Citation Nr: 18106966 Decision Date: 06/01/18 Archive Date: 05/31/18 DOCKET NO. 12-28 263 DATE: June 1, 2018 ORDER Entitlement to service connection to hypertension is granted. Entitlement to an initial 70 percent rating for the period prior to December 7, 2016 for posttraumatic stress disorder (PTSD) is granted. Entitlement to an initial rating in excess of 70 percent is denied. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran’s favor, the evidence of record favors a finding that the Veteran’s hypertension disability is related to his service-connected PTSD disability. 2. For the period since November 2, 2009, the impairment from the Veteran’s PTSD more nearly approximates occupational and social impairment with deficiencies in most areas. 3. The Veteran’s service-connected PTSD has not resulted in total occupational and social impairment due to 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; disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension are met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 2. For the period since November 2, 2009, the criteria for an initial 70 percent evaluation for service-connected PTSD have been met. 38 U.S.C. § 1155 (2012) 38 C.F.R. § 4.71a, Diagnostic Code 9411 (2017). 3. The criteria for an initial evaluation in excess of 70 percent for service-connected PTSD have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1968 to November 1969. These matters come before the Board of Veterans’ Appeals (Board) on appeal from January 2012 and December 2016 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In October 2016, the Board remanded these issues for additional development. In the December 2016 rating decision, the RO granted a higher initial 70 percent rating for PTSD, effective December 7, 2016. The Board notes that the increase from 30 to 70 percent for the PTSD disability did not constitute a full grant of the benefits sought. Accordingly, the issue of entitlement to an initial rating in excess of 70 percent for PTSD for the period since December 7, 2016 remains in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). The Board also notes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the U.S. Court of Appeals for Veterans Claims (“Court”) held that a TDIU claim is part of an increased rating claim when such claim is raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case, in a March 2010 correspondence, a private psychologist indicated that the Veteran was not capable of sustaining substantial gainful work activity. As a result, the Board finds that a TDIU claim has been raised by the record and the issue is added to the issues on appeal. Entitlement to service connection to hypertension Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain diseases, to include hypertension may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112 (2012); 38 C.F.R. §§ 3.307, 3.309 (2017). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden for certain chronic disabilities such as hypertension is through a demonstration of continuity of symptomatology. In relevant part, 38 U.S.C. § 1154(a) requires that the VA give “due consideration” to “all pertinent medical and lay evidence” in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.” Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency (“a legal concept determining whether testimony may be heard and considered”) and credibility (“a factual determination going to the probative value of the evidence to be made after the evidence has been admitted”). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). Under 38 C.F.R. § 3.310(a), service connection may be granted for disability that is proximately due to or the result of a service- connected disease or injury. Such permits a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation to a nonservice- connected disability by a service- connected disability. Id. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310(b). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Factual Background and Analysis The Veteran underwent a VA examination in January 2010. The diagnosis was hypertension but no etiology opinion was provided. In a February 2012 correspondence, a private physician opined that it was at least as likely as not that the Veteran’s hypertension was caused by his PTSD. The September 2016 Appellant’s Brief also submitted the article “Posttraumatic Stress Disorder and Cardiovascular Disease by Steven S. Coughlin” which indicated that individuals who had PTSD had demonstrated an increased risk of hypertension and that the reported link between PTSD and hypertension may partly account for the observed associations between PTSD and heart disease. Per the December 2016 Board remand instructions, the Veteran underwent a VA examination in December 2016. The examiner, a nurse practitioner, noted that the Veteran was diagnosed with hypertension in 1998 and was diagnosed with PTSD in 2010. The examiner also noted that she reviewed the evidence to include the article by Steven Coughlin describing the link between hypertension and PTSD. The examiner opined that it was less likely than not that the Veteran’s hypertension was proximately due to or the result of the Veteran’s service-connected PTSD. The examiner noted that insufficient evidence was found in the medical literature which confirmed chronic hypertension as being directly caused by PTSD. There was also insufficient evidence found in the medical literature to confirm that hypertension was caused by anxiety or neurosis. The examiner also noted that insufficient evidence was found in the medical literature which confirmed chronic hypertension as being directly aggravated by PTSD. There was also insufficient evidence found in the medical literature to confirm that hypertension was permanently aggravated by anxiety or neurosis. The examiner noted that while it was well known that stress could transiently elevate blood pressure in all individuals, this was a normal response and such temporary elevation did not aggravate or cause the underlying condition of hypertension. The examiner also opined that it was less likely than not that the Veteran’s hypertension was directly related to his service to include as secondary to his conceded herbicide exposure. In January 2017, the Veteran again submitted new information regarding a positive association between the development of hypertension and PTSD. The Veteran submitted multiple articles discussing medical research which found that depressive symptoms were predictive of later hypertension. After resolving all reasonable doubt in favor of the Veteran, the Board finds service connection for a hypertension disability as secondary to his service-connected PTSD disability is warranted. The Board notes that there are conflicting opinions as to whether the Veteran’s current hypertension disability is related to his service-connected PTSD disability. In a December 2016 opinion, the VA examiner opined that it was less likely than not that the Veteran’s hypertension was proximately due to, the result of or permanently aggravated by the Veteran’s service or a service-connected PTSD disability. Conversely, the February 2012 private physician indicated that there was a positive relationship between the Veteran’s hypertension and his PTSD. Significantly, in her December 2016 negative opinion, the VA examiner’s reasoning for the negative nexus was that there was insufficient evidence found in the medical literature to confirm that hypertension was caused by or aggravated by the service-connected PTSD. However, the Board notes that while the VA examiner indicated that she reviewed the medical literature of Stephen Coughlin which found a relationship between hypertension and PTSD, she did not specifically address why the medical literature was insufficient aside from noting that elevated blood pressure due to stress was a normal response and such temporary elevation did not aggravate or cause the underlying condition of hypertension. As noted above, in addition to the materials authored by Stephen Coughlin, the Veteran in January 2017 submitted additional medical literature which again noted an association between hypertension and PTSD. Additionally, while the December 2016 VA examiner specifically noted that the Veteran was diagnosed with hypertension in 1998 and was diagnosed with PTSD in 2010, a March 2010 correspondence from a private psychiatrist specifically noted that the Veteran had felt emotionally numb, had been void of feelings and had been on anti-anxiety medication since he had returned from Vietnam. The physician provided a diagnosis of chronic PTSD, delayed. On VA examination in July 2010, the VA examiner also noted that the Veteran had PTSD symptoms on and off since Vietnam. As a result, the Board finds that there is an approximate balance of positive and negative evidence regarding the question of whether the Veteran has a current hypertension disability that was caused or aggravated by his service-connected PTSD. Additionally, a remand for a new VA examination is not necessary because the evidence of record is sufficient to grant the Veteran’s claim, and a remand would only serve to unnecessarily delay final adjudication of the claim. In sum, for the reasons and bases discussed above, the Board has resolved doubt in favor of the Veteran, and service connection for hypertension as secondary to his service-connected PTSD disability is granted. See 38 U.S.C. § 5107(b). Increased Rating Laws and Regulations The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claims or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claims, in which case, the claims are denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2017). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). The Veteran’s entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2017). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the “staging” of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See also Hart v. Mansfield, 21 Vet. App. 505 (2008). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2017). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. §4.7 (2017). In this case, the Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). He is also competent to report symptoms of his PTSD. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The Veteran is competent to describe his symptoms and their effects on employment or daily activities. His statements have been consistent with the medical evidence of record, and are probative for resolving the matter on appeal. The Board will consider not only the criteria of the currently assigned diagnostic codes, but also the criteria of other potentially applicable diagnostic codes. In this case, the RO granted service connection for PTSD and assigned an initial 10 percent disability evaluation, effective November 2, 2009 under Diagnostic Code 9411. A January 2012 rating decision increased the evaluation assigned to the Veteran’s service-connected PTSD to 30 percent, effective November 2, 2009. As noted above, a December 2016 rating decision granted a higher initial 70 percent rating for PTSD, effective December 7, 2016. The Board notes that psychiatric disabilities other than eating disorders are rated pursuant to the criteria for General Rating Formula. See 38 C.F.R. § 4.130. Under the general rating formula for mental disorders, a 30 percent evaluation is assigned when the Veteran exhibits occupational and social impairment with occasional decreases 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, or mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating requires 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; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating requires 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 affected 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); and inability to establish and maintain effective relationships. A 100 percent rating is assigned when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The evidence considered in determining the level of impairment for psychiatric disorders under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the rating code. Disability ratings are assigned according to the manifestation of particular symptoms, but the use of the term “such as” in the General Rating Formula demonstrates that the symptoms after the phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Accordingly, the evidence considered in determining the level of impairment from psychiatric disorder under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in Diagnostic Code 9411. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436 (2002). When evaluating the level of disability 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 (2017). One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the “psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness.” Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). According to the DSM-IV, GAF scores ranging between 61 to 70 reflect 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 generally functioning pretty well, and has some meaningful interpersonal relationships. 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]. Scores ranging from 41 to 50 reflect 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]. 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; child frequently beats up other children, is defiant at home, and is failing at school]. VA has changed its regulations, and now requires use of DSM-5 effective August 4, 2014. Among the changes, DSM-5 eliminates the use of the GAF score in evaluation of psychiatric disorders. The change was made applicable to cases certified to the Board on or after August 4, 2014; and is not applicable to cases certified to the Board prior to that date. 79 Fed. Reg. 45093 (Aug. 4, 2014). As the Veteran’s claim was certified to the Board prior to this date, the amendment is not applicable, and as such, the DSM-IV applies to the Veteran’s claim, and it is appropriate to consider GAF scores as a factor in assessing the severity of his psychiatric disorder. Factual Background and Analysis In a March 2010 correspondence, a private psychologist noted that the Veteran had been married to his current wife since 1972 and they had 3 grown children. The physician noted that the Veteran had difficulty staying asleep as he woke up after 3 to 4 hours. He also sometimes had physical reactions such as sweating or being frightened. Almost nightly he had dreams/nightmares of his military experience. He had waves of intrusive and involuntary thoughts regarding Vietnam and had experienced flashbacks in the past. He became extremely upset around places, people and events that reminded him of the military and tried to avoid them at all costs. The Veteran had felt emotionally numb and void of feelings since his return from the military. He had difficulty trusting others, had no close friends and had rocky interpersonal relationships. He felt alienated and separate while also having a sense of doom and negativity. He had lost interest in things he had previously enjoyed including socializing and fishing. There were blanks in his memories regarding certain aspects of his traumas. He had frequent bouts of irritability and outbursts of anger which were not always related to issues at hand. His concentration was impaired and his mind wandered as he often thought about Vietnam. He was hypervigilant and had an exaggerated startle response. The physician indicated that the Veteran had severe social, personal and occupational impairment due to difficulty concentrating, generalized anxiety with occasional panic attacks, severe short-term memory loss, some long-term memory loss, flashbacks/intrusive thoughts, sleep disturbance, overwhelming feelings of anger with crying spells, withdrawal and isolation and bouts of moderately severe depression. The diagnosis was chronic, delayed PTSD. The physician assigned a GAF score of 46. The physician also noted that the Veteran was not a rehabilitation candidate nor was he capable of sustaining sustainable gainful work activity. The Veteran underwent a VA examination in July 2010. The Veteran reported problems with nightmares, feeling uptight and anxious. He did not feel like talking to anyone, was very lonely, had trouble sleeping, and felt moody and irritable. He indicated that he had nightmares once or twice a week and had flashbacks when watching news about Iraq. He lived with his wife who he had been married to since 1972 and they got along well. He was lonely, did not have any friends and did not have any hobbies as he mainly stayed at home. On examination, he was cooperative and his speech was spontaneous. He was well oriented to time, place and person. His mood was somewhat anxious. He denied suicidal ideations. His thought processes were logical, relevant and goal oriented. His memory was reasonable and his judgment, intelligence and insight were fair. He reported having problems sleeping, falling asleep and with nightmares. He was a loner and did not have any friends. He got along with his wife but the examiner noted that the Veteran’s wife complained that the Veteran did not show any feelings. The Veteran had these problems on and off since Vietnam. The examiner noted that the Veteran retired in 2007 but that his PTSD symptoms did not affect his job functioning. The diagnosis was PTSD and the examiner assessed a GAF score of 65. The Veteran underwent a VA examination in December 2016. The examiner noted that the Veteran had PTSD with anxiety and depressive symptoms. The Veteran’s level of occupational and social impairment with regards to his mental diagnosis was best summarized as occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking and/or mood. He continued to live with his wife but described their relationship as “pretty rocky because I am not always the nicest person”. He noted having daily problems with irritability and anger. His anger resulted in physical altercations with his wife where had punched her without injury. He had 3 sons that he typically saw on holiday occasions. He had a physical altercation with his one son which resulted in him breaking multiple ribs but they have since reconciled. The Veteran spent most of his days in house watching television or mowing the lawn. He liked to hunt and spend time outdoors when he could. He indicated that he did not have many close friends as most of his friends had died in the recent years. The Veteran reported that his primary effort to manage his symptoms was through avoidance of crowds or interactions with groups of people. He noted chronic problems with racing heartbeat and anxiety attacks when he got into unavoidable anxiety provoking situations. He continued to have problems with terrifying dreams as he estimated he slept about 6 hours each night. He had recurrent problems with a depressed mood a few days a week. He had lost interest in most activities that he used to enjoy. He had suicidal ideation without a plan, attempt or history of attempts. He did not have homicidal ideation. He denied hallucinations but he did have an illusory experience where he saw figures or people or movement that were not there. He did not endorse delusions. He had problems with concentration and attention. He had a bad memory for names of people and places. On examination, he presented with excellent grooming and hygiene. He was alert, cooperative and polite. His speech was appropriate. He was oriented to all spheres with grossly intact memory, judgment, attention, concentration and insight observed. He also had the noted problems with memory, concentration and attention. His affect was blunted with brief tearfulness at a couple of points. His mood was depressed. His thought process was fluid, reality based, logical and goal oriented. He neither endorsed nor demonstrated evidence of current delusions, hallucinations, or suicidal or homicidal ideation but acknowledged a history of recurrent suicidal ideation without plan or intent. The examiner noted moderate to mostly severe distress from PTSD symptoms over the past month. 1. Entitlement to a rating in excess of 30 percent for the period prior to December 7, 2016 for PTSD Under the circumstances of this case, and with resolution of all reasonable doubt in the Veteran’s favor, the Board concludes that an initial 70 percent disability rating is warranted for PTSD for the period prior to December 7, 2016. For the period since November 7, 2009, the Board finds that the Veteran’s PTSD symptoms more nearly approximate a degree of occupational and social impairment consistent with deficiencies in most areas. Overall, the Veteran had severe social, personal and occupational impairment due to difficulty concentrating, isolation, generalized anxiety with occasional panic attacks, severe short-term memory loss, some long-term memory loss, flashbacks/intrusive thoughts, sleep disturbance, withdrawal and isolation and bouts of moderately severe depression. The Veteran has also had GAF scores ranging from 45 to 65. Notably, GAF scores ranging between 41-50 are largely consistent with the assignment of a 70 percent disability rating. While the July 2010 VA examiner assigned a GAF score of 65, it was also noted that the Veteran was lonely, did not have any friends, did not have any hobbies, mainly stayed at home and that his mood was somewhat anxious. Accordingly, this evidence and the evidence currently of record can be read as showing deficiencies in most of the areas listed under the criteria for a 70 percent rating. As a result, the Board finds that an initial 70 percent rating for PTSD for the period prior to December 7, 2016 is warranted. The Board acknowledges that the results of the private evaluation and VA examination and the symptoms described in the mental health treatment notes do not indicate that the Veteran experiences all of the symptoms associated with a 70 percent disability rating for PTSD. However, the Court has held that the symptoms enumerated under the schedule for rating mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular disability rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, a finding that there are deficiencies in most areas is sufficient to warrant a 70 percent disability rating, even though all the specific symptoms listed for a 70 percent rating are not manifested. Thus, for all the foregoing reasons, the Board finds that an initial 70 percent rating for PTSD for the period prior to December 7, 2016 is warranted. 2. Entitlement to an initial rating in excess of 70 percent for PTSD After reviewing evidence of record as a whole, to include the Veteran’s private treatment reports, his ongoing VA treatment reports, his VA examination reports, and his credible lay statements, the Board finds that the assignment of a disability rating greater than 70 percent for the Veteran’s service-connected PTSD is not warranted. The Board notes that while a private psychologist in a March 2010 correspondence indicated that the Veteran was not capable of sustaining substantial gainful work activity, at no point did any VA examiner or treating physician find that the Veteran’s PTSD caused total occupational and social impairment, as is required for the assignment of a 100 percent rating. In not granting a 100 percent schedular rating for the Veteran’s service-connected PTSD, the Board is not minimizing the severity of the Veteran’s symptoms. The Board notes that the evidence demonstrates that the Veteran experienced significant social impairment as a result of his PTSD. Notably, the Veteran reportedly has no real close friends and now had a “rocky relationship” with his longtime wife. However, as noted above, the maximum rating of 100 percent requires total occupational and social impairment. The private records, VA treatment records and VA examinations show no gross impairment in thought processes or communication, grossly inappropriate behavior, persistent danger of hurting self or others, disorientation to time or place, or memory loss for names of own relatives, own occupation, or own name. The Board also notes that the December 2016 VA examiner indicated that the Veteran experienced decreased interest in pleasurable activities, suicidal ideation, depressed mood, had illusory experiences where he saw figures or people or movement that were not there, had problems with concentration and attention and had a bad memory for names of people and places. However, the examiner also noted that the Veteran’s attention was intact and he was oriented. The Veteran also did not have inappropriate behavior and did not have obsessive or ritualistic behavior. The Board also notes that the December 2016 VA examiner specifically described the Veteran’s symptoms as occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking and/or mood, which fits squarely for the criteria for a 70 percent evaluation under the General Rating Formula. Thus, for all the foregoing reasons, the Board finds that an initial rating of 70 percent, but no higher, for PTSD is warranted, effective November 2, 2009. REASONS FOR REMAND The Board finds that more development is necessary prior to final adjudication of the entitlement to a TDIU claim remaining on appeal. As discussed above, the Board has granted the Veteran’s claim for service connection for hypertension in this decision. The agency of original jurisdiction (AOJ) will assign a disability rating for this disability in the first instance. Clearly, the AOJ has not had the opportunity to consider the Veteran’s TDIU claim in light of the Board’s grant of service connection for hypertension. The matter is REMANDED for the following action: Following the implementation of the new disability rating assignment for hypertension and any other development, the Veteran’s TDIU claim remaining on appeal must be readjudicated. If any benefit sought on appeal remains denied, the Veteran and his representative must be furnished a supplemental statement of the case and be   given the opportunity to respond thereto. The appeal must then be returned to the Board for appellate review. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD James A. DeFrank, Counsel