Citation Nr: 1807023 Decision Date: 02/02/18 Archive Date: 02/14/18 DOCKET NO. 10-40 565 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for residuals of meningitis. 2. Entitlement to service connection for hearing loss. 3. Entitlement to service connection for skin rash. 4. Entitlement to service connection for migraine headaches, including as secondary to service connected disability. 5. Entitlement to service connection for a left lower extremity disorder, including as secondary to service connected disability. 6. Entitlement to an initial rating in excess of 30 percent, for the period prior to April 17, 2014, and in excess of 50 percent thereafter, for posttraumatic stress disorder (PTSD) with alcohol dependence in remission. 7. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Robert J. Burriesci, Counsel INTRODUCTION The Veteran served on active duty from December 1965 to September 1967. These matters come to the Board of Veterans' Appeals (Board) on appeal from April 2006 (service connection for hearing loss and migraine headaches), June 2009 (service connection for meningitis and rash) and July 2011 (increased rating for PTSD and service connection for a left lower extremity disorder) rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. A hearing was held before the undersigned in August 2015. A transcript of the hearing is of record. The claims were previously before the Board in December 2015 when they were remanded for additional development. In a March 2017 rating decision, the RO increased the evaluation of the Veteran's PTSD from 30 percent to 50 percent, effective April 17, 2014. As the increase does not represent the maximum rating available for the condition, the Veteran's claim for a higher evaluation remains in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993). The issues of entitlement to service connection for residuals of meningitis; skin rash; migraine headaches, and; a left lower extremity disorder; and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The competent and probative evidence shows that the Veteran's bilateral hearing loss was likely incurred in service. 2. During the period on appeal prior to April 9, 2014, the Veteran's PTSD resulted in occupational and social impairment with reduced reliability and productivity, but not more severe. 3. During the period on appeal beginning April 9, 2014, the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, but not more severe. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for bilateral hearing loss have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.385 (2017). 2. The criteria for an initial disability rating of 50 percent, and no higher, for the period prior to April 9, 2014, and 70 percent, and no higher, for the period beginning April 9, 2014, for PTSD have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. §§ 1110, 1131. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The Veteran seeks entitlement to service connection for bilateral hearing loss. At the hearing before the undersigned the Veteran argues that his hearing loss is due to his exposure to loud noise in service. Review of the claims file reveals that the Veteran has been diagnosed with bilateral hearing loss, and his hearing loss is a disability for VA compensation purposes pursuant to 38 C.F.R. § 3.385. See, e.g., VA Examination Report, April 2009. A VA medical opinion was obtained in March 2017 with regard to his claim for hearing loss. The Veteran's service entrance and separation examinations were discussed as well as the Veteran's in-service meningitis. Articles regarding hearing loss and meningitis were discussed. The examiner rendered the opinion that the Veteran's hearing loss was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The Veteran entered and exited the military service with clinically normal hearing. There were no shifts in hearing when comparing entrance examination to exit examination for either ear, and 8 decibel average shift for left ear only, no shift noted for right ear. The separation examination was silent for hearing loss, ENT trouble, headaches or dizziness. Hearing loss was not caused by acoustic trauma per no shift noted for either ear. The Veteran suffered N. meningitis, was hospitalized and treated without complications in 1966, according to his service treatment records and his personal statements/history. Research reviewed regarding meningitis and hearing loss suggests that hearing loss due to meningitis can be gradual and late onset for adults. The Veteran provided numerous research articles on severe hearing loss and meningitis; however, the majority of these were related to childhood meningitis. According to the examiner's research, meningitis can have no effects on those treated quickly, have minimal effects or major effects when there are complications or treatment is delayed. The examiner did not feel based on the service treatment records review that there was any sequelae to the Veteran's meningitis that would have resulted in hearing loss. However, because there were no serial audiograms completed following military service, until recently since 2005 and the present, there is no way to equate changes in hearing that may have been related to meningitis. The Veteran's vocation was a balloon pilot and it is very likely that the Veteran was exposed to hazardous noise without hearing protection for several years. The examiner further found it likely that the Veteran suffered presbycusis type hearing loss. However, the examiner noted that the amount of hearing loss caused from vocational/avocational noise exposure and the aging process compared to meningitis also cannot be equated. The examiner stated that because research suggests that in 30 percent of the adult population there is some gradual hearing change due to bacterial meningitis, the examiner opined opine in favor of the Veteran even though the Veteran's hearing was grossly normal at separation exam. Although the examiner addresses several different possible causes for the Veteran's hearing loss, she ultimately provides a positive nexus opinion. Thus, service connection for hearing loss is warranted. II. Higher Evaluation The Veteran seeks an initial evaluation in excess of 30 percent, for the period prior to April 17, 2014, and an evaluation in excess of 50 percent thereafter, for PTSD. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's PTSD disability is currently evaluated pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. When evaluating a mental disorder, consideration shall be given to the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation will be based on all the evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of examination. It is the responsibility of the rating specialist to interpret reports of examinations in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. Under the provisions of Diagnostic Code 9411 a rating of 30 percent is assignable for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A rating of 50 percent is assignable for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once per week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly-learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A rating of 70 percent is assignable for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work like setting); inability to establish and maintain effective relationships. Id. A rating of 100 percent is assignable for 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. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a Veteran's symptoms, but it must also make findings as to how those symptoms impact a Veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442; see also Sellers v. Principi, 372 F.3d 1318 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran's impairment must be "due to" those symptoms, 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. Vazquez-Claudio, 713 F.3d at 118. Psychiatric examinations frequently include assignment of a GAF score, which is defined by DSM-IV as number between zero and 100 percent, that represents the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health illness. Higher scores correspond to better functioning of the individual. The GAF score and the interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF scores assigned in a case, like an examiner's assessment of the severity of a condition, are not dispositive of the rating 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). GAF scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994). GAF scores of 41-50 indicate 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). Id. GAF scores ranging from 31 to 40 reflect 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). Id. VA had previously adopted the American Psychiatric Association: Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), for rating purposes. VA implemented DSM-5, effective August 4, 2014, and the Secretary, VA, determined that DSM-5 applies to claims certified to the Board on and after August 4, 2014. See 79 Fed. Reg. 45,093 (Aug. 4, 2014). As the Veteran's increased rating claim was originally certified to the Board in April 2015 (after August 4, 2014), the DSM-5 is applicable to this case. Effective August 4, 2014, VA also amended the regulations regarding the evaluation of mental disorders by removing outdated references to DSM-IV. The amendments replace those references with references to the recently updated DSM-5. However, according to the DSM-5, clinicians do not typically assess GAF scores. The DSM-5 introduction states that it was recommended that the GAF be dropped from DSM-5 for several reasons, including its conceptual lack of clarity (i.e., including symptoms, suicide risk, and disabilities in its descriptors) and questionable psychometrics in routine practice. The Veteran reported in April 2010 that he was not sleeping, feeling tense, easily startled, exaggerated startle response, emotionally numb, stressed out for long time after any conflict or danger, anger and irritability, with outbursts and self-destructive behavior, heavy drinking for over 40 years, a sense of having no future. In April 2010 the Veteran's spouse reported that the Veteran was ready to go off at any time, no patience with waiting, no standing in lines, crowds made the Veteran uncomfortable. The Veteran was afforded a VA examination in April 2011. Psychiatric symptoms included chronic depression, anxiety, sleep disturbance, hypervigilance, and some paranoia, worse at night. There were no hallucinations, delusions, or history of suicide attempts. He had some social dysfunction and isolation with hypervigilance in crowds. The Veteran was noted to be alert and oriented times three. He denied being suicidal or homicidal. There were no episodes of violence, no DUI's, and no prison time. He was restricted with socialization. He had some acquaintances and socialized with family. He went to church. Dress and hygiene were casual but adequate. He bathed most days but some days he did not have the motivation to bathe. Judgement and insight were intact. The examiner noted that the Veteran had no significant employment dysfunction. The examiner diagnosed the Veteran with PTSD and alcohol dependence in remission, secondary to PTSD. The Veteran was assigned a GAF score of 55. In May 2012 the Veteran was alert and oriented times four. Attention and concentration were normal. Mood was euthymic with affect of normal range and amplitude. Stream of thought was rational. Insight and judgment appeared fair. The Veteran was diagnosed with PTSD and assigned a GAF score of 57. In September 2012 the Veteran's psychomotor behavior was within normal limits. There were no perceptual disturbances. Judgment and insight were good. The Veteran was not suicidal or homicidal. He reported nightmares that interfered with his sleep. He was alert and oriented times three. The Veteran was friendly, cooperative, relevant, and coherent. Grooming, hygiene, and dress were good. Speech was clear. Thoughts were organized. Eye contact was good. Affect and mood were congruent with content. Overall affective tone remained fairly bright, with euthymic mood. There was no gross impairment of memory, attention or concentration noted. Diagnosed with depression, PTSD, and insomnia related to another mental disorder and was assigned a GAF score of 55. In April 2013 grooming was good and dress was casual. The Veteran was engaging and friendly/polite. Speech was clear with normal rate and volume. Eye contact was good. No unusual movements were noted. The Veteran was alert and orientated. Thought processes were organized and goal-directed. Hallucinations and delusions were not present. Mood was mildly dysphoric and affect was consistent with mood. Attention and concentration were satisfactory and memory was intact. Judgment and insight were good. He had symptoms of anxiety, guilt, sleep disturbance, hypervigilance, and intrusive memories and imagery. The Veteran denied suicidal and homicidal ideation, plan, or intent. The Veteran was diagnosed with PTSD and assigned a GAF score of 55. In August 2013 and October 2013 grooming was good and dress was casual. The Veteran was engaging and friendly/polite. Speech was clear with normal rate and volume. Eye contact was good. No unusual movements were noted. The Veteran was alert and orientated. Thought processes were organized and goal-directed. Hallucinations and delusions were not present. Mood was mildly dysphoric and affect was consistent with mood. Attention and concentration were satisfactory and memory was intact. Judgment and insight were good. The Veteran denied suicidal and homicidal ideation, plan, or intent. The Veteran was diagnosed with PTSD and assigned a GAF score of 55. In December 2013 grooming was good and dress was casual. The Veteran was engaging and friendly/polite. Speech was clear with normal rate and volume. Eye contact was good. No unusual movements were noted. The Veteran was alert and orientated. Thought processes were organized and goal-directed. Hallucinations and delusions were not present. Mood was mildly anxious and affect was consistent with mood. Attention and concentration were satisfactory and memory was intact. Judgment and insight were good. The Veteran denied suicidal and homicidal ideation, plan, or intent. In a statement dated in March 2014, the Veteran's sister reported that the Veteran was easy to anger and lash out at people he loves, specifically his wife and son. He had depression and not wanting to get too close to people. He had guilt over unpleasant things that had happened in his life. He showed involuntary responses when planes or helicopters are flying overhead. She reported that the Veteran had flashbacks of traumatic situations that are triggered by noises, crowds, or event television shows. He had an inability to relax or socialize with groups of people. He was always the first guy who wants to leave. He was unable to remember certain situations. She noted that for 45 years he was unable to sleep without drugs or alcohol. He was still unable to sleep without medication. An April 9, 2014 report details a private psychological evaluation. The provider noted that the Veteran had significant anxiety and depression and had significantly impaired psychological functioning. The Veteran was very uncomfortable around others and spent most of his time at home with his wife. The Veteran's symptoms of panic, depression, and poor impulse control have had debilitating effects on his ability to function reliably and productively. It has also led to marked impairment in interpersonal relationships at work and exercising appropriate judgment. His thinking was colored by a paranoid perception that prevents him from becoming close to others and seeing the world even those who wish to help him as dangerous and to be avoided. He was angered and frustrated quite easily and avoided others in part because of fears of loss of control. Flashbacks were reported. The Veteran had clinical signs consistent with PTSD, including nightmares, chronic sleep impairment, flashbacks on an almost daily basis, and no close friends and no desire for closeness. He had intense anxiety when watching news that involves Iraq, Middle East conflict, Afghanistan, or terrorists. Due to multiple triggers for his flashbacks he was constantly tense, hypervigilant, easily startled, and agitated. He had symptoms consistent with panic disorder. He had panic attacks at least twice a week and frequently much more often, including multiple times in a day. Symptoms appeared to date back to his combat exposure and even with ongoing treatment have an extremely disruptive impact on his functioning. He had major impairment in multiple areas, including interpersonal relationships, work, judgment, and mood. He attempted to work on a part time seasonal basis giving balloon rides. Due to his depression, withdrawal, and panic attacks, he worked very little and had not made money in many years. He had marked difficulty getting along with others, had outbursts of uncontrolled rage and his relationships with both his sons and wife have been scarred by his unstable behavior. Given the severity of symptoms and length of time in which he has gone untreated the prognosis for change was viewed as poor and it was anticipated that the Veteran will remain severely disabled. The Veteran was diagnosed with PTSD and panic disorder without agoraphobia and assigned a GAF score of 35. In a private therapy progress report dated in October 2014 the Veteran was noted to be more anxious and fearful of the future the weaker his wife became due to her cancer. He had nightmares. He had panic attacks twice a week. He had increasing lethargy and depression. He continued to be quite limited in his day to day functioning. He showered infrequently. He showed very little interest in his ballooning work and rarely left the house. For many years the Veteran found it harder to continue to work as a balloon pilot, which had been the only occupation he had been able to stick to. His memory continued to worsen and he felt quite pessimistic regarding his future. He was to continue to be seen on an individual basis but it was strongly recommended that his medications be reviewed to target his worsening depression, anxiety, and sleep impairment. The prognosis was noted to be poor given the severity and chronic nature of his symptoms. He was assigned a GAF score of 35 with the high GAF score for the prior year at 38. A private therapy progress report dated in February 2015 revealed diagnoses of PTSD and panic disorder. The Veteran was generally cooperative though remained rather defensive and guarded. He continued to have trust issues in his therapy and relationships. His anxiety appeared to be worsening. He was quite dependent on his wife. Sleep was poor and not restorative. He was easily startled. He continued to have frequent, almost daily nightmares. He rarely slept more than three hours at a time. He felt depressed and hopeless and had little to look forward to. He denied suicidal ideation; however, he related that the only thing keeping him going was his wife and that he did not know what he might do if she died. He continued to have panic attacks and attempted to limit them by self isolating. It was not uncommon for him to have three attacks a week. He had more difficulty in leaving the safe confines of his home as this increased his panic attacks. He had little interest in or involvement in ballooning work which had been his only source of employment. The Veteran's memory remained quite poor with marked difficulties with organization and concentration. He felt compelled to write down everything though he frequently misplaced the notes. The Veteran's prognosis was noted to be poor and his GAF score was 38 with a high of 38 over the prior year. In a statement dated in April 2014 the Veteran's psychologist stated that the Veteran was diagnosed with PTSD and panic disorder without agoraphobia. While other known risk factors may possibly exist, it was his professional opinion that the Veteran's diagnoses are clearly a direct result of his military experience and have had a debilitating affect on his ability to maintain employment, and interact with others in social and vocational environments. In a statement dated in February 2015 the Veteran's psychologist stated that diagnoses, identified as PTSD, panic disorder without agoraphobia and cognitive disorder are a direct result of the Veteran's military experience and have had a debilitating affect on his ability to maintain employment and interact with others in social and vocational environments. In a July 2016 VA treatment note the Veteran had fair hygiene, an anxious mood, and was oriented to time, day, and location. There was no evidence of psychosis. The Veteran denied suicidality and being a threat to others. There was no evidence of any suicidal or homicidal ideation or intent. In May 2016, June 2016, September 2016, November 2016, January 2017, and March 2017 VA treatment notes the Veteran had satisfactory grooming and was engaging, cooperative, and friendly/polite. Speech was clear with normal rate and volume, eye contact was good, and there were no unusual movements noted. The Veteran was alert and oriented, thought processes were organized, hallucinations and delusions were not present, mood was dysphoric to euthymic, affect was consistent with mood; attention and concentration were satisfactory, memory was intact, judgment was good, and insight was fair to satisfactory. The Veteran was afforded a VA examination in March 2017. The Veteran was diagnosed with PTSD, other specified depressive disorder, uncomplicated bereavement, and alcohol use disorder. The symptoms for the disabilities could not be differentiated. The examiner noted that the Veteran had occupational and social impairment with reduced reliability and productivity. The Veteran was married from 1969 until his wife's death in 2016. His history of alcohol abuse caused difficulties in his marriage. He reported that he and his son love each other. Socially, the Veteran reported that he had Vietnam veteran friends, but added they do not see each other much. He stated that he was isolated but he had a "swell" and supportive "bunch of guys" at the American Legion. The Veteran had been self-employed as a balloon pilot since 1980. However, he stated he has not been able to make an income from his business in "forever," as he was unable to stand long enough to pilot the balloon. The Veteran reported that he did not "put up" with screaming children, adding he warned parents about same beforehand. He went on to say that if people were polite there was "no problem." A letter from the Social Security Administration (SSA) dated in February 2010 revealed that the Veteran had been disabled from working since August 2005 secondary to migraine headaches. The VA examiner discussed the private psychological evaluations. The Veteran reported symptoms of depression, anxiety, guilt, and grief. Regarding anxiety, the Veteran cited worry regarding what others think of him, in regard to his being "loony tunes" or "off the deep end." He also cited crowds, unexpected loud noises, and being approached from behind as being triggers for anxiety. In addition, the Veteran reported that the sound of helicopters and loud airplanes trigger panic attacks, as well as flashbacks. He stated he avoids most war-related movies. Regarding suicide, the Veteran stated that it scares him when he has such thoughts, adding he tries not to think about it. He did not want to traumatize his children by taking his own life, denied making any attempts, and denied any current plan/intent to harm himself. He also denied homicidal ideation. The Veteran reported a 45 to 60 minute delay in the onset of his sleep, adding he will take 1 or 2 Hydroxyzines if he is unable to fall asleep. Once asleep, the Veteran reported interruptions approximately every two hours. He also reported nightmares of being a prisoner of war. His late wife used to be able to calm him, but now she is gone. The Veteran reported that he is chronically fatigued, and will take naps during the day. He reported that his short- and long-term memory "sucks." The Veteran reported migraines as occurring an average of twice a week. He added he was able to significantly reduce the effects of those headaches if he takes his Imitrex as soon as he feels one coming, but that he is still "down for the rest of the day." He also reported tension-type headaches occurring "almost every day." Symptoms were listed as depressed mood, anxiety, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, flattened affect, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. He was casually dressed and his grooming was fair. He was alert and fully oriented. He was able to correctly spell "WORLD" forward, but not backward. He was also not able to accurately complete serial 7s. He was able to recall one of three words after delay, which did not improve with prompting. He was cooperative with the assessment process. His mood was dysphoric, but his affect appropriate to content. He displayed good eye contact. The Veteran's speech was normal in rate and tone, spontaneous and goal-directed, though there were indications that he tends to minimize his symptoms. His thought processes were generally organized with no evidence of formal thought disorder, hallucinations, delusions, mania, or obsessive-compulsive features. He was capable of abstract thinking and displayed fair insight into his PTSD and related emotions and behaviors. The Veteran displayed no difficulties with activities of daily living due to his mental health issues. Since his VA examination for PTSD in 2011, the Veteran's psychosocial functioning has apparently declined, though he likely under-reported symptoms at the time of that last evaluation. Results of current examination revealed continued presence of very severe signs and symptoms of PTSD, as described above, with comorbid symptoms of depression secondary to his experiences in Vietnam, as well as chronic pain, inability to work, the loss of his wife, and the incarceration of his son. Prognosis for substantial improvement of psychiatric symptoms and functional status was poor, as Veteran has been involved in therapy and on psychiatric medications for several years, with minimal response. In a treatment note dated in April 2017 the Veteran reported increasing thoughts of suicidal ideation. Grooming was satisfactory, dress was casual, and the Veteran was engaging, cooperative, friendly/polite. Speech was clear with normal rate and volume. Eye contact was good. There were no unusual movements. He was alert and oriented. Thought process was organized and hallucinations and delusions were not present. Mood was dysphoric, anxious. Affect was consistent with mood. Attention and concentration were satisfactory. The Veteran's memory was intact and judgment and insight were fair. In April 2017 the Veteran was noted to have access to weapons and to have thought of shooting himself and perhaps it being better if he were gone. Denied suicidal intent or active plan and indicated that he did not believe he would ever harm himself. The Veteran underwent a private psychological evaluation in April 2017. The Veteran was noted to have a fitful reoccurring dream regarding his service. He typically woke up drenched in sweat and unable to fall back asleep. His inability to fall and stay asleep has been problematic as he rarely slept more than two hours at a time. He continued to have panic attacks, at least two to three times a week. Depressive symptoms increased in severity over the last year. He had become even more withdrawn and isolative. He endorsed suicidal ideation and reported having a plan to kill himself with one of his many guns. He reported that the provider was the first person he had told and that he felt he had just been put on an antidepressant due to that. He related that the only reason he has not committed suicide is because of his grandson who lived with him. He had signs consistent with a diagnosis of major depression that included fatigue, feelings of worthlessness, impaired concentration, anhedonia, and suicidal ideation. He had no interest in leaving the house or having contact with others. He cared little about his personal hygiene or appearance. Until recently he had let his beard grow for almost a year giving him a very unkempt look. He was paranoid and agitated. He was noted to be quite volatile and unpredictable. He reported that he had no friends as "nobody can be trusted." He had difficulty recognizing the boundaries of others. He had symptoms consistent with a panic disorder. Panic attacks occurred at least twice a week, frequently much more often, and at times he may have multiple attacks in a day. His attacks had increased in both intensity and frequency since his wife passed. He had multiple triggers. Symptoms included palpitations, sweating, shaky hands, chest pain, nausea, lightheadedness, fear of losing control, and hot flushes. Symptom onset appeared to date back to his combat exposure and has an extremely disruptive impact on his functioning. He had signs consistent with a diagnosis of PTSD. These included nightmares, chronic sleep impairment, and almost daily flashbacks. He had no close friends and had no desire for closeness. He experienced intense anxiety when watching news that involved Iraq, Middle East conflict, Afghanistan, or terrorism. Hearing explosions on television, fireworks, loud sounds and many holidays, function as some of his triggers. The strongest triggers were the smell of burnt meat and low flying helicopters. Other triggers for flashbacks and panic attacks included high humidity. Given the multiple triggers he was constantly tense, hypervigilant, easily startled, and agitated. The Veteran was diagnosed with chronic PTSD, major depression, panic disorder without agoraphobia, and cognitive disorder. The Veteran was assigned a current GAF score of 33 and a past GAF score of 41. The provider reported that the Veteran is impaired in virtually all aspects of functioning. He no longer worked and cannot cope with the demands associated with employment. He had no contact with family other than his teenage grandson that lives with him. He did not answer phone calls or return messages. His judgment was severely impaired. He exhibited paranoia approaching a level of delusional thinking regarding the VA. He was quite depressed and attempted to minimize the severity of his symptoms. He was suicidal and had a plan involving a gun. He rarely left the house other than to doctor appointments. He was obsessed with finding information in his VA file to prove that he has intentionally been mistreated and lied to by the VA. He was volatile, withdrawn and explosive. He attempted to manage his anger by avoiding contact with others. He was unable to adapt to stressful circumstances or changes in his routine. He becomes quite anxious and panicky in response to changes in routine. Given his fragile psychiatric condition, years of impairment, and limited coping skills the prognosis for the Veteran was viewed as quite poor. Based on a review of the complete record, the Board finds that entitlement to an evaluation of 50 percent, and no higher, for PTSD, is warranted for the period prior to April 9, 2014. Prior to April 9, 2014, the Veteran's PTSD manifested symptoms of sleep disturbance, nightmares, flashbacks, anger, lack of patience, and dysphoric mood. During this time period the Veteran was alert and oriented, his thought processes were organized and goal-directed, and he did not have any hallucinations or delusions. He had intact memory and his attention and concentration were at least satisfactory. Although the Veteran reported that some days he did not have the motivation and bathe, the Veteran's dress and hygiene were adequate. During this time period the Veteran was assigned GAF scores of 55 and 57 representing moderate symptoms or moderate difficulty in social, occupational, or school functioning. However, prior to April 9, 2014, the Veteran's PTSD did not manifest suicidal ideation, obsessional rituals that interfered with routine activities, illogical, obscure, or irrelevant speech, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, impaired impulse control, spatial disorientation, difficulty adapting to stressful circumstances, or an inability to establish and maintain effective relationships. As such, the Board finds that the Veteran's symptoms of PTSD, prior to April 9, 2014, more nearly approximate the criteria for an evaluation of 50 percent, and no higher. Therefore, an evaluation of 50 percent for PTSD, and no higher, is granted for the period prior to April 9, 2014. Entitlement to an evaluation of 70 percent, and no higher, for PTSD, is warranted for the period beginning April 9, 2014. During the period beginning April 9, 2014, the Veteran's PTSD manifested symptoms identified as causing significant impairment of psychological functioning. The Veteran's symptoms of panic, depression, and poor impulse control have had debilitating effects on his ability to function reliably and productively. It has also led to marked impairment in interpersonal relationships at work and exercising appropriate judgment. During this period he was noted to have panic attacks at least twice a week and frequently much more often, including multiple times in a day. He had marked difficulty getting along with others, had outbursts of uncontrolled rage. He was reported to shower infrequently and to have intact to poor memory. He reported that the only thing keeping him going was his wife. During this period he reported in March 2017 and April 2017 the Veteran reported that he had had suicidal thoughts but he did not have a suicidal intent or active plan. During the period beginning April 9, 2014, the Veteran was assigned GAF scores of 33, 35, 38, and 41, representing major impairment in several areas to serious impairment in social, occupational, or school functioning. However, at no point during the period on appeal did the Veteran's PTSD manifest total occupation and social impairment. Notably, during the entire period on appeal the Veteran lived with either his wife or his grandson. As the Veteran's symptoms of PTSD beginning April 9, 2014, represent occupational and social impairment with deficiencies in most areas, an evaluation of 70 percent, and no higher, is granted. ORDER Service connection for bilateral hearing loss is granted. Entitlement to an initial disability rating of 50 percent, and no higher, for the period prior to April 9, 2014, and 70 percent, and no higher, for the period beginning April 9, 2014, for PTSD, is granted. REMAND In December 2015 the Board remanded and requested medical opinions in the claims of entitlement to service connection for residuals of meningitis; skin rash; migraine headaches; and left lower extremity disorder. Pursuant to the remand, the Veteran was afforded VA examinations in March 2017. After examination the examiner did not comment on whether the Veteran had any current residuals of his in service meningitis. With regard to skin rashes the examiner reported that the Veteran stated that he did not have any diagnosed skin condition that was related to his military service to claim at that time. He claimed in the past about a rash which was a symptom of his meningitis. He did not have it any more to claim. The statement was reported to have been read to the Veteran and that the Veteran agreed with the statement. However, in a statement dated in July 2011 the Veteran reported that he had a petechial rash in service that preceded his meningitis. In a statement dated in January 2016 the Veteran reported that he had a rash that started in October 1966. He still used hydrocortisone on it and in December 2015 was treated at the VA. He reported that his head, arms, neck, back, legs, and feet were impacted. He stated that he was treated with liquid nitrogen, cream and lotion and he was still working on it in January 2016. Furthermore, a VA treatment record dated in September 2016 indicates multiple skin diagnoses. The examiner did not comment upon the Veteran's listed diagnoses of skin disabilities during the period on appeal. With regard to the claims of service connection for migraine headaches and left lower extremity disorder, the examiner rendered the opinion that there was no medical literature support to say that treated meningitis leads to complications like migraine and unilateral peripheral neuropathy. However, the examiner did not render an opinion regarding whether the Veteran's migraine headaches and/or left lower extremity disorder were otherwise related to the Veteran's active service, including treatment for urticaria or as due to herbicide exposure in service. Furthermore, the examiner deferred to a psychiatry examiner with regard to whether any migraines and/or left lower extremity disorder was caused by or aggravated by the Veteran's PTSD. In March 2017 the Veteran was afforded a VA examination with regard to his PTSD. However, the examiner did not render an opinion with regard to whether any migraines and/or left lower extremity disorder was caused by or aggravated by the Veteran's PTSD. As the examiners did not discuss whether the Veteran had any residuals of meningitis, did not offer an opinion regarding whether the Veteran's listed diagnoses were related to his active service including diagnosis of and treatment for meningitis, and did not offer an opinion regarding whether the Veteran's PTSD caused or aggravated the Veteran's migraines and/or left lower extremity disorder, the examinations are inadequate. Therefore, the claims must be remanded for the Veteran to be afforded additional VA examination(s) and to obtain adequate medical opinions. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran's claim for entitlement to TDIU may be impacted by the implementation of the above decision to grant service connection for bilateral hearing loss, and the outcome of the remanded claims for service connection. Thus, these issues are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180 (1991). As such, the Board is unable to review the claim for TDIU until the Veteran is assigned an initial evaluation and effective date for bilateral hearing loss and the remanded issues regarding entitlement to service connection are resolved. Review of the claims file reveals that the Veteran receives continued treatment from VA. VA treatment records regarding the Veteran dated since April 2017 have not been obtained and associated with the claims file. On remand, attempts must be made to obtain and associate with the claims file all VA treatment records regarding the Veteran dated since April 2017. See 38 C.F.R. § 3.159. Accordingly, the case is REMANDED for the following action: 1. Implement the Board's decision granting entitlement to service connection for bilateral hearing loss. 2. Obtain and associate with the claims file all VA treatment records regarding the Veteran that are dated since April 2017. Any additional pertinent records identified by the appellant during the course of the remand should also be obtained, following the receipt of any necessary authorizations from the appellant, and associated with the claims file. 3. After completion of the foregoing, arrange for the Veteran to be examined by an appropriate examiner to determine the presence of residuals of meningitis and the nature and likely etiology of his headaches, skin rash and left lower extremity disorder. The Veteran's claims file (including this remand) must be reviewed by the examiner in conjunction with the examination. Based on examination of the Veteran and review of his claims file, the examiner should provide an opinion that responds to the following: a) Please identify (by clinical diagnosis) each residual of meningitis found to be present. If no residuals are identified the examiner should indicate such. b) Please identify (by clinical diagnosis) any headache disability found. c) Please identify (by clinical diagnosis) any skin disorders found. In doing so, the examiner should comment on the Veteran's reports of skin rash and the diagnoses of skin disorders identified in treatment records. d) Please identify (by clinical diagnosis) any left lower extremity disability found. e) As to each diagnosed disability entity which is determined to be a residual of meningitis, please opine whether it is at least as likely as not (a 50 percent or better probability) that such residual disability entity is related to the January 1966 laboratory finding of "N. Meningitis types B & C isolated Sulfa Resistant." f) As to each diagnosed headache, skin rash and left lower extremity disability, please opine whether it is at least as likely as not (a 50 percent or better probability) that such disability is related to the Veteran's military service, to include the January 1966 laboratory finding of meningitis and treatment for urticaria or as due to herbicide exposure therein. g) If it is determined that a headache and/or left lower extremity disability is not related to the Veteran's military service, please opine whether such is caused or aggravated by his service-connected PTSD. If no specific headache, skin and/or left lower extremity disability is diagnosed, please reconcile such finding with the Veteran's complaints and treatment for headaches, skin rash and left leg neuralgia/neuropathy noted in the VA treatment records. In providing these opinions, the examiner should acknowledge and discuss the Veteran's assertions and other lay evidence of record concerning his observable symptoms as well as the articles he has submitted in support of his claims which address the correlation between meningitis and/or PTSD and his claimed disabilities. The examiner must explain the rationale for all opinions, citing to supporting factual data or medical texts/treatises, as appropriate. 4. After completing the above, and any other development deemed necessary review the record and readjudicate the claims. If any claim remains denied, issue an appropriate supplemental statement of the case and afford the Veteran and his representative an opportunity to respond before the record is returned to the Board. The appellant has the right to submit additional evidence and argument on the matters 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.A. §§ 5109B, 7112 (West 2014). ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs