Citation Nr: 19112387 Decision Date: 02/19/19 Archive Date: 02/19/19 DOCKET NO. 14-32 096 DATE: February 19, 2019 ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for hypertension, to include as secondary to post-traumatic stress disorder (PTSD), is granted. Entitlement to service connection for migraines, to include as secondary to PTSD, is granted. Entitlement to a 50 percent rating, but no higher, for PTSD is granted. FINDINGS OF FACT 1. The Veteran does not have a hearing loss disability as defined by VA regulation. 2. The Veteran’s hypertension is aggravated by his service-connected PTSD. 3. The Veteran’s migraine headaches are aggravated by his service-connected PTSD. 4. The Veteran’s PTSD manifested with symptoms of irritability, hypervigilance, anger, nightmares, flashbacks, sleep impairment, and avoidance, and were controlled by medication causing social and occupational impairment with reduced reliability and productivity. The Veteran’s symptoms did not cause occupational and social impairment with deficiencies in most areas or total impairment. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.385 (2018). 2. The criteria for entitlement to service connection for hypertension, to include as secondary to PTSD, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310 (2018). 3. The criteria for entitlement to service connection for migraines, to include as secondary to PTSD, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310 (2018). 4. The criteria for a 50 percent rating, but no higher, for PTSD, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.7, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from September 1998 to February 1999, and from September 2002 to April 2006. As an initial matter, the Board notes that evidence has been added to the record since the last Supplemental Statement of Case (SSOC) was issued; however, the Veteran’s representative submitted a waiver of AOJ review. Thus, the Board may proceed with adjudication of the Veteran’s claims. Additionally, the Board notes that the Veteran was scheduled for a VA examination in August 2017. In February 2018, the Veteran reported that he did not receive notification of the examination and requested a rescheduling. However, in a December 2018 correspondence, the Veteran’s representative waived the request to reschedule the Veteran’s examinations. As such, the Board will proceed with adjudication of the Veteran’s claims based on the evidence of record. Increased Rating Entitlement to a rating greater than 10 percent for PTSD. Disability ratings are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2018). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical, as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10 (2018). 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. See 38 C.F.R. § 4.7 (2018). Reasonable doubt regarding the degree of disability will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3 (2018). Separate ratings can be assigned for separate periods of time based on facts found, a practice known as “staged” ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran’s service-connected disability. 38 C.F.R. § 4.14 (2018); see Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102 (2018). The Veteran’s PTSD has been evaluated as 10 percent disabling for the entire period on appeal under Diagnostic Code 9411. Diagnostic Code 9411 uses the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2018). Under the General Rating Formula, a 30 percent rating is assigned under the revised rating criteria for PTSD manifested by occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of an 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). 38 C.F.R. § 4.130, Diagnostic Code 9411 (2018). A 50 percent rating is assigned when a veteran’s PTSD causes 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-term 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; or difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2018). A 70 percent evaluation 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); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2018). The maximum schedular rating of 100 percent 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; and memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2018). In addition, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the lengths of remissions, and the Veteran’s capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a) (2018). The rating agency shall assign an evaluation based on all evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b) (2018). Use of the term “such symptoms as” in § 4.130 indicates that the list of symptoms that follows is “non-exhaustive,” meaning that 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 v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013); see Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir.2004); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). However, because “[a]ll nonzero disability levels [in § 4.130] are also associated with objectively observable symptomatology,” and because the plain language of the regulation makes clear that “the veteran’s impairment must be ‘due to’ those symptoms,” a veteran “may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” Vazquez-Claudio, 713 F.3d at 116-17. Global Assessment of Functioning (GAF) scores are a scale reflecting the “psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness.” See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), p. 32. Scores ranging from 41 to 50 are assigned when there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). See 38 C.F.R. § 4.130 (incorporating by reference the VA’s adoption of the DSM-IV for rating purposes). Lower numbers on the GAF scale reflect more severe symptoms; higher numbers reflect less severe symptoms. The Board notes that although the DSM has been updated with a 5th Edition (“DSM-V”), to include GAF scores being dropped due to their “conceptual lack of clarity,” since some of the Veteran’s examinations took place prior to the adoption of the DSM-V, the DMS-IV criteria will be utilized in conjunction with all other pertinent evidence of record. The Board has reviewed all of the evidence in the Veteran’s claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a Veteran or obtained on his behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Factual background Factual background shows that the Veteran presented to the Terre Haute CBOC in November 2009 for his first annual evaluation. During the visit, the Veteran complained of PTSD symptoms, including nightmares, difficulty being affectionate, problems with anger control, problems sleeping, hypervigilance, and problems with driving- as he still drives in the middle of the road to avoid bombs, and avoids driving under overpasses. The examiner noted probable PTSD and referred the Veteran to psychiatry for evaluation. In March 2010, the Veteran received a psychiatric assessment where he complained of anger issues and irritability. He reported that his symptoms just started again, and that he was isolating himself for a while. He further reported a past DUI in 2006, but that he has had no alcohol since January 2009. The Veteran reported that he recently started going to church with his mom, and that he was trying to be with his family, girlfriend, and others more. He reported having a bad attitude for a long time and still having problems driving under overpasses. The Veteran reported being married and divorced twice, and currently engaged. He has a total of five children, three that currently live with him, and two other children in Louisiana, which he would be getting custody of this summer. The Veteran also reported recreation/leisure activities include sports, baseball, art, video games, reading, running, hunting, and fishing. During his mental status examination, the Veteran reported that his mood is irritable, he has anxiety, and obsessive/compulsive behavior in that he bathes three times per day, and the bed has to be made a certain way. He denied suicidal/homicidal ideation, and reported that flashbacks are very rare now. The examiner noted the Veteran was oriented in all spheres and the Veteran’s behavior was within normal limits. Thought process was logical; thought content and affect was appropriate. There was no evidence of hallucinations or delusional thinking. Judgment was noted as fair and insight was limited. The examiner diagnosed the Veteran with PTSD, r/o OCD; and assigned a GAF score of 48. The Veteran was referred for individual psychotherapy, but the Veteran noted that he did not want to take medication. In his first follow-up appointment on April 5, 2010, the Veteran complained of ongoing dreams and nightmares from events in Iraq. He also reported anger issues where he noted several instances of getting upset with his girlfriend, his daughter, his dad, and at work. The Veteran agreed that medication would be helpful and the examiner referred him to a prescriber. The examiner also recommended the Veteran continue with the treatment plan and practice breathing techniques. On April 22, 2010, the Veteran reported a decrease in nightmares to about 3 times per week, being less angry, and less agitated. He reported that he has put into practice the relaxation breathing and is finding some benefit from it. He also reported that he has a difficult co-worker, but is doing alright in dealing with her. In May 2010, the Veteran reported having no nightmares since starting the medication. He reported that he has been getting excellent amounts of sleep, feeling rested, improved mood, no difficulty with becoming too angry, and that he had no complaints today. He further reported that he has been exposing himself to the mall, and continues to use breathing techniques. The examiner noted the Veteran had a number of good things happening for him and that he feels like his life is on the right track. He further noted the Veteran was responding well to medication. In a June 2010 psychiatric visit, the Veteran reported that he now has his two middle children and was starting the process on legal custody. He reported that he has continued working on avoidant behaviors, and that he went to the mall on a Saturday while it was busy, and it went well. He further reported that he has purposefully driven under overpasses, and that he is doing better and not having flashbacks and nightmares. He reported that he is actively working on his symptoms, and adjustment to family changes have gone well. In July 2010, the Veteran received a VA examination for his PTSD where the Veteran reported taking trazodone for sleep, prazosin for nightmares, and citalopram for depression, and that the medications have helped decrease his symptoms immensely. He reported that he currently lives with all of his biological children and that the relationship with his children and fiancé is good. He reported that they do not argue much since he started taking the medication, and that he enjoys spending time with his children, and does so as much as possible. He also reported being friends with people he went to high school with, and that he feels he can sit down and talk with his dad if he is troubled. He further reported that he enjoys fishing and playing video games with his children. Mental status examination showed the Veteran was clean and neatly groomed, psychomotor, speech, thought process, and content were all unremarkable; attitude was cooperative; affect and memory were normal; mood, judgment, and insight were good. The examiner noted that the Veteran was experiencing nightmares 4 to 5 times a week prior to starting medication; however, since starting medication, his nightmares have almost completely stopped. The Veteran reported sleeping 7 to 8 hours of undisturbed sleep, and that nightmares occur once a week, or less frequently. There was no evidence of hallucinations, panic attacks, homicidal or suicidal thoughts, or episodes of violence. The examiner noted the Veteran is able to control his anger at this time. The examiner also noted obsessive/ritualistic behavior in that the Veteran has to take 3 showers daily to feel clean and the bed has to be made a certain way; however, the Veteran denied that these symptoms cause any functional impairment. The examiner diagnosed the Veteran with PTSD and assigned a GAF score of 65, noting that his current symptoms appear to be mild in severity and infrequent in occurrence. The examiner explained that the Veteran meets the criteria for PTSD; however, at this time he is actively engaged in treatment for his mental health issues and reports that his symptoms are well managed with medication and psychotherapy. In general, he is functioning pretty well, has meaningful relationships, is sleeping well, and is successfully employed. The examiner concluded that the Veteran’s symptoms are controlled by continuous medication and his symptoms are not severe enough to interfere with occupational and social functioning. Analysis After considering the above and remaining evidence, the Board finds that the Veteran’s symptoms more nearly approximated the criteria for a 50 percent rating, but no higher, throughout the entire appeal period. The evidence shows that the Veteran’s PTSD symptoms of anger, sleep impairment, nightmares, flashbacks, irritability, isolation, and hypervigilance caused no more than mild to moderate impairment throughout the entire appeal period as the Veteran actively sought treatment and his symptoms were controlled by medication. Although subsequent evidence shows the Veteran had an increase in symptoms, this was due to the Veteran being off his medication for a period of time. Additionally, the Veteran’s increased symptoms did not rise to the level of occupational and social impairment with deficiencies in most areas, nor total impairment. Further, his symptoms were not of the severity, frequency, or duration, that would warrant a rating any greater than 50 percent disabling. In support of the Board’s conclusion, the Board initially notes the Veteran’s November 2009 and March 2010 medical visits where he reported symptoms of nightmares, anger, problems sleeping, hypervigilance, and irritability. The Board recognizes that the Veteran was assigned a GAF score of 48, indicative of severe symptoms; however, the assigned GAF score is merely an indicator as to the severity level of the Veteran’s symptoms. The Board must also consider the severity, frequency, and duration of the Veteran’s symptoms in determining the level of impairment. Here, the Veteran’s symptoms in March 2010, and thereafter, were not of the severity, frequency, or duration that would warrant a higher rating as the Veteran showed sustained improvement as early as two months later. Further, the symptoms reported by the Veteran were not severe enough to cause occupational and social impairment with deficiencies in most areas or total social and occupational impairment. As noted above, during his March 2010 visit, the Veteran reported that his symptoms had just started. He reported that he started going to church with his mom, and that he was actively trying to be with his family, girlfriend, and others more. The Veteran also reported that the relationship with his fiancé and children was good and he would be getting custody of his other children in the summer. He participated in recreational activities, and had friends of which he went to high school with. Mental status examination showed the Veteran was oriented in all spheres and the Veteran’s behavior was within normal limits. Thought process was logical; thought content and affect was appropriate. There was no evidence of hallucinations or delusional thinking. Judgment was noted as fair and insight was limited. Moreover, in his July 2010 examination, it was noted that he had been employed at Staples for 1 to 2 years, and that time lost from work in the last 12 months was less than one week due to doctors’ appointments. After being prescribed medication, the Veteran reported a decrease in symptoms in April 2010, to include being less angry, less agitated, and a decrease in nightmares to about 3 times per week. However, in May 2010, he reported having no nightmares since starting medication. He further reported that he has been getting excellent amounts of sleep and feeling rested, improved mood, and that he has not had any difficulty with becoming too angry. He began exposing himself to the mall and continuing with the breathing techniques. The examiner also found an improvement in the Veteran’s symptoms as he noted the Veteran had a number of good things happening for him and that he feels like his life is on the right track. He further noted the Veteran was responding well to medication. Likewise, as a result of the Veteran’s continuous improvement, the July 2010 examiner found that the Veteran’s symptoms were mild and controlled by continuous medication, and that his symptoms were not severe enough to interfere with occupational and social functioning. Subsequent evidence continued to show sustained improvement with the Veteran continuing to report a decrease in irritability and nightmares. In addition, the Veteran’s GAF scores consistently noted mild to moderate levels of impairment as evidenced in his July 2010 VA examination and October 2010 psychiatric visit where the Veteran was assigned a GAF score of 65 and 58, respectively. Moreover, in July 2011 and March 2012 psychiatric visits, the Veteran was assigned GAF scores of 59 and 60, respectively. The Board recognizes that the Veteran began reporting increased irritability in February 2011; however, it was noted that he stopped taking his prescribed Celexa for one week, but started it again because he became irritable. Additionally, he attributed his recent anger to his first killing in Iraq which happened in March 2005. Alternatively, in April 2011, he again reported less irritability, and that he hasn’t had a nightmare in 2 to 3 weeks, nor did he need to take the prazosin. The examiner also noted that the Veteran’s PCL continued to show progress. In his March and June 2012 therapy visits, the Veteran reported that his attitude has gotten worse and that he was feeling more negative, easier to get into conflicts with others, and feeling like he would rather withdraw than deal with others. The examiner also noted that the Veteran looked more stressed out and that he scored his highest score on his PCL. However, the Veteran attributed this increase to his grandmother being in the final stages of Alzheimer’s. He also reported that this time of year is very stressful for him as May through September was the deadliest time for them in Iraq, and that a couple of weeks ago was the anniversary of the loss of his friend. Further, his girlfriend, also a veteran, kept a notebook of triggering situations which he saw recently. It was also noted that the Veteran had not been taking his medications. In April 2016 and May 2016, the Veteran reported that he stopped taking his medications approximately three years prior and had difficulties with irritability. He further reported that he was unable to play catch with his son for no more than five minutes because he becomes so hypervigilant that he feels the need to go to a safe location. However, despite the absence of medications, testing showed that the Veteran exhibited low anxiety, moderate depression, and “symptoms of traumatic distress,” which were not noted as severe. After being started on his medications again, the Veteran again reported a decrease in symptoms as evidenced in a June 2016 treatment note where he reported Zoloft was working, and that he was able to joke with his son in the yard while doing work. He also reported being more comfortable in public. Additionally, in September 2016, again, he reported a positive response to Zoloft, and that he was no longer getting mad over little things. He further reported a decrease in anxiety and irritability, and attributed difficulty initiating sleep to working the evening shift. The Board recognizes the private psychiatric evaluations submitted by the Veteran in December 2018 from Dr. A.F. and Dr. L.C.; however, the Board finds that the opinions from these physicians offer low probative value as some of the physicians’ findings are inconsistent with the evidence of record. In particular, and with respect to Dr. A.F.’s examination and opinion, the Board notes the physician diagnosed the Veteran with PTSD, unspecified depressive disorder, due to a medical condition, and alcohol use disorder, in remission. The physician further found that the Veteran exhibited occupational and social impairment with reduced reliability and productivity. While the Board agrees with the physician’s finding of impairment with reduced reliability, as this is indicative of moderate impairment, the Board notes that some of the physician’s findings do not coincide with the evidence. First, the Board initially notes that the physician noted symptoms of panic attacks that occur weekly or less often, amongst others; however, there is no evidence of record to support that the Veteran ever suffered from panic attacks. While the Veteran exhibited anxiety and hypervigilance, to include when going out in a crowd and when playing with his son, there is no evidence of record showing that the Veteran’s anxiety and hypervigilance rose to the level of panic attacks. The Veteran has never reported having panic attacks; nor has this symptom ever been noted by any other examiner. Similarly, the examiner found symptoms of persistent delusions or hallucinations; however, there has been no evidence of either. The Board notes that in a May 2016 psychiatric assessment, a mental status examination described the Veteran’s thought content to include perceptual disturbances/delusions described as “hyper-reactive to various situations.” Additionally, an April 2010 treatment record noted “possible tactile hallucination,” as the Veteran reported “sitting there like something touch my shoulder. I just say it’s grandma.” While the characterizations of these two instances are questionable, they are not the equivalent of persistent. Moreover, the remaining evidence of record continues to show no evidence of delusions or hallucinations. Further, the examiner did not note a particular instance during his examination of the Veteran to support his finding of delusions/hallucinations. Further, the examiner seems to suggest that the Veteran’s tinnitus and hearing loss contributes to the Veteran’s psychiatric impairment as he noted that the omission of tinnitus as an Axis III diagnosis on his July 2010 examination is significant in that it affects the Axis I diagnosis, the assigned GAF, and the rating of occupational and social impairment. The physician also included medical literature on the relationship of hearing difficulties and mental health problems. The examiner concluded that the overall impact of the Veteran’s service-connected PTSD and tinnitus is significant, in terms of both occupational and social functioning, and is more likely than not, chronic. While the literature may be true, this correlation is not applicable to the Veteran’s case. On the contrary, there is no evidence that shows the Veteran’s service-connected tinnitus or hearing affected the Veteran’s functional impairment. First, the Veteran was found to have normal hearing in his audiology examination. Further, there is one isolated complaint of hearing loss and tinnitus in March 2016, however, there was no recommended treatment for either. Additionally, medical records prior to, and after his isolated complaint in March 2016, show no complaints or treatment for the Veteran’s tinnitus. In fact, it was noted that the Veteran’s tinnitus was intermittent; and, in his July 2010 audiology examination, the Veteran reported having daily tinnitus, which lasts about 20 to 30 seconds, but that his tinnitus does not impact his daily activities. Therefore, although the Board agrees with the physician’s end conclusion of social and occupational impairment with reduced reliability, the Board finds the substance of the opinion offers low probative value as findings used to support his conclusion are not supported by the record. Likewise, the Board finds the opinion from Dr. L.C. also shows some inconsistencies with the record. In his opinion regarding employability, the physician noted that the Veteran mentioned suicidal ideation; however, there is no evidence of suicidal or homicidal ideations in the Veteran’s treatment records. Notably, the examiner himself did not note this as a symptom in his own examination of the Veteran, and in fact, noted that the Veteran denied suicidal ideation. In an April 2010 therapy visit, the Veteran denied suicidal ideation noting that, with his children, he has so much to live for. He further reported that it has never been an issue for him. Further, subsequent treatment records show that the Veteran has consistently denied suicidal ideations. Similarly, the physician also noted that the Veteran’s inability to establish and maintain effective social and work relationships will cause isolation, avoidance of work situations, and increased panic attacks; however, again, the Veteran’s records are absent of any panic attacks. Notably, the examiner did not mention panic attacks as a symptom in his examination of the Veteran. Further, although the evidence shows the Veteran has changed jobs numerous times, there is no evidence the Veteran’s PTSD symptoms was the cause of his job changes, nor is there evidence that his symptoms have significantly affected his employment. For example, in a May 2011 treatment note, the Veteran reported that he was no longer working for Sony due to a change in the foreman, and he was only getting an hour or two of work. In November 2011, it was noted that the Veteran had a recent job loss/change; however, there was no indication that this was due to his PTSD symptoms. Likewise, in October 2016, the Veteran reported being fired for missing work due to his pipes bursting at home, which is wholly unrelated to his PTSD symptoms. Evidence suggesting that the Veteran’s PTSD may have impacted his work was noted in an October 2010 treatment note where the Veteran reported that he lost his job at Staples, and that his supervisor told him that it would not count against him to have VA appointments, but “turns out that wasn’t true.” While his loss of employment may have been due to missing work due to appointments for PTSD, there is no evidence that his resulting symptoms impaired his ability to work. Further, in a March 2012 therapy visit, the Veteran reported working in the same place, but noted that he was finding it easier to get into conflicts with others and wanting to withdraw; however, it was noted that the Veteran had not been to therapy since October 2011, and a subsequent July 2012 treatment record revealed that the Veteran had been off his medication and had been having trouble taking them due to his twelve-hour work shift. In spite of his numerous job changes and any impairment caused by his PTSD, the Board finds the impairment was not as significant as the Veteran’s therapist consistently reported that the Veteran had a strong work ethic and functions better when working. This finding was reiterated by the Veteran as he reported in an October 2011 therapy visit that he has much less distress now that he has a job. The examiner also agreed, noting that the Veteran looked more settled and functions better when working. Therefore, while the Veteran’s PTSD may have impacted the Veteran’s employability to some degree, the impact was not significant to the extent that it caused occupational and social impairment with deficiencies in most areas, or total impairment. With respect to the Veteran’s sleep impairment, the physician noted that the Veteran takes trazadone for sleep which makes him very tired and lethargic with no energy; however, this finding is also unsupported by the evidence. While the Veteran was prescribed trazodone for sleep difficulties, the Veteran consistently reported that his sleep remained stable and adequate while taking the medication. This is evidenced in his earlier treatment records from 2010 to 2011, as well as, subsequent medical records. Particularly, in a July 2010 therapy visit, the Veteran reported “the sleeping pill is working.” In November 2011, the examiner noted that the Veteran was sleeping without problems on trazodone. In a September 2016 treatment note, the Veteran reported that he gets 7 to 8 hours of sleep per night and feels rested in the morning; and, in December 2016, the Veteran also reported that his sleep is better since beginning the trazodone. Further, the physician also noted that the Veteran exhibited an intermittent inability to perform activities of daily living (ADLs), including maintenance of personal hygiene; however, again, this finding was also not found within the Veteran’s record. At most, it was noted in a March 2011 treatment record that the Veteran’s goatee and moustache was unshaven, and other records showed that he was missing his upper front teeth; however, this does not equate to the Veteran being unable to maintain his personal hygiene. There are no reports from the Veteran or any of his other examiners that note the Veteran is unable to perform ADLs or that his appearance was inadequate. Notably, none of his family, including his parents or his wife, reported this in their personal statements. Moreover, treatment records have consistently shown that the Veteran’s hygiene appears to be good. Likewise, the physician reported symptoms of obsessional rituals; however, the only evidence that can support this finding is the Veteran’s report of having to bathe three times a day to feel clean, and that the bed has to be made a certain way; but, there is no evidence of record showing that either of these interfere with his routine activities. In light of the above, the Board finds that the private opinions offered are of low probative value due to the numerous inconsistencies. The Board has also considered the lay statements submitted by the Veteran’s mother, father, and wife; however, these statements do not offer additional symptomatology that have not already been discussed. Overall, the evidence shows that the Veteran primarily exhibited symptoms of irritability, hypervigilance, anger, nightmares, flashbacks, sleep impairment, and avoidance, but the Veteran’s symptoms were controlled by medication. As explained above, the Veteran consistently reported an improvement in symptoms while he was on medication in 2010-2012, and again when he was restarted on medications in 2016. Moreover, his assigned GAF score of 48 was isolated and his reported symptoms at the time were not of the severity, frequency, or duration that would warrant a higher rating. Further, the remaining evidence of record shows no more than mild to moderate impairment as evidenced by the Veteran’s subsequent GAF scores, as well as, the July 2010 examiner’s opinion noting mild impairment, and testing which showed the Veteran exhibited low anxiety, moderate depression, and symptoms of traumatic distress, despite the absence of medications. Therefore, given that the evidence shows the Veteran’s symptoms ranged from mild to moderate, the Board resolves reasonable doubt in favor of the Veteran and finds that the Veteran’s symptoms more nearly approximated the criteria of a 50 percent rating for the entire appeal period. The Veteran is not entitled to a higher rating as his symptoms were not of the severity, frequency, or duration warranting a higher rating, nor did they cause occupational and social impairment with deficiencies in most areas, or total impairment. As such, the Board finds the preponderance of evidence weighs in favor of the claim. Accordingly, a 50 percent rating, but no higher, is granted. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (a) (2017). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 38 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Additionally, secondary service connection may be granted where a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 48 (1995). Whenever there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107(b). 1. Entitlement to service connection for hypertension, to include as secondary to PTSD. The Veteran’s service treatment records (STRs) do not contain complaints, treatment, or a diagnosis relative to hypertension. Post-service records show that the Veteran was initially diagnosed with hypertension in March 2009. Treatment records also show that the Veteran has had periods of controlled and uncontrolled blood pressure. In his July 2010 VA examination for PTSD, the Veteran reported that he developed hypertension caused by his PTSD. He reported that he can feel his blood pressure elevate and that this occurs when he gets angry or anxious. The examiner found that it is unlikely the Veteran’s hypertension was caused by his PTSD; however, it is at least as likely as not that his hypertension is exacerbated by his PTSD symptoms. Similarly, in the private medical opinion from L.C., the physician also found it at least as likely as not that the Veteran’s hypertension is exacerbated by the Veteran’s PTSD symptoms. He further explained that in most cases, hypertension is not caused by one single factor, and that his PTSD would have only been one of several factors which combined to cause or exacerbate hypertension. It is not possible to determine how much each individual factor contributed. The Board also notes that treatment records showed that the Veteran’s hypertension was generally controlled by medication; however, the Veteran experienced unexplained rises in his blood pressure. For example, in August 2011, the Veteran’s blood pressure was noted as high in which lisinopril was added to his medication regiment. In a September 2011 follow-up visit, the examiner noted that his systolic blood pressure was fine, while his diastolic blood pressure was borderline. Notably, a November 2011 psychiatric treatment note revealed that the Veteran complained of increased irritability. The examiner also noted that the Veteran’s attendance to sessions had become more “hit and miss,” and that he has changed jobs a couple of times. In light of the above, the Board finds the preponderance of evidence weighs in favor of granting the claim. The Board finds the medical opinions probative as they are consistent and supported by rationale. Additionally, there is no other evidence of record that shows a plausible explanation as to the Veteran’s periods of uncontrolled hypertension. Therefore, as the preponderance of evidence weighs in favor of the claim, the Board finds that service connection for hypertension, secondary to PTSD, is warranted. 2. Entitlement to service connection for migraines, to include as secondary to PTSD. With respect to the Veteran’s claim of service connection for migraines, the Board finds that service connection is warranted. The Veteran’s service treatment records (STRs) do not contain complaints, treatment, or a diagnosis relative to migraines. However, post-service records show that the Veteran was diagnosed with migraines, shortly after discharge from service, in July 2006 by his family practice doctor. The record contains several complaints of headaches which have been related to the Veteran’s PTSD and hypertension in some instances. For example, in August 2009, the Veteran reported occasional headaches when he first wakes up in the morning that lasts for one hour, mostly in the frontal part of the head, but sometimes the back. In a November 2009 medical visit, the Veteran complained of migraines noting that they may be stress related. Notably, in the same visit, the Veteran also complained of PTSD symptoms and was referred for a psychiatric assessment. In April 2011, he reported having a headache after taking a higher dosage of Zoloft, and in September 2016, he reported sometimes waking with a headache in the morning after taking trazadone. Further, in a November 2012 medical visit, the Veteran complained of his headaches being worse and more frequent, and that he has had a headache for seven days straight. The examiner noted that the Veteran’s recent flair of headaches may be related to poor sleep and an increase of his PTSD symptoms. Similarly, Dr. L.C. opined that the Veteran’s migraines are exacerbated by his PTSD. Alternatively, in his July 2010 VA examination, the examiner noted that the Veteran has a history of headaches related to hypertension. This correlation was also shown in November 2013 and March 2016 medical visits when the Veteran complained of both elevated blood pressure and headaches. Considering the above, the Board finds the preponderance of evidence weighs in favor of the claim. The evidence shows that the Veteran complained of headaches during times when his PTSD symptoms increased, as well as, in response to his PTSD medications. Further, the evidence suggests the Veteran’s hypertension may have exacerbated the Veteran’s headaches, which the Veteran has been service-connected for in the decision herein. Moreover, the evidence shows the Veteran was first diagnosed with migraines in July 2006, merely three months after being discharged from active duty; and, it was also noted that the condition may have pre-existed service as the Veteran reported having migraines his entire life. While the Veteran’s migraine headaches are not a chronic disease listed under 38 C.F.R. § 3.309(a), thus warranting presumptive service connection, the Board finds the close proximity of his discharge date and diagnosis date make it plausible that the Veteran’s service may have aggravated his migraines. Considering the evidence as a whole, and resolving all doubt in favor of the Veteran, the Board finds that service connection for migraines, secondary to PTSD, is warranted. 3. Entitlement to service connection for bilateral hearing loss. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Veteran contends that he has bilateral hearing loss that is related to his service. Specifically, he contends that his hearing loss is a result of being exposed to IED explosions, gun firing, and as a tank driver while in service. After reviewing the record, the Board finds that service connection must be denied as there is no evidence that the Veteran has a bilateral hearing loss disability for VA purposes. See 38 C.F.R. § 3.385 (2018). Service treatment records (STRs) do not show complaints, treatment, or a diagnosis relating to hearing loss. Post-service records show that the Veteran received a VA audiology examination in July 2010 for his hearing loss. Audiometric findings with respect to the right ear were recorded as follows: 10 decibels (dB) at 500 Hertz (Hz), 5 dB at 1000 Hz, 5 dB at 2000 Hz, 10 dB at 3000 Hz, and 10 dB at 4000 Hz. The findings with respect to the left ear were recorded as follows: 10 decibels (dB) at 500 Hertz (Hz), 5 dB at 1000 Hz, 10 dB at 2000 Hz, 15 dB at 3000 Hz, and 10 dB at 4000 Hz. Speech recognition was 100 percent in both ears. The examiner found that the Veteran exhibited normal hearing bilaterally. Given these findings, the Veteran does not meet the requirements of hearing loss for VA compensation purposes, nor are there any other medical records on file which indicate that the Veteran has a bilateral hearing loss disability consistent with the requirements of 38 C.F.R. § 3.385. Further, while the Veteran is competent to report symptoms of decreased hearing acuity, he is not competent to diagnose himself with hearing loss for VA purposes. A diagnosis of hearing loss for VA purposes requires medical expertise, clinical testing, and knowledge that are outside the realm of common knowledge of a layperson. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, the Veteran is not competent to provide a diagnosis in this case. For a disability to be service connected, it must be present at the time a claim for VA disability compensation is filed or during or contemporary to the pendency of the claim. McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Here, there is no evidence of record showing that the Veteran has bilateral hearing loss disability for VA purposes. Congress has specifically limited entitlement to service-connected benefits to cases where there is a current disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). Accordingly, the Board finds that the preponderance of the evidence is against the claim and entitlement to service connection for bilateral hearing loss disability is not warranted. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Laffitte, Associate Counsel