better off without me." A mental status examination found his affect to be constricted, cognition to be alert, insight and judgment to be intact, and his perception devoid of audio or visual hallucinations. His GAF score was deemed 65. A mental status examination in October 2010 found similar results. In November 2010, the Veteran's wife stated to a psychiatric clinician, "I wonder about my safety sometimes." The Veteran reported that he was afraid to be around other people, was angry, and could not leave his house to attend his child's soccer games, but denied suicidal or homicidal ideation. A mental status examination reported that the Veteran was uncooperative and interrupting, with agitated motor function, loud and pressured speech, angry mood and affect, and poor insight and judgment. A GAF score of 55 was given. The Veteran's daily prescribed medications had their dosages increased. Also in 2010, an examination and a review of the Veteran's medical history was conducted by the California Department of Social Services Disability Determination Service Division, which determined that the Veteran's condition appeared to have become increasingly worse. He was given a GAF score of 50. In January 2011, a regular mental health examination report noted increased severity in the Veteran's PTSD symptoms and ordered increased medication dosages. A GAF score of 45 was determined. The Veteran joined weekly depression management group therapy sessions in February 2011. In 2011, he continued to attend individual therapy sessions and his medication dosages were adjusted. GAF scores of 40 were routinely given. In November 2011, he underwent a VA examination where he described symptoms of depressed mood, anxiety, mild memory loss, impairment of short- and long-term memory, and memory loss for names of close relatives, own occupation, or own name. The examiner observed that the Veteran was anxious, depressed, irritable, had impaired impulse control, and had outbursts of anger. Communication, speech, orientation, appearance, hygiene, thought processes, and judgment were all normal. Memory was mildly to moderately abnormal. Suicidal and homicidal ideations were absent. The examiner determined that the Veteran had occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. In March 2012, the Veteran's medications were decreased and the Veteran reported feeling better. In April 2012, his dosages were increased again and a GAF score of 40 was given. The Veteran reported having good weeks and bad weeks at his regular therapy sessions. In July 2013, the Veteran reported that it seemed like things were getting worse, noting he had more triggers than before. He later got a service dog to help him cope with his PTSD symptoms. The Veteran underwent another VA psychiatric evaluation in February 2014. He stated to the examiner that his overall functioning "gradually declined" since his last examination and that he had not had improvement in his symptoms. He reported depression, anxiety, difficulty sleeping, nightmares, flashbacks, chronic sleep impairment, poor impulse control, anger issues, difficulty concentrating, poor frustration tolerance, and hypervigilance. The Veteran stated he limited his social interaction with others and was confined mostly to his home. He stated he now required the assistance of a service dog to help him manage his anxiety attacks and poor balance from vertigo. The examiner determined he had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Board finds that as early as July 2010, the Veteran consistently reported symptoms of panic attacks, quick temper, hypervigilance, hyperarousal, intrusive thoughts, nightmares, problems sleeping, depressed mood, low energy level, constricted affect, and passive suicidal ideation. He described instances with others where he displayed a lack of impulse control and unprovoked irritability with violent responses. Accordingly, the Veteran's symptoms most closely approximate a rating of 70 percent disabling from July 29, 2010, to February 8, 2014. The Veteran's symptoms prior to February 8, 2014, do not warrant a rating higher than 70 percent, however. Although his symptoms caused deficiencies in most areas, he did not display symptoms describing total occupational and social impairment. He did not display gross impairment in thought processes or communication, persistent delusions or hallucinations, disorientation to time or place, or problems with hygiene. Nor did he have symptoms of a similar nature and severity to those enumerated in the 100 percent rating criteria. It is clear from the record that the Veteran's depressive symptoms have been constant throughout the appeal period and that he has suffered a lack of impulse control, quick temper, and irritability which has caused him to isolate and has caused problems with his family. However, a clear decline in his symptoms was noted over time, with his symptoms shown to be their most severe at the February 2014 VA examination. As such, a 70 percent disability rating, but no higher, is granted from July 29, 2010, to February 8, 2014. Neither the Veteran nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (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). ORDER A 70 percent disability rating, but no higher, from July 29, 2010, to February 8, 2014, for PTSD is granted. Service connection for sleep apnea is denied. Service connection for COPD is denied. REMAND The Veteran has contended that his service-connected PTSD caused or aggravated his fibromyalgia. The only medical evidence of record addressing a possible correlation between the conditions is a February 2014 VA examination and opinion. The examiner determined that the Veteran's fibromyalgia was less likely as not (less than 50 percent probability) proximately due to or the result of his service-connected PTSD. He explained that although fibromyalgia has been seen in a higher rate in patients with PTSD, there is no evidence to suggest PTSD causes fibromyalgia. The pathophysiology was undetermined. As noted above, establishing service connection on a secondary basis requires evidence sufficient to show that the current disability was either proximately caused by or proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. at 448. The medical opinion did not address whether the Veteran's PTSD has aggravated his fibromyalgia. The Court of Appeals for Veterans Claims holding in El-Amin v. Shinseki, 26 Vet.App. 136 (2013), indicates that in circumstances such as this case, a medical opinion addressing that question should be sought. Accordingly, the issue of entitlement to service connection for fibromyalgia must be remanded for an addendum opinion before it can be adjudicated. 38 C.F.R. §§ 3.159, 3.310. Accordingly, the case is REMANDED for the following action: 1. Contact the Veteran and request that he provide information as to any outstanding records pertaining to his fibromyalgia, specifically to include any outstanding private treatment records. He should be asked to authorize the release of any outstanding pertinent non-VA medical records. 2. Attempt to obtain relevant outstanding VA treatment records. 3. After the above development is completed, obtain an addendum opinion from an appropriate VA clinician. Make the claims file available to the examiner for review of the case. The clinician is asked to review the case and note that this case review took place. The need for an examination is left to the discretion of the clinician selected to write the addendum opinion. The clinician is asked to opine on the following: a. Regarding the Veteran's fibromyalgia, the clinician should opine as to whether it is at least as likely as not (probability of 50 percent or better) that such disability is etiologically related to an in-service disease or injury; and b. The clinician should opine as to whether it is at least as likely as not (probability of 50 percent or better) that his fibromyalgia was caused by his service-connected PTSD; and c. The clinician should opine as to whether it is at least as likely as not (probability of 50 percent or better) that his fibromyalgia was aggravated (i.e., permanently worsened beyond the natural progression) by his service-connected PTSD. In determining whether his fibromyalgia is aggravated by the service-connected PTSD, the clinician must opine upon a baseline level of severity of his fibromyalgia established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of fibromyalgia. 38 C.F.R. § 3.310(b). The clinician is asked to provide a rationale and explain the reasons behind any opinions expressed and conclusions reached. 4. After completing the requested actions, and any additional development deemed warranted, readjudicate the claim in light of all pertinent evidence and legal authority. If the benefit sought remains denied, furnish to the Veteran and his representative a Supplemental Statement of the Case and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ L. M. BARNARD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs