Citation Nr: 19119080 Decision Date: 03/15/19 Archive Date: 03/15/19 DOCKET NO. 15-34 304 DATE: March 15, 2019 ORDER Service connection for bilateral hearing loss is granted. Service connection for high blood pressure is denied. Service connection for posttraumatic stress disorder (PTSD) is granted. Service connection for cluster headaches is granted. Entitlement to an effective date prior to September 27, 2012 for the award of service connection for depressive disorder is denied. A 50 percent rating prior to February 6, 2015; and a 70 percent rating thereafter for depressive disorder is granted. REMANDED Entitlement to service connection for a right elbow disability is remanded. Entitlement to service connection for a bilateral wrist disability is remanded. Entitlement to service connection for a bilateral hip disability is remanded. Entitlement to service connection for a bilateral shoulder disability is remanded. Entitlement to an initial compensable rating for status post left 5th metacarpal fracture and left foot plantar fasciitis is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran has a current diagnosis of bilateral sensorineural hearing loss that it etiologically related to his in-service exposure to aircraft noise. 2. The Veteran has a current diagnosis of hypertension, but the evidence does not establish a nexus between the disability and his active service. 3. The Veteran has a current diagnosis of PTSD in accordance with 38 C.F.R. § 4.125(a) that is etiologically related to three in-service stressors whose occurrence is confirmed by his service treatment records. 4. The Veteran has a current diagnosis of migraine cephalgia and the evidence establishes it is secondary to his service-connected disabilities. 5. VA received a claim for a psychiatric condition on September 27, 2012. The date of receipt was recorded via date stamp. 6. Prior to February 10, 2017, the depressive disorder more nearly approximated occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal. 7. From February 10, 2017, the depressive disorder more nearly approximated occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.385. 2. The criteria for service connection for high blood pressure have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for PTSD have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 4.125. 4. The criteria for service connection for cluster headaches have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for an effective date prior to September 27, 2012 for the award of service connection for depressive disorder have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 6. The criteria for a 50 percent rating prior to February 10, 2017; and a 70 percent rating thereafter for depressive disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.16, 4.125-4.130, Diagnostic Code 9434. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Navy from August 1995 to July 1998. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from July 2012, August 2013, and December 2016 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). The appeal previously included a claim for dependency benefits for the Veteran’s mother. This claim was granted in a December 2017 decision. It is no longer before the Board. In December 2018, the Veteran’s representative submitted a waiver of initial consideration of all new evidence by the agency of original jurisdiction (AOJ). 38 C.F.R. § 20.1304(c). The Veteran asserts there was clear and unmistakable error (CUE) in an August 2013 rating decision that assigned an initial rating for depressive disorder. The Board notes, however, that the August 2013 rating decision which assigned the initial rating is not final. Hence, it cannot be reversed or revised via a CUE motion, and the Board can take no further action on the CUE assertion at this time. See 38 C.F.R. § 3.105; Link v. West, 12 Vet. App. 39, 45 (1998) (where a rating decision is rendered nonfinal by the appellant’s timely appeal to the Board, a claim of CUE does not exist, as a matter of law, as to that RO decision.). The generalized assertion of CUE is, therefore, dismissed. See, e.g., Simmons v. Principi, 17 Vet. App. 104, 111-15 (2003). The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). 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. Service connection may also be granted for a disability that is proximately due to or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310. 1. Entitlement to service connection for bilateral hearing loss The Veteran seeks service connection for bilateral hearing loss. For the reasons that follow, the Board finds that service connection is warranted. The Veteran has a current diagnosis of bilateral sensorineural hearing loss. Objective test results confirm his hearing impairment is considered a disability for VA purposes. 38 C.F.R. § 3.385; see, e.g., November 2018 VA examination report. The Veteran contends his hearing loss is related to exposure to aircraft noise serving on the flight deck of the USS Constellation. His military personnel records (MPRs) show he served as an electrical/mechanical equipment repairman and confirm his service on the flight deck of the USS Constellation. As there is a high probability of noise exposure associated with such service, an in-service incurrence of military noise exposure is conceded. The Veteran’s February 1995 entrance examination and May 1998 separation examination included audiometric testing for hearing loss. Both examination reports showed hearing within normal limits, bilaterally. On the Report of Medical History, the Veteran completed with each examination, he also marked “no” to hearing loss. In August 2013 and November 2018 VA examiners provided opinions concerning the etiology of his current hearing loss. The August 2013 VA examiner opined that the Veteran’s hearing loss was less likely than not related to his active service. The examiner reasoned that while the Veteran was exposed to hazardous noise levels during service, audiometric testing at the time of discharge from service showed normal hearing. No further explanation was provided. As VA regulations do not preclude service connection for a current hearing disability where hearing was within normal limits on audiometric testing at separation from service, the August 2013 opinion is inadequate for rating purposes and afforded no probative value. Hensley v. Brown, 5 Vet. App. 155 (1993). The November 2018 VA examiner opined that the Veteran’s hearing loss was at least as likely as not related to his active service. The examiner reasoned that the Veteran’s current hearing loss was of mild-to-moderate severity and consistent with his reports of exposure to extreme noise during service. This opinion is adequate for rating purposes, and the Board finds it probative based on consideration of the current severity of hearing loss relative to the in-service noise exposure. Accordingly, the competent evidence of record weighs in favor of a nexus between the Veteran’s current hearing loss and his in-service noise exposure. In sum, the Veteran has current bilateral sensorineural hearing loss that is related to his in-service exposure to aircraft noise. Service connection for bilateral sensorineural hearing loss is warranted. 2. Entitlement to service connection for high blood pressure The Veteran seeks service connection for high blood pressure. For the reasons that follow, the Board finds that service connection is not warranted. The Veteran has a current diagnosis of hypertension. See, e.g., VA treatment record (1/28/2015). The Veteran’s blood pressure was measured at least 19 times during active service, with elevated systolic readings appearing in October 1996, November 1996, January 1998, and on separation examination in May 1998. The Veteran was not diagnosed or treated for elevated blood pressure during service, and he marked “no” to high or low blood pressure on the Report of Medical History completed with the separation examination. Post-service medical records show blood pressure within normal limits from 2004 to 2012. There were several elevated systolic readings in the range of 130-132, two occurring in 2008 and one occurring in 2010; however, those levels are considered pre-hypertensive. A May 2013 printout from MyHealth.VA.gov shows the Veteran was prescribed Verapamil HCL medication on May 1, 2013, and the Veteran annotated on the printout that this was a new medication for high blood pressure. Review of the May 1, 2013 VA treatment record shows this medication was for prophylaxis, in other words, it was a preventative measure. In July 2013, a prescription of Lisinopril was added because the Veteran was not achieving his blood pressure goals on Verapamil alone. Another July 2013 VA treatment record showed a past medical history of hypertension with onset in 2003. The Board finds this record to be outweighed by the other evidence of record, which shows the Veteran had normal blood pressure during that time. Based on review of the evidence of record, the Board finds there is not a nexus between the Veteran’s current hypertension and his active service. The evidence shows four elevated systolic readings during service; however, the Veteran was never diagnosed with or treated for hypertension. On discharge from service he indicated that he did not have problems with high or low blood pressure. He was prescribed Verapamil in 2013 as a preventative measure. It is apparent from the records that the disease onset over a decade after his discharge from active service in 1998. There is no competent evidence relating the condition to his active service. The Board notes that the Veteran did have training as a nurse assistant from September 1998 to December 1998. The training and responsibilities of a nursing assistant generally involve helping patients with activities of daily living and other healthcare needs under the direct supervision of a registered nurse. The training and expertise attained through such a program are not sufficient to allow him to competently answer a complex medical question concerning the etiology of a disease, particularly hypertension, an internal disease process. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007); Certified Nursing Assistant, https://nurse.org/resources/certified-nursing-assistant-cna/ (last accessed 2/24/2019). While the Veteran has a current diagnosis of hypertension and in-service readings of elevated systolic pressure, there is no indication that his current disability is related to those readings, or his active service in general. Thus, VA does not have a duty to assist him in substantiating his claim by providing a medical examination or opinion. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). In the absence of a nexus between the current diagnosis of hypertension and active service, the elements of service connection have not been met. Service connection for high blood pressure is not warranted. 3. Entitlement to service connection for posttraumatic stress disorder The Veteran seeks service connection for PTSD. For the reasons that follow, the Board finds that service connection is warranted. Service connection for PTSD requires (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) a link, established by medical evidence, between current symptoms and an in-service stressor; and (3) credible supporting evidence that the in-service stressor occurred. 38 C.F.R. § 3.304(f). The Veteran asserts three in-service stressors. See, e.g., July 2013 VA Form 21-0781. First, he was in a motor vehicle accident where his vehicle was run over by a semi-tractor trailer. Second, while serving on the flight deck of the USS Constellation, the hydraulic system, designed to catch landing aircraft, malfunctioned and the cable whipped around. He went to catch the cable with the push pole, but the force of the cable caused the handle of the push pole to strike his body, knocking him to the ground. Third, while serving on the USS Constellation, he fell about 10 feet down a ladder from one deck to another, breaking his ankle and parts of his foot. The Board notes that all three incidents are documented in the Veteran’s service treatment records (STRs); thus, their occurrence is established. In July 2013, the Veteran underwent a psychiatric evaluation in connection with a claim for disability benefits from the Social Security Administration (SSA). He reported the same three traumatic in-service incidents described above. The examining psychiatrist found the Veteran did have moderate symptoms of PTSD secondary to his traumatic events in service. Descriptions of these symptoms were provided in the examination report. A diagnosis of PTSD was provided. In August 2013, the Veteran underwent a VA examination. He again reported the same three traumatic in-service experiences described above. The examiner opined that it was less likely than not that the Veteran developed PTSD related to these incidents because he did not report any psychological difficulties at the time of the injuries or at discharge from service and was never treated for psychological difficulties related to these incidents during service. The medical evidence pertaining to the diagnosis of PTSD and nexus between the corroborated stressors and PTSD diagnosis are in relative equipoise. In sum, the Veteran has a current diagnosis of PTSD, three established in-service stressors, and resolving reasonable doubt in his favor, medical evidence supporting a link between his PTSD and those stressors. Accordingly, service connection for PTSD is warranted. 4. Entitlement to service connection for cluster headaches The Veteran seeks service connection for cluster headaches. For the reasons that follow, the Board finds that service connection is warranted. In April 2013 correspondence, the Veteran reported that he began having cluster headaches the prior month while on physical therapy. A May 2013 VA treatment record confirms a diagnosis of migraine cephalgia. In May 2018, Dr. H.S. completed a Migraine and Migraine Variants Disability Benefits Questionnaire (DBQ). The Veteran reported he has at least five headaches per week brought on by neck pain, back pain, and stress caused by his PTSD. The private doctor opined that his headaches were at least as likely as not caused and permanently aggravated by the service-connected neck, back, and PTSD. The doctor’s opinion was based on the Veteran’s interview, a review of the claims file, and a medical study which determined that mental health disorders can both cause and aggravate headaches. The Board finds the May 2018 medical opinion to be probative because it applied relevant medical literature to the Veteran’s credible complaints regarding onset of headaches. This is the only competent evidence of record concerning an etiological connection between the Veteran’s headaches and his service connected disabilities. The Board has granted service connection for PTSD in the instant appeal. Accordingly, the evidence weighs in favor of a nexus based on a secondary theory of entitlement. Service connection for headaches is warranted. 38 C.F.R. § 3.310. Effective Date Generally, “the effective date of an award based on an original claim, a claim reopened after final adjudication, or a claim for increase, of compensation, dependency and indemnity compensation, or pension, shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor.” 38 U.S.C. § 5110(a). The effective date for an award based on an original claim of compensation shall be the “[d]ay following separation from active service or date entitlement arose if [the] claim is received within 1 year after separation from service; otherwise, date of receipt of claim, or date entitlement arose, whichever is later.” 38 C.F.R. § 3.400(b)(2)(i). 5. Entitlement to an effective date prior to September 27, 2012 for the award of service connection for depressive disorder The Veteran seeks an effective date prior to September 27, 2012 for the award of service connection for depressive disorder. For the reasons that follow, the Board finds that an earlier effective date is not warranted. The Denver, Colorado, RO received a VA Form 9 on September 27, 2012. The date of receipt was confirmed via date stamp. The filing included a new claim of service connection for PTSD, and an attached letter from the Veteran. The attached letter indicated that the claim for PTSD was a new claim. The Veteran indicated that he did not add the claim earlier because he thought that VA was going to take care of him, but he was wrong. Review of the record shows no earlier claim, formal or informal, for a psychiatric disorder. In an August 2013 rating decision, the RO awarded service connection for depressive disorder. The effective date of service connection was set to September 27, 2012, the date of receipt of the claim for PTSD. In sum, the current effective date of service connection for depressive disorder is September 27, 2012. This is the date of receipt of the claim, and it is the earliest effective date allowed under VA law and regulations. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(b)(2)(i). There is no doubt to be resolved in the Veteran’s favor. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. An effective date prior to September 27, 2012 for the award of service connection for depressive disorder is not warranted. Increased Rating Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 6. Entitlement to an initial rating in excess of 30 percent for depressive disorder The Veteran seeks an initial rating in excess of 30 percent for depressive disorder. The relevant appeal period before the Board is from September 27, 2012, the effective date of the award of service connection. For the reasons that follow, the Board finds that a 50 percent rating is warranted prior to February 10, 2017, and a 70 percent rating is warranted thereafter. The Veteran’s depressive disorder has been evaluated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Diagnostic Code (DC) 9434. Under the General Rating Formula, a 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more often 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. Id. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation, obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The rating of psychiatric disorders is ultimately based upon their resultant level of occupational and social impairment. 38 C.F.R. § 4.130; Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117-18 (2013). The evaluation, however, is symptom-driven, meaning that the symptomatology should be the fact-finder’s primary focus in determining the level of occupational and social impairment. Vazquez-Claudio, 713 F.3d at 116-17. This includes consideration of the frequency, severity, and duration of those symptoms. 38 C.F.R. § 4.126(a); Vazquez-Claudio, 713 F.3d at 117. Significantly, however, the symptoms enumerated in the rating criteria are merely examples of those that would produce such level of impairment; they are not exhaustive, and VA is not required to find the presence of all, most, or even some of the enumerated symptoms to assign a particular evaluation. Vazquez-Claudio, 713 F.3d at 115; Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). If the Board finds that the Veteran suffers from symptoms of similar severity, frequency, and duration that cause occupational and social impairment equivalent to that which would be produced by the specific symptoms enumerated in the rating criteria, then the appropriate equivalent rating will be assigned. 38 C.F.R. 4.21; Mauerhan, 16 Vet. App. at 443; see also Vazquez-Claudio, 713 F.3d at 117. VA intends the General Rating Formula to provide a regulatory framework for placing veterans on a disability spectrum based on their objectively observable symptoms. Vazquez-Claudio, 713 F.3d at 117 (emphasis added). Accordingly, in evaluating the Veteran’s disability the Board will place great probative value on the Veteran’s observable symptoms as demonstrated in clinical treatment notes and mental status evaluation. The Board notes that this claim for increase was pending before the AOJ on or after August 4, 2014. Therefore, the Board finds that the DSM-5 applies to the current appeal. See 53 Fed. Reg. 14308 (March 19, 2015); 38 C.F.R. §§ 3.384, 4.125, 4.126, 4.127, 4.130. Accordingly, the Board’s adjudication of this claim cannot include any discussion of the Global Assessment of Functioning (GAF) scores found in the record. Golden v. Shulkin, 29 Vet. App. 221 (2018). The Board also notes that the Veteran has additional psychiatric diagnoses of alcohol abuse and PTSD. The evidence does not allow for the symptoms and functional effects of these conditions to be separated from those of the depressive disorder; thus, all of the Veteran’s psychiatric symptomology will be considered in this evaluation. Mittleider v. West, 11 Vet. App. 181 (1998). Based on consideration of all evidence of record, the Board finds that the Veteran’s depressive disorder should be rated 50 percent prior to February 10, 2017, and 70 percent thereafter. The Board will address these staged ratings in order. Period prior to February 10, 2017 Review of the claim file reflects that prior to February 2017, the symptomology associated with the Veteran’s depressive disorder more closely approximated the level of social and occupational impairment contemplated by a 50 percent rating. Indeed, the evidence showed the Veteran had symptoms of impaired judgment (related to his struggles with alcoholism), regular disturbances of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. The August 2013 and October 2014 VA examinations noted flattened affect, though this symptom was not present on any mental status examination conducted during the period. The October 2014 VA examination report also noted impairment of short- and long-term memory. While the evidence during this period contained subjective complaints of memory impairment, it was not shown on mental status examination. With regard to the enumerated symptomology corresponding to a 70 percent rating, there was evidence of suicidal ideation, impaired impulse control, difficulty adapting to stressful circumstances, and an inability to establish and maintain effective relationships. Suicidal thoughts were mentioned twice by the Veteran. See VA treatment records (8/13/2013, 5/2/2014). The first time, he mentioned that he had thoughts of not wanting to live. These related to his problems with drinking and separation from his spouse. The second time, he mentioned that his physical pains get so bad sometimes he wishes he were not alive. Both instances are considered suicidal ideation under the rating criteria. Bankhead v. Shulkin, 29 Vet. App. 10 (2017). However, there was no apparent social or industrial impairment related to this infrequent symptomology which occurred without any associated intent or plan. Impaired impulse control was present throughout this period. The evidence regularly showed the Veteran’s difficulty with irritability and anger, to a moderate degree. There was no associated fighting or physical outbursts. This symptom also manifested in connection with the Veteran’s tendency to deal with stress via alcohol. His alcoholism did have a serious impact on his social functioning, leading to separation and eventual divorce from his spouse. The impact of this symptom on occupational functioning would be more limited, with the October 2014 examiner opining that the Veteran would have difficulty working with others, in part, due to being irritable, non-communicative, and angry. Difficulty adapting to stressful circumstances was also present throughout this period. The Veteran dealt with stress via drinking alcohol. He also clearly showed this symptom in dealing with the separation and divorce from his spouse. This emotional event caused increased symptomology such as isolation, depression, anxiety, anger, sleep impairment, and, as noted above, impaired impulse control and suicidal ideation. As this symptom presented itself in response to the Veteran’s marital strife and his reaction to that situation, there was no clear effect on occupational functioning. An inability to establish and maintain effective relationships was noted on the October 2014 VA examination report, generally without explanation. A review of the evidence during this period clearly showed the Veteran had marital problems and few, if any, friends. He did retain a good relationship with his three children. Mental status examinations throughout this period showed him to have a good attitude and be cooperative. A July 2013 psychiatric evaluation completed in connection with a claim for SSA benefits showed a clinician described him to have mild to moderate limitations in social functioning and he would be capable of accepting instructions from a supervisor and interacting with co-workers and the public. The August 2013 VA examiner opined that his social functioning was impaired by alcohol abuse and mildly impaired by withdrawal or isolation. Based on consideration of all evidence of record, the Board does not find the Veteran’s depressive disorder manifested in the symptom of inability to establish and maintain effective relationships. While it was noted on the October 2014 examination report, other evidence during the period showed that he maintained social relationships with his children and, though he shied away from it, was capable of creating effective relationships with others, to include in a work-like setting. With regard to the enumerated symptomology seemingly corresponding to a 100 percent rating, there was one instance where the Veteran reported occasional hallucinations, audio and visual in nature, described as hearing noises and seeing shadows. See VA treatment record (3/4/2013). The Board notes, however, that this symptom was not “persistent” as required by the rating criteria and manifested in no apparent effect in social or occupational functioning. During this portion of the appeal period, the Veteran’s depressive disorder also manifested with symptoms corresponding to a rating less than 50 percent. These included depressed mood, anxiety, chronic sleep impairment, subjective mild memory loss, hypervigilance and exaggerated startle response, flashbacks, and subjective difficulty with concentration. With regard to overall functioning during this period, the Veteran’s social impairment was much greater than his occupational impairment. He presented with increased isolation and withdrawal from social activities, as well as increased anger, irritability, and alcohol use. The symptoms he showed corresponding to ratings in excess of 50 percent generally manifested in social impairment. Their effects on occupational functioning were minimal, most of the impact resulting from impaired impulse control. Moreover, both the August 2013 and October 2014 VA examiners opined the depressive disorder was productive of reduced reliability and productivity, equivalent to the criteria corresponding to a 50 percent rating. The Board does not disagree with these opinions given the limited occupational impact of the symptoms corresponding to a rating in excess of 50 percent. From February 2015 to February 2017 there continued to be evidence of symptomology (i.e. impaired judgment, disturbance of motivation and mood, and difficulty in establishing and maintaining effective relationships) that more nearly approximated a 50 percent rating. Impaired judgment once more appeared due to problems with alcohol abuse, though this was much less frequent. E.g., VA treatment record (10/21/2015) (admitted to drinking a 6-pack of beet once in a week and getting drunk), (3/3/2016) (drank only one 40-ounce beer once in a month), (4/29/2016) (reported still drinking periodically, last time two weeks ago), (6/17/2016) (admitted drinking a 6-pack of beer on his birthday nine days ago). Not only was there reduced frequency, there was no apparent impact on social or occupational functioning. The Veteran continued to exhibit a disturbance of motivation and mood throughout this period; however, it was much improved. He frequently reported to treating physicians that he was doing better, feeling less depressed, and his motivation was improved. He was going to the gym and worked to improve the relationship with his 16-year-old son, which had deteriorated. He also related that he was sleeping much better. Given the forgoing, the Board finds that this symptom was present, but it was of a lesser degree of severity with limited functional impact. The Veteran also continued to exhibit difficulty establishing and maintaining effective relationships. He continued to isolate. He was more involved with his kids, effectively acting as daycare for his ex-wife while she was at work and taking his kids to school. He also worked to repair a fractured relationship with his 16-year-old son, which was effective to some degree, but he admitted that he still had to spend more time with his son. Given the forgoing, the Board finds that this symptom was present, but it was of a lesser degree of severity with limited occupational impact. With regard to the enumerated symptomology corresponding to a 70 percent rating, there was evidence of impaired impulse control and difficulty adapting to stressful circumstances. Impaired impulse control showed with his irritability and anger. There was one instance where he reported to a treating physician that he gets argumentative (described as getting loud, without fighting or making threats), but throughout the period he generally reported that his temper was under better control and he was feeling less irritable and argumentative. In May 2016 he related that he only got into an argument once a week or less. Given the forgoing, the Board finds the severity and frequency of this symptom to be decreased and its effect on social and occupational functioning to be less as well. Difficulty adapting to stressful circumstances related to the Veteran’s continued adjustment to divorce. In this regard, this symptom continued to be present; however, the Veteran related that he was coping much better and the ability to spend time with his children was helpful as well. The Board finds this symptom to be of limited severity during this period and affecting his social functioning not occupational functioning. There was no evidence of enumerated symptomology corresponding to a 100 percent rating during this period. The Board believes with regard to overall functioning, the Veteran appeared somewhat improved between February 2015 and February 2017. The Veteran reported depression, anxiety, and chronic sleep impairment symptoms were improved, with lesser severity and frequency. Nonetheless, his depressive disorder continued to manifest in some symptoms corresponding to 50 and 70 percent ratings; however, there were less of these types of symptoms present and those which did appear were less severe and produced limited social and occupational effects. Even his symptoms of depressed mood, anxiety, and chronic sleep impairment, whose presence had been constant with his depressive disorder, were of less severity and frequency. The Veteran took meaningful steps to be more active (e.g., go to the gym) and to improve relationships with his family members. The Board does recognize that towards the end of 2016 his relationship with his ex-wife took a downward turn, resulting in frequent court visits and a restraining order and allegations from her that he was abusive to their children. While such information is serious, there was not a clear indication that his symptomology or social or occupational functioning decreased concurrently. Overall, the Board finds the Veteran’s disability more nearly approximated the criteria corresponding to a 50 percent rating for the entire period prior to February 10, 2017. While some symptoms corresponding to higher ratings were present, they were of limited severity and functional effect as it related to the Veteran’s occupational and social functioning. For these reasons, a 50 percent rating, and no higher, is assigned for the depressive disorder prior to February 10, 2017. Period Beginning February 10, 2017 From February 10, 2017, the Veteran’s depressive disorder worsened as his relationship with his spouse and children ended and he moved out-of-state to Phoenix, Arizona. During this portion of the appeal period, his depressive disorder more nearly approximated the criteria corresponding to a 70 percent rating, but not higher. This is the first point where it was factually ascertainable that worsening had occurred, and to an overall degree that more closely corresponded to a 70 percent rating. Swain v. McDonald, 27 Vet. App. 219, 224 (2015). With regard to the enumerated symptomology corresponding to a 70 percent rating, there is various evidence showing suicidal ideation, near-continuous depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control, neglect or personal appearance and hygiene, difficulty adapting to stressful circumstances, and inability to establish and maintain effective relationships. An August 2018 Disability Benefits Questionnaire (DBQ) completed by a private psychiatrist also noted a symptom of intermittently illogical, obscure, or irrelevant; however, no mental status examination was included in the examination report and all other treatment records during this period described his thought content and process as normal, insight as good, and speech was described as normal in all instances but one, where it was described as impoverished. The Board finds those findings to outweigh the unsupported symptom noted on the August 2018 DBQ based on their objectivity and frequency. With regard to the enumerated symptomology corresponding to a 100 percent rating, there is evidence of gross impairment of thought process or communication, hallucinations, and intermittent inability to perform activities of daily living. The symptom of gross impairment of thought process or communication was noted on an August 2018 Disability Benefits Questionnaire (DBQ) completed by a private psychiatrist. There was no example of this symptom provided. The examination report contained no mental status examination. All other treatment records during the relevant period showed the Veteran’s thought content and process was normal on examination and speech generally normal, though one instance where it was described as impoverished. The Board places greater weight on those treatment records based on their frequency and objective observation of the Veteran and finds that they outweigh the August 2018 DBQ notation. Thus, the Veteran did not have gross impairment of thought process or communication. Hallucinations were noted at several points during this period. During VA treatment in October 2017, the Veteran reported seeing visual hallucinations of angels who told him everything was going to be ok and also other people who had died, e.g., his grandmother, grandfather, and others, who had conversations with him and laughed at him for seeing people who were not actually there. He also reported hearing voices that said everything was going to be ok and that people are mean. A May 2018 evaluation by a private psychiatrist showed the Veteran experiences visual and auditory hallucinations in which he sees people, colors on the wall, and hearing derogatory or distorted voices. An August 2018 DBQ completed by a private psychiatrist showed the Veteran had persistent delusions and hallucinations, without further explanation. Contrary to these findings, all other medical records during the appeal period showed the Veteran was without delusions or hallucinations and presented with normal thought content, process, and insight. Given the forgoing, the Board finds that the Veteran did experience hallucinations during this period, but their frequency was not persistent. The May 2018 evaluation by a private psychiatrist and August 2018 DBQ completed by a different private psychiatrist showed that the Veteran had an intermittent inability to perform activities of daily living. The May 2018 evaluation expanded on this finding, noting that the Veteran has no motivation or energy. He admitted his mother performs nearly all the household tasks such as grocery shopping, cooking, cleaning, and helps manage his finances. He reported he lays in bed most days and watches TV or naps and does not leave home except for doctor appointments or absolute necessities. The August 2018 DBQ was consistent in stating that his mother helps manage his finances as he tends to overspend. Weighing against this symptom is the fact that the Veteran moved to Phoenix, Arizona, to be closer to his family and lives with his mother. He does not have his own household such that he would necessarily be expected to perform activities such as grocery shopping, cooking, or cleaning on his own. Moreover, the May 2018 examination report was authored in such a way as to attribute his lack of doing such activities to his depression and lack of motivation, while the Veteran did not actually say that was the case. Accordingly, the Board will accept that this symptom is present; however, it places less probative value on its severity, as related by these reports. During this period, the Veteran presents with two symptoms corresponding to a rating in excess of 70 percent. One of those symptoms is hallucinations, and their occurrence is less frequent. The other symptom is an intermittent inability to perform activities of daily living, and its severity is adjudged to be less than is generally alleged in the two examination reports in which it appeared. The evidence does not show that he has been unable to maintain a relationship with his mother, and he has generally been involved and compliant with VA treatment for his other non-psychiatric conditions, indicative of some motivation to continue to better himself. Those records also showed the Veteran was working on exercising and eating better, again indicative that he is trying to better himself. The August 2018 DBQ showed the private psychiatrist opined the Veteran’s depressive disorder results in deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. The Board generally agrees with this assessment based on the level of the Veteran’s symptomology and his apparent social and occupational impairment. The May 2018 psychiatric evaluation asserted that the Veteran’s depressive disorder would preclude him from the ability to secure and maintain substantially gainful employment. The examiner generally identified a number of symptoms corresponding to a rating of 70 percent or less and explained how they would affect his employability. At this time, the Board makes no determination as to whether the depressive disorder would preclude the Veteran from substantially gainful employment, as that will be considered in the claim for TDIU, which is discussed in the REASONS FOR REMAND section below. The Board does note that the evaluation of a psychiatric disorder is symptom-driven, and in that regard, the vast majority of symptoms described in the May 2018 evaluation did not correspond with those that are enumerated in the 100 percent criteria or would otherwise approximate such symptomology. Vazquez-Claudio, 713 F.3d at 116-17. Given the minimal symptomology corresponding to a 100 percent rating and its limited frequency and/or severity, the Board finds that the Veteran’s depressive disorder does not more nearly approximate such a rating. His resultant social and occupational impairment, as discussed above, is also in agreement. The Board also notes that the effective date of February 10, 2017 for the increased 70 percent rating was chosen based on a treatment record of the same date that showed the Veteran’s affect was very flat, his speech impoverished, and the examiner noted he was in some kind of emotional distress. During that visit, the Veteran noted he was moving away to Phoenix, Arizona, leaving his ex-wife and children. Treatment records from later on in 2017 confirmed that he had moved to Phoenix, Arizona, and he began to experience an increase in symptomology. While there were indications in the latter part of 2016 that this familial relationship was ending, this was the first point where it was factually ascertainable that the Veteran’s psychiatric functioning had deteriorated in response to this event. Swain, 27 Vet. App. at 224. In sum, the Veteran’s depressive disorder does warrant an increased evaluation, to 50 percent, but no higher, prior February 10, 2017; and 70 percent, but no higher, thereafter. REASONS FOR REMAND 1. Entitlement to service connection for a right elbow disability is remanded. 2. Entitlement to service connection for a bilateral wrist disability is remanded. 3. Entitlement to service connection for a bilateral hip disability is remanded. 4. Entitlement to service connection for a bilateral shoulder disability is remanded. The Veteran seeks service connection for disabilities of the right elbow, bilateral wrists, bilateral hips, and bilateral shoulders. Remand is required to afford him an examination. The Veteran contends all of his joints have degenerative arthritis and are related to three in-service incidents: (1) a motor vehicle accident wherein his vehicle was hit by a semi-tractor trailer; (2) a hydraulic system malfunction on the flight deck of the USS Constellation where a cable meant to catch landing aircraft whipped into his push pole, causing the handle of the push pole to strike his body and knock him to the ground; and (3) a 10 foot fall down a ladder connecting two decks on the USS Constellation. Medical records show the Veteran’s shoulders have degenerative arthritis and his right shoulder also has a SLAP tear. VA treatment records (8/15/2012, 7/16/2014). His left wrist has no specific diagnosis and his right wrist has carpal tunnel syndrome. VA treatment record (10/1/2014). His left and right hips have no specific diagnoses. He also has possible diagnoses of fibromyalgia and chronic pain syndrome. Remand is required to schedule an examination to determine the nature and etiology of these problems. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The Board also recognizes the Veteran’s MPRs show he was stationed aboard the USS constellation during its deployment to WESTPAC/Arabian Gulf. See Evaluation report for January 1997 to July 1997. Thus, the Veteran is considered a Persian Gulf veteran, and it must be considered whether any of his joint problems are resulting from an undiagnosed illness or from a diagnosable but medically unexplained multi-symptom illness of unknown etiology. 38 C.F.R. § 3.317(a)(2). The medical examination and opinion obtained on remand will consider this as well. 5. Entitlement to an initial compensable rating for status post left 5th metacarpal fracture and left foot plantar fasciitis. The Veteran seeks an initial compensable rating for status post left 5th metacarpal fracture and left foot plantar fasciitis. Remand is required for reexamination. The Veteran’s left foot condition was evaluated in a July 2012 VA examination. More recent evidence is scarce. VA treatment records generally show the Veteran has a bony mass over the base of the 5th metatarsal, a small exostosis in the same location, increasing pain, and degenerative changes in other areas of the foot, though it is unclear if they are related. Given a paucity of evidence, the Board does not have a clear picture of the current severity of the service-connected disability. Accordingly, reexamination is warranted. 38 C.F.R. § 3.327(a). 6. Entitlement to a total disability rating based on individual unemployability The Veteran seeks entitlement to a TDIU. The relevant appeal period is from July 27, 2011 onward. His compensation record shows that, at this time, a schedular evaluation is appropriate only from September 27, 2012, and prior to that time extraschedular consideration would be required. The Board is, however, remanding a claim for increase for his left foot disability, the appeal period for which dates back to July 27, 2011. Moreover, the remanded claims of service connection for right and left shoulder disabilities also date back to July 27, 2011 and could afford him a higher combined evaluation if granted. Accordingly, the Board finds that the claim of entitlement to a TDIU to be inextricably intertwined, and its adjudication is deferred. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following actions: 1. Obtain and associate with the claims file all outstanding VA treatment records. 2. Schedule a VA Gulf War examination to determine the current nature and etiology of the Veteran’s right elbow, right and left wrist, right and left hip, and right and left shoulder disabilities. The examiner must review the entire claims file, to include a copy of this REMAND, in conjunction with the examination. The examiner is asked to provide responses to the following: A) Identify the disabilities of the right elbow, right and left wrist, right and left hip, and right and left shoulder. The Board’s review of the file indicates medical records show the Veteran’s shoulders have degenerative arthritis and his right shoulder also has a SLAP tear. VA treatment records (8/15/2012, 7/16/2014). His left wrist has no specific diagnosis and his right wrist has carpal tunnel syndrome. VA treatment record (10/1/2014). His left and right hips have no specific diagnoses. He also has possible diagnoses of fibromyalgia and chronic pain syndrome. The above diagnoses should be confirmed or ruled out. If ruled out, a clear explanation should be provided. B) For each diagnosed disability, is it at least as likely as not (a 50 percent or greater probability) that it was incurred in, or is otherwise related to, the Veteran’s active service? The examiner should note the Veteran has related the occurrence of these injuries to his three in-service accidents, as described in the REASONS FOR REMAND section above. C) For any arthritis diagnosed, is it at least as likely as not that such onset within a year of service discharge? D) If a nexus cannot be established for any abnormality, please provide an opinion as to whether the disability pattern is consistent with (1) an undiagnosed illness; (2) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology; (3) a diagnosable chronic multisymptom illness with a partially explained etiology; or (4) a disease with a clear and specific diagnosis and etiology. A complete rationale must be provided for all opinions expressed. 3. Schedule the Veteran for a VA examination to determine the current severity of his status post left 5th metacarpal fracture and left foot plantar fasciitis. The examiner must review the claims file. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Mike A. Sobiecki, Associate Counsel