Citation Nr: 19159377 Decision Date: 07/31/19 Archive Date: 07/31/19 DOCKET NO. 1523031 DATE: July 31, 2019 ORDER Restoration of a 60 percent evaluation for residuals of prostate cancer effective December 1, 2014 is granted. Entitlement to an initial rating for service-connected adjustment disorder, in excess of 30 percent prior to January 27, 2017 and 50 percent thereafter, is denied. REMANDED Entitlement to service connection for hypertension, to include as secondary to service-connected prostate cancer, is remanded. FINDINGS OF FACT 1. In rating decisions dated August 2014 and November 2014, the RO reduced the rating for service-connected residuals of prostate cancer to 20 percent, effective December 1, 2014. 2. The record then available did not reflect that there had been improvement in the service-connected residuals of prostate cancer under the ordinary conditions of life and work. 3. Prior to January 27, 2017, the Veteran’s adjustment disorder was manifested by no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to symptoms of anxiety, depression, chronic sleep impairment, difficulty concentrating, and fatigue. 4. From January 27, 2017, the Veteran’s adjustment disorder has been manifested by occupational and social impairment with reduced reliability and productivity due to symptoms of anxiety, depression, chronic sleep impairment difficulty concentrating, social isolation, and disturbances of motivation and mood. CONCLUSIONS OF LAW 1. Restoration of a 60 percent disability rating for the Veteran’s service-connected residuals of prostate cancer is warranted. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.105, 4.119, Diagnostic Code 7528. 2. Prior to January 27, 2017, the criteria for a rating in excess of 30 percent for adjustment disorder with depression and anxiety are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9440. 3. From January 27, 2017, the criteria for a rating in excess of 50 percent for adjustment disorder with depression and anxiety are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9440. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1969 to October 1971. Service in the Republic of Vietnam is indicated by the record. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions dated August 2014 and January 2015 of the Department of Veterans Affairs (VA) Regional Office (RO) in Providence, Rhode Island. The August 2014 rating decision reduced the evaluation for the Veteran’s service-connected prostate cancer from 60 percent to 20 percent; the Veteran disagreed with the reduction and perfected a timely appeal in June 2015. The June 2015 rating decision awarded service connection for adjustment disorder and assigned a 30 percent evaluation; the rating decision also denied service connection for hypertension. The Veteran disagreed with the June 2015 rating decision and perfected a timely appeal in October 2015. In a September 2017 rating decision, the RO increased the assigned initial rating for adjustment disorder to 50 percent from January 27, 2017. The Veteran has not expressed satisfaction with the increased initial rating; this matter thus remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (when a veteran is not granted the maximum benefit allowable under the VA Schedule for Rating Disabilities, the pending appeal as to that issue is not abrogated). In January 2019, the Veteran was scheduled to appear for a videoconference hearing with a Veterans Law Judge, as his attorney had requested on the October 2015 VA Form 9. Although both he and his attorney were notified of the time and date of the hearing by mail, neither reported for the hearing and neither provided an explanation for their failure to do so. The Veteran has not since asked for the hearing to be rescheduled. Accordingly, the hearing request is deemed withdrawn. See 38 C.F.R. § 20.704(d). 1. Whether the reduction of the evaluation for service-connected residuals of prostate cancer from 60 percent to 20 percent was proper. When a reduction in the rating of a service-connected disability or employability status is contemplated and the lower rating would result in a reduction or discontinuance of compensation payments, a rating proposing the reduction or discontinuance will be prepared setting forth all material facts and reasons. The beneficiary must be notified at his or her last address of record of the contemplated action and furnished detailed reasons therefor. The beneficiary must be given 60 days for presentation of additional evidence to show that compensation payments should be continued at the present level. 38 C.F.R. § 3.105(e). If additional evidence is not received within that period, final rating action will be taken and the award will be reduced or discontinued effective the last day of the month in which a 60-day period from the date of notice to the beneficiary of the final rating action expires. Id. These are such important safeguards that the Court has held that where VA has reduced a veteran’s rating without observance of applicable law and regulation, such a rating is void ab initio. Brown v. Brown, 5 Vet. App. 413, 422 (1993). Thus, to remedy such cases, the decision must be reversed as unlawful. Dofflemyer v. Derwinski, 2 Vet. App. 277 (1992). Under 38 C.F.R. § 3.344(c), when a disability rating has been in effect for less than five years, reexaminations disclosing improvement will warrant a rating reduction. Rating agencies will handle cases affected by change of medical findings or diagnosis so as to produce the greatest degree of stability of disability evaluations consistent with the laws and VA regulations governing disability compensation and pension. It is essential that the entire record of examination and the medical-industrial history be reviewed to ascertain whether the recent examination is full and complete, including all special examinations indicated as a result of general examination and the entire case history. Examinations which are less thorough than those on which payments were originally based will not be used as a basis for reduction. Ratings for diseases subject to temporary or episodic improvement, such as epilepsy, asthma, ulcers, and many skin diseases, will not be reduced on the basis of any one examination, except in those instances where all of the evidence of record clearly warrants the conclusion that sustained improvement has been demonstrated. Moreover, where material improvement in the physical or mental condition is clearly reflected, the rating agency will consider whether the evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life. 38 C.F.R. § 3.344(a). The above considerations are required for ratings which have continued for long periods at the same level, i.e. five years or more. 38 C.F.R. § 3.344(c). Prior to reducing a veteran’s disability rating, however, VA is required to “comply with several general VA regulations applicable to all rating-reduction cases, regardless of the rating level or the length of time that the rating has been in effect.” Faust v. West, 13 Vet. App. 342, 349 (2000), citing 38 C.F.R. § 4.1, 4.2, 4.10. These general provisions “impose a clear requirement that VA rating reductions, as with all VA rating decisions, be based upon review of the entire history of the veteran’s disability.” Id., citing Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). In considering the propriety of a reduction, the Board must focus on the evidence available to the RO at the time the reduction was effectuated, although post-reduction medical evidence may be considered in the context of evaluating whether the conditions had demonstrated actual improvement. Dofflemyer v. Derwinski, 2 Vet. App. 277 (1992). The Veteran’s service-connected prostate cancer residuals are rated under Diagnostic Code (DC) 7528, malignant neoplasms of the genitourinary system, which assigns a 100 percent for active malignancy and then assigns an evaluation for residuals following active malignancy under the appropriate genitourinary dysfunction which predominates. A note after DC 7528 provides that, following the cessation of surgical, X-ray, antineoplastic chemotherapy, or other therapeutic procedure, the rating of 100 percent shall continue with a mandatory VA examination at the expiration of six months. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of 38 C.F.R. § 3.105(e). If there has been no local reoccurrence or metastasis, the disability is to be rated on residuals, as voiding dysfunction or renal dysfunction, whichever is predominant. See 38 C.F.R. § 4.115b, DC 7528, Note. Here, the Veteran contends that the reduction from 60 percent to 20 percent for his service-connected prostate cancer was not warranted. He argues that the evaluation should be restored. See, e.g., the notice of disagreement (NOD) dated November 2014. As an initial matter, the Board finds that the evidence does not indicate, and the Veteran does not contend, that the relevant notice requirements in effectuating the reduction have not been met in this case. The procedural requirements set forth in 38 C.F.R. § 3.105(e) regarding reduction in benefits (i.e. the issuance of a rating decision proposing the reduction or discontinuance and setting out all material facts and reasons underlying the proposal; notification to the Veteran; and providing the Veteran 60 days for the presentation of additional evidence to show that compensation payments should be continued at the present level) do not apply in this case as its reduction did not affect his overall combined evaluation or monthly monetary amount. See 38 C.F.R. § 3.105(e). The question that remains is the substantive question of whether the reduction was proper. In essence, as explained above, the law requires that the service-connected disability must have demonstrated improvement in order for an assigned rating to be reduced. 38 C.F.R. § 4.13. In a September 2010 rating decision, the RO granted service connection for prostate cancer; a 100 percent rating was assigned from June 10, 2010. In a January 2012 rating decision, the Veteran’s rating was reduced to 60 percent from April 1, 2012. The Veteran filed a NOD as to the reduction and a statement of the case (SOC) was issued in August 2012. The Veteran did not perfect an appeal and the decision became final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. Following a VA examination in April 2014, the RO proposed to reduce the assigned 60 percent rating for residuals of prostate cancer to 20 percent. The reduction was initially effectuated in an August 2014 rating decision with a 20 percent rating assigned from November 1, 2014. However, in a subsequent November 2014 rating decision, the RO changed the effective date of the reduction to December 1, 2014 because the Veteran did not receive the notification letter until the month of September. The Veteran contends that the reduction from 60 percent to 20 percent for his service-connected residuals of prostate cancer was not warranted. He argues that the 60 percent evaluation should be restored. See, e.g., the NOD dated November 2014. As the 60 percent disability rating was not in effect for five years or more, the provisions of 38 C.F.R. § 3.344(a) and (b) do not apply. In an April 2014 VA telephonic examination, the Veteran reported that he has not had a recurrence of prostate cancer and his radiation treatment was completed in July 2010. The Veteran continues to take Flomax as described for urinary symptoms. He endorsed voiding dysfunction; specifically, urine leakage, which requires absorbent that must be changed less than two times per week. He also reported urinary frequency with daytime voiding interval between one and two hours. He has three to four awakenings to void per night. The Veteran also endorsed signs or symptoms of obstructed voiding; in particular, hesitancy, slow stream, weak stream, and decreased force of stream. The examiner indicated that these symptoms are not marked in severity. The Veteran has no other symptoms of obstructive voiding. The examiner indicated that the Veteran’s residuals of prostate cancer do impact his ability to work. He explained, the Veteran cited urinary frequency as one of the major factors in taking early retirement. In an August 2014 rating decision, the RO reduced the Veteran’s disability rating from 60 percent to 20 percent based upon a finding that his residuals of prostate cancer require the wearing of absorbent materials which must be changed less than two times per day, awakenings to void three to four times per night, and daytime voiding interval between one and two hours. The RO indicated that the Veteran therefore no longer met the criteria for a 60 percent evaluation under DC 7528. As indicated above, pursuant to the Court’s holdings in Faust and Brown, in any rating reduction case not only must it be determined that an improvement in a disability has actually occurred but also that that improvement actually reflects an improvement in a veteran’s ability to function under the ordinary conditions of life and work. See Faust, 13 Vet. App. at 350; see also Brown, 5 Vet. App. at 421. Although the April 2014 VA examination findings indicated that the Veteran’s urine leakage required absorbent materials which must be changed less than two times per week, the Veteran has repeatedly disagreed with this finding. In a June 2014 statement, he asserted that he must change absorbent pads four to six times per day. Moreover, the Veteran has argued that he suffers from significant daily functional impairment due to his urinary frequency and voiding dysfunction. See the Veteran’s NOD dated November 2014; see also the DRO Conference Report dated April 2016. He has described symptoms including urine leakage, bleeding, dizziness, and anemia as residuals of his service-connected prostate cancer. Significantly, the Board cannot conclude that there had been improvement over the disability previously characterized by the 60 percent rating. Consequently, the Board concludes that the record did not reflect an improvement in the Veteran’s ability to function under the ordinary conditions of life and work. The previously assigned 60 percent rating for the service-connected residuals of prostate cancer is therefore restored. The appeal is allowed to that extent. See 38 C.F.R. § 3.344. 2. Entitlement to an initial rating for service-connected adjustment disorder in excess of 30 percent prior to January 27, 2017 and 50 percent thereafter. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, analysis in this decision has therefore been undertaken with consideration of the possibility that different ratings may be warranted for different time periods as to the pending claim. In all cases, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a “competent” source. The Board must then determine if the evidence is credible, or worthy of belief. Barr, at 308 (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff’d, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the “authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence”). The Board has considered all evidence of record as it bears on the issues before it. See 38 U.S.C. § 7104(a) (“Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record”); 38 U.S.C. § 5107(b) (“Secretary shall consider all information and lay and medical evidence of record in a case”). Although the Board has an obligation to provide reasons and bases supporting these decisions, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran’s appeal. The Veteran’s adjustment disorder with depression and anxiety is evaluated under 38 C.F.R. § 4.130, DC 9440. Under this diagnostic code, a 30 percent evaluation is assigned for 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). A 50 percent evaluation is for assignment 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 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 establishing effective work and social relationships. Id. A 70 percent evaluation is contemplated for 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. 38 C.F.R. § 4.130, DC 9440. A 100 percent evaluation is warranted when there is evidence of 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 and place; memory loss for names of close relatives, own occupation or name. Id. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is a veteran’s symptoms, but it must also make findings as to how those symptoms impact a veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran’s impairment must be “due to” those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. In this matter, the Veteran was granted service connection for adjustment disorder with mixed depression and anxiety in a January 2015 rating decision; a 30 percent rating was assigned from November 11, 2014. The Veteran filed a NOD in June 2015 and he perfected a timely appeal of the initial rating claim in October 2015. As indicated above, the RO granted a higher rating of 50 percent for the service-connected adjustment disorder from January 27, 2017, the date of a VA examination. For the reasons set forth below, the Board finds that entitlement to higher ratings is not warranted for the Veteran’s service-connected adjustment disorder with depression and anxiety. VA treatment records dated in March 2013 documented the Veteran’s report of experiencing weird dreams and worry. He stated that he was drinking an average of five to six beers per day. The treatment provider indicated that the Veteran had normal judgment and insight, and was well-oriented. See the VA treatment record dated March 2013. The Veteran’s recent and remote memory were intact. His mood and affect were normal. Id. VA treatment records dated in November 2013 indicated that the Veteran suffered from depression. A November 2014 VA mental health outpatient initial evaluation note documented the Veteran’s feelings of discouragement related to his health issues. He reported that he has been married for 46 years and has three adult children. The Veteran described his marriage as happy. In his free time, “he tends to work on the house and yard.” The treatment provider indicated that the Veteran “achieved occupational success working his way to a supervisory position” as a utility plant operator. The Veteran is retired. He exhibited normal speech and a euthymic mood. His affect was ranging and appropriate. The Veteran’s thought process was linear, logical, and goal-directed. He denied hallucinations and delusions. His insight and judgment were normal. The Veteran was diagnosed with adjustment disorder with depressed mood by history. The Veteran was afforded a VA psychological examination in January 2015 at which time the examiner confirmed a diagnosis of adjustment disorder with mixed depression and anxiety. The examiner reported, “[a] mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication.” The Veteran has been married for 46 years. He has three adult children. He reported that he retired prematurely secondary to side effects of his cancer treatment. The Veteran “denied ever having any problems with peers or supervisors on the job.” He stated, “I get along with everyone great.” The Veteran worries, at times excessively, about finances. The examiner reported that the Veteran’s “worry has not caused significant impairment outside of sleep difficulties which are well managed with medications.” He denied symptoms indicative of major depression, obsessive compulsive disorder, psychosis, mania/hypomania, and panic disorder.” The Veteran consumes a six-pack of beer per day; although, he has recently decreased his intake to two to three beers per day. The Veteran endorsed anxiety and chronic sleep impairment. The examiner noted the Veteran to be appropriately groomed and dressed. He was well-oriented. The Veteran’s speech and thought process were clear, coherent, and goal-directed. He denied psychosis and hallucinations. The Veteran also denied suicidal and homicidal ideation. The Veteran was afforded another VA psychological examination at which time the examiner diagnosed him with adjustment disorder and alcohol use disorder. The examiner stated that the Veteran’s psychological symptoms manifest in “occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress or; controlled by medication.” His spouse indicated that the Veteran is a “functional alcoholic.” He drinks seven to eight beers per day. The Veteran endorsed depressed mood and anxiety. He also reported difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including work or a work-like setting, and an inability to establish and maintain effective relationships. The Veteran’s mood was relaxed, and he exhibited mild depression. He also reported impaired concentration. The Veteran denied suicidal and homicidal ideation. He did not exhibit psychosis. The examiner opined, “[t]here is not demonstrable evidence from a mental health perspective that would render the Veteran unable to work.” The examiner explained that the Veteran is able to understand, remember, and carry out simple direction. However, his impaired concentration could interfere, to a mild to moderate degree, with more complex tasks. The Veteran was most recently afforded a VA psychological examination in April 2018 at which time the examiner diagnosed persistent depressive disorder. The examiner indicated that the Veteran’s psychological symptoms manifest in “[o]ccupational and social impairment with reduced reliability and productivity.” The Veteran has been married for 50 years. He stated that his alcohol use has been an on-going issue in his marriage. The Veteran described a good relationship with his two older children; his youngest child is incarcerated. The Veteran “[e]xplained that he has [had] minimal social interaction aside from his family since he began having medical problems in 2010/2011.” The Veteran endorsed episodic periods of depression and anxiety, as well as chronic sleep disturbance and fatigue. He “[d]isclosed some level of discouragement and lack of interest.” He also reported difficulty concentrating and impaired memory. The Veteran denied suicidal and homicidal ideation, as well as hallucinations and psychosis. He does not currently receive mental health treatment. The Veteran endorsed depressed mood, anxiety, chronic sleep impairment, and mild memory loss such as forgetting names, directions, or recent events. He exhibited flattened affect. The Veteran additionally reported disturbance of motivation and mood, as well as difficulty in establishing and maintaining effective work and social relationships. The examiner stated that the Veteran was neat and casually dressed. His speech was clear and he was well-oriented. His thought process was organized, and he exhibited fair concentration. The examiner stated that the Veteran’s “[r]ecent memory appeared somewhat impaired. His mood was dysthymic. The examiner indicated that the Veteran’s psychological disability does impact his ability to work. In this regard, the examiner explained that the Veteran “has difficulty maintaining concentration and focus on work over a period of time, tends to skip from one task to another without completing the prior task.” The examiner further stated that the Veteran’s “sleep is so disrupted that he is usually fatigued at work, making concentration and focus on work assignments difficult.” The Board has thoroughly reviewed the record and has given full consideration to 38 C.F.R. § 4.7 (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) and 38 C.F.R. § 3.102 (when there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the veteran). In determining whether the Veteran meets the schedular criteria for a higher initial rating, the Board’s inquiry is not necessarily limited to the criteria found in the VA rating schedule. See Mauerhan, supra. Upon review of the evidence of record, the Board notes that the Veteran has been diagnosed with nonservice-connected psychiatric disabilities other than adjustment disorder during the claim period, including alcohol use disorder and persistent depressive disorder. However, where an examiner is unable to distinguish the symptoms of a service-connected disability from non-service connected manifestations, all the manifestations will be considered part of the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996)). To this end, there is no evidence to clearly distinguish the symptoms of the Veteran’s service-connected adjustment disorder from his other diagnosed nonservice-connected psychiatric disabilities. In fact, the examiners and treatment providers have repeatedly indicated that they Veteran’s psychiatric disabilities have over-lapping symptoms and are of common etiology. Thus, the Board will attribute all of the Veteran’s psychiatric symptoms to adjustment disorder for the purposes of assessing the severity of that disability. Based on the above, for the period prior to January 27, 2017, the Board finds that the Veteran’s adjustment disorder has been objectively manifested by anxiety, depression, difficulty concentrating, and chronic sleep impairment. Critically, the evidence demonstrates that the Veteran’s psychological symptoms prior to January 27, 2017 are, at most, indicative of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. His adjustment disorder was not shown to result in occupational and social impairment with reduced reliability and productivity at any time prior to January 27, 2017. 38 C.F.R. § 4.130, DC 9440. The Veteran maintained healthy social relationships with family members. Moreover, although the Veteran undoubtedly experienced mood disturbances, there is no indication that his occupational and social functioning was impaired with reduced reliability and productivity prior to January 27, 2017. For the period from January 27, 2017, the Board finds that the impact of the Veteran’s adjustment disorder with depression and anxiety symptoms on his social and industrial functioning is not sufficient to approximate the degree of impairment in excess of a 50 percent rating. The evidence demonstrates that the Veteran’s psychological symptoms from January 27, 2017 have manifested as occupational and social impairment with reduced reliability and productivity due to disturbances of mood, depression, anxiety, impaired concentration, chronic sleep impairment, and difficulty in adapting to stressful circumstances, including work or a work-like setting. Critically, VA evaluation and treatment records, as well as the VA examination reports, have not shown that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as near-continuous depression; suicidal ideation, obsessional rituals, illogical speech, near continuous panic or depression affecting the ability to function independently; spatial disorientation; neglect of personal appearance; impaired impulse control with periods of unprovoked irritability; and difficulty in adapting to stressful circumstances. 38 C.F.R. § 4.130, DC 9440. The Board recognizes that the January 2017 VA examiner indicated that the Veteran has an inability to maintain effective work and social relationships; however, there is no indication that the Veteran’s occupational and social functioning was indicative of deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood at any time from the date of service connection. See Vazquez-Claudio, supra. In spite of social impairments, the Veteran has maintained good relationships with his spouse and children. Moreover, total occupational and social impairment has not been shown at any time during the appeal period. Specifically, the evidence does not demonstrate total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; intermittent inability to perform activities of daily living; or disorientation to time or place. There is no indication of total occupational and social impairment in the record. The evidence of record does not show that the Veteran’s adjustment disorder with depression and anxiety has caused total occupational impairment. Although he was unemployed during the appeal period, the evidence does not show that the Veteran is incapable of obtaining or maintaining substantially gainful employment due to his psychological symptoms. Significantly, no medical professional has provided any opinion indicating that the Veteran’s psychological symptoms have caused an inability to obtain or maintain gainful employment. Moreover, the evidence of record does not show that the Veteran’s service-connected psychiatric disability has produced total social impairment. Accordingly, in this case, the symptoms shown in the examination and treatment records do not equate to the symptoms contemplated for a 100 percent schedular rating at any time during the appeal period. While there may have been day-to-day fluctuations in the manifestations of the Veteran’s service-connected adjustment disorder with depression and anxiety, the evidence shows no distinct periods of time during the appeal period, when his disability varied to such an extent that a rating greater or less than the assigned ratings would be warranted. Hart, supra. In sum, the probative evidence of record does not support a finding that a rating in excess of 30 percent is warranted for the Veteran’s service-connected adjustment disorder with depression and anxiety prior to January 27, 2017 or in excess of 50 percent from January 27, 2017. The preponderance of the evidence is against the Veteran’s claim for higher initial ratings for his service-connected adjustment disorder with depression and anxiety. Consequently, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 55. REASONS FOR REMAND 1. Entitlement to service connection for hypertension, to include as secondary to service-connected prostate cancer, is remanded. The Veteran has asserted entitlement to service connection for hypertension as secondary to his service-connected prostate cancer. See the Veteran’s claim dated November 2014. To this end, he was afforded a VA examination and medical opinion in January 2017 at which time the examiner confirmed a diagnosis of hypertension. The Veteran reported that he was diagnosed with hypertension in 1984 when elevated blood pressure was discovered during a routine medical examination. As to the question of nexus, the examiner determined that the Veteran’s hypertension was not caused or aggravated by his service-connected prostate cancer. The examiner explained, “[t]here is no evidence to affirm that the Veteran’s hypertension is aggravated by the prostate cancer.” The examiner continued, “[t]o prove that, the medical records should demonstrate that it required either an increase of his medications or the addition of other medications. It would also need to show an uncontrolled hypertension. None of these are found in the Veteran’s medical records.” Significantly, the Board notes that, as the Veteran had service in the Republic of Vietnam during the Vietnam era, he is presumed to have been exposed to herbicide agents during service. VA regulations provide that, if a veteran was exposed to an herbicide agent during active military, naval, or air service, certain enumerated diseases shall be service connected if the requirements of 38 U.S.C. § 1116, 38 C.F.R. § 3.307 (a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C. § 1113; 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). Although the enumerated diseases do not currently include hypertension, service connection may be established with evidence of actual causation. 38 C.F.R. § 3.309(e); Stefl v. Nicholson, 21 Vet. App. 120 (2007). In that regard, the Board notes that the National Academies of Sciences, Engineering and Medicine (NAS) recently upgraded hypertension from its previous classification in the category of “limited or suggestive” evidence to “sufficient” evidence of an association with exposure to Agent Orange and other herbicides used during the Vietnam War and states that this category “indicates that there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. Accordingly, in order to afford the Veteran all benefit of the doubt, the Board finds that this matter should be remanded in order to obtain a VA medical opinion as to whether the Veteran’s diagnosed hypertension is due to his presumed exposure to herbicides. The matter is REMANDED for the following action: 1. Refer the VA claims file to a medical professional with appropriate expertise to provide an opinion as to the claimed hypertension. The examiner is requested to review the claims file in its entirety including all service treatment records, VA, and private treatment records. The examiner should then respond to the following: (a) Is it at least as likely as not that the diagnosed hypertension was incurred in the Veteran’s active duty service? In rendering this opinion, the examiner should address the NAS study referenced above noting a positive association between hypertension and herbicide exposure. (b) If not, is it at least as likely as not that the diagnosed hypertension was caused by a service-connected disability, to specifically include prostate cancer? (c) If not, is it at least as likely as not that the Veteran’s diagnosed hypertension is aggravated (made worse as shown by comparing the current disability to medical evidence created prior to any aggravation) by a service-connected disability, to specifically include prostate cancer? (d) If the Veteran’s diagnosed hypertension is aggravated by a service-connected disability, the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. If the clinician is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. The examiner must provide a rationale for each opinion given. K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. K. Buckley, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.