Citation Nr: 18111911 Decision Date: 06/18/18 Archive Date: 06/18/18 DOCKET NO. 11-19 326 DATE: June 18, 2018 ORDER The claim of entitlement to service connection for a bilateral knee disability, claimed as osteoarthritis of the knees with bone spurs is denied. The claim of entitlement to service connection for obesity is denied. The claim of entitlement to a disability rating in excess of 60 percent for chronic fatigue syndrome is denied. The claim of entitlement to a disability rating in excess of 50 percent prior to February 6, 2012 and in excess of 70 percent thereafter for posttraumatic stress disorder (PTSD) to include depression is denied. REMANDED The claim of entitlement to service connection for urinary incontinence is remanded. The claim of entitlement to service connection for a gynecological disability, claimed as hysterectomy with early menopause and loss of use of a creative organ secondary to venereal disease is remanded. The claim of ehntitlement to a total disability rating based upon individual unemployability (TDIU) due to service connected disabilities is remanded. FINDINGS OF FACT 1. The Veteran’s bilateral knee disability did not manifest during service and is not causally related to the Veteran’s active service. 2. Obesity, in and of itself, is not a disability for VA compensation purposes. 3. The Veteran’s chronic fatigue syndrome manifested with debilitating fatigue, cognitive impairments (such as inability to concentrate, forgetfulness, confusion), or a combination of other signs and symptoms, which were nearly constant and restricted routine daily activities to less than 50 percent of the pre-illness level and resulted in periods of incapacitation of at least six weeks total duration per year but were not nearly constant and so severe as to restrict routine daily activities almost completely. 4. Prior to February 6, 2012, the Veteran’s PTSD to include depression, manifested with occupational and social impairment with reduced reliability and productivity, but without occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 5. From February 6, 2012 forward, the Veteran’s PTSD to include depression manifested with occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, but without total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for a bilateral knee disability are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 2. The criteria for establishing entitlement to service connection for obesity are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 3. The criteria for establishing entitlement to a disability rating in excess of 60 percent for chronic fatigue syndrome have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.88b, Diagnostic Code 6354 (2017). 4. The criteria for establishing entitlement to a disability rating in excess of 50 percent prior to February 6, 2012 and in excess of 70 percent thereafter for PTSD to include depression have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from September 1986 to October 1987 in the United States Navy. The Veteran testified at a videoconference hearing before the Board in September 2013. A transcript of that hearing has been associated with the claims file. The Board remanded the issue for further development in August 2014. The issue of entitlement to service connection for obesity was addressed in an August 2015 Joint Motion for Remand (JMR). All issues were remanded again in February 2016. The case has been returned to the Board for appellate review. Service Connection 1. Entitlement to service connection for a bilateral knee disability, claimed as osteoarthritis of the knees with bone spurs The Veteran contends that she has a current bilateral knee disability that manifested during service or is causally related to service. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a diagnosis of degenerative joint disease (DJD) of the bilateral knees, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The Veteran was afforded a VA examination in October 2014. The examiner reviewed the claims file and performed a physical examination. The examiner diagnosed DJD of the knees. The Veteran reported that she fell while running during basic training resulting in no fracture, but crutches for seven weeks. The examiner noted that a childhood injury caused bone spurs in the knees. The examiner opined that the current knee condition of DJD and the history of torn right meniscal tissue is less likely than not related to her active service. The Veteran’s service treatment records were silent for complaints of knee issues. The examiner cited a September 1987 mental health exam that showed orthopedic structural examination demonstrated full range of motion. The Board obtained an additional nexus opinion in February 2017 to clarify the October 2014 opinion. The examiner found that the Veteran’s bilateral knee condition was less likely than not incurred in or caused by the Veteran’s in-service injury, event, or illness. Rheumatology report from 2014 is the first documented history of spurs and was a subjective report by the Veteran. X-ray reports in 2000 document osteophytes on both knees. Service treatment records were silent regarding bilateral knee complaints or a diagnosed bilateral knee condition. The Veteran separated from the military in 1987. The Veteran’s lay statements in the claims file were reviewed but were not substantiated by the objective medical records. The first objective evidence of a bilateral knee condition is dated in 2000, a lapse of 13 years after separation from service. MRI imaging showed mild degenerative joint disease of the knees. The Veteran was age 33 at the time of the diagnosis. The mild DJD of the knees first documented in 2000 was consistent with aging, obesity status, and physical labor employment. There is no objective evidence of an in-service event that would have contributed to the later development of mild DJD of the knees. The available treatment records showed that the current disability of the knees was bilateral osteoarthritis. The Veteran’s bilateral knee disability was less likely than not proximately due to or a result of the Veteran’s service-connected conditions. The Veteran’s bilateral knee DJD is likely multifactorial, secondary to aging, obesity, and physical labor employment. It would be merely speculative to attempt to attribute the degree of DJD that is secondary to each risk factor. The operative report from bilateral knee arthroscopic surgery indicates that the Veteran had lateral release bilaterally. Lateral release surgery is performed due to abnormal patellar tracking. Abnormal patellar tracking is often the result of structural or congenital anatomy and can contribute to the development of DJD. The issue as to whether the Veteran’s bilateral knee disability pre-existed her entry into service was addressed by the VA examiners. The examiner October 2014 examiner found that, other than a note in the orthopedic visit in 2012 where she stated that there was a knee injury as a child, the examiner could not find any statement to this effect in any other documentation or in her service treatment records; however, this makes the knee condition pre-existing. Although the examiner noted that this makes the knee condition pre-existing, he then used ambivalent language regarding pre-existence. The examiner noted that “if” pre-existing, then the effects of the fall and physical over use while in the military certainly “could have” aggravated the condition and hastened degenerative disease of those joints. The Board finds that the use of the phrases “if” and “could have” is so tentative, by its own terms, so as to be of very little probative value. The Court has previously held that an opinion that is unsupported and unexplained is purely speculative and does not provide the degree of certainty required for medical nexus evidence. See Bloom v. West, 12 Vet. App. 185, 187 (1999); See also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (finding a doctor’s opinion that “it is possible” and “it is within the realm of medical possibility” too speculative to establish medical nexus); Goss v. Brown, 9 Vet. App. 109, 114 (1996) (using the word “could not rule out” was too speculative to establish medical nexus); Warren v. Brown, 6 Vet. App. 4, 6 (1993) (medical opinion expressed only in terms such as “could have been” is not sufficient to reopen a claim of service connection); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (medical opinion framed in terms of “may or may not” is speculative and insufficient to support an award of service connection for the cause of death); Obert v. Brown, 5 Vet. App. 30, 33 (1993) (physician’s statement that the Veteran “may have been having some symptoms of his multiple sclerosis for many years prior to the date of diagnosis” was insufficient to award service connection); Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996) (a generic statement about the possibility of a link between chest trauma and restrictive lung disease was “too general and inconclusive” to support an award of service connection). The February 2017 VA examiner noted no clear and unmistakable evidence that the reported bone spurs pre-existed the Veteran’s military service. Enlistment examination as well as all available service treatment records were silent regarding a knee condition. The Veteran’s lay statements in the claims file were reviewed but were not substantiated by the objective medical records. The first objective evidence of a bilateral knee condition is dated in 2000, a lapse of 13 years after separation from service. While the Veteran believes her bilateral knee disability is related to her active service, the Board reiterates that the preponderance of the evidence weighs against findings that her current disability is causally related to service. As a lay person, the Veteran has not shown that she has specialized training sufficient to render such an opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the diagnosis and etiology of a bilateral knee disability are matters not capable of lay observation, and require medical expertise to determine. Accordingly, her opinion as to the diagnosis or etiology of her bilateral knee disability is not competent medical evidence. Moreover, whether the symptoms the Veteran experienced in service or following service are in any way related to her current disability is also a matter that also requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) (“Although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with.”). Thus, the Veteran’s own opinion regarding the etiology of her current bilateral knee disability is not competent medical evidence. The Board finds the opinion of the VA examiner to be significantly more probative than the Veteran’s lay assertions. In sum, the Veteran’s knee disability did not manifest during active duty service. The disability was first documented over a decade after separation from service. The examiner noted multiple causes for the knee disability, to include aging, obesity, and physical labor employment. Additionally, the Veteran’s knee disability did not pre-exist entry into service. Based on the evidence cited above, the Board finds that the preponderance of the evidence is against the claim of service connection for a bilateral knee disability. As the preponderance of the evidence is against the claim for service connection for a bilateral knee disability, the benefit of the doubt rule does not apply. 38 C.F.R. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for obesity. The Veteran asserts that her obesity is causally related to service or to a service-connected disability, to include her psychiatric disability. The Board notes, however, that obesity is not a disability for VA compensation purposes. In the JMR issued in August 2015, the denial of entitlement to service connection for obesity was vacated and remanded. The JMR noted that the Board provided no citation or analysis for its finding that obesity of a particularity of body type is a condition for which service connection may not be established instead of a disease or other form of disability. Specifically, the JMR found issue that the Board did not note if such a finding was a medical determination or a factual or legal determination that the Board may make on its own. The Board notes that the finding that obesity is not a disability for VA compensation purposes is a legal finding. This issue was recently brought before the Court of Appeals for Veterans Claims (CAVC). The Court affirmed a Board decision that denied service connection for obesity, to include as secondary to the Veteran’s service-connected bilateral knee osteoarthritis, based on a finding that obesity, in and of itself, is not a disability for VA compensation purposes. See Marcelino v. Shulkin, No. 16-2149, 2018 U.S. App. Vet. Claims LEXIS 64 (Vet. App. Jan. 23, 2018). The Board decision in that instance was also issued prior to a January 2017 precedential opinion by VA’s Office of General Counsel (OGC), VAOPGCPREC 1-2017, which the Secretary relied heavily upon in its arguments to the CAVC. As relevant to this case, the OGC opinion held that obesity is not a “disease” or “disability” for VA purposes and, therefore, is not eligible for service connection on a direct or secondary basis. The CAVC held that it does not have jurisdiction to review the content of the rating schedule, to include whether VA should consider obesity as a disability, after discussing its statutory jurisdiction and applicable Federal Circuit cases. Accordingly, it affirmed the Board decision. Id. at 6. This case parallels the issues of the Marcelino case. The Board’s original decision was issued prior to the January 2017 precedential opinion and denied entitlement to service connection for obesity finding that it was not a disability for VA purposes. The Board therefore finds that entitlement to service connection for obesity is denied as obesity is not a disability for VA purposes, which is determined as a matter of law and is not a medical determination. The Board acknowledges that although service connection is not allowed for obesity on its own, obesity could act as an “intermediate step” to establish service connection for another disability as secondary to an already service-connected disability under certain circumstances. In this instance, the Board notes that the Veteran’s obesity did not manifest during service and is not related to a service-connected disability. Specifically, a February 2017 VA examiner opined that the Veteran’s obesity is less likely than not proximately due to or the result of the Veteran’s service-connected conditions. The first available treatment records that document obesity status are dated November 1996 and indicate a BMI of 34.2 (class 1 obesity). The record indicates weight gain secondary to Norplant device. The first available treatment records that document morbid obesity status are dated February 2002 and indicate a BMI of 40.8. The claim form from February 2009 indicated a claim for obesity secondary to depression or PTSD medications. The Veteran was not on any medications for depression or PTSD at the onset of the obesity. Most cases of obesity are related to behaviors such as a sedentary lifestyle and increased caloric intake. Secondary causes of obesity are uncommon. The examiner cited uptodate.com for his findings. The available objective treatment records indicate weight gain since having Norplant inserted. Weight gain is a recognized adverse effect of Norplant therapy. The examiner noted no objective evidence that supports that the weight gain is secondary to the Veteran’s PTSD. There is no objective evidence that supports that the weight gain was aggravated beyond its natural progression by the PTSD. As such, the Veteran’s obesity may not be used as an intermediate step to establish service connection for any other disability. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person’s ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 3. Entitlement to a disability rating in excess of 60 percent for chronic fatigue syndrome. The Veteran’s chronic fatigue syndrome is rated at 60 percent under Diagnostic Code 6354. Under that regulation, chronic fatigue syndrome is rated in part as follows: Debilitating fatigue, cognitive impairments (such as inability to concentrate, forgetfulness, confusion), or a combination of other signs and symptoms, which are nearly constant and so severe as to restrict routine daily activities almost completely and which may occasionally preclude self-care warrant a 100 percent disability rating. Debilitating fatigue, cognitive impairments (such as inability to concentrate, forgetfulness, confusion), or a combination of other signs and symptoms, which are nearly constant and restrict routine daily activities to less than 50 percent of the pre-illness level, or; which wax and wane, resulting in periods of incapacitation of at least six weeks total duration per year warrant a 60 percent disability rating. 38 C.F.R. § 4.88b. The Veteran was afforded a VA examination in October 2014. The examiner diagnosed chronic fatigue syndrome. The Veteran required continuous medication that controlled the Veteran’s symptoms. The Veteran’s debilitating fatigue has reduced daily activity level to less than 50 percent of her pre-illness level. The examiner noted cognitive impairment to include an inability to concentrate. The symptoms were nearly constant and restricted routine daily activities as compared to the pre-illness level. Symptoms restricted her routine daily activities to 50 to 75 percent of the pre-illness level. The Veteran’s periods of incapacitation last at least six weeks total duration per year. The Veteran’s treatment records consistently show that she is easily fatigued. The Veteran also reported feeling run down on multiple occasions. The Veteran subjectively reported extreme fatigue. To receive a higher disability rating, the evidence must show debilitating fatigue, cognitive impairments (such as inability to concentrate, forgetfulness, confusion), or a combination of other signs and symptoms, which are nearly constant and so severe as to restrict routine daily activities almost completely and which may occasionally preclude self-care. The Board notes that the Veteran’s disability did not manifest to a level that more nearly approximates the criteria for a higher disability rating. Per the Veteran’s October 2014 VA examination, the Veteran’s symptoms restricted her routine daily activities to 50 to 75 percent of her pre-illness level. The Veteran’s treatment records did show that she had extreme fatigue and reported feeling run down, but they did not rise to a level that restricted her routine daily activities and precluded self-care. The Board notes that the Veteran’s psychiatric treatment records show that she attended her daughter’s activities and drove her to work. Given the findings of the VA examiner and the lack of additional treatment records showing significant fatigue that restricted her routine daily activities, the Board finds that a higher disability rating is not warranted. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the current appeal. See 38 U.S.C. § 5107(b) (West 2014). 4. Entitlement to a disability rating in excess of 50 percent prior to February 6, 2012 and in excess of 70 percent thereafter for PTSD to include depression. The Veteran’s PTSD to include depression is rated at 50 percent prior to February 6, 2012 and at 70 percent thereafter under Diagnostic Code 9411. Diagnostic Code 9411 refers to the General Rating Formula for Mental Disorders. Under that regulation, PTSD is rated in part as follows: 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 warrants a 100 percent disability rating. 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 worklike setting); inability to establish and maintain effective relationships warrants a 70 percent disability rating. Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships warrants a 50 percent disability rating. 38 C.F.R. § 4.130. Prior to February 6, 2012, the Veteran’s PTSD was rated at 50 percent. To receive a higher disability rating, the evidence must show 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 worklike setting); inability to establish and maintain effective relationships. The Veteran was afforded a VA examination in October 2009. The examiner diagnosed PTSD with features of anxiety and depression. The Veteran’s symptoms were described as mild to moderate on a daily basis. The Veteran attended church, but denied relationships outside of family. She took her daughter to the library and sporting events. The Veteran had no history of assaultiveness. The examiner noted avoidance, short-term memory problems, and arousal. She experienced startle responses, flashbacks two to three times per week, psychic numbing, dissociation, and nightmares once per week. The Veteran did not have impairment of thought process but did have impairment of communication. She did not exhibit any delusions or hallucinations. She had no suicidal or homicidal plans or intent. She was able to maintain minimal personal hygiene and other basic activities of daily living. Her orientation was normal. She had some short and long-term memory loss or impairment, described as mild. The Veteran had no obsessive or ritualistic behavior that interfered with routine activities. The Veteran did not have any irrelevant, illogical, or obscure speech patterns. She had no panic attacks. The Veteran’s depression was mild to moderate. She felt inadequate and sad and had mildly reduced concentration. The Veteran noted anxiety once per week again described as mild to moderate. The Veteran had no impaired impulse control. Her sleep was disturbed on a nightly basis to a mild or moderate degree. The examiner noted no other symptoms. The examiner noted PTSD signs and symptoms that were transient or mild, which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. The Veteran’s treatment records consistently showed depression and anxiety. The Board will not cite every mental health treatment as the Veteran attended regular psychological appointments, but will provide a general overview of the Veteran’s treatment. A June 2010 mental status examination was significant for the Veteran appearing exhausted, ambulating slowly, and exhibiting pain-like behaviors. Her affect was restricted in range and congruent with a tired mood. The examiner noted no evidence of mania, anxiety, cognitive impairment, or formal thought disorder. The Veteran denied thoughts, urges, or intentions to harm herself or others. Her insight was fair and judgment, reasoning, concentration, and memory functions were intact. A May 2011 mental status examination was unremarkable for any significant or acute changes. The Veteran was alert and oriented. She was cooperative and in good grooming and hygiene. Her affect was appropriate and her mood was endorsed and appeared neutral. Her insight was described as partial. Her cognitive and higher executive functions were intact. The Board notes that prior to February 6, 2012, the Veteran does not have total occupational and social impairment due to her PTSD. The Veteran also did not experience 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 worklike setting), or inability to establish and maintain effective relationships. The VA examiner in October 2009 specifically noted that the Veteran’s PTSD signs and symptoms were transient or mild, which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. The Board finds that the Veteran’s occupational and social impairment more closely approximates the criteria for a 50 percent disability rating prior to February 6, 2012. From February 2012 forward, the Veteran’s PTSD was rated at 70 percent. To receive a higher disability rating, the evidence must show 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. 38 C.F.R. § 4.130. The Veteran was afforded another VA examination in February 2012. The examiner noted a diagnosis of PTSD, depressive disorder NOS, and personality disorder NOS. The examiner noted that the Veteran’s disability resulted in occupational and social impairment with reduced reliability and productivity. The Veteran reported significant deficits in interpersonal functioning. The estimated decline in functioning since the 2009 VA examination was mild. The Veteran reported that she did not get along with her neighbors and had a great deal of interpersonal conflict within the home with her two teenage children. She had limited interactions with her family. The Veteran has disengaged from church services and activities. The Veteran has consistently reported moderate to severe levels of anxiety and depression. Current symptoms included avoidance behaviors, hyperarousal, intrusive recollections, depressed mood, intermittent passive suicidal ideation, anhedonia, amotivation, anergia, irritability, problems with concentration and memory, poor sleep, inconsistent attendance to personal hygiene, and once weekly panic attacks. The examiner also noted irritability or outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated startle response. The Veteran had depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, disturbance of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or worklike setting, suicidal ideation, and neglect of personal appearance and hygiene. The Veteran was casually dressed. Her grooming appeared adequate. She was cooperative and attentive. She presented as emotionally labile, anxious, and dramatic. She was alert and oriented to person, place, and time. Her speech was spontaneous, articulate, and normal in rate and tone. Her thought process and content were generally coherent and relevant with no flight of ideas, disorganization, bizarre delusional content, or hallucinations. Suicidal and homicidal ideations were denied. Her remote and working memory appeared within normal limits. Insight and judgment were limited. The VA examiner in October 2014 diagnosed PTSD, other specified personality disorder, and other specified depressive disorder. The Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The Veteran’s daughter continued to live with her and they got along well. Her relationship with her son was strained. She maintained infrequent contact with her parents. She stated that she has one friend, a neighbor, whom she is beginning to get to know. The Veteran rarely left the house outside of driving her daughter back and forth to work. She reported difficulty with sleep. The Veteran denied a history of suicide attempts, but did acknowledge struggling with occasional episodes of passive suicidal ideation. She acknowledged onset of picking behavior during the prior year. She noted problems with memory. She noted periods of time where she had no motivation to shower occurring about four times per year. The examiner noted recurrent, involuntary, and intrusive distressing memories and dreams, as well as intense or prolonged psychological distress and physiological reactions to internal or external cues. The Veteran noted persistent avoidance, persistent and exaggerated negative beliefs or expectations, persistent negative emotional state, markedly diminished interest or participation in significant events, and feelings of detachment or estrangement. The Veteran also exhibited irritable behavior or angry outbursts, hypervigilance, exaggerated startle response, problems with concentration, and sleep disturbance. The examiner also reported symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, inability to establish and maintain effective relationships, and suicidal ideation. The Veteran was dressed in sweatpants and a T-shirt and was malodorous. The Veteran had a large number of scabs on her face and was observed to pick at them throughout the session. Her affect was broad, intense, and notably labile. She was alert and oriented. Her speech was spontaneous, articulate, and normal in rate and tone. Her thought process and content were generally coherent and relevant with no flights of ideas, disorganization, bizarre delusional content, or hallucinations. She denied suicidal or homicidal ideations. Her remote and working memory appeared within normal limits. Insight and judgment were considered limited. May 2013 VA mental health records showed depressed mood and agitation or anxiety. The Veteran had chronically low self-esteem. The examiner noted PTSD and major depressive disorder. A February 2014 VA psychiatry note showed no suicidality, homicidality, or side effects from the medication. The Veteran was alert and oriented in all spheres. Her speech was normal, her affect full, her mood neutral, and her thought content logical and goal directed. She showed no lethality and no psychosis. The Veteran’s insight and judgment were intact. April 2015 VA treatment records showed an anxious mood and poor insight and judgment. The Veteran was oriented in all spheres. Thoughts were linear and goal-directed. Memory appeared intact. Attention and concentration appeared intact. The Veteran had no suicidal or homicidal ideation. In September 2016, the Veteran’s mood was labile. Her thoughts were generally linear and goal-oriented. She was oriented in all spheres. She spoke at an average rate and usually at an average volume. Memory appeared adequate. Attention and concentration may have been impaired. The Veteran had no suicidal or homicidal ideation. In November 2016, the Veteran’s mood was sad. Her thoughts were linear and goal-oriented. The Veteran was oriented in all spheres. She spoke at an average rate and volume. Her memory appeared adequate. Her attention and concentration appeared adequate. She showed no suicidal or homicidal ideation. In January 2018, the Veteran called the VA National Suicide Prevention Hotline. The Veteran was having negative thoughts about herself. The Veteran was very lonely. The Veteran was able to be assessed and presented with no suicidal ideation nor any suicidal attempts. The Veteran reported that she did not take her medication as prescribed. In March 2018, the Veteran’s psychiatric treatment records showed that the Veteran felt run down due to her bills and credit rating. She reported more flashbacks and nightmares. Her family was stressing her. She reported not sleeping well. Her mood was downtrodden. She was always anxious. She had no lethality or psychosis. She was alert and oriented in all spheres. Her appearance was casual. Her speech was regular and her eye contact was good. Her mood was described as down. Her affect was neutral and distressed. She had no suicidal or homicidal ideation and no psychosis. Her thoughts were coherent and her memory was intact. The Board notes that the Veteran does not have total occupational and social impairment due to her PTSD. The Veteran did not experience gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent ability to perform activities of daily living, disorientation to time or place, or memory loss for names of closest relatives, own occupation, or own name. The VA examiner in February 2012 and October 2014 noted no total occupational and social impairment, but rather found occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The Veteran’s occupational and social impairment more closely approximates the criteria for a 70 percent disability rating from February 6, 2012 forward. Throughout the entire period on appeal, the Board has considered that the symptoms listed in Diagnostic Code 9411 are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Vazquez-Claudio; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). As such, the Board notes that the Veteran experiences other symptoms that are not listed in the criteria, but may reflect the severity of her PTSD. These include, but are not limited to nightmares, flashbacks, avoidance, hypervigilance, and isolation. Specifically, the Board has also considered many of the Veteran’s symptoms as “like or similar to” the schedular rating criteria of occupational and social impairment with reduced reliability and productivity due to such symptoms as disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships or as “like or similar to” occupational and social impairment, with deficiencies in most area, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: impaired impulse control, difficulty in adapting to stressful circumstances, and an inability to establish and maintain effective relationships. See Mauerhan, 16 Vet. App. 436. The Board recognizes that the Veteran believes she is entitled to the highest available evaluation of 100 percent for her service-connected PTSD. However, at no time during the pendency of this appeal has the Veteran submitted any evidence to demonstrate that she meets the schedular criteria for the highest available evaluation of 100 percent. Namely, she has failed to provide evidence or testimony of symptomatology of such severity to result in both total occupational and total social impairment. See 38 C.F.R. § 4.71a. As such, her lay assertions fail to demonstrate that a schedular evaluation of 100 percent is warranted at any time during the pendency of this claim. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the current appeal. See 38 U.S.C. § 5107(b) (West 2014). REASONS FOR REMAND 1. Entitlement to service connection for a gynecological disability, claimed as hysterectomy with early menopause and loss of use of a creative organ secondary to venereal disease, is remanded. The VA examiner in February 2017 noted that the actual records from the medical provider leading up to the recommendation for the hysterectomy as well as the operative report and surgical pathology results from the surgical procedure were not available for review. The examiner was unable to provide further opinion in the absence of the primary source documents which show the factual etiology beyond the hysterectomy. The only indication for hysterectomy secondary to HPV would be in the setting of a diagnosis of cervical cancer, which is not supported by the available records. As the Veteran is claiming entitlement to service connection for a hysterectomy, the Board finds that the records leading up to and the operative report should be obtained prior to a decision on the merits. Should the records be obtained, an addendum opinion should be obtained. 2. Entitlement to service connection for urinary incontinence is remanded. 3. Entitlement to a TDIU is remanded. The Veteran’s claim of service connection for a hysterectomy affects the disabilities considered under her TDIU claim and may affect her claim of entitlement to urinary incontinence as the October 2014 VA examiner noted that the Veteran’s hysterectomy increases the risk of urinary incontinence; therefore, the service connection and TDIU claims are inextricably intertwined. Thus, a decision by the Board on the claim for TDIU or for urinary incontinence would, at this point, be premature. The matters are REMANDED for the following action: 1. Obtain and associate with the claim file all gynecological treatment records leading up to the recommendation for a hysterectomy and the operative report regarding the Veteran’s hysterectomy. All attempts to obtain these records should be documented in the claims file. If the records cannot be obtained, a formal finding of unavailability should be documented. 2. If the above records are obtained, obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s hysterectomy is at least as likely as not related to her military sexual trauma during service, to include any diagnosed HPV, physical trauma or other findings. A complete rationale must be provided for all opinions offered. If any opinion cannot be provided without resort to mere speculation, the examiner should fully indicate why this is the case and identify what additional evidence, if any, might allow for a more definitive opinion. If an additional examination is required for the examiner to sufficiently address the above questions, then a new examination should be afforded. 3. After undertaking the development above and any additional development deemed necessary, the Veteran’s claims regarding her hysterectomy, urinary incontinence, and TDIU should be readjudicated. If the benefits sought on appeal remain denied, the appellant and his representative should be furnished a supplemental statement of the case and be given an appropriate period to respond thereto before the case is returned to the Board, if in order. B. MULLINS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Patricia Veresink, Counsel