Citation Nr: 1815007 Decision Date: 03/09/18 Archive Date: 03/19/18 DOCKET NO. 14-22 018 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to a disability rating in excess of 50 percent for a major depressive disorder with anxiety (MDD). 2. Entitlement to service connection for posttraumatic stress disorder (PTSD). ATTORNEY FOR THE BOARD RLBJ, Associate Counsel INTRODUCTION The Veteran served honorably in the United States Navy from June 2000 to July 2006. The Veteran's DD Form 214 indicates seventeen months of sea service, and no foreign service is documented in his military personnel file. The issues on the title page arrive before the Board of Veterans' Appeals (Board) on appeal from an April 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office in Philadelphia, Pennsylvania. In May 2014, the Veteran elected to forgo a Board hearing on these issues. Consequently, no transcript is available for review in the electronic claims file. The Veteran's claims file is located in the Veteran Benefits Management System (VBMS) and/or Legacy Content Manager (LCM) databases. In March 2016, the Board remanded the issues on the title page for further evidentiary development. Following the March 2016 Board remand, the record shows that the Veteran's private attorney withdrew representation in this and future matters. See Woods & Woods, LLP Letter (January 25, 2017). In April 2017, the Board notified Attorney Woods that the databases no longer reflected his representation of the Veteran. To date, the Veteran has not elected to appoint another representative. FINDINGS OF FACT 1. On and after January 2, 2013, the Veteran's service-connected major depressive disorder with anxiety is manifested by psychiatric symptoms causing occupational and social impairment with reduced reliability and productivity; occupational and social impairment with deficiencies in most areas is not shown. 2. The most probative evidence establishes that the Veteran does not have a current diagnosis of PTSD in accordance within the applicable VA regulation. CONCLUSIONS OF LAW 1. On and after January 2, 2013, the criteria are not met for a disability rating greater than 50 percent for the Veteran's service-connected major depressive disorder with anxiety. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.21, 4.126, 4.130, Diagnostic Code 9434 (2017). 2. The Veteran did not incur PTSD as a result of his active service. 38 U.S.C.A. §§ 1110, 1154, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 4.125 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (noting that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (finding that the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). I. VA's Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). For the increased rating issues on appeal, the Veteran has not advanced any procedural arguments in relation to VA's duties to notify and assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "absent extraordinary circumstances . . . we think it is appropriate for the Board and the Veterans Court to address only those procedural arguments specifically raised by the veteran . . ."). VA's duty to notify for the PTSD issue was satisfied by a letter dated March 2013. See 38 U.S.C.A. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). With respect to the duty to assist, the RO has obtained the Veteran's service treatment records (STRs), service personnel records (SPRs), and VA outpatient treatment records. The Veteran was afforded an adequate psychiatric examination in March 2013. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). For his part, the Veteran has submitted personal statements. The Veteran has not identified any additional, outstanding evidence that is relevant to his PTSD claim being decided herein. With regard to the previous March 2016 Board remand, the Board finds that the RO substantially complied with the Board's remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial compliance would be required, not strict compliance). Specifically, pursuant to the remand directives, the RO obtained and associated missing evidence with the Veteran's claims file. For the PTSD issue on appeal, the Veteran has not advanced any procedural arguments in relation to VA's duties to notify and assist. See Scott, 789 F.3d 1375. In conclusion, for both issues listed on the title page, the Board is satisfied that the RO has provided all notification and assistance required by the VCAA. 38 U.S.C.A. § 5103A. Hence, there is no error or issue that precludes the Board from addressing the merits of both issues on appeal. II. Increased Ratings, Generally Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. A claimant need only demonstrate an approximate balance of positive and negative evidence in order to prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). For a claim to be denied on the merits, a preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and coordination of rating with impairment of function. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). 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 a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). The Board must also assess the competence and credibility of lay statements and testimony. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). In increased rating claims, a Veteran's lay statements alone, absent a negative credibility determination, may constitute competent evidence of worsening, at least with respect to observable symptoms. See Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102 (2010), rev'd on other grounds by Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009). The Veteran is uniquely suited to describe the severity, frequency, and duration of his service-connected psychiatric disability. See Falzone v. Brown, 8 Vet. App. 398 (1995); Heuer v. Brown, 7 Vet. App. 379 (1995). III. MDD, Currently Rated at 50 Percent Disabling In his May 2014 VA Form 9, the Veteran posited that, "I feel I deserve an increased rating for my service connected Major Depressive Disorder with Anxiety Disorder. I also feel my Post Traumatic Stress Disorder is service connected and should be rated accordingly." Mental health disorders are evaluated under the general rating formula for mental disorders, a specific rating formula presented under 38 C.F.R. § 4.130. In addition, the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-5) provides guidance for the nomenclature employed within 38 C.F.R. § 4.130. When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). In addition, the evaluation must be 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. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the DSM-IV and replace them with references to the recently updated Diagnostic and Statistical Manual (Fifth Edition) (the DSM-5). See 79 Fed. Reg. 45,094 (August 4, 2014). VA adopted as final, without change, this interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board on or before August 4, 2014. See Schedule for Rating Disabilities - Mental Disorders and Definition of Psychosis for Certain VA Purposes, 80 Fed. Reg. 14,308 (March 19, 2015). In the present case, the RO certified the Veteran's appeal to the Board in May 2014, which is before August 4, 2014. Thus, the amended 38 C.F.R. § 4.125 conforming to the DSM-5 is not applicable in the present case. Therefore, the Board is cognizant that DSM-IV diagnoses and GAF scores are evidence that should be considered in assessing these claims. As provided by the General Rating Formula, a 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A 70 percent rating is in order when 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; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is in order 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; and memory loss for names of close relatives, own occupation, or own name. Id. A veteran need not exhibit "all, most, or even some" of the symptoms enumerated in the General Rating Formula for Mental Disorders to warrant the assignment of a higher rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Rather, the use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. Id. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant's social and work situation. Mauerhan, 16 Vet. App. at 442. The Federal Circuit has clarified that the General Rating Formula for Mental Disorders requires not only (1) sufficient symptoms of the kind listed in the percentage requirements, or others of similar severity, frequency, or duration, but also (2) that those symptoms cause the level of occupational and social impairment specified in the regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). The Federal Circuit endorsed an approach whereby the Board would identify the symptoms associated with the service-connected mental health disability, determine whether they are of the kind enumerated in the regulation, and if so, assess whether they result in the level of occupational and social impairment specified by a particular rating. Id. The 70 percent disability rating regulation, in particular, contemplates initial assessment of the symptoms displayed by a veteran, and if they are of the kind enumerated in the regulation, an assessment of whether those symptoms result in occupational and social impairment with deficiencies "in most areas." Id. Reading §§ 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. Id. at 117. In evaluating the evidence, the Board has also notes various GAF scores contained in the DSM-IV, which clinicians have assigned. A GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV at 32). An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. See generally 38 C.F.R. § 4.126; VAOPGCPREC 10-95. Stated another way, GAF scores may be considered in assigning the appropriate disability rating, but they are not the dispositive element in rating the level of impairment. See Caluza, 7 Vet. App. at 506. Higher GAF scores denote increased overall functioning of the individual. For instance, a score of 31 to 40 represents "(s)ome 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; child frequently beats up younger children, is defiant at home, and is failing at school)." DSM-IV at 46-47. A score of 41 to 50 illustrates "(s)erious 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. A score of 51 to 60 represents "(m)oderate 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)" Id. Finally, a score of 61-70 illustrates "(s)ome 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 generally functioning pretty well, has some meaningful interpersonal relationships." Id. The Veteran has appealed the April 2013 rating decision that denied an increased rating for his service-connected psychiatric disability. The Veteran's service-connected MDD is currently rated at 50 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 9434. Staged ratings are appropriate when the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). In September 2008, before the onset of the applicable claim period, the Veteran underwent a VA examination to identify the nature, etiology and severity of any psychiatric disorder. At the conclusion of that examination, the VA provider diagnosed MDD and assigned a GAF score of 48. The VA provider reported that, "(t)he Veteran stated that he is able to maintain basic activities of daily living including personal hygiene eating and dressing. . . He does not have interest in anything besides playing video games on his computer, listening to music on his computer, or at times he writes stories on his computer. He said he works eight hours most days and other than coming home and going straight to his computer on occasion he sees his friend." The Veteran denied suicidal or homicidal ideation at this examination. A VA psychology note dated in November 2012, notes that while the Veteran had been unemployed for the past year, he had been attending school full time and was taking courses in computer repair and photography at a community college. He had also found a new roommate. His current symptoms included reports of depression, social withdrawal, fatigue, loss of some interests, low motivation, low self-esteem, and difficulty sticking to his decision. While he had mistrust in relationships, he had one close friend and his family. The examiner noted that he his mood was depressed and anxious. His affect was appropriate to content. He had no suicidal or homicidal ideations. His though processes were logical and goal directed with no auditory or visual hallucinations. His insight and judgment were intact. In March 2013, the Veteran underwent another VA examination to identify the nature and severity of any psychiatric disorder. After identifying diagnoses of MDD and Anxiety Disorder (NOS), the provider assigned a GAF score of 52. During the examination, the Veteran reported that, "he has a number of successful friendships and report that 2 of these friends have been in his life since high school. The Veteran reports he has not experienced any significant impairment in social skills and feels that his social skills are intact and readily applicable in his daily life." During the examination, the Veteran reported that he continued to meet with Dr. D (biweekly) and that, "he has found this to be of significant therapeutic benefit in terms of symptom management." Ultimately, the VA provider opined that the Veteran's demonstrated psychiatric symptoms aligned with, "Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation." At this examination, the Veteran reported, "seeking treatment in 2005 was after a result of his experiencing active suicidal ideations and making what he describes as benign suicide attempt." During the March 2013 VA examination, the Veteran denied any current or recent suicidal ideations. The Veteran reported that, "he had experienced passive suicidal ideations approximately 3 times in the distant past." (Emphasis added). In September 2014, the Veteran's former representative submitted a brief on behalf of his client at that time. The former representative believed that two facets of the March 2013 C&P examination warrant a 70 percent disability rating: 1) "a (GAF) score of 52 saying 'this assessed value is based on the veteran's reporting a moderate level of impairment in his daily functioning related to identified psychiatric symptoms.' The veteran admitted he has suicidal ideation." and 2) "the veteran endorsed experiencing symptoms consistent with full range of criteria for diagnosis of major depressive disorder with low mood, low energy, anhedonia, self-depreciating ideation, appetite changes, and history of experiencing suicidal ideations." In August 2016, VA treatment notes (covering June 2007 thru March 2016) were associated with the Veteran's claims file; pursuant to the Board's March 2016 remand directives, the RO obtained this medical evidence for Board consideration. The Board has thoroughly reviewed the evidence in the Veteran's claims file, and it concludes that the 50 percent rating is appropriate for the Veteran's service-connected MDD. While the Veteran's recorded GAF scores are consistent with moderate to serious symptoms, the weight of the evidence is against a finding that the Veteran service connected acquired psychiatric disorder is manifested by symptoms consistent with total occupational and social impairment with deficiencies in most areas as contemplated by a higher evaluation. Notably, the March 2013 examination report notes that the Veteran did not have obsessional rituals which interfere with routine activities; speech that was 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); or an inability to establish and maintain effective relations as contemplated by a higher evaluation. The Veteran's symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, and disturbances of motivation and mood are contemplated by the currently assigned 50 percent evaluation. In making this decision, the Board has considered the Veteran's report of a history of suicidal ideation. However, as noted in the March 2013 examination report, this history of suicidal ideation predates the current appeal period with the most recent active suicidal ideation occurring in 2004. Review of the June 2007 thru March 2016 VA treatment notes encounters multiple instances of the word "suicide." However, most of the suicide notations pertain to an in-service (2004) attempt made with cuticle scissors, which the Veteran describes as "benign." See March 2013 VA Examination. While a March 12, 2015 social worker noted that the Veteran endorsed a current passive suicidal ideation and hopelessness as the Veteran reported "I want peace, all I see is despair. Death is the only way out." It was noted that he denied homicidal and suicidal ideations. During a later visit with a psychiatrist that same day, the Veteran rescinded his comment regarding current suicidal ideations. The psychiatrist felt that the Veteran was not a danger to himself or others and could be discharged. A subsequent psychology note dated the next day (March 13, 2015), the Veteran expressed grief over the death of his father and more recently, his cat. He reported depression, social withdrawal, and low self-esteem. Mental status examination revealed that he was tearful and sad. His mood was depressed and anxious. His affect was appropriate to content with no suicidal or homicidal ideation. His thought processes were logical and goal directed with no hallucinations. His insight and judgment were intact. Despite, the one instance of reported passive suicidal thoughts in March 2015, the Board concludes that the weight of the evidence is against a finding that the Veteran acquired psychiatric disorder is manifested occupational and social impairment with deficiencies in most areas. With respect to his current level of functioning, the March 2013 VA examiner noted that the Veteran "as not experienced any significant impairment in social skills and feels that his social skills are intact and readily applicable in his daily life." Similarly, subsequent post service VA outpatient treatment records do not show that the Veteran's acquired psychiatric disability was consistent with occupational and social impairment with deficiencies in most areas. On the contrary, in March 2016 the Veteran continued to report depression, social withdrawal, fatigue, loss of some interests, low motivation, low self-esteem, and difficulty sticking to his decision. However, it was noted that his appetite and sleep were not impaired. Despite his symptoms, he was able to work as a security guard. With respect to social interactions, the Veteran lived with his closest friend's family. While an earlier treatment record in September 2015 noted that his mood was depressed and anxious, in March 2016, the treating provider noted that the Veteran was cooperative and open with a euthymic mood and an affect appropriate to content. He had no suicidal or homicidal ideations. His thought processes were logical and goal directed with no auditory or visual hallucinations. Another treatment record also dated in March 2016, notes that the Veteran expressed feeling more hopeful about his relationships and enjoyed some friendships at work. In summary, consideration of the above psychiatric symptoms and circumstances are most consistent with occupational and social impairment with reduced reliability and productivity and that occupational and social impairment with deficiencies in most areas is not shown. This fully supports 50 percent rating for the time period between January 2, 2013 and present. See 38 C.F.R. § 4.130. The Board has considered the above medical and lay evidence in its entirety, and the evidence of record does not provide a basis for assigning a different (staged) rating during the claim period. See Hart, 21 Vet. App. at 509-10; Fenderson, 12 Vet. App. at 126; see also Mauerhan, 16 Vet. App. 436 (stating that the rating criteria provide guidance as to the severity of symptoms contemplated for each rating; they are not all-encompassing or an exhaustive list). The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 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). IV. PTSD, Service Connection In his January 2013 Statement in Support of Claim, the Veteran initiates his PTSD claim to entitlement for service connection. Therein, the Veteran posits that, "I have been experiencing PTSD on top of depression, which has from time to time interfered with daily life. The constant mood swings and images from the time of war have made it hard to sleep. Finding joy even harder and pleasure from favorite past times. PTSD has also made it hard for me to maintain a relationship with constant images of death even with family who I have kept a distance so they wouldn't know who damaged I've gotten. I have sought help with PTSD through the VA hospital psychiatric ward locate at Woodland Ave, Philadelphia." (sic) Service connection for PTSD has unique evidentiary requirements. It generally requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a) (i.e., DSM-IV or DSM-5); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304 (f); see also Cohen v. Brown, 10 Vet. App. 128 (1997). Before turning to the evidence, the Board notes that the Veteran is in receipt of a 50 percent disability rating for MDD. Consideration of a higher rating for that disability was the subject of the preceding sections of this opinion. The 50 percent rating (for MDD) was based on symptoms to include depression, relationship issues, and anxiety. As such, even if entitlement to service connection were found for PTSD, evaluation of the same manifestations of his depression under a different diagnosis (PTSD) is to be avoided. 38 C.F.R. § 4.14. To do so would be pyramiding ratings. In January 2013, the Veteran underwent a VA examination to determine the nature and etiology of any currently endured psychiatric condition. The VA provider assigned diagnoses of Major Depressive Disorder and Anxiety Disorder, not otherwise specified (NOS). The Veteran was not assigned a PTSD diagnosis. Within the examination report, the VA provider opined that, "(t)he veteran also provided evidence indicating that at present he is experiencing a mild level of impairment in daily functioning related to the identified symptoms of anxiety disorder. However the veteran symptoms do not currently meet the full diagnostic criteria for any specific anxiety disorder including claimed posttraumatic stress disorder. The veteran's reported symptoms did meet certain criteria but did not meet the full series of criteria necessary for a diagnosis of posttraumatic stress disorder according to the DSM-IV manual." During the January 2013 VA examination, the Veteran identified three stressor incidents. Excerpts from those incident reports include: 1) "He reports he became extremely distressed when he recognized that it was real after viewing footage from New York, Pentagon in Washington DC and Shanksvill, Pennsylvania plane crash." 2) The Veteran describes an anxiety attack / panic attack aboard a Navy vessel. The VA provider commented that, "He has not had anxiety or panic attacks since that time and was told by the psychiatrist that the panic attack may have been prompted by his experiencing increasing level of depression and discontent with shipboard life." and 3) "(t)he veteran reports when their warnings were not heeded he contacted his superior officer to get permission to fire if the MiGs violated a certain perimeter of air space around the Nimitz. The Veteran reports that while they were waiting there were a lot of tense moments wondering whether the 2 MIGs () were inbound." (sic). The VA provider determined that the stressor incidents provided did not satisfy the DSM-IV criteria for a PTSD diagnosis. See 38 C.F.R. § 4.130, Diagnostic Code 9411. In August 2016, VA treatment notes, covering June 2007 thru March 2016, were associated with the Veteran's claims file. Pursuant to the Board's March 2016 remand directives, the RO obtained this medical evidence for Board consideration. Within these notes, in June 2008, Dr. D assigned a diagnosis of depression secondary to PTSD. She also assigned a GAF score of 50. Dr. D noted that, "Pt. suffers from guilt because of his role in killing hundreds of innocent people which was justified under the fabric of war. He no longer works with computers and is depressed and anxious about his role in the Gulf war. He also suffers from low self-esteem due to childhood trauma issues and because of his sexual identity. Although he 'was not asked and did not tell' he was singled out and sexually harassed for being gay. Pt. is a sensitive young man who is suffering from PTSD and is experiencing difficulties with readjustment to his civilian life. At this time he does not want meds, but does want psychiatric treatment." As noted above, the Veteran's military personnel records are silent for any combat medals or any foreign service. His seventeen months of sea service included, service on the USS Carl Vinson in late 2001 and a WESTPAC deployment on the USS Nimitz. Also within the VA treatment notes (associated with Veteran's claims file in August 2016) was the May 2012 BHS MHC intake evaluation. Therein, PTSD and MDD diagnoses were identified from the patient/Veteran's history. No GAF score was assigned. The VA provider supplied the following commentary, "(p)atient is a 30 y.o. SWM, hx PTSD, Depression, who presents for initial eval to re-engage in MH care. Patient was seen a few years ago in therapy by Dr. (D), but states that he has a pattern of withdrawing 'when the walls start to come down. It gets uncomfortable,' and so left tx. States he has noticed his mood is progressively worsening. Having significant problems w/ mood lability and is interfering w/ his concentration, social life, school. States he will switch from feeling good, to feeling depressed or irritable suddenly. Notes it may last for hours to a day. Is not sustained low or irritable mood. Does report there are several triggers for the switch in mood, such as an intrusive memory about his past traumatic experiences, a reflection on his current situation, etc. Denies any SI/HI at all. Denies any problems w/ sleep, denies any panic attacks. Denies any symptoms of mania/hypomania at present or in the past. Denies any AVH, no delusions." During this VA treatment report, a history of military sexual trauma was identified, "sexual harassment by another soldier in the military-posted many topless men photos on his rack once." As noted earlier, the requisite, first element of an entitlement to service-connection claim is the existence of a current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Here, the preponderance of the probative evidence indicates that the Veteran currently endures the symptoms of arising from MDD. Importantly, the latest VA examination report conclusively found that the Veteran did not satisfy the DSM-IV criteria for a PTSD diagnosis. See March 5, 2013 C&P Examination Report. The Board finds that the conclusion reached by the 2013 examination outweigh the outpatient treatment records as the examination report is more thorough and provides a detailed rationale for why a diagnosis of PTSD is not warranted discussing each of the elements necessary to establish a diagnosis of PTSD according to the appropriate DSM criteria. As the preponderance of the credible evidence is against the Veteran's entitlement claim, the Board finds that an award of service connection for PTSD is unwarranted. Service connection for PTSD is denied. In denying the Veteran's claim for service connection for PTSD, the Board acknowledges that his current psychiatric disorder (MDD) has been attributed to service and rated as 50 percent disability. This rating contemplated all of the psychiatric symptomatology shown by the Veteran. The rule against pyramiding prohibits compensating a Veteran twice for the same symptoms, regardless of diagnosis. As such, to the extent that the Veteran seeks additional compensation for PTSD when he is already compensated for his psychiatric symptomatology, and he would not be entitled to additional compensation for these same underlying symptoms if he were awarded service connection for PTSD. See 38 C.F.R. §§ 4.14, 4.25; but see Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). ORDER Entitlement to a disability rating in excess of 50 percent for a major depressive disorder with anxiety is denied. Service connection for PTSD is denied. ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs