Citation Nr: 18141434 Decision Date: 10/10/18 Archive Date: 10/10/18 DOCKET NO. 15-35 190A DATE: October 10, 2018 ORDER Entitlement to service connection for an eye disability is granted. Entitlement to service connection for hyposmia is denied. Entitlement to service connection for headaches is granted. An initial compensable disability rating for maxillary sinusitis prior to July 26, 2016, is denied; a 30 percent disability rating for maxillary sinusitis from July 26, 2016, is granted. Entitlement to an initial compensable disability rating for erectile dysfunction is denied. Entitlement to an initial disability rating in excess of 50 percent for post-traumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for gum disease is remanded. FINDINGS OF FACT 1. The Veteran’s eye disability is etiologically related to his service. 2. The Veteran’s diagnosis of hyposmia has resulted only in loss of sense of smell; the Veteran is already service connected for loss of sense of smell as a symptom of his service-connected sinusitis. 3. The Veteran’s headaches are a symptom of his service-connected sinusitis. 4. Prior to July 26, 2016, the record does not reflect one or two incapacitating episodes per year of sinusitis requiring prolonged antibiotic treatment nor at least three non-incapacitating episodes per year of sinusitis. 5. From July 26, 2016, the record reflects seven or more non-incapacitating episodes per year of sinusitis. 6. The Veteran’s erectile dysfunction has been productive of loss of erectile power, but not deformity of the penis. 7. Throughout the appeal period, the Veteran’s PTSD was manifested by occupational and social impairment with reduced reliability and productivity, but not occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. The criteria for service connection for an eye disability have been met. 38 U.S.C. §§ 1110, 5107(b) (West 2012); 38 C.F.R. § 3.303 (2017). 2. The criteria for service connection for hyposmia have not been met. 38 U.S.C. §§ 1110, 5107(b) (West 2012); 38 C.F.R. §§ 3.303, 3.317 (2017). 3. The criteria for service connection for headaches as secondary to the service-connected sinusitis have been met. 38 U.S.C. §§ 1110, 5107(b) (West 2012); 38 C.F.R. §§ 3.303, 3.310 (2017). 4. Prior to July 26, 2016, the criteria for an initial compensable rating for sinusitis are not met. 38 U.S.C. § 1155 (West 2012); 38 C.F.R. §§ 3.321, 4.1, 4.7, 4.97, Diagnostic Code 6513 (2017). 5. From July 26, 2016, the criteria for a 30 percent rating for sinusitis are met. 38 U.S.C. § 1155 (West 2012); 38 C.F.R. §§ 3.321, 4.1, 4.7, 4.97, Diagnostic Code 6513 (2017). 6. The criteria for an initial compensable rating for erectile dysfunction have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.115b, Diagnostic Code 7522 (2017). 7. Throughout the appeal period, the criteria for a disability rating in excess of 50 percent for service-connected PTSD have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.7, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the U.S. Army from March 1988 to December 1991, from May 2005 to September 2006, and from October 2011 to December 2012. The Board notes that VA received the Veteran’s opt-in form for the Rapid Appeals Modernization Program (RAMP) in August 2018. However, as the Veteran’s claims are already before the Board, these claims are no longer eligible for RAMP. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Entitlement to service connection requires: (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the in-service disease or injury and the current disability. 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); Allen v. Brown, 8 Vet. App. 374 (1995). In order to prevail on the issue of secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). 1. Entitlement to service connection for an eye disability The Veteran contends that he has an eye disability, red eye, related to sandstorms in Desert Storm. In July 2016, the Veteran was afforded a VA examination for eye conditions, and the examiner indicated a diagnosis for pterygium of both eyes. As such, a current diagnosis is established. As the Veteran served in Desert Storm, his reports of sand and wind causing eye redness are consistent with his service and as such, the Board finds his assertions to be credible. As to a nexus, the July 2016 VA examiner explained that pterygia of both eyes causes eye irritation and eye redness without impact on the Veteran’s visual acuity. The examiner opined that the condition was at least as likely as not incurred in or caused by service. The examiner reasoned that the Veteran’s disability pattern fits a diagnosable chronic multi-symptom illness with a partially explained etiology. The examiner explained that pterygia typically develops following a history of exposure to irritants (eg. sand, wind, and sun), which the Veteran was exposed to during his service in the Gulf War. As the examiner physically examined the Veteran, considered the Veteran’s symptoms, history and lay statements, and provided a reasoned opinion, the Board finds the opinion probative. Given the probative opinion, a nexus has been established, and the criteria for service connection for an eye disability have been met. Accordingly, the appeal for service connection for an eye disability is granted. 2. Entitlement to service connection for hyposmia The Veteran is seeking service connection for a nose condition, which he has indicated as loss of sense of smell due to environmental conditions during service. The Veteran contends that he should be granted service connection for this condition under 38 C.F.R. § 3.317 for undiagnosed illnesses due to his service in the Gulf War. However, the record reflects that the Veteran’s hyposmia has only resulted in loss of sense of smell and that he is already service connected for loss of sense of smell as a symptom of his sinusitis. The July 2017 sinus conditions Disability Benefits Questionnaire (DBQ) lists loss of sense of smell as a symptom of the Veteran’s sinusitis and reflects his reports dating the symptom to his service. The RO has also explicitly recognized the Veteran’s loss of sense of smell as a symptom of his sinusitis as he is service connected for sinusitis, claimed as loss of sense of smell. Additionally, in July 2014, the Veteran underwent a VA Gulf War General Medical examination, and the examiner provided a diagnosis for hyposmia, which is a nasal condition. The examiner indicated that the condition is a symptom of an undiagnosed illness and indicated to see the DBQ for loss of sense of smell. The loss of sense of smell DBQ lists a current diagnosis for hyposmia. The only symptom indicated by the examiner in the DBQ is loss of sense of smell. The DBQ also reflects the Veteran’s report of decreased smell since returning from Desert Storm. The examiner also noted the Veteran’s reports that while serving in the Gulf, he was exposed to smoke/fumes and a significant number of sand storms and did not have a mask or other protection for the nose during these exposures. Similarly, the Veteran has only indicated that his hyposmia causes loss of sense of smell. In a written statement received by VA in October 2014, the Veteran stated that he disagrees with the decision denying him service connection for hyposmia because his smell is gone. He stated that the condition is due to sand going up his nose during Desert Storm and other deployments. In the October 2015 notice of disagreement, he stated that his nose condition has worsened and that he cannot smell anything in both nostrils. He stated that he has to breathe very heavily in order to smell something. He stated that he was diagnosed with hyposmia and the DBQ reflects the same results. He stated that he served in Desert Storm where there were numerous sand storms and that he did not have proper equipment to stop the sand from coming into the nose. As the Veteran is already service connected for the symptom of loss of sense of smell, a separate claim for the same symptom cannot be sustained. The Board explains that a veteran is service connected for symptoms, not diagnoses, and a Veteran cannot be compensated for the same symptomology more than once, as such would constitute pyramiding in violation of 38 C.F.R. § 4.14. The medical evidence does not indicate any additional symptoms of the Veteran’s hyposmia other than loss of sense of smell. As such, the appeal for hyposmia, indicated as loss of sense of smell, is denied. However, as will be discussed later in this decision in regard to the Veteran’s claim for an increased rating for sinusitis, the Board has considered the applicability of an extraschedular rating for the Veteran’s symptom of loss of sense of smell. 3. Entitlement to service connection for headaches The Veteran contends that he has headaches, which he has linked to his active service. As to a current diagnosis, the Veteran was afforded a VA headaches examination in June 2016, and the examiner indicated a diagnosis for headaches. As such, a current diagnosis is established. While the Veteran has linked his headaches to his service, the Board notes that the Veteran’s service treatment records (STRs) are silent for any complaints or treatment for headaches. Nor is there a medical opinion of record linking the Veteran’s headaches to his service. However, having reviewed the evidence of record, the Board finds that service connection for headaches is warranted as secondary to the Veteran’s service-connected sinusitis. The Veteran was afforded a VA sinus conditions examination in July 2017, and the examiner indicated that headaches are a symptom of the Veteran’s maxillary sinusitis. As the sinus examination was adequate, this opinion is sufficient to establish a medical link between the Veteran’s headaches and his service-connected sinusitis. As such, service connection for headaches is granted. Increased Rating The Veteran’s entire history is reviewed when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). At the time of an initial rating, consideration of the appropriateness of a staged rating is also required. Fenderson v. West, 12 Vet. App. 119 (1999). Disability evaluations are determined by comparing a Veteran’s symptoms with criteria set forth in VA’s Schedule for Rating Disabilities, which are based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher of the two evaluations is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 1. Entitlement to an initial compensable disability rating for maxillary sinusitis The Veteran has been assigned a noncompensable rating for sinusitis under Diagnostic Code 6513 for sinusitis, maxillary, chronic. 38 C.F.R. § 4.97. Chronic maxillary sinusitis is rated under the General Rating Formula for Sinusitis. Under the General Rating Formula, a noncompensable rating is assigned for a condition detected by x-ray only. A 10 percent evaluation is assigned for one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; three to six non-capacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent evaluation is assigned for three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-capacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 50 percent evaluation is assigned following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. 38 C.F.R. § 4.97. A Note to the General Rating Formula for Sinusitis indicates that an incapacitating episode of sinusitis means one that required bed rest and treatment by a physician. 38 C.F.R. § 4.97, Diagnostic Codes 6510-6514, Note. Having reviewed the evidence of record, the Board finds that staged ratings are warranted. Fenderson v. West, 12 Vet. App. at 119. Specifically, staged ratings are warranted prior to and from July 26, 2016, one year prior to the date of the Veteran’s most recent VA examination for sinus conditions. Prior to July 26, 2016 The evidence during this period of the appeal includes a June 2015 radiology report from SXR Medical, which establishes a diagnosis for sinusitis. In June 2015, the Veteran underwent a VA examination for sinus conditions. The examiner indicated that the Veteran has chronic maxillary sinusitis and allergic rhinitis. The Board notes that the Veteran is also service connected and separately rated for allergic rhinitis. As that issue is not on appeal, the Board will not discuss findings pertaining to the Veteran’s rhinitis. As to findings, signs or symptoms attributable to chronic sinusitis, the June 2015 VA examiner indicated that the Veteran has pain and tenderness of affected sinus. The examiner indicated that there had been no non-incapacitating episodes of sinusitis characterized by headaches, pain and purulent discharge or crusting in the past 12 months. The examiner indicated that there had been no incapacitating episodes of sinusitis requiring prolonged (4 to 6 weeks) of antibiotics treatment in the past 12 months. The examiner also indicated that the Veteran has not had sinus surgery. The examiner indicated that there are no larynx or pharynx conditions. The examiner also indicated that the Veteran does not have a deviated nasal septum due to trauma and no benign or malignant neoplasm or metastases related. As to other pertinent physical findings, complications, conditions, signs or symptoms related to the condition, the examiner indicated that the Veteran has a nodule on the left septum and swollen turbinates. The examiner indicated that there is no sinus tenderness or associated scars. As to the Veteran’s nose, the examiner indicated the following: there is no loss of part of the nose or other scars of the nose exposing both nasal passages; no loss of part of the nose or other scars causing loss of part of one ala; no loss of part of the nose or other scars causing other obvious disfigurement; and no biopsy of the larynx or pharynx. As to lay statements, the Veteran stated in his January 2016 notice of disagreement that chronic sinusitis is a constant problem with his nostrils. He stated that the condition is a chronic problem in his life and needs to be examined again soon. The Board notes that this statement was made prior to the July 2017 VA examination. As such, subsequent to this correspondence, the Veteran was afforded a new VA examination regarding his sinus condition. In a March 2016 written statement, he stated that he cannot smell anything out of his nose. Having reviewed the evidence of record, the Board finds that a noncompensable rating is warranted during this period of the appeal. The evidence reflects a diagnosis per x-ray, which is provided for in a noncompensable rating. However, a compensable rating of 10 percent would require at least one incapacitating episode or three non-incapacitating episodes due to sinusitis in a 12-month time period. The medical evidence during this period of the appeal indicates that the Veteran did not have any incapacitating or non-incapacitating episodes due to his sinusitis. Nor has the Veteran indicated as such. As such, the Board finds that the evidence does not support a higher rating of 10 or 30 percent during this period of the appeal based on incapacitating or non-incapacitating episodes. Nor is a 50 percent rating warranted. The medical evidence during this period of the appeal indicates that the Veteran has not had any surgery for his sinus condition. Thus, it follows that the record does not reflect that the Veteran has had radical surgery or repeated surgeries for his sinusitis. While the medical evidence during this period of the appeal indicates that the Veteran had pain or tenderness of affected sinuses, there is no indication that the symptoms were near constant and followed repeated surgeries. The evidence also reflects that the Veteran did not have headaches, purulent discharge or crusting during this period of the appeal. As a 50 percent rating requires radical surgery or specific symptoms following repeated surgeries and the Veteran has not had any surgery for his sinuses, a 50 percent rating is not warranted. While a higher rating is not warranted under the General Rating Formula for Sinusitis, the Board has considered whether a higher rating is warranted under other potentially applicable diagnostic codes regarding disorders of the nose and throat. However, the medical evidence during this period of the appeal indicates that the Veteran does not have a deviated nasal septum, scars, or loss of part of the nose. Nor has the Veteran alleged any such conditions. As such, a higher rating cannot be granted under the diagnostic codes for those conditions or for scars. 38 C.F.R. § 4.97, Diagnostic Codes 6502 and 6504; 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805. As noted, while the Veteran also has rhinitis, he is already service connected for this condition, and that rating is not on appeal. Given the evidence, the Board finds that a noncompensable rating is warranted for the Veteran’s sinusitis during the appeal period prior to July 26, 2016. From July 26, 2016 In July 2017, the Veteran underwent another VA examination for sinus conditions. The examination report indicates that the Veteran has chronic maxillary sinusitis and allergic rhinitis. As to findings, signs or symptoms attributable to chronic sinusitis, the examiner indicated that the Veteran has episodes of sinusitis, headaches, pain of affected sinus, tenderness of affected sinus, and also describes intermittent vertigo on wakening in the morning. The examiner indicated that the Veteran had seven or more non-incapacitating episodes of sinusitis characterized by headaches, pain and purulent discharge or crusting in the past 12 months. The examiner indicated that the Veteran had not had incapacitating episodes of sinusitis requiring prolonged (4 to 6 weeks) of antibiotics treatment in the past 12 months. As to other pertinent physical findings, complications, conditions, signs or symptoms related to the condition, the examiner indicated that the Veteran has a nodule on the left septum and swollen turbinates. The examiner indicated that there is no sinus tenderness or associated scars. As to the Veteran’s nose, the examiner indicated the following: there is no loss of part of the nose or other scars of the nose exposing both nasal passages; no loss of part of the nose or other scars causing loss of part of one ala; no loss of part of the nose or other scars causing other obvious disfigurement; and no biopsy of the larynx or pharynx. Having reviewed the evidence of record, the Board finds that a 30 percent rating is warranted from July 26, 2016. The July 2017 examiner indicated that the Veteran had seven or more non-incapacitating episodes due to sinusitis, which is sufficient to meet the criteria for a 30 percent rating. As the examiner indicated that the symptoms had occurred in the previous 12 months, the Board finds that the record supports an increase in the severity of the Veteran’s sinusitis symptoms at least one year prior to the July 2017 VA examination. As such, the Board finds that the evidence supports a rating of 30 percent from July 26, 2016. However, a higher rating of 50 percent is not warranted. The medical evidence during this period of the appeal also indicates that the Veteran has not had any surgery for his sinus condition. While headaches, pain or tenderness of affected sinuses, and purulent discharge or crusting were noted, they were not indicated to be near constant and following repeated surgeries. As discussed, a 50 percent rating requires radical surgery or specific symptoms following repeated surgeries. As the Veteran has not had any surgery for his sinuses, a 50 percent rating is not warranted. The Board has again considered whether a higher rating is warranted under other potentially applicable diagnostic codes regarding disorders of the nose and throat. However, the medical evidence during this period of the appeal also indicates that the Veteran does not have a deviated nasal septum, scars, or loss of part of the nose. Nor has the Veteran alleged any such conditions. As such, a higher rating cannot be granted under the diagnostic codes for those conditions or for scars. 38 C.F.R. § 4.97, Diagnostic Codes 6502 and 6504; 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805. The Board reiterates that while the Veteran also has rhinitis, he is already service connected for this condition, and that rating is not on appeal. Given the evidence, the Board finds that a 30 percent rating is warranted for the Veteran’s sinusitis during the appeal period from July 26, 2016. Extraschedular Consideration Additionally, as to the Veteran’s symptom of loss of smell, the Board finds that the issue of an extra-schedular rating has been raised under 38 C.F.R. § 3.321(b)(1) for exceptional cases where schedular evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Consideration of referral for an extraschedular rating requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008). First, as a threshold issue, the Board must determine whether a veteran’s disability picture is contemplated by the rating schedule. If the veteran’s disability level and symptomatology are not contemplated by the rating schedule, the Board must turn to the second step of the inquiry. The second step of the inquiry is whether the veteran’s exceptional disability picture exhibits other related factors, such as those provided by the regulation as “governing norms.” These include marked interference with employment and frequent periods of hospitalization. Third, if the first and second steps are met, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran’s disability picture requires the assignment of an extraschedular rating. As discussed, loss of sense of smell is listed as a symptom of the Veteran’s sinusitis. Loss of sense of smell is not contemplated in the General Rating Formula for sinusitis. As such, the Board finds that the threshold issue for extra-schedular consideration has been met. As the threshold issue is applicable, the next step is to determine whether the Veteran’s exceptional disability picture exhibits other related factors, such as those provided by the regulation as “governing norms.” As noted, these include marked interference with employment or frequent periods of hospitalization. Here, the Veteran has not indicated and the record does not suggest that his sinusitis has interfered with his employment. Nor does the record reflect any hospitalization due to the Veteran’s sinusitis. The July 2017 VA examination report reflects seven or more non-incapacitating episodes due to symptoms such as headaches and pain. However, the examiner did not indicate any periods of hospitalization. Nor has the Veteran alleged as such. Lacking evidence of marked interference with employment or frequent periods of hospitalization, the Board finds that the second element of extra-schedular consideration has not been met. As such, the criteria for referral for an assignment of an extraschedular rating are not met. 38 C.F.R. § 3.321(b)(1). 2. Entitlement to an initial compensable disability rating for erectile dysfunction The Veteran is currently in receipt of a noncompensable disability rating for erectile dysfunction under Diagnostic Code 7522. 38 C.F.R. § 4.115b. Under Diagnostic Code 7522, a 20 percent rating is warranted for deformity of the penis with loss of erectile power. Id. A footnote to Diagnostic Code 7522 indicates that the disability is to be reviewed for entitlement to special monthly compensation for loss of use of a creative organ under 38 C.F.R. § 3.350(a). No other evaluation is provided for under this diagnostic code. Two requirements must be met before a 20 percent evaluation can be assigned: (1) the deformity must be evident; and (2) the deformity must be accompanied by loss of erectile power. Simply stated, the condition is not compensable in the absence of penile deformity. VBA Manual M21-1, III.iv.4.I.3.b. Here, the record does not reflect that the Veteran has penile deformity. The Veteran underwent VA examinations for the reproductive organ in January 2016 and again in July 2017. Each examination report indicates that the Veteran has erectile dysfunction and is not able to achieve an erection sufficient for penetration and ejaculation without medication. Each examination report also indicates that the Veteran has not had had an orchiectomy and does not have renal dysfunction due to erectile dysfunction or a voiding dysfunction. Each examination report indicates that the Veteran’s erectile dysfunction is not at least as likely as not attributable to a service-connected disability. Each examination report indicates that the Veteran does not have retrograde ejaculation or a history of chronic epididymitis, epididymo-orchitis or prostatitis. Each examination report also indicates that there is no benign or malignant neoplasm or metastases and no associated scars. Neither examination report indicates that the Veteran has penile deformity. The Board acknowledges that the Veteran’s penis was not physically examined during these examinations. However, the Veteran has not indicated or suggested that he has penile deformity. In various written statements, the Veteran has stated and reiterated that he is unable to achieve or maintain an erection. See January 2016 Notice of Disagreement; April 2016 Form 9; and July 2017 Statement in Support of Claim. He has stated and reiterated that he cannot perform sexually without medication. He has also stated and reiterated that his erectile dysfunction has caused relationship and intimacy problems for him with various women. He has not stated that he has penile deformity. Absent evidence of penile deformity, a 20 percent rating for erectile dysfunction is not warranted. Nor is a separate rating warranted for related conditions as the medical evidence is consistent that the Veteran’s erectile dysfunction is not related to a service-connected disability and that he does not have any additional associated conditions due to his erectile dysfunction. In addition, the Veteran is already in receipt of special monthly compensation for loss of use of a creative organ, effective from April 30, 2015, under 38 U.S.C. § 1114, subsection (k) and 38 C.F.R. § 3.350(a). 3. Entitlement to an initial disability rating in excess of 50 percent for PTSD The Veteran’s PTSD with alcohol use has been evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411, which is covered under The General Rating Formula for Mental Disorders. The General Rating Formula for Mental Disorders provides that 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 is rated 50 percent disabling. 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 is rated 70 percent disabling. 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 is rated a maximum 100 percent disabling. The symptoms associated with the rating criteria are not intended to constitute exhaustive lists but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). A Veteran may only qualify for a disability rating under 38 C.F.R. § 4.130 by demonstrating the particular symptoms associated with that percentage or others of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The rating agency shall assign a rating 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. 38 C.F.R. § 4.126(a). VA will also consider the extent of social impairment but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126(b). At the outset, the Board notes that the Veteran is in receipt of a 100 percent rating for PTSD from June 13, 2017, to August 1, 2017, due to psychiatric hospitalization. As such, the claim for an increased rating for PTSD is moot during this period of the appeal. Turning to the clinical evidence of record, a July 2013 mental health report from Dr. M.M. documents the Veteran’s reports of insomnia and hypervigilance. He also endorsed the following: feeling on edge much of the time, avoidance of people, emotional numbing, tendency to isolate, intrusive memories, hyperstartle response and insomnia characterized by initial insomnia and frequent awakenings. He denied nightmares/flashbacks. The examiner indicated that however, he endorses occasional intrusive memories of combat experiences. The examiner indicated that the Veteran endorses that he is “hyperalert” to the extent that he needs to sleep next to his gun at night. The examiner indicated that he denied depressed mood or anhedonia. The examiner indicated that however, the Veteran endorses guilt about not being able to spend much time with his children due to his hectic work schedule. The examiner also indicated that he endorses OK energy/concentration. An October 2013 treatment note from Dr. M.M. indicates a diagnosis for PTSD. The report reflects the Veteran’s statements that he had been married twice and that his first marriage in the 1990s ended largely due to infidelity. He reported that he and his current wife argue frequently over finances and his drinking. He stated that he has never been physically aggressive towards her. He stated that they currently were living apart due to work circumstances. He stated that he has eight children by five mothers. He indicated that he is busy working trying to pay child support and unable to see them. He stated that he does not have close friends; he indicated that he occasionally spends time with army buddies. As to legal history, the examiner noted that the Veteran had a DUI in the 1990s. The Veteran denied any other legal charges. The examiner indicated that the Veteran arrived on time, casually dressed and appropriately groomed, with no obvious signs of neglect of hygiene. The examiner indicated that the Veteran was alert and oriented but seemed to need several seconds to process verbal information and to respond. The Veteran’s mood was indicated as somewhat irritable. His speech was normal. He denied current suicidal or homicidal ideations. His judgment and insight were indicated to be intact. He endorsed having threatened to kill others in the past, but he denied current intent or plan. As to current symptoms, Dr. M.M. noted symptoms of insomnia and hypervigilance. The Veteran endorsed depression, trouble concentrating, and sleep impairment. A GAF score of 55 was assigned. In May 2014, the Veteran underwent an initial PTSD VA examination. The examiner indicated that the Veteran relates a history of anger outbursts and fights. The Veteran also indicated that he drinks beer at home alone most of the time when he is not at work. He stated that his wife objected to his drinking when they were together. As to symptoms, the examiner indicated the following: depressed mood; anxiety; suspiciousness; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; inability to establish and maintain effective relationships; and suicidal ideations. As to behavioral observations, the examiner indicated that the Veteran has consistent anxiety and depression. The examiner indicated that the Veteran was completely oriented and understood the purpose of the evaluation. The examiner also indicated that the Veteran reported suicidal ideation that is limited and does not involve intent. He stated that he has the number for the VA crisis line. The examiner also indicated that he volunteered the statement that, “I was a nice little kid before the Army; I turned into a beast when I was in the Army. I’m more aggressive than I ever was.” An August 2014 speech pathology note from Durham VA Medical Center (VAMC) indicates a GAF score for PTSD of 55. In January 2015, the Veteran underwent another VA examination. The examiner indicated that the Veteran has occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. As to the Veteran having multiple psychiatric diagnoses, the examiner stated that while it is possible that the majority of the Veteran’s occupational and social impairment can be attributed to his PTSD, his alcohol use can have primary and secondary effects and possibly at times separate dysfunctional episodes. As to symptoms, the examiner indicated that the Veteran reports being easily irritated and angered and a decreased need for social interaction. The Veteran also reported nightmares, flashbacks and that intrusive images emerged as his career continued. The examination report also reflects the Veteran’s report of a DWI in 1992. He admitted to daily drinking, which he stated is a pattern he has had since 1988. As to current symptoms, the examiner indicated anxiety, suspiciousness, and chronic sleep impairment. A letter from Dr. D.M. received by VA in March 2015 indicates that the Veteran has the following PTSD symptoms: insomnia, nightmares, flashbacks, irritability, anger, anxiety, social isolation, negative beliefs, recurrent memories, avoidance, alcohol to treat symptoms, and significant relationships isolation. Dr. D.M. also stated that the severity of the Veteran’s symptoms was lower a few months prior. Dr. D.M. also stated that however, the Veteran is in a new position in his workplace, which is increasing his overall anxiety level. In June 2016, the Veteran underwent another VA PTSD examination. As to the Veteran’s mental health treatment prior to this examination, the examiner noted the July 2013 and October 2013 reports of Dr. M.M. The Board has discussed each examination in this decision and notes that the June 2016 VA examiner accurately notated the clinical findings of the examinations. The June 2016 VA examiner also indicated that since the 2015 mental health VA examination, the Veteran reported symptoms to treating providers prominently including anger and irritability as well as isolating himself. The June 2016 VA examiner indicated that the Veteran’s presentation during this evaluation indicates inaccurate self-report consistent with embellishment of symptoms and impairment. The examiner stated that the Veteran endorsed high levels of symptoms not typically seen in psychiatric patients and also endorsed symptoms that are not consistent with actual mental health disorders. The examiner stated that with that being said, individuals who present with inaccurate self-report of symptoms may very well have mental health symptoms that are clinically significant and distressing. The examiner indicated that the Veteran shows a long history of mental health symptoms and participation in trauma-focused treatment. The examiner also indicated that at a previous mental health evaluation on October 2013, the Veteran completed objective psychological testing that supported a PTSD diagnosis with validity indicators that were not consistent with malingering. The examiner indicated that as a result, current diagnoses and impairment information can be identified by integrating findings from record review, behavioral observations, and objective psychological testing. With that said, the examiner indicated that since his last exam, the Veteran has prominent symptoms of anger, irritability, and isolation. The examiner indicated that multiple providers have noted hypervigilance with negative beliefs about safety and trust. The examiner also indicated that the Veteran reported a history of sleep disturbance that has been documented as having recent improvement with medications. The examiner indicated that the record reflects inconsistent reports of re-experiencing symptoms as the Veteran’s current psychiatric provider has documented nightmares and intrusive memories while the Veteran previously has denied nightmares and reported sub-clinical levels of intrusive memories. The examiner also noted past problems with alcohol. As to the Veteran having multiple diagnoses, the examiner indicated that the Veteran’s alcohol use disorder likely exacerbates symptoms but does not appear to independently cause additional symptoms. The examiner noted the Veteran’s reports that he and his wife are still separated. He also stated that he has eight children. He stated that it hurts him not being there for them. He noted that it is partly his fault as he does not get along with their mothers. He noted that he is a loner and does not get along with anyone. He said his kids will reach out and text him and he will not respond. The examiner indicated that however, the Veteran noted that his children will often ask for money. He indicated that he avoids groups. He stated that he tried to go to a cookout and got into a verbal argument. He said he does not have any friends. He said that he has people whom he classifies as buddies, but not friends. He reported that he does not visit his mother. He reported that years ago, he put a gun to his brother’s head and his brother committed suicide that night. He stated that he therefore knows that his mother blames him for his brother’s death. He indicated that he has a female “associate” and some buddies with whom he spends time. In response to this statement, the examiner noted that the record reflects reports of the Veteran going to friends’ houses. The Veteran reported that he was still drinking every day. He said that his wife tells him that he is disrespectful to her friends. He also stated that his wife would kick him out due to alcohol. He stated that his PTSD is “really severe” and that he avoids other people. He reported that he does not run like he used to and does not exercise, noting that he does not have interest in anything except for drinking a beer and watching TV. As to his occupational functioning, the Veteran stated that he was working full time as a forklift driver. He described coworkers as having difficult personalities. He reported that a lot of coworkers did not like him because he is irritable and negative with them. He reported having a verbal altercation on the first day of his current job. He reported that other coworkers are rude or hostile towards him. He indicated that his supervisor submitted a statement indicating that another employee said that the Veteran threatened him, although both employees were given a verbal warning regarding the altercation. The examiner also noted that the Veteran’s supervisor had indicated that the Veteran has not had another incident of having any anger outbursts or altercations at the job in the three months since then. The Veteran reported a history of 2-3 verbal altercations at his previous job. As to this statement, the examiner indicated that current objective psychological testing indicates concerns about the validity of the Veteran’s self-report, consistent with exaggeration of symptoms and impairment. Having noted concerns regarding the Veteran’s validity as to some statements, the examiner considered the overall record and clinical assessments and stated that integrating these findings, the Veteran is assessed as having 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. An October 2016 consult note from San Antonio VAMC indicates that the Veteran has symptoms of depression, anger, irritability, dysfunctional, avoidance, hypervigilance, hates people being around him, has a bad mood, and is very anxious. The Veteran denied suicidal and homicidal ideation, intent or plan. The Veteran underwent numerous group counseling sessions in 2017 and 2018 at Durham VAMC. Consistently, the reports indicate that the Veteran did not have suicidal or homicidal ideation or other acute indicators observed. He expressed a goal to sustain abstinence and work on decreasing PTSD symptoms, specifically irritability, isolation, hypervigilance/arousal, emotional numbing (absence of emotion awareness), and negative thinking, which he was indicated to have every day. The session notes also indicate that the Veteran is also interested in learning how to communicate in social settings. He cited his irritability and inability to express himself emotionally with intimate partners as barriers to sustaining relationships as desired. In July 2017, the Veteran underwent another VA mental health examination. The examiner opined that the Veteran has occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The examiner indicated that the Veteran remains married but separated four years ago and that he has eight children. The examiner noted that none of the Veteran’s children live with him. He reported that he lives alone and has a female friend. He reported that he has contact with relatives every 4-6 months. He denied having friends and stated that he does not have pets. He denied having hobbies. He stated that he does his own household chores. He stated that he goes to grocery stores and goes to drive through restaurant windows only. He reported that he last attended worship service two months prior. As to a typical day, he reported that he gets up and “sits around” and watches TV all day. He stated that he snacks during the day. He stated that after supper, he watches TV. He indicated that he goes to AA meetings three times a week. As to relevant mental health history, the examination report indicates that the Veteran reported recent intrusive memories. He said he gets a headache when reminded of the stressors. With regard to this statement, the examiner indicated that the Veteran’s response was not consistent with physiological reactivity. The Veteran reported that he tries to avoid thoughts and feelings about the stressors by using relaxation techniques. As to this statement, the examiner indicated that the Veteran’s response was not consistent with avoidance due to military trauma. The examiner indicated that the Veteran was asked about panic but did not describe panic symptoms. The examiner indicated that the Veteran reported strong negative feelings about himself and others. Asked if he blamed himself for anything in regard to the stressors, the Veteran stated that, “I blame myself for a long time for not being in my kids’ life for one, all the pain that I was having, I was drinking.” The examiner indicated that the Veteran’s response was not related to military trauma. Asked whether he had strong negative feelings, such as fear, the Veteran reported that he sleeps with his gun every night from fear someone will break in. As to usual activities changing, he said he has been told he is “boring, sexual things,” as of about five years ago. He said he feels distant or cut off from others but loves his children. He reported having angry outbursts and arguing with his wife. He said he pulls his gun on people when he is really angry. The examiner indicated that the Veteran endorsed hypervigilance. As to concentration and memory, the Veteran indicated that he has to write things down. He said that he has delayed sleep as he ruminates about problems he has in life. He denied current suicidal and/or homicidal ideation, intent, or plan. As to how his emotional issues impact his relationship with others, he indicated that he does not have any relationships. As to how his emotional issues impact his work, he indicated that he does not go to work and does not want to be around civilians ever again. As to substance abuse, he reported that he drank daily until October 2016. He also indicated that he was using cannabis until 2015. He denied use of any other illicit substances. He reported a DWI in the 1990s and denied any other legal history. As to current symptoms, the VA examiner identified anxiety and suspiciousness. As to appearance, the examiner indicated that the Veteran was wearing a “torn shirt in front and down the middle of the back with crisp edges to the cuts.” The examiner indicated that the tears “were inconsistent with wear.” The examiner indicated that the Veteran’s hygiene was good. His eye contact was indicated as good. His mood was indicated as frustrated and irritated. His speech was normal. The examiner indicated that there was dramatic presentation as to volunteering statements of sleeping with guns and pulling guns on others. The examiner indicated that the Veteran’s thought process was liner and logical. The examiner indicated that there was no sign of thought disorder, delusions, or hallucinations. The examiner indicated that the Veteran was fully oriented to person, place, time, and circumstances. The examiner also indicated that the Veteran’s immediate memory was screened, and his effort was poor. The examiner noted discrepancies and stated that psychological testing at the previous VA examinations reflect attempts to exaggerate symptoms and dysfunction. The July 2017 VA examiner found the Veteran to be a dis-credible historian. An August 2017 intake note indicates that the Veteran has an inability to express himself emotionally with intimate partners. A July 2018 psych note from Durham VAMC indicates that the focus of the Veteran’s visit was to assess his current PTSD symptoms. The examiner noted that the Veteran reported that he has been separated from his wife for approximately five years and recently filed for divorce. The examiner indicated that he reported that he feels more stressed as a result and is concerned about relapsing into alcohol. He reported that he does not typically leave the house except to go to AA; he cited worry about relapse, anger, and wanting to avoid others. He stated that however, this results in a depressed mood. He stated that he would like help coping with stress and depressed mood. The examiner indicated that the Veteran endorsed the following symptoms: intrusion symptoms, including recurrent involuntary trauma recollection; avoidance symptoms; negative alterations in cognition and mood, such as an inability to remember parts of the trauma and a persistent negative emotional state; and irritable behavior and angry outbursts. He reported that he continues to be abstinent from alcohol use. As to lay statements, in a May 2014 written statement, the Veteran indicated that he and his wife are always arguing and that she tells him all the time that he needs help. He said that his family says he has a serious problem with drinking. He also stated that he gets mad quickly and cannot stand to be around people too long. In a September 2014 written statement, the Veteran stated that the PTSD medication he takes is not working. He stated that he drinks daily due to his emotions and social isolation. The Veteran stated in his May 2015 notice of disagreement that he has “social impairment and occupational disagreements with people and cannot stand a crowd of people.” He stated that he has suicidal ideation sometimes at home and cannot keep a relationship with others. He stated that he knows himself better than anyone and although it is not showing up in the records, he has all of the issues stated for a 70 percent rating for PTSD or better. A written statement from the Veteran’s supervisor received by VA in September 2015 states that the Veteran’s frustration has gotten worse over the past year. The supervisor indicated that although the Veteran has increased his use of leave, he cannot say that the Veteran does not work one of his second jobs. He stated that the Veteran has a strong work ethic and has worked at least two jobs since 2012. The supervisor stated that despite the time he spends de-conflicting issues between the Veteran and a coworker, he considers the Veteran an asset. He stated that as foreman, the Veteran is “focused on what needs to be [done].” He stated that the Veteran’s biggest downfall is taking issues personally and not being able to vent his frustration in a less heated manner with other personnel. The supervisor stated that the Veteran’s frustration has increased over the past months. In a written statement from the Veteran received by VA in October 2015, the Veteran stated that he still finds himself drinking heavily at times and is hypervigilant. He stated that he has spoken with his doctor and is trying to improve his drinking. He stated that however, it has taken a turn for the worse. He stated that he and his spouse are separated because of his drinking. In the January 2016 Form 9, the Veteran stated that his PTSD should be rated more than 50 percent because his PTSD provider Dr. S. at Hillendale Clinic states that he has chronic/severe PTSD along with anxiety disorder. He stated that he takes daily medication. He stated that he has been socially impaired for a long time. He stated that he does not like people and cannot be around a crowd without thinking that they are the enemy. He also stated that he takes medication for his mood but it does not work because he is always angry/upset with society. He stated that he has attended eight classes on seeking safety. In a January 2016 written statement from the Veteran, he stated that his PTSD should be at least 90 percent because he cannot get along with anyone and is a threat to society due to getting into fights with people or co-workers. He stated that he and his wife had not been together for two years and that his life needs a makeover. He stated that he is a bad person who is trying to change but something in his brain will not allow him to. He stated that he drinks daily and does not trust anyone. He also indicated that he has severe anxiety disorder and avoidance. A written statement from the Veteran’s supervisor received by VA in June 2016 addresses a verbal warning issued to the Veteran and a coworker for communicating threats in the workplace. In a January 2017 written statement, the Veteran stated that he is suffering from the following: depression, anxiety, severe alcohol dependency, isolation, nightmares, fears, suicidal ideation, anger, guilt, relationship problems, overall numbness, resentment, and avoidance from others. He stated that he has had an extremely difficult time coping with society due to these symptoms. He indicated that he had been deployed three times and takes medication for nightmares. In a written statement from the Veteran received by VA in March 2017, he stated that his life is a total wreck and his relationships with others “suck.” In a July 2017 written statement, the Veteran stated that he had PTSD treatment in July 2017 and learned some effective tools to use in life. He noted that it caused him to reflect on his behavior. He stated that he has isolated himself for years and does not like being around crowds or people and also stays away from his family and children because he will get into fights easily. He stated that he has been in many fights and arguments in the last few years. He stated that he has poor communication and thought process. He stated that he has negative thoughts about people and his life. He stated that he has lost relationships because of his actions triggered by PTSD. He stated that he is unable to maintain or sustain gainful occupation. He stated that he engages in heavy drinking. He reported avoidance. He stated that he is socially impaired with grossly inappropriate behavior when he is around others. He stated that he has been told that he is a pervert because of his actions and behaviors. He stated that he always has thoughts of hurting someone or actively killing himself. He stated that he has no reason to live, so he thinks about taking his life. He indicated that he is a persistent danger because he sleeps with his gun. He stated that he has bad memory and forgets to take his medication. He stated that he would forget his head if it were not screwed to his shoulders. He stated that he forgets to do tasks. He stated that he feels unworthy and ashamed. He stated that he told his wife they need to divorce because after all this time apart (four years), he does not see them getting back together. He stated that he does not communicate well with others. He stated that he has a monster inside of him that keeps him from communicating with his kids or family. He stated that he feels discouraged most of the time. He stated that he does not actively involve himself in activities and “just sit[s] on the couch and rock back and forth all day.” He stated that he really hates his life and wants to die. He stated that he feels like his life is a revolving cycle of loneliness and boredom. He stated that his family is concerned for his safety and thinks he will harm himself. He reiterated that he takes medication for nightmares and also has serious sleep problems. He also reiterated that he has deployed three times and has seen combat and dead bodies. In asserting that he believes his PTSD warrants a 100 percent rating, he indicated that his PTSD has “[illegible] me from society and the ability to cope with others.” He stated that he does not have any friends and rarely sees his family. He stated that he is a bad person and does not know when his anger will release and harm someone. He reiterated that he does not communicate well with others. He also stated that he has fainting spells. He stated that he has not gotten better since his last PTSD exam in 2013. Additionally, a July 2017 written buddy statement from a classmate, Mr. J.S., of the Veteran’s states that the Veteran has shown hypervigilance by always looking around constantly and checking doors. Mr. J.S. indicated that the Veteran is fidgety and jumpy. He also indicated that the Veteran stays angry all the time. He indicated that anger, hostility and irritation are easily noticed with the Veteran. He indicated that the Veteran is “constantly irritated and always in a bad mood.” He stated that the Veteran normally does not care to talk to anyone or participate in activities. He indicated that the Veteran does not feel safe leaving the treatment center. In a written statement from the Veteran received by VA in September 2017, he stated that he is separated from his wife and does not see his kids. He stated that his life is “so messed up.” He stated that he is isolated and feels guilty because he has killed innocent people in Iraq. Having reviewed the evidence of record, medical and lay, the Board finds that the Veteran’s PTSD with alcohol use is best reflected by a 50 percent disability rating for the entire period on appeal. Throughout the appeal period, the Veteran has reported symptoms of depression, anger, anxiety, an impaired mood, sleep impairment, some nightmares, hypervigilance, isolation, lack of interest, irritability, difficulty in maintaining social relationships, and alcohol use, which are consistent with the evidence of record. The Board acknowledges the Veteran’s various reports of violence, concentration issues, and inappropriate behavior and grooming. As to these assertions, the Board finds that the overall record suggests inconsistencies. The June 2016 and July 2017 VA examiners indicated that some of the Veteran’s reports of symptoms are not entirely credible and at times exaggerated. The Board acknowledges that the medical assessment of the Veteran’s level of disability at the moment of the examination alone cannot determine the rating. 38 C.F.R. § 4.126(a). Instead, all evidence of record is to be considered. However, the Board also notes that in weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). As the record raises concerns regarding the Veteran’s credibility, the Board has considered these factors in the case at hand. The June 2016 and July 2017 VA examiners did not find that the Veteran’s assertions of violence, poor grooming and poor concentration were not present, and were not credible. Private and non-C&P examination reports make no mention of violence, poor grooming or impaired concentration. To the contrary, clinical evidence throughout the appeal period indicates that the Veteran consistently denied homicidal or suicidal ideation, and his thought process was indicated as linear. As to memory and concentration impairment, these issues were not noted by examiners or reported by the Veteran in any clinical assessments. Additionally, the September 2015 letter from the Veteran’s supervisor states that he has a strong work ethic and maintains focus despite his frustration and anger issues. Given the overall record, as the finder of fact and the entity responsible for assessing credibility, the Board finds that the Veteran’s reports of violence, concentration issues, and inappropriate behavior and grooming are not credible as they are inconsistent with the evidence of record. The Board acknowledges the Veteran’s statements that he knows himself better than anyone and that his PTSD has been characterized as severe. However, the use of terminology such as “mild,” “moderate,” or “severe,” although evidence to be considered by the Board, is not dispositive of an issue. 38 C.F.R. §§ 4.2, 4.6. Instead, the entire record is to be considered. As such, while the Board affords deference to the Veteran’s characterization of his symptoms, the Board’s assessment cannot be based solely on his statements without regard to how these statements contradict the clinical evidence of record. As such, the Board finds, as noted, that the overall record establishes that the Veteran’s PTSD manifested in depression, anger, anxiety, an impaired mood, fragmented sleep, hypervigilance, isolation, lack of interest, irritability, difficulty in maintaining social relationships, and alcohol use during the appeal period. The Board now considers whether a higher rating than 50 percent is warranted for these symptoms. However, the Board does not find that a higher rating is warranted. There is no indication of deficiencies in most areas, such as work, family relations, judgment, thinking or mood due to symptoms such as suicidal ideations, impaired impulse control or near-continuous panic or depression. The Board acknowledges the Veteran’s social impairment, which includes isolation, separation from his wife, and difficulty maintaining relationships. However, the Board emphasizes that a rating cannot be based on social impairment alone. 38 C.F.R. § 4.126(b). Moreover, the Veteran has consistently indicated that he has a female friend and buddies. While he stated that the female friend is not a girlfriend and that he would not call his buddies “friends,” these relationships establish that the Veteran is able to maintain some effective forms of a relationship. Additionally, while the Veteran reports that he does not see his children often, the overall record supports that this is also due to the Veteran working and/or having money issues. As to occupational impairment, while he has had verbal conflicts with a coworker, the Veteran’s supervisor stated, as noted, that the Veteran is focused and an asset. The supervisor also stated that the Veteran has a history of working two jobs at once. Nor has the Veteran indicated that he has been terminated or unable to maintain a job due to his PTSD or otherwise. While the Veteran admittedly has anger issues at work, there is no indication that it has resulted in more than an occasional decrease in his work efficiency as exhibited by the verbal warning he received. There are no other occupational disciplinary actions reported. Also, as noted, the supervisor stated that he still considers the Veteran an asset. Thus, the Board does not find that the Veteran’s PTSD has resulted in occupational impairment greater than that recognized in the assigned 50 percent disability rating. As to mood, motivation, and judgment, while the record reflects consistent mood impairment during this period of the appeal, (depression, anxiety, anger, and irritability) and lack of interest/motivation, there is no indication of impairment in other areas, such as thought and judgment. While the Veteran endorses anger, frustration and irritability, there are no indications of violence. The Board acknowledges the Veteran’s verbal warning at work for making threats with a coworker. While he has also made statements to the effect that he sleeps with a gun, is a monster, and thinks about killing people, the clinical evidence reflects that he has consistently denied homicidal ideations. The clinical evidence also indicates that the Veteran does not pose as a danger to self or others. The clinical reports are in line with the overall record as the Veteran has no legal history other than a DWI in the early 1990s. As such, overall, the record does not suggest that the Veteran lacks impulse control such that his anger has manifested in violence towards others. As to whether the Veteran is a threat to himself, the Board acknowledges the Veteran’s July 2017 statement that he has thought about suicide. The Board also notes that this statement follows the Veteran’s June 2017 psychiatric hospitalization. As noted, the Veteran is already rated at 100 percent for that period of the appeal. At other times throughout the appeal period, the record reflects that the Veteran has consistently denied suicidal ideations. There are also no indications, from either clinical evidence nor the Veteran’s statements, of compulsive behaviors or obsessional rituals which interfere with routine activities. The Veteran also presented as groomed and with normal speech throughout the appeal period. The Board acknowledges the torn shirt worn by the Veteran to the July 2017 VA PTSD examination, which may suggest neglect of grooming. The Board notes that poor grooming is relevant in assessing the severity of psychiatric disorders. Particularly, neglect of hygiene speaks to total social and occupational impairment of 100 percent and an inability to perform basic daily functions. However, the July 2017 VA examiner indicated that the Veteran’s torn shirt was consistent with cutting, not wear. Additionally, the overall record consistently reflects that the Veteran presented as appropriately groomed. As such, the Board does not find that the record supports neglect of grooming or an inability to perform basic daily functions during the appeal period. The Board also acknowledges the Veteran’s reports that he has been told he is inappropriate and a pervert. While the Board has no reason to doubt the credibility of the Veteran’s statements and these statements suggest some social impairment, there is no evidence of record to support that the Veteran has grossly inappropriate behavior. As noted, he has no legal history and no reported difficulties with others outside of verbal arguments. As such, his statements are not indicative of grossly inappropriate behavior such as that contemplated in a total rating of 100 percent. As also noted, the record does not support that the Veteran has concentration issues as a result of his PTSD. While the Veteran has also reported some memory issues, the evidence does not suggest that he had memory loss for the names of close relatives, his own occupation or his own name. Moreover, the evidence of record does not reflect that he experienced problems adapting to stressful circumstances. The Board acknowledges the Veteran’s alcohol use. Per his statements, the Veteran reached a goal of abstinence from alcohol in October 2016. During those periods of the appeal when he was drinking heavily, the record does not reflect that his symptoms had manifested in deficiencies in most areas. As discussed, he maintained some effective relationships, employment, and avoided violence or legal issues. Nor are there any indications of thought or judgment impairment in the years the Veteran drank heavily. Without minimizing the Veteran’s previous alcohol use, the Board finds that even in considering the Veteran’s alcohol use, his overall symptoms did not result in social and occupational impairment greater than that recognized in the assigned 50 percent disability rating. Overall, the Veteran has not demonstrated symptoms consistent with the general level of impairment that would warrant a 70 percent rating or akin to the symptoms that are listed in the rating criteria. The overall record does not reflect that the Veteran’s symptoms were near-continuous and affected his ability to function independently, appropriately, and effectively. The evidence also fails to show that his symptoms equate in severity, frequency and duration to occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking or mood. See Vazquez-Claudio v. Shinseki. As noted, while the Veteran had some deficiencies in mood, social relations and engages in verbal altercations, he has some effective relationships and is indicated to have a strong and effective work ethic. In the other areas, his symptoms did not indicate consistent deficiencies. The Board has also considered the Veteran’s assigned GAF score of 55 during the appeal period. The Board notes that GAF scores alone do not support the assignment of any higher rating. An examiner’s classification of the level of psychiatric impairment, by words or by a GAF score, is to be considered but is not determinative of the percentage rating to be assigned. See 38 C.F.R. § 4.130; Barr v. Nicholson, 21 Vet. App. at 303. Rather, it is considered in light of all of the evidence of record. According to the DSM-IV, a range of 51 to 60 represents moderate symptoms: flat affect and circumstantial speech, occasional panic attacks or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with coworkers). Here, the record reflects moderate difficulty in social settings and some occupational conflicts. As such, the Board finds that the overall record supports the assigned rating in line with the assigned GAF score. Consideration has also been given to assigning staged ratings. Fenderson v. West. However, the Veteran’s symptoms were consistently depression, isolation, anger, lack of interest, anxiety, hypervigilance and some sleep issues. Accordingly, the Board finds that the disorder has not significantly changed, and a uniform rating is warranted. In light of the evidence, the Board finds that a 50 percent rating, but no higher, is warranted for the Veteran’s PTSD throughout the appeal period. REASONS FOR REMAND 1. Entitlement to service connection for a right knee disability is remanded. Having reviewed the evidence of record, the Board finds that further development is necessary prior to adjudicating the Veteran’s claim for service connection for a right knee disability. The Veteran contends that his right knee disability is related to in-service combat activity, such as crawling, standing, and walking for long distances. The record reflects a current diagnosis for arthritis of the right knee. However, currently the criteria for presumptive service connection are not met as the Veteran was not diagnosed with a chronic right knee disability during service or within the presumptive period. However, additional development is necessary in regard to direct service connection. The Veteran underwent VA knee examinations in July 2015 and January 2016. Yet, the record does not reflect a medical opinion as to whether the Veteran’s current right knee disability is etiologically linked to his active service. As such, remand is necessary to obtain a VA opinion. 2. Entitlement to service connection for sleep apnea is remanded. The Veteran contends that his current sleep apnea is secondary to his PTSD. An April 2015 VA opinion provides the opinion that the Veteran’s sleep apnea is not secondary to PTSD. Essentially, the VA examiner indicated that medical literature does not indicate any link between PTSD and sleep apnea. The examiner explained that sleep apnea is a sleep disorder characterized by abnormal pauses in breathing or instances of abnormally low breathing during sleep. The examiner also indicated that literature supports that risk factors for sleep apnea include the following: male gender and race, with African Americans more likely to have obstructive sleep apnea than their white counterparts. The examiner indicated that the Veteran has all of the above risk factors, which has contributed to the development of sleep apnea. As to aggravation, the examiner indicated that there is no evidence of record which shows documentation of worsening or aggravation of the Veteran’s obstructive sleep apnea by service connected PTSD. However, this opinion does not adequately address aggravation. The opinion relies solely on lack of documented evidence. Yet, the examiner did not assess whether PTSD may aggravate sleep apnea and explain why those factors, if they exist, are not present in this Veteran’s case. As such, remand is necessary for an adequate opinion as to aggravation. The Board notes that the term “aggravation” refers to a chronic or permanent worsening of the underlying condition above and beyond its natural progression. 3. Entitlement to service connection for gum disease is remanded Having reviewed the evidence of record, the Board finds that further development is necessary prior to adjudicating the Veteran’s claim for service connection for gum disease. The Veteran contends that he has gum disease as a result of the water he drank during Desert Storm. See November 2015 Notice of Disagreement. A private dental treatment record from Dr. B.B. indicates a current diagnosis for chronic apical periodontitis. However, the record is not sufficient to grant a claim for a dental disability for compensation or treatment purposes. The record does not reflect that the Veteran has a dental condition for which compensation is warranted, such as impairment of the mandible, loss of a portion of the ramus, and loss of a portion of the maxilla. See 38 C.F.R. § 4.150. Nor does the record reflect that the Veteran sustained dental trauma or disease, such as osteomyelitis, during service. As for conditions warranting service connection for purposes of treatment, while the record reflects a diagnosis for a periodontal disease, there is no medical opinion linking the condition to the Veteran’s service. However, the treatment record from Dr. B.B. suggests that the Veteran may have a dental condition linked to his sinusitis. Specifically, Dr. B.B. stated that the Veteran has a questionable localized perio #3 due to moderate bone loss mesial and chronic boneless distal; history of sinus infection, suspect potential oral antral communication. As the Veteran is service-connected for a sinus condition (maxillary sinusitis), the Board finds that the issue of secondary service connection has been raised. However, as Dr. B.B. indicated that the condition is questionable, the Board is not clear as to whether the Veteran has a current diagnosis for this condition. As such, remand is necessary to clarify this issue. The Veteran has not undergone a VA dental examination. However, as the record suggests a current diagnosis and link to a service connected condition, the Board finds that the low bar for providing a VA examination have been met. See McClendon v. Nicholson, 20 Vet. App. 79 (2006); 38 C.F.R. § 3.159(c)(4). As such, the Veteran should be afforded a VA dental examination to assess all current dental conditions and whether they are related to his service-connected maxillary sinusitis. The matters are REMANDED for the following action: 1. Return the claims file, to include a copy of this remand, to the June 2016 VA examiner who conducted the examination for the Veteran’s right knee. If the examiner who drafted the June 2016 opinion is unavailable, the opinion should be rendered by another appropriate medical professional. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. For all opinions requested, the claims file and a copy of this remand must be made available to the reviewing examiner, and the examiner should indicate in the report that the claims file was reviewed. Each examiner is also advised that the Veteran is competent to attest to observable symptoms. Each opinion provided must be accompanied by a rationale. As to the Veteran’s right knee, the examiner is asked to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s current right knee arthritis was incurred in or is otherwise related to his active service. Importantly, the examiner must demonstrate consideration of the Veteran’s lay statements pertaining to his knee. Notably, the Board points out his statements that his right knee condition is due to crawling, marching, and walking for prolonged periods of time during service. 2. As to the Veteran’s claim for sleep apnea secondary to PTSD, return the claims file, to include a copy of this remand, to the April 2015 VA examiner who conducted the examination for the Veteran’s sleep apnea. If the examiner who drafted the April 2015 opinion is unavailable, the opinion should be rendered by another appropriate medical professional. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. The examiner is asked to readdress whether it is at least as likely as not that the Veteran’s sleep apnea has been aggravated (permanently worsened beyond the natural progression) by his PTSD. In the April 2015 opinion, the examiner provided an opinion without supporting rationale other than lack of documented evidence. Importantly, any opinion provided on remand must be supported by a rationale that is not reliant solely on lack of documented medical evidence. 3. Schedule the Veteran for a VA dental examination. First, the examiner is asked to address the September 2018 report from Dr. B.B. stating that the Veteran has a questionable localized perio #3 due to moderate bone loss mesial and chronic boneless distal; history of sinus infection, suspect potential oral antral communication. The examiner is asked to indicate whether this assessment establishes a current diagnosis for a dental condition and if so, identify that diagnosis. If there is a current diagnosis, the examiner is asked to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the dental condition was caused (in whole or in part) or aggravated (permanently worsened beyond the natural progression) by the Veteran’s service-connected sinusitis. 4. After completing the above actions, readjudicate the claims on appeal. If the benefits sought on appeal remain denied, the Veteran should be furnished an appropriate Supplemental Statement of the Case and be provided an opportunity to respond. Thereafter, the case should be returned to the Board for further appellate consideration, as appropriate 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). Gayle Strommen Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Smith, Associate Counsel