Citation Nr: 20023029
Decision Date: 04/02/20	Archive Date: 04/02/20

DOCKET NO. 18-17 276
DATE: April 2, 2020

ORDER

An effective date of January 2, 1997, but no earlier, for service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder, bipolar disorder, anxiety disorder, and major depressive disorder (hereinafter “PTSD”), is granted.

For the entire period on appeal, an initial rating of 100 percent for PTSD is granted, subject to the laws and regulations governing payment of monetary benefits.

For the period on appeal prior to July 19, 2019, the appeal seeking entitlement to a total disability rating based on individual unemployability (TDIU), having now been rendered moot, is dismissed.

FINDINGS OF FACT

1. The Veteran’s original claim for service connection for PTSD was denied by the RO in a final February 1997 rating decision.

2. The Veteran subsequently filed a petition to reopen, and in March 2017, the Board granted service connection for PTSD.  In a May 2017 rating decision, the RO set the effective date for the grant of service connection for PTSD as August 27, 2009, the date the most recent petition to reopen was received.

3. Prior to the grant of service connection, but following the prior final denial, the Veteran submitted to VA relevant official service department records that existed and had not been associated with the claims file when VA previously decided the claim, and the Board’s award of service connection in March 2017 was based, at least in part, on the subsequently received service records.

4. The evidence is in equipoise as to whether the Veteran’s PTSD symptoms most nearly approximated total occupational and social impairment for the entire initial rating period on appeal, and his only other service-connected disability is hypertension, rated as noncompensable.

5.  For the period on appeal prior to July 19, 2019, the claim of entitlement to a TDIU is now rendered moot in light of the Board’s grant herein of a total schedular disability rating for PTSD for the entire initial rating period on appeal.

CONCLUSIONS OF LAW

1. The criteria for an effective date of January 2, 1997 for the grant of service connection for PTSD are met.  38 U.S.C. § 5103, 5103A, 5107(b), 5110; 38 C.F.R. §§ 3.155, 3.156(c), 3.400.

2. Resolving any reasonable doubt in the Veteran’s favor, the criteria for an initial rating of 100 percent for PTSD have been met for the entire period on appeal.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.130, Diagnostic Code (DC) 9434. 

3.  The matter of entitlement to a TDIU for the period on appeal prior to July 19, 2019, has been rendered moot by the award of a total (100 percent) schedular rating for PTSD for the entire appeal period, leaving no question of law or fact to decide regarding that issue.  38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 3.340, 3.341, 4.14, 4.16.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran, who is the appellant in this case, served on active duty from November 1988 to November 1992.

This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2017 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO).

The Board observes that relevant VA medical records and records from the Social Security Administration have been added to the claims file since the RO’s adjudication in the February 2018 Statement of the Case (SOC), with a waiver of initial RO consideration.  See January 2020 Correspondence; see also Honoring America’s Veterans and Caring for Camp Lejeune Families Act of 2012, Public Law No. 112-154, 126 Stat. 1165 (amending 38 U.S.C. § 7105 to provide that if new evidence is submitted with or after a substantive appeal received on or after February 2, 2013, then it is subject to initial review by the Board unless the Veteran explicitly requests agency of original jurisdiction (AOJ) consideration).

The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions 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); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016).

Procedural History

As detailed below, this case has a complicated procedural history.

In a January 1997 letter, the RO indicated that an informal claim for PTSD was raised during a June 1993 VA Persian Gulf Registry Examination and stated that it was assembling all evidence necessary to properly evaluate the Veteran’s claim.  The Veteran was afforded a VA examination in February 1997.

In a February 1997 rating decision, the RO denied the Veteran’s claim for service connection for PTSD.  The Veteran did not appeal the February 1997 rating decision, nor was new and material evidence received within a year of notification of the rating decision.  38 C.F.R. § 3.156(b).  Therefore, the February 1997 rating decision became final.  38 U.S.C. § 7105(c); 38 C.F.R. § 3.104(a).

In January 2008, the Veteran filed a petition to reopen his claim for service connection for PTSD.  In a June 2008 rating decision, the RO denied the Veteran’s claim for service connection for PTSD.

In August 2009, the Veteran filed another petition to reopen his claim for service connection for PTSD.  In an August 2010 rating decision, the RO denied the Veteran’s claim for service connection for PTSD.  The Veteran then perfected an appeal to the Board.

In a January 2015 decision, the Board found new and material evidence had been received to open a claim for service connection for PTSD and remanded for additional development.

In a January 2016 Supplemental Statement of the Case, the RO denied the Veteran’s claim for service connection for PTSD.

In a March 2017 decision, the Board granted service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder, bipolar disorder, anxiety disorder, and major depressive disorder (hereinafter PTSD).

In a May 2017 rating decision, the RO assigned a 70 percent rating for the Veteran’s PTSD pursuant to DC 9434, effective August 27, 2009, the date the most recent petition to reopen was received.  The Veteran then perfected the instant appeal to the Board.

In a September 2019 rating decision, the RO awarded a TDIU, effective July 19, 2019, the date the Veteran’s Application for Increased Compensation Based on Unemployability was received.

1. Entitlement to an earlier effective date for service connection for PTSD

In general, the effective date of an award based on an original claim shall be fixed in accordance with the facts found, but shall not be earlier than the date of the receipt of the application. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400.  However, if the claim is received within one year after separation from service, the effective date of an award of disability compensation shall be the day following separation from active service.  38 U.S.C. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2)(i).

Additionally, section 3.156(c) may apply in cases in which VA receives certain records after it has already issued a decision on a claim.  Under 38 C.F.R. § 3.156(c)(1), “if VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim.”  As part of the regulation, the Secretary has included a nonexhaustive list of records that could constitute official service department records.  Id.  The applicability of this regulation is tempered by subsection (2), which provides that § 3.156(c) “does not apply to records that VA could not have obtained when it decided the claim because the records did not exist when VA decided the claim” or because the claimant did not “provide sufficient information for VA to identify and obtain the records.”  38 C.F.R. § 3.156(c)(2).  “An award made based all or in part on the records identified by paragraph (c)(1)…is effective on the date entitlement arose or the date VA received the previously decided claim, whichever is later.”  38 C.F.R. § 3.156(c)(3).

Here, the Veteran asserts that an earlier effective date is warranted for the award of service connection for PTSD due to the receipt of relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim in February 1997.  

As an initial matter, the Board finds that VA already “reconsidered” the Veteran’s service-connection claim for PTSD pursuant to § 3.156(c)(1) after receiving relevant official service department records.  In this regard, in March 2012, the Veteran submitted “after action reports” and service records of his unit commander, L.R., describing combat exposure.  These records existed and had not been associated with the claims file when VA first decided the claim in a final rating decision dated February 1997, and the Board readjudicated the Veteran’s service connection claim for PTSD, with consideration of these records, in a March 2017 decision.   

Next, the Board finds that the exception in § 3.156(c)(2) does not apply because the aforementioned records existed when VA first decided the claim in February 1997 and the Veteran provided sufficient information, such as the name of his unit, for VA to identify and obtain the records.  

Thus, the remaining question before the Board is whether the Board’s March 2017 grant of service connection was based all or in part on the official service department records submitted by the Veteran.  In its March 2017 decision, the Board relied upon an August 2014 private psychiatric evaluation report rendered by Dr. M.L.C.  In his report, Dr. M.L.C. wrote, “The service records provided to me reveal exposure to combat when [the Veteran] served in the 602ed Maintenance Company providing combat support for the 3ed Armored Cavalry Regiment and was attached to the 553D Combat Support Battalion. He operated in hostile, austere, and forward battle areas during the period of November 1990 through April 1991. After action reports verify these units experienced enemy contact, engaged in firefights with Iraqi border elements, and encountered small arms fire with engagement with the enemy.”  The Board observes that the “after action reports” and other service records to which Dr. M.L.C. refers were submitted by the Veteran in March 2012.  Thus, the Board finds that, at the very least, the Board’s March 2017 grant of service connection for PTSD was based in part on the subsequently submitted service department records.  Accordingly, an earlier effective date is warranted pursuant to § 3.156(c).

Finally, as previously mentioned, an award made based all or in part on later-received official service department records is effective on the date entitlement arose or the date VA received the previously decided claim, whichever is later.  38 C.F.R. § 3.156(c)(3).  In this matter, a letter dated January 2, 1997 from the RO indicated that an informal claim for PTSD was raised during a June 1993 VA Persian Gulf Registry Examination, wherein the examiner diagnosed the Veteran with PTSD and referred him for a psychiatric evaluation.  The Board acknowledges the Veteran’s assertion that the grant of service connection should be effective as of the date of his May 1996 claim application.  See July 2019 Appellate Brief.  However, the May 1996 claim application did not raise a service connection claim for a psychiatric condition, either formally or informally.  No mention was made of any psychiatric condition in the May 1996 claim application itself, nor is the Board able to ascertain whether any medical records referenced in the claim application contain a reasonably ascertainable diagnosis pertaining to a psychiatric condition, which would raise an informal claim under 38 C.F.R. § 3.155(a).  See Shea v. Wilkie, 926 F.3d 1362 (Fed. Cir. 2019).  This is because the Veteran’s service treatment records, apart from September 1988 Reports of Medical Examination and Medical History at service entrance, are unavailable.  See Formal Findings of Unavailability dated October 1996 and August 2010.  Thus, the appropriate effective date for the grant of service connection for PTSD is January 2, 1997, the date of the RO’s letter indicating that an informal claim for PTSD had been raised, as this is the date VA received the previously decided claim, and this date is later than the date entitlement may have arisen by any other means.  38 C.F.R. § 3.156(c)(3).

2. Entitlement to a compensable rating for PTSD prior to August 27, 2009, and in excess of 70 percent thereafter

Disability evaluations are determined by comparing a Veteran’s present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity.  38 U.S.C. § 1155; 38 C.F.R. Part 4.  When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7.  After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran.  38 C.F.R. § 4.3.

The Veteran’s entire history is to be considered when making disability evaluations.  See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995).  Staged ratings are appropriate for any initial rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings.  Fenderson v. West, 12 Vet. App. 119, 126 (1999).

In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material favorable to the claimant.  Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990).  Competency of evidence differs from weight and credibility.  Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted.  Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). 

When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether a veteran’s particular disability is the type of disability for which lay evidence may be competent.  Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007).  A Veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to her through her senses.  See Layno, 6 Vet. App. 465, 469.  Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation.  Barr v. Nicholson, 21 Vet. App. 303 (2007).  Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional.  Jandreau, 492 F.3d 1372, 1377.

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.

The criteria for rating psychiatric disabilities, other than eating disorders, are set forth in the General Rating Formula for Mental Disorders (General Rating Formula).  38 C.F.R. § 4.130.

Under the General Rating Formula, a 30 percent rating is warranted for 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).  Id.

A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.  Id. 

A 70 percent rating is warranted if the evidence establishes 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 (total occupational and social impairment) is warranted 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.

Effective August 4, 2014, VA amended the portion of the Rating Schedule dealing with mental disorders and its adjudication regulations that define the term “psychosis” to remove outdated references to the DSM-IV and replace them with references to the updated Fifth Edition (DSM-5).  See 79 Fed. Reg. 149, 45094.   The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the Agency of Original Jurisdiction on or after August 4, 2014.  Id.  VA adopted as final, without change, the interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board as of August 4, 2014.  See 80 Fed. Reg. 53, 14308 (March 19, 2015). 

Here, the RO certified the instant appeal to the Board after August 4, 2014; therefore, the PTSD claim is governed by DSM 5 and GAF scores are not relevant for consideration.  See Golden v. Shulkin, 29 Vet. App. 221, 225-26 (2018) (holding that the Board errs when it uses GAF scores to assign a psychiatric rating in cases where DSM-5 applies).

When determining the appropriate disability evaluation to assign, the Board’s primary consideration is the 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 (Fed. Cir. 2013).  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, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating.  Mauerhan v. Principi, 16 Vet. App. 436 (2002).  Thus, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating.  Id. at 442.  

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 rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.  Vazquez-Claudio, 713 F.3d at 118.  The Board recognizes that the Court in Mauerhan, 16 Vet. App. 436, stated that the symptoms listed in VA’s General Rating Formula is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating.  However, the Court further indicated that without those examples, differentiating between rating evaluations would be extremely ambiguous.

Where a veteran is diagnosed with multiple disabilities of the same body part/system, and it is unclear from the record which symptoms are attributable to each distinct disability, the Board is precluded from differentiating between the symptomatology and the disabilities.  See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam).

In this matter, the Veteran is currently in receipt of a 70 percent rating for his PTSD effective August 27, 2009.  He asserts that a compensable rating is warranted prior to August 27, 2009, and that a rating in excess of 70 percent is warranted thereafter.

For the reasons expressed below, the Board finds, after resolving all reasonable doubt in favor of the Veteran, that the record reflects PTSD symptoms and impairment consistent with the criteria for an initial rating of 100 percent for the entire period on appeal.

By way of background, in a June 1993 VA Persian Gulf Registry Examination report, the examiner diagnosed the Veteran with PTSD and referred him for a psychiatric evaluation.  The Veteran endorsed symptoms of insomnia.

In February 1997, the Veteran was provided a VA examination for his claimed PTSD.  The VA examiner, a medical doctor, wrote, “This 35 years old male veteran was referred from Adjudication Office for Original Psychiatric Evaluation after his request for post traumatic stress [disorder] benefits. He was seen with hospital record only. Veteran is unemployed since Mar 1996. He lives with his wife. He does odd jobs…”  During the examination, the Veteran reported that after his active duty service, he was irritable and his personality had changed.  The VA examiner noted the following objective findings: “The veteran is clean, slightly overweight, adequately dressed and groomed. He is alert oriented x 3. His mood is slightly anxious. His affect exhibits full range. His attention is good. His concentration and memory are good. Speech is clear and coherent. No thought or perceptual disorders are elicited. He is not hallucinating. He is not suicidal or homicidal. Insight and judgment are good. He exhibits good impulse control.”  Ultimately, the VA examiner diagnosed the Veteran with a mild anxiety disorder, not otherwise specified.

During an August 2014 private psychiatric evaluation, Dr. M.L.C. elicited responses from the Veteran about the severity of his PTSD at the time that the February 1997 VA examination report was rendered.  Dr. M.L.C. wrote, “In 1997 a compensation and pension examination report was completed to assess the extent of [the Veteran’s] mental illness. This report notes that prior to his military service he was involved in a variety of different occupational settings with no difficulty.  Subsequent to his military service [the Veteran] began working in a paint factory. He became irritable, displayed significant personality changes, and was very anxious. [The February 1997 VA examination] report diagnoses [the Veteran] with anxiety disorder not otherwise specified, as the full constellation of symptoms associated with [his] PTSD had not yet become evident. Retrospectively, I discussed with [the Veteran] his condition at the time of this report. Like many veterans he was loath to discuss the extent and intensity of his symptoms with the examiner due to shame, guilt, and disgust at what he had become. By this point he was experiencing extensive nightmares, flashbacks, dissociative episodes, irritability, anger, thoughts of suicide, an escalated startle response, hypervigilance, social isolation, and a sense of foreshortened future. By 1997 he was already displaying significant signs and symptoms of mental illness which would later become so severe as to cause him to become nonfunctional in his basic day-to-day life…[The Veteran] described to me, beginning by at least 1997 persistent and recurrent and intrusive recollections of the events that occurred in the Persian Gulf. This included distressing dreams of the events, periods of dissociation, illusions, hallucinations, dissociative periods when awakening, and severe flashbacks. Many of these symptoms are what other examiners had described as being psychotic episodes... These are not hallucinations or delusions associated with schizophrenia, but forms of flashbacks and dissociation associated with Criterion B of the DSM-IV...”

In a lay statement dated June 2014, the Veteran’s spouse, C.D.A., described the changes she observed in the Veteran when he returned from his deployment in 1991.  She noted that she had been married to the Veteran for 26 years and wrote, “[he] always was a happy and very kind person. We would go out, travel and get together with friends. In 1988 he joined the United States Army and in 1990 he was sent into the Iraq conflict. After he returned, we were sent to Ft. Hood, Texas, and it was then that the change occurred. When he arrived, he came back nervous, almost didn’t sleep, and I couldn’t touch him or speak to him suddenly/abruptly because he would react aggressively (as if to hit me). His temperament towards me started changing; everything bothered him. I thought that it would eventually go away, but as the years have gone by, it has worsened to the extent that he has to take medicine because he wakes up hearing voices and wanted to leave the house. Nowadays he gets in the shower and quickly leaves the bathroom because he can’t spend a lot of time in a closed space, he panics. And he is always locked in his room and hardly talks; he doesn’t have the same desires that we had when we met, where we would go out and travel…” 

In an October 2003 VA primary care note, the Veteran endorsed having insomnia since his active duty service.

In an October 2003 VA psychiatry admission evaluation note, the provider indicated that the Veteran was referred by his primary care provider due to a depressive mood.  The Veteran reported he was suspended from work approximately one month prior due to a discussion with his boss. He reported that since more than one month ago he had been feeling depressed, with loss of interest in activities, feelings of worthlessness and hopelessness, fatigue, loss of energy, increased appetite, and problems sleeping at night.  On mental status examination, the provider noted that the Veteran appeared his stated age, was “well kept,” exhibited mild psychomotor agitation, a cooperative attitude, and speech was spontaneous, fluent, had normal tone, and normal production.   The provider noted the Veteran had a depressed mood, a restricted affect, no suicidal or homicidal ideas, and no beliefs, preoccupations, obsessions, phobias, or delusions.  The Veteran exhibited a relevant, coherent, logical thought process, no visual or auditory hallucinations, no illusions, was oriented to person, time, and place, and had an intact memory and good concentration.  Ultimately, the provider diagnosed the Veteran with depressive disorder, not otherwise specified.

In an August 2004 VA treatment record, screenings for PTSD, a mood disorder, and for alcohol abuse were negative. 

In a June 2009 VA primary care note, the Veteran reported he visits a private psychiatrist “which has given different treatment. but he discontinues the treatment.”  The Veteran denied feeling suicidal or having any plans and stated that he does not like that question to be asked.  The provider assessed the Veteran with “Hx of anxiety will consult to psychiatry for further evaluation.”

In a June 2009 VA psychiatric consultation, the provider noted the Veteran was anxious and spoke very fast.  The Veteran endorsed an anxious mood for the past 3 to 4 months since losing his job and his mother-in-law’s passing, which occurred in the same week.  He reported he had difficulty maintaining sleep, with early morning awakening, which he said had happened all of his life.  He mentioned usually did not need to sleep much to feel refreshed.  The Veteran reported he was irritable, verbally aggressive, especially with his wife, started many projects at once and never completed any, was easily distractible, and had spending sprees.  He also said he was hyperactive and talkative, and that these symptoms lasted at the most 1.5 to 2 weeks.  The Veteran endorsed a lack of motivation, fair concentration, good energy levels, and good appetite.  The provider noted that the Veteran “endorsed psychosis, namely hearing his mother-in-law, seeing shadows and feeling like there is a someone telling him what to do, as if the good and bad are in his shoulders all the time.”  He denied delusions, nightmares, and active suicidal or homicidal ideas; however, he said at times he thinks his family would be better off without him and the thought of ending his life crosses his mind, “but stated in a way to make it look like an accident, falling off a ladder or having a motor vehicle accident.”  When asked about his history of violence, assaulting others, or legal problems, the Veteran indicated he was verbally aggressive with neighbors.  On mental status examination, the provider noted the Veteran was alert and attentive, fully oriented, was cooperative and reasonable, grooming was appropriate, he was ambulating without difficulty, his speech was a normal rate and rhythm, his language was intact, his mood was anxious and his affect was congruent with his mood, he had auditory and visual hallucinations at times, he had some ideas of references such as “good and bad telling him what to do,” he had no unusual thought content, denied suicidal or violent ideation, had limited insight, impulsive judgment, intact immediate and remote memory and fair recent memory, and had an average fund of knowledge.  The provider found the Veteran endorsed symptoms consistent with bipolar I disorder “most recent episode manic.”  

During an August 2009 VA psychiatry appointment, the Veteran reported he had not been sleeping well.  His spouse, C.D.A., accompanied him to the appointment and stated that the Veteran was very irritable and that this was affecting her and their children, noting that he became loud and angry.  On mental status examination, the provider noted the Veteran was alert, oriented, cooperative, ambulating without difficulty, was very well groomed, had fair eye contact, speech was clear and minimally productive, mood was “okay” and affect was blunted, he  denied active suicidal or homicidal ideas and psychosis, and insight and judgment were good.  The provider wrote, “Patient has been very irritable and has severe insomnia. This translates to problems at [home since] the tolerance to frustration is minimal…” 

In an August 2009 letter, Dr. N.O. wrote that the Veteran “presents changes in his sleep pattern, continuous flashbacks of experience he had at combat, and nightmares. He does not tolerate loud noises or explosion like sounds because he enters in a panic status that does not let him to perform in a correct way. He can not handle stress; maintain his concentration and attention span. He can not react appropriately to his physical and social environment. He’s very irritable, and anxious. He does not like to talk about what happen at war. He re-experiences continuously traumatic situations he had at war and combat through repetitive intrusive images, dreams, and flashbacks. In an adaptive attempt, he makes the effort to avoid recollection of the events and avoidance of circumstances that evoke recall. [The Veteran] also presents evidence of autonomic hyper arousal (e.g., difficulty sleeping, exaggerated startle response). There is clear impairment in functional status and quality of life due to trauma exposure…”

In an August 2009 Disability Report submitted as part of his claim for disability benefits through the Social Security Administration (SSA), the Veteran indicated that his illnesses, injuries, or conditions limit his ability to work as follows: “I have problems concentrating and remembering things. I see a doctor because I’m depressed. I am taking medication and it keeps me from seeing the world as hopeless, but I still have no interest in life anymore. I don’t care whether or not I get up in the morning. Unless I have to go to the doctor’s office I don’t see much reason to get up. I don’t answer the phone or the door bell. I don’t want to see people or have them see me like this”  The Veteran reported that his illnesses, injuries, or conditions first interfered with his ability to work on April 3, 2009, and that he became unable to work because of his illnesses, injuries, or conditions on April 3, 2009.  He reported that he had worked in the past and that he did not work at any time after the date his illnesses, injuries, or conditions first interfered with his ability to work.  He indicated he stopped working “Because of my condition and other reasons I was lay off from my job and cause me more depression.”  The Veteran further noted, “I don’t feel able to work, also I have trouble concentrating and have become more and more forgetful. My friend reminds me about important things that I need to do.”	

In a September 2009 VA psychiatry note, the Veteran reported he had been better with recent medication changes, but that he still felt somnolent, absent-minded, and at times was irritable.  He denied hallucinations or suicidal behavior, stated that he ate and slept well, and denied drug use.  The provider noted that the Veteran showed “improvement of his schizoaffective disorder.” 

In a September 2009 Function Report submitted as part of his claim for SSA benefits, the Veteran was asked what he was able to do before his illnesses, injuries, or conditions that he could not do presently, and he responded, “working as a service technician.”  He indicated that his illnesses, injuries, or conditions affected his sleep, stating, “Can’t sleep due to nightmares and insomnia.”  He noted that he did not do any house or yard work, explaining, “Because my depression don’t feel like working with anything.”  The Veteran indicated that he goes outside once a day and that he cannot go out alone because “I don’t tolerate loud noises due to get panic attack.”  He reported that he did not drive because of his depression and bipolar conditions and that he was not able to pay bills, handle a savings account, count change, or use a checkbook/money order “because I forget things and can’t concentrate.”  He indicated that his ability to handle money changed since his illnesses, injuries, or conditions began.  The Veteran noted that he needed to be reminded to go places and needed someone to accompany him.  He indicated that he had problems getting along with family, friends, neighbors, or others, stating, “I’m very irritable and anxious.”  When asked to describe any changes in social activities since the illnesses, injuries, or conditions began, he wrote, “I was able to handle a conversation with people, now I can’t.”  The Veteran reported that his illnesses, injuries, or conditions affected his memory, completing tasks, concentration, understanding, following instructions, and getting along with others.  He noted that he does not handle stress well because “I get irritable and anxious often” and that he does not handle changes in routine well because he cannot remember a lot.  The Veteran reported that he had noticed unusual behaviors or fears in that now, he does not communicate with others. 

In a November 2009 VA mental health note, the Veteran reported he was not sleeping well and was getting angry with his family.

In a March 2010 VA psychiatry note, the Veteran reported that a psychiatrist discontinued all of his medications and that most of his depressive symptoms returned.  He stated that he had been “very moody, irritable, unable to sleep, with episodes of frequent thoughts, rapid thoughts, many thoughts.”  He denied hallucinations or suicidal behavior.  The provider noted that the Veteran “has history of paranoid schizophrenia, with a history of schizoaffective disorder and a past history of alcohol and cannabis and cocaine abuse which has been in full sustained remission since 1986. The patient reports a relapse of depressive symptomatology and moodiness. This is secondary to the fact that all medications were discontinued several months ago.  The patient is very concerned that this irritability and mood swings have been affecting his marriage…” 

In a March 2010 Function Report completed as part of his application for SSA benefits, the Veteran indicated that before his illnesses, injuries, or conditions, he was able to take care of his kids, and that he is unable to do so now.  He reported that his illnesses, injuries or conditions affected his ability to sleep, stating, “I need medications in order to sleep, because I can’t sleep. I get up a lot every night.”  He noted that he needs reminders from his spouse to take his medication, and that he does not prepare his own meals.  The Veteran reported that he does not do household chores and that his spouse tries to motivate him, but he does not feel like doing anything because of his depression and anxiety.  He indicated that he only leaves the house for medical appointments and that he cannot go out alone because of his depression and anxiety, and his spouse does not want him to be alone.  The Veteran noted that he was not able to pay bills, manage a checking account, or use checkbook/money orders, and he indicated there had been changes in his ability to manage money since his illnesses, injuries or conditions began.  He reported, “I used to be able to read and concentrate, I would watch movies and be on the computer for longer periods of time, which I don’t do now.”  The Veteran noted that he does not spend time with other people and needs reminders to go places.  He indicated that he has trouble getting along with family, friends, neighbors or others due to his “depressive state. It bothers me to talk with and be around family, friends, neighbors. I would like to be alone all of the time.”  He noted that his depression has changed the way he behaves around other people, and that his illnesses, injuries, or conditions affected his ability to remember, finish tasks, concentrate, understand, follow instructions, and get along with others.  He indicated he had never been fired or suspended from a job because he had problems getting along with people, that he did not have control to manage his stress because of his depression and anxiety, stating, “Everything people say to me bothers me,” and that he did not like changes to his routine, stating, “They stress me out and I fight about everything.”  When asked whether he had noticed any behavior or fear that was out of the ordinary, the Veteran indicated he had, stating, “Before I had depression and anxiety I could control my behavior, which I can’t now. My home has been affected by my condition because I don’t like to spend time with anyone. That has had a bad effect on the lives of my wife and children.”

In a March 2010 psychiatric evaluation completed as part of the Veteran’s claim for SSA benefits, J.B.M., MD, psychiatrist, noted, “The claimant does have past psychiatric history since 1993-94 and 2003. Past diagnosis was Post Traumatic Stress Disorder. His recent psychiatric history began in April 2009. Current diagnosis is PTSD and depressive symptomatology. His clinical psychiatric sign and symptoms were the following: insomnia, irritability, auditory hallucinations and anxiety. He hasn’t identified any primary or secondary stressors of psychiatric illness.”  Dr. J.B.M. opined that the Veteran could not work “primarily due to his mental conditions” and noted, “His independence, quality and persistence are mildly affected by his mental health status.”  In terms of social functioning, Dr. J.B.M. wrote, “He doesn’t show interest in visiting relatives, friends or neighbors. He doesn’t maintain good relations with family, neighbors, friends and people around him. He doesn’t like participating in activities of interest outside town of residence. He doesn’t communicate effectively in social gatherings, family events or others. He doesn’t visit church of choice. Manages complex situations anxiously.”  On mental examination, Dr. J.B.M. found that the Veteran’s mood was slightly anxious and that his “Remote memory isn’t preserved. He didn’t recall some past events.  Dr. J.B.M diagnosed the Veteran with paranoid schizophrenia and depressive disorder NOS both “by history.” 

During an April 2010 VA psychiatry appointment, the Veteran reported that he feels anxious in the morning and sometimes in the afternoon.  He also reported chronic auditory hallucinations which have not responded well in the past to medications.  The provider wrote, “He hears voices but are not of a commanding nature.”  The Veteran indicated he was used to these voices and he ignores them. 

In a May 2010 private treatment record, the provider, Dr. R.G.G., wrote “[The Veteran] has a history of emotional problems, which started after he was engaged in the Gulf War and discharged from the Army. Has been diagnosed as having post-traumatic stress disorder and at the present time is on psychiatric therapy at the VA Hospital. His condition worsened after he had to stop working. However, had some improvement with present medication.  Upon a review of systems, in relevant part, the Veteran endorsed insomnia and depression.  Dr. R.G.G. opined that the Veteran “Has mental problems which is a major limitation.”

In a June 2010 Mental Residual Functional Capacity Assessment completed as part of the Veteran’s claim for SSA benefits, the examiner found the Veteran had remote memory difficulties, was able to remember and carry out simple instructions but not complex ones, that he could sustain attention for two-hour intervals, and could interact with supervisors and adapt to changes in the work setting.

In an August 2010 Disability Report submitted as part of the Veteran’s claim for SSA benefits, M.A. was asked whether there had been any change in the Veteran’s illnesses, injuries, or conditions since a disability report was last completed.  M.A. responded that there had, and wrote, “[The Veteran’s] psychiatric conditions have gotten substantially worse in the past few months. Now he has more trouble sleeping and will basically talk to no one. He spends most of the day sleeping and only leaves his house for medical appointments and needs to be accompanied by his wife. The medications he is taking make him very sleepy during the day, substantially delay his responses and turn him numb and groggy. His mood swings have become worse and he gets angry very easily. As to his memory, [the Veteran] needs to be constantly reminded by his wife of his doctors’ appointments, to take a shower, to get properly dressed and to eat. Likewise, due to his memory lapses and forgetfulness, he can no longer cook because he forgets to shut off the stove and could burn the house. In addition, his wife has to take care of the children because [the Veteran] will forget to attend them properly or leave them alone and unsupervised.”  M.A. indicated that the approximate date this change occurred was in February 2010.   M.A. was also asked what changes occurred in the Veteran’s daily activities since a disability report was last completed.  He responded, “[The Veteran] is no longer interested in watching tv or reading and, when he does try to do those activities he falls asleep and doesn’t finish them. He no longer has a desire to do anything and cannot finish even the simplest of tasks around the house like washing the dishes. He now only leaves the house to go to doctor’s appointments and doesn’t go to any social activities.”

During a September 2010 VA psychiatry appointment, the Veteran reported he was irritable.

In a September 2010 Work History Report submitted as part of the Veteran’s claim for SSA benefits,  the Veteran indicated he worked as a wheel vehicle mechanic in the U.S. Army from November 1988 to March 2000, as a service technician in a banking business from August 1998 to September 2003, and as a service technician in a pharmaceutical business from September 2004 to April 2009.  He reported that as a service technician at a banking business, he installed, repaired, and maintenance currency counters and other banking equipment, and as a service technician at a pharmaceutical business, he installed, repaired, and maintenance pharmaceutical equipment for coating and pressing tablets.  

In a September 2010 Function Report submitted as part of the Veteran’s claim for SSA benefits, the Veteran’s spouse, C.D.A., indicated that from the time the Veteran wakes up from the time he goes to bed, he eats breakfast, walks around the house, sits during the day, eats lunch, sleeps, eats dinner, and takes a shower.   She indicated that before his illnesses, injuries, or conditions, he was able to take care of his children, but he cannot now.  C.D.A. noted that the Veteran’s illnesses, injuries, or conditions affect his sleep, that he needs special help or reminders to take care of his personal needs and grooming, and that he needs reminders to take medicine.  She reported that the Veteran does not prepare his own food because he does not remember to turn off the stove, burns food, and leaves the stove unattended.  C.D.A. indicated that the Veteran does not do house or yard work because he cannot concentrate or think of what has to be done.  She noted that the Veteran cannot go out alone or drive because he is under medications daily.  C.D.A. indicated that the Veteran is not able to pay bills, count change, or handle a savings account, and that his ability to handle money changed since his illnesses, injuries, or conditions began, as he has trouble thinking, concentrating, and making decisions.  She reported that the Veteran has a loss of interest and pleasure in normal activities and hobbies, that he has problems getting along with family, friends, neighbors, or others because he gets irritable and frustrated even over small matters, and that before his illnesses, injuries, or conditions began, he could get along with everybody.  C.D.A. noted that the Veteran has problems paying attention, finishing what he starts, following spoken and written instructions, and remembering things.  She indicated that the Veteran did not have any problems getting along with bosses, teachers, police, landlords, or other people in authority, and that he had never lost a job because of problems getting along with people.  C.D.A. noted that stress or changes in schedule affect the Veteran by making him irritable and frustrated.

In an October 2010 VA psychiatry initial evaluation note, the provider wrote, “Patient describes history of hearing voices calling him, talking, doors closing, sees shadows, last [episodes] 3-4 days ago. [He] describes episodes in which he has more energy than usual this [episode] lasting 1 day. He describes poor sleep pattern in which he sleep[s] 1-2 hours and wake[s] up. He refer[s] this to be chronic and lasted for several years. Denies spending money at this moment since wife control[s] fina[n]ces, refer in the past [spent] money buying computer, clothes spending up [to] $2,000.00/day. He refer[s] on and off get on the roof to see the sight. Denies other high risk behavior. Denies feeling paranoid. Denies thought insertion, or any other delusion. At this encounter patient denies suicidal, homicidal ideas, hallucinations or delusion. He describes irritable mood and poor sleep pattern, poor [tolerance], easily frustrated.”

In a November 2010 VA psychiatry note, the provider wrote, “Patient reports he has continued with irritable mood, verbally ag[g]ressive, not sleeping well. Describes to awakes frequently at night. Patient refer to snores, and then the next day is tired. He refer to hears voices, [laughes], calling his names. Denies visual hallucinations. Describes on and off death wishes, but denies self harm ideas, express he will never harm himself…At this encounter, he adamantly denies any suicidal ideas, intention, or plans. He denies any homicidal ideation/intention or plan. He denies disorganized speech or behavior. Denies active hallucinatio[ns] or delusion. 

In a November 2010 Disability Report submitted as part of the Veteran’s claim for SSA benefits, the Veteran’s spouse, C.D.A., indicated that there had been changes in the Veteran’s illnesses, injuries or conditions since his last disability report in April 2010, writing, “[The Veteran] has become more aggressive, is more depressed, does not leave his house except for medical appointments and will not talk to anyone outside his family. [He] continues to have suicidal thoughts and tendencies and his family has to supervise him to make sure that he does not injure himself. [The Veteran] cannot concentrate on anything and can’t even finish watching an entire television show. Because of his depression, [he] now rarely sleeps during the night and is suffering from hallucinations where he thinks that people are calling him.”  C.D.A. reported that the approximate date this change occurred was in April 2010.  She was asked how the Veteran’s illnesses, injuries, or conditions affect his ability to care for his personal needs, and she responded, “[The Veteran’s] family has to supervise him to make sure that he does not injure himself because of his suicidal tendencies. He also does not perform any tasks around the house and his family has to do it for him because he has no concentration, no desire to do anything and constantly forgets everything that he is told.”

In a January 2011 VA psychiatry note, the provider wrote, “[The Veteran] reports he has been with lack of motivation, insomnia, neglecting his self care, unshaved, with depressed mood and continues hearing voices calling his name or making noises.”  The provider noted the following assessment: “49 years old male patient, with above history, who comes on [follow] up appointment [complaining] of depressive symptoms and perceptual disturbances. At present denies suicidal, homicidal ideas, hallucinations or delusions of any kind.” 

In a January 2011 private report rendered by Dr. J.R.C. as part of the Veteran’s claim for disability benefits through New York, the Veteran reported that he could not sleep, was having problems with his spouse, and was worried.  Dr. J.R.C. noted, “He was observed to be worried and in his [illegible], he acted like an aggressor…His thoughts revolved around the flashbacks that he is having...His affect appeared blunted and his mood was [illegible] depression and anxiety. He has post-traumatic manifestations...”  In regards to the Veteran’s attention and concentration, Dr. J.R.C. found “there is some deterioration and need to repeat things to him,” and he noted that although the Veteran was oriented to person and place, he did not know the date.  Dr. J.R.C. noted a deterioration of the Veteran’s recent memory.  As to his ability to function in a work setting, Dr. J.R.C. observed, “With regard to the emotional condition, [illegible] and poor tolerance negatively affect his ability to deal with people and situations.”  Dr. J.R.C. found that the Veteran is not capable of handling any payment benefits, and he noted that the Veteran “has a lot of episodes where he can’t tolerate noise and groups of people.”  Ultimately, Dr. J.R.C. opined, “Based on the medical findings provided in my report, my medical opinion regarding this individual’s ability to do work related mental activities is as follows: This patient is unable to work...Understanding and memory is limited. Sustained concentration and persistence is limited. His ability to [illegible], attend and hold to an organized sequence of [illegible]is affected and that makes the prognosis worse.... Social interaction is limited. Adaptation: limited. He has little capacity for adapting...” 

In February 2011, the SSA issued a disability decision for the Veteran.  In pertinent, the decision read as follows: “After careful review of the entire record, the undersigned finds that the claimant has been disabled from July 1, 2009, through the date of this decision...Findings of Fact and Conclusions of Law...The claimant has not engaged in substantial gainful activity since July 1, 2009, the amended alleged onset date...The claimant has the following severe impairments: diabetes mellitus; high blood pressure; chronic obstructive pulmonary disease; right shoulder bursitis, and bipolar disorder, manic type I... [T]he claimant has anhedonia, sleep disturbance, decreased energy, feelings of guilt or worthlessness, and difficulty concentrating or thinking. [T]he claimant’s impairment causes marked restriction in activities of daily living, marked difficulties in maintaining social functioning, marked difficulties in maintaining concentration, persistence or pace, and no episodes of decompensation, each of extended duration. The claimant is a younger individual with a high school education and past relevant work as industrial mechanic... Dr. Ramon Fortuno, a psychiatrist, testified as an impartial medical expert on behalf of the Social Security Administration. Having thoroughly reviewed the medical evidence, Dr. Fortuno testified that the claimant has diagnosis of bipolar disorder type I with a current manic episode. He stated that the medical evidence substantiates a bipolar disorder with depressive characteristics. The claimant began psychiatric treatment on July 2009 through the Veterans Administration (VA) Hospital...”

In December 2011, the Veteran was provided a VA examination to assess his claimed PTSD.  The VA examiner, a psychiatrist, found that the Veteran does not have a diagnosis of PTSD that conformed to the DSM-IV criteria, instead diagnosing the Veteran with “Bipolar disorder as per record.”  When asked about the Veteran’s level of occupational and social impairment, the VA examiner indicated 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.  In terms of work history, the Veteran indicated he worked as an industrial mechanic for 5 years and retired in 2009 due to “leg thromboflevitis and [bipolar] disorder.”  The VA examiner found that although the Veteran experienced, witnessed, or was confronted with an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of himself or others, the traumatic event was not persistently re-experienced, he had no persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness, and no persistent symptoms of increased arousal.  The VA examiner did not indicate that the Veteran had any symptoms.

In an October 2012 VA psychiatry note, the provider wrote, “Patient has noticed that since discontinuing bupropion he has been having increased [forgetfulness] and decreased concentration. Reports is also having very early morning awakening…Also reports [he] has been having combat related nightmares.”

In a January 2013 VA psychiatry note, the provider wrote, “[The Veteran] reports [he] has been having combat related nightmares.”

In a March 2013 VA psychiatry note, the provider wrote, “Today patient reports since last visit has been feeling sad and anxious. States he is having nightmares about combat experience every night. Reports feels anxio[u]s during most of the day but more so at bedtime and when taking a shower. States at those times gets the feeling ‘that something bad is going to happen, that I may die and not wake up tomorrow.’ Also reports [occasional] flashbacks…In addition to combat experience, a year ago patient found his son’s godfather dead after falling off a tree. Reports thinks about this on a daily basis as well. Reports on days when sad ten[d]s to become isolated and withdrawn. Has been [having] difficulty initiating sleep…Also denies racing thoughts or grandiosity. Does complain of [occasional] irritability. Interested in anger [management] group to help in this area. Feels current treatment is helpful. Does ventilate about financial stressors but feels he is coping well considering the circumstances. At this time denies hearing voices and no delusional thought content is elicited. Past history of depressive and manic episodes as well as hearing voices in the past.”

During an April 2013 VA psychiatry consultation, the Veteran reported increased worries about his health, sometimes thinking that he will not wake up.  He also reported feeling worried about his bath time, only being able to take a bath before his children take their bath, stating “I think that an earthquake might happen.”  The Veteran noted that his worries came worse approximately 1 year prior.  He was unable to identify recent stressors except for deterioration of his physical health and being unable to do the things that he used to do, such as working.  The Veteran reported that he also has depressed mood, most of the days, with markedly diminished interest in the daily activities.  He reported a history of episodes of increased energy, with goal directed activities, and decreased need for sleep.  He indicated that these episodes can last 3 to 4 days and are always followed by periods of depression.  The last such episode was one week prior.  The Veteran reported that he feels angry and sad when remembering the time he spent in the Persian Gulf, but the provider noted no major dysfunctions related to those recollections.  The Veteran also endorsed recurrent nightmares, as frequently as twice a month, associated with his military service, not necessarily relating to a specific traumatic event.  He reported difficulty sleeping with early morning awakenings and difficulties falling asleep.  He reported irritability, poor concentration, and some hypervigilance, stating, “I would check the doors before going to sleep and sometimes during the night.”  The Veteran indicated that his symptoms have made it very difficult to do his work, take care of things at home, or get along with other people.  The provider ultimately assessed the Veteran with a history of bipolar disorder, “now presenting depressive symptoms and anxiety mostly associated to changes in life.”

During a December 2013 VA psychiatry appointment, the Veteran reported that his family has shown some concern as he seems less interested in socializing and he spends 10 to 12 hours in bed per day.

In a June 2014 lay statement from the Veteran’s spouse, C.D.A., she wrote, “Nowadays, in 2014, he neither goes out nor does he take part in any activity. After 15 years of marriage, God gave us 2 children, one boy of 10 years of age, and another boy of 7 years of age. [H]e doesn’t share with his children, barely speaks to them, doesn’t play with them, neither does he attend to their school activities; everything is done by me. He barely even speaks to me. Before, when he would leave the house, he would get into arguments with the neighbors. Nowadays he mostly stays shut inside the house. Before, we would argue a lot, but after the medicines he started taking, he barely even speaks; he’s changed a lot, nothing makes him happy, and life has no sense/meaning for him; it’s all the same to him, it’s as if he was in another world. Different to the person that I met: happy, kind, talkative, and loving, who I married 26 years ago. It is very difficult because I’ve lived all of those difficult moments with him, and more so when he was in the Persian Gulf, and for everything that happened there. He came back very changed and nervous, since it was not easy for us.”

In August 2014, Dr. M.L.C. conducted a private psychiatric evaluation of the Veteran.  In his report, Dr. M.L.C. wrote, “[The Veteran] is profoundly impaired as a result and subsequent to his active-duty service...Since discharge, treatment records and a statement from his spouse describe him as a completely changed individual marked by irritability, verbal aggression, loss of focus, loss of concentration, easy distractibility, suicidality, and perceptual alterations. A November 2010 report describes the veteran as experiencing death wishes, irritable mood, verbal aggression, poor sleep, and experiencing perceptual alterations. In January 2011, he was lacking motivation, had insomnia, neglected his self-care, had neurocognitive symptoms of depression, and was hearing voices...He was a completely changed individual after his discharge, no longer able to function especially given his above-average intellect and capacity. In treatment records, he described frequent nightmares about his combat experiences, flashbacks, anxiety, a sense of foreshortened future, hypervigilance, and an escalated started response, which are all symptoms consistent with PTSD. An April 2013 mental health nursing progress note revealed objective data to support his diagnosis of PTSD consistent with the above-mentioned symptoms...There was a dramatic difference from [the Veteran’s] capacity to function subsequent to his active-duty service, as all the qualities described above were obliterated by mental illness. The person who existed subsequent to his active-duty service was a shadow of himself, profoundly and pervasively mentally ill, and incapable of managing even the simplest tasks of day-to-day life, no longer able to function in occupational setting.”  Dr. M.L.C. further stated, “A detailed review of his medical record describes extensive deterioration due to mental illness subsequent to his active-duty service present through the current day...The symptoms have been steadily progressive over the course of his life and have prevented him from functioning adequately in either a social or occupational setting. As [he] is barely able to function in the most basic of social settings, his occupational capacity does not exist. He has severe social isolation, significant anger, irritability, altered behavior, unpredictability, volatility, and is completely unsuitable for an occupational environment where he would have to engage coworkers, supervisors, and the public on a day-to-day basis. The extent of his PTSD has led him to have symptoms that are too severe to tolerate the stressors in an occupational setting.”

In a January 2015 VA psychiatry note, the provider noted that the Veteran presented with depression and anxiety symptoms. 

In a March 2015 VA psychiatry note, the Veteran reported irritability, anxiety, and being upset for the past few weeks.  He also endorsed difficulty initiating and maintaining sleep. 

In a July 2015 VA psychiatry note, the provider noted the Veteran’s most prominent symptoms were depression and anxiety.  The Veteran reported that in past weeks, he has been sad, feels like crying, is unmotivated, barely going out, not pursuing his hobbies, and not socializing.  He endorsed difficulty initiating and maintaining sleep.  

In a December 2015 VA psychiatry note, the provider indicated that the Veteran’s spouse accompanied him to the appointment and verified his symptoms of sadness, feeling like crying, being unmotivated, barely going out, not pursuing his hobbies, and not socializing.  The Veteran reported that at night, sometimes he hears something like the sound of cars or murmurs, and when he checks, no one is there.  He denied any identifiable conversations or commands, which C.D.A. confirmed.

In December 2015, the Veteran was provided another VA examination to assess his claimed PTSD.  The VA examiner, a psychiatrist, found that the Veteran did not have a diagnosis of PTSD that conformed to the DSM-5 criteria, instead diagnosing him with unspecified depressive disorder with anxiety symptoms.  The examiner also noted that obstructive sleep apnea was a medical diagnosis relevant to the understanding or management of the Veteran’s mental health disorder.  The examiner indicated that the Veteran had occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication.  The Veteran described his marital relationship as “regular, we have been married for 28 years now, with its ups and downs.”  He indicated that they have two sons, ages 8 and 11, and that they are both disabled.  The Veteran reported he worked as photographer supervisor at a private company prior to active duty, that he worked as an industrial mechanic at a pharmaceutical equipment manufacturing company. and that he was determined to be disabled by the SSA in 2008 “for Bipolar and Ptsd problem, outside the VA and feet problems.”  In terms of legal and behavioral history, the Veteran stated he has “turned assaultive to neighbors: ‘in 2005 or 2006 and arguments all the time, I fought with a neighbor who was constructing and he left panels and wood at my house and we started fighting, he didn’t want to accuse me, my wife always intervenes…’  The VA examiner found the Veteran exhibited the following symptoms: depressed mood, anxiety, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, chronic sleep impairment, and disturbances of motivation and mood.  The examiner also wrote, “Veteran states to feeling depressed and not having desire to spend time with relatives, avoids crowded places and ‘I always feel guilty for my sons’ conditions...’, sleep disturbances described as: ‘I’m using the sleep apnea machine and I can’t sleep during the day, difficulties getting and staying asleep almost every night [for a] fairly long time, 15 years’…‘I hear voices and I get up and I have nightmares, memories from combat and things that happened...’” 

In a December 2015 VA medical opinion, the VA examiner opined that the Veteran’s claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness, reasoning that “Unspecified Depressive Disorder with anxiety symptoms seems to have been triggered by laboral difficulties, ‘’a discussion with his Boss’ as per first available psychiatric note dated 10/31/2003 at the San Juan VAMC MHC.”

In an October 2016 lay statement, the Veteran’s spouse, C.D.A., wrote that when the Veteran returned from deployment, “he went to the doctor because he had problems sleeping and always appeared anxious, his mood was changing and he was bothered by any little thing...Everything began to change, our communication was deteriorating, there was more fighting, we stopped going to the places where we had always used to go. Our friends were pulling away because of his attitude…”  She noted that when they returned to Puerto Rico in November 1992, the Veteran “continued to get worse every day and even so, he continued working. Several times he went to his appointment in the Veterans Hospital, but he couldn’t tolerate the wait and would leave. In several of the jobs he had, he would fight with his coworkers and bosses, which made communication difficult. At home he would apply himself to do something and would not finish what he was doing. His family members believed that it was because of me that he had this attitude because he no longer wanted to visit them and if they visited us he would shut himself up in his room. The situation was getting worse by the day and as the years passed it got worse.”  C.D.A. further stated, “In the year 2003, I became pregnant with my first child after having waited for 15 years; thinking that this would make him change and that it would make him happy, but it was not the case. When our son was born, we noticed several things that were not common in children his age. At the age of three they evaluated him because the child behaved differently and they gave him a diagnosis of autism. Then the situation was made worse because [the Veteran] blamed himself for the fact that his son had been born with this condition. It was a very difficult situation, he spent time crying and he always blamed himself for the child being this way. He hardly spent time with his son, and he didn’t carry him either. He didn’t affectionately touch the child and every day it got worse. In the year 2005, I became pregnant and they had to perform an abortion. We suffered a lot because it was an ectopic pregnancy. In 2006 I got pregnant again and in 2007 our second son was born. Our second son has problems with speech and [the Veteran] also blames himself for this... We have experienced a lot of suffering due to his change. He forgets a lot. We don’t spend time together as a family. He couldn’t work anymore. He won’t go out unless I go with him to the appointments. We have been almost at the point of getting divorced because it has become a hell to live with him. [The Veteran] closes himself off and can spend the entire day shut up in this room and it doesn’t bother him. He hardly sleeps and hears voices, he says. I have seen him lying on the floor and he says that they harass him. Nowadays, he has many health conditions, he hardly grooms himself, I have to convince him to let me help him with his hygiene. He doesn’t have friends, our family members don’t come to our house. Today, our sons are 12 and 9 and they can’t even have a friend over. He doesn’t talk on the phone, doesn’t watch television. For the time being, he sets off crying for no reason, he puts towels on the windows to cover them. It’s excruciating to live with a person like this. I got married when in love with him and it makes me very sad because as the years pass, he has been deteriorating and every day he gets worse. Since the moment he went to Iraq, he returned another person, full of problems and illnesses with different things appearing every day…[The Veteran] has told me that he wants to die, that he should no longer exist in this world since we have suffered because of him…Sometimes in the early morning, he gets up and says he hears voices, sometimes at one, two, or three in the morning. I get up because it makes me afraid that he might do something to endanger his life. He depends on me a lot. I don’t know how long I can continue to bear all of this. God has given me a lot of strength, but this situation for almost 25 years has been hell because there’s no relief…In the community were barely talk to our neighbors because he has fought with everyone and they don’t visit us because he’s turned everyone against him. In truth, I don’t know what more to do, with the two boys, and in truth I feel sorry for [the Veteran] because I know that he was not like this. All of this change and his sicknesses began after returning from the Persian Gulf War...As a married couple, we no longer spend time together, he is in his own world and I am laboring with the children. I go with him to medical appointments, but he doesn’t want to leave to go to any other place. When he goes to the appointments, he gives up wanting to go and I convince him to stay and also to take his medications. Before, I would ask him what happened in the war and he didn’t want to talk about it, he would just begin to cry...”

In February 2017, L.C.R., psychologist, authored a private assessment of the Veteran after reviewing the Veteran’s medical and service history, his spouse’s statements, conducting a personal and comprehensive psychological examination, clinical observation, applying a PTSD checklist, and considering statements made by the Veteran’s spouse in a separate interview.  In the assessment, Dr. L.C.R. wrote, “Treatment records clearly show that [the Veteran’s] psychiatric symptoms began following his military discharge. As early as June 1993, a VA Clinical Record noted that the veteran was reporting symptoms of insomnia and had been diagnosed with PTSD. At a February 1997 VA examination, [the Veteran] had been out of work for almost a year and was found to be irritable with poor sleep and a changed personality, resulting in a diagnosis of Anxiety Disorder, NOS.”  The Veteran reported that he still does not sleep well despite the use of medication and that he awakens frequently at night and being tired the next day, stating, “everything has to do with issues of war, they get me bad and do not let me sleep well at night.”  He also stated, “As usual I make an effort to avoid reminders of the traumatic events suffered during military duty such as news reports and portrayals of war, and I avoid talking about it because that sets me off.”  He reported having the feeling that something could happen at any time, with episodes where he feels scared, nervous and hypervigilant.  He referred to having decreased interest and pleasure in most of his usual activities, as well as irritability and anxiety.  The Veteran expressed that he often seeks isolation, avoids places where there are many people, and many times simply stays at home.  During Dr. L.C.R.’s interview with the Veteran’s spouse, she stated, “I’ve been married for twenty-eight years and I’ll tell you that he came from the army completely changed. Before leaving he was a gentleman, sociable, and he was loving with me. But after he returned what I live with him is like hell. He has his ups and downs, and usually gets very angry. He gets up at night startled, sometimes wakes up crying and moves a lot while sleeping. It’s like he has nightmares.”  On mental status examination, Dr. L.C.R. noted, “[The Veteran] came into the exam dressed in appropriate casual clothes. He was observed to be restless and presented in an anxious mood with expressions of agitation. His speech was spontaneous and his attitude cooperative. He is alert and oriented to person, place and time. No tics or abnormal movements were noted. He admits to suicidal rumination, ideas but without self-attempt. There was evidence of additive hallucinations and occasional nightmares. He denies homicidal ideas. His insight and judgement appear to be poor.”  Ultimately, Dr. L.C.R. opined as follows: “[The Veteran] was clearly exposed to an event that involved threatened serious injury...[The Veteran] experiences involuntary and intrusive upsetting memories of the traumatic event...[The] Veteran presents frequent avoidance of conversations or activities that bring up memories of his military event...[The] Veteran presents irritability, depressive and anxiety symptoms, difficulty concentrating and problems sleeping...The above symptoms last for more than one month and his psychiatric condition interfere[s] greatly with his daily life...The symptoms cause clinically significant distress or impairment in social and occupational areas of functioning as [the Veteran] has not worked since July 2009. His psychiatric condition has caused such impairment as to render him incapable of gainful employment and social activities.”

In a February 2017 private psychological evaluation report, Dr. M.L.C., the same examiner who rendered the August 2014 evaluation, wrote, “After a second review of [the Veteran’s] medical records, the updated treatment records provided, the available service records, and the 2015 Compensation and Pension examination report, there is no question that his diagnosis is PTSD. He simply does not meet the criteria for bipolar affective disorder, an unspecified depressive disorder, an unspecified anxiety disorder, major depressive disorder, schizophrenia, or any other psychiatric illness besides PTSD and a substance use disorder in remission. There is no need to diagnose unspecified depressive and anxiety disorders, when [the Veteran’s] symptoms are remarkably specific for PTSD and clearly associated with combat-related trauma... There is no other psychiatric illness that causes nightmares of trauma, flashbacks of trauma, avoidance, hypervigilance, an escalated startle response, and all the other symptoms that I have documented in my 2014 report and reiterated in this current report…The 2015 VA examiner documented signs and symptoms of PTSD in the body of the report, referred to the medical record indicating that the veteran has PTSD, and concluded that the veteran had a diagnosis of an unspecified depressive disorder with anxiety, a diagnosis that does not even exist. The examiner in 2015 had to overlook large portions of the medical record to reach this erroneous conclusion, and even ignore the documentation in the body of her own report in coming to her spurious diagnosis. In general, there is no need to make a diagnosis of an unspecified psychiatric disorder, such as a nonspecific depressive disorder or anxiety disorder when there is a clear diagnosis of another psychiatric illness that provides a detailed description of a patient’s clinical condition. In the case of [the Veteran], PTSD fits his symptomatology and matches the diagnostic criteria for the disease processes in an obvious, clear, and comprehensive fashion…In addition, [the Veteran] has had severe psychiatric disease for decades, present since his return from active-duty service. This long predated 2003, and veteran had presented with symptoms of pervasive mental illness, consistent with PTSD, since his discharge from active duty service. It is possible that the initial assessment of the veteran could reasonably have led to a diagnosis of depression and anxiety, but as his clinical condition unfolded and he began describing nightmares of the trauma, dissociative episodes, avoidance, and all the other criteria described above, the diagnosis should have been changed to reflect the obvious, PTSD in a combat veteran... The symptoms described by the veteran are only captured within a diagnosis of PTSD, and are not associated with a variety of unspecific psychiatric disorders... These symptoms are totally disabling and have prevented [the Veteran] from engaging in gainful employment since he stopped working in July 2009.”

On review, the Board finds that the evidence is in equipoise as to whether the Veteran’s PTSD resulted in symptoms productive of total occupational and social impairment for the entire rating period on appeal.

First, the evidence demonstrates that the Veteran experienced persistent hallucinations throughout the entire rating period.  During an August 2014 private psychiatric evaluation, Dr. M.L.C. elicited responses from the Veteran about the severity of his PTSD at the time that the February 1997 VA examination report was rendered.  In his report, Dr. M.L.C. wrote, “[The Veteran] described to me, beginning by at least 1997 persistent and recurrent and intrusive recollections of the events that occurred in the Persian Gulf. This included distressing dreams of the events, periods of dissociation, illusions, hallucinations, dissociative periods when awakening, and severe flashbacks. Many of these symptoms are what other examiners had described as being psychotic episodes... These are not hallucinations or delusions associated with schizophrenia, but forms of flashbacks and dissociation associated with Criterion B of the DSM-IV...”  In a June 2009 VA psychiatric consultation, the provider noted that the Veteran “endorsed psychosis, namely hearing his mother-in-law, seeing shadows and feeling like there is a someone telling him what to do, as if the good and bad are in his shoulders all the time.”  The provider characterized these experiences as auditory and visual hallucinations.  In an August 2009 letter, Dr. N.O. wrote that the Veteran presented with “continuous flashbacks of experience he had at combat.”  In VA treatment records and examination reports, records received from the SSA, and in private psychological assessments dated March 2010 to February 2017, the Veteran continued to endorse auditory and visual hallucinations, such as hearing voices and seeing shadows.  In an October 2016 lay statement, the Veteran’s spouse, C.D.A., wrote that the Veteran “hardly sleeps and hears voices, he says. I have seen him lying on the floor and he says that they harass him… Sometimes in the early morning, he gets up and says he hears voices, sometimes at one, two, or three in the morning. I get up because it makes me afraid that he might do something to endanger his life.” 

Second, the evidence shows that the Veteran has exhibited an intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene.  In an August 2010 Disability Report, M.A. wrote, “As to his memory, [the Veteran] needs to be constantly reminded by his wife of his doctors' appointments, to take a shower, to get properly dressed and to eat. Likewise, due to his memory lapses and forgetfulness, he can no longer cook because he forgets to shut off the stove and could burn the house.”  In a September 2010 Function Report, C.D.A. indicated that the Veteran needs special help or reminders to take care of his personal needs and grooming, and that he needs reminders to take medicine.  She reported that the Veteran does not prepare his own food because he does not remember to turn off the stove, burns food, and leaves the stove unattended.  She stated that the Veteran does not do house or yard work because he cannot concentrate or think of what has to be done.  She noted that the Veteran cannot go out alone or drive because he is under medications daily.  She also indicated that the Veteran is not able to pay bills, count change, or handle a savings account, and that his ability to handle money changed since his illnesses, injuries, or conditions began, as he has trouble thinking, concentrating, and making decisions.  In a November 2010 Disability Report, C.D.A. was asked how the Veteran’s illnesses, injuries, or conditions affect his ability to care for his personal needs, and she responded, “[The Veteran's] family has to supervise him to make sure that he does not injure himself because of his suicidal tendencies. He also does not perform any tasks around the house and his family has to do it for him because he has no concentration, no desire to do anything and constantly forgets everything that he is told.”  In an October 2016 lay statement, C.D.A wrote, “Nowadays, [the Veteran] has many health conditions, he hardly grooms himself, I have to convince him to let me help him with his hygiene…He depends on me a lot.”

Third, the evidence shows that the Veteran has demonstrated at least some danger of hurting himself or others.  During a June 2009 VA psychiatric consultation, the Veteran reported he was irritable and verbally aggressive, especially with his spouse.  He also stated that at times, he thinks his family would be better off without him and the thought of ending his life crosses his mind, “but stated in a way to make it look like an accident, falling off a ladder or having a motor vehicle accident.”  When asked about his history of violence, assaulting others, or legal problems, the Veteran indicated he was verbally aggressive with neighbors.  In a November 2010 Disability Report, C.D.A. indicated “[The Veteran] has become more aggressive…[He] continues to have suicidal thoughts and tendencies and his family has to supervise him to make sure that he does not injure himself.”  During a November 2010 VA psychiatry appointment, the Veteran reported an irritable mood, being verbally aggressive, and described “on and off death wishes.”  In a lay statement dated June 2014, C.D.A. described the changes she observed in the Veteran when he returned from his deployment in 1991.  She wrote, “When he arrived, he came back nervous, almost didn't sleep, and I couldn't touch him or speak to him suddenly/abruptly because he would react aggressively (as if to hit me).”  In an August 2014 private psychiatric evaluation report, Dr. M.L.C. found that as early as 1997, the Veteran was experiencing irritability, anger, thoughts of suicide, and a sense of foreshortened future.  During a December 2015 VA examination, the Veteran reported that he has “turned assaultive to neighbors: ‘in 2005 or 2006 and arguments all the time, I fought with a neighbor who was constructing and he left panels and wood at my house and we started fighting, he didn’t want to accuse me, my wife always intervenes…’”  In an October 2016 lay statement, C.D.A., wrote “[The Veteran] has told me that he wants to die, that he should no longer exist in this world since we have suffered because of him…Sometimes in the early morning, he gets up and says he hears voices, sometimes at one, two, or three in the morning. I get up because it makes me afraid that he might do something to endanger his life…In the community were barely talk to our neighbors because he has fought with everyone and they don’t visit us because he’s turned everyone against him.”  In a February 2017 private psychological assessment of the Veteran, Dr. L.C.R. noted that the Veteran “admits to suicidal rumination, ideas but without self-attempt.”

Fourth, the evidence shows that the Veteran has some impairment in communication.  In a September 2009 Function Report, the Veteran reported that he had noticed unusual behaviors or fears in that now, he does not communicate with others.  In a March 2010 psychiatric evaluation, Dr. J.B.M. noted, “[The Veteran] doesn’t show interest in visiting relatives, friends or neighbors. He doesn’t maintain good relations with family, neighbors, friends and people around him. He doesn’t like participating in activities of interest outside town of residence. He doesn’t communicate effectively in social gatherings, family events or others. He doesn’t visit church of choice. Manages complex situations anxiously.”  In a March 2010 Function Report, the Veteran indicated that he has trouble getting along with family, friends, neighbors or others due to his “depressive state. It bothers me to talk with and be around family, friends, neighbors. I would like to be alone all of the time.”  In an August 2010 Disability Report, M.A. was asked whether there had been any change in the Veteran's illnesses, injuries, or conditions since a disability report was last completed.  M.A. responded that there had, and wrote, “[The Veteran’s] psychiatric conditions have gotten substantially worse in the past few months. Now he has more trouble sleeping and will basically talk to no one.”  In a November 2010 Disability Report, C.D.A. indicated that there had been changes in the Veteran’s illnesses, injuries or conditions since his last disability report in April 2010, writing, “[The Veteran] has become more aggressive, is more depressed, does not leave his house except for medical appointments and will not talk to anyone outside his family.”  During a December 2013 VA psychiatry appointment, the Veteran reported that his family has shown some concern as he seems less interested in socializing and he spends 10 to 12 hours in bed per day.  In a lay statement dated June 2014, C.D.A. noted that the Veteran “is always locked in his room and hardly talks.”  In an October 2016 lay statement, C.D.A. wrote that when the Veteran returned from deployment, “Everything began to change, our communication was deteriorating, there was more fighting, we stopped going to the places where we had always used to go. Our friends were pulling away because of his attitude…In several of the jobs he had, he would fight with his coworkers and bosses, which made communication difficult….[The Veteran] closes himself off and can spend the entire day shut up in this room and it doesn't bother him.”

Fifth, the Board acknowledges that the Veteran worked in various positions after his separation from military service in November 1992 until July 2009.  See September 2010 Work History Report; July 2019 TDIU application.  Nevertheless, the record reflects that even when he was working, the Veteran’s symptoms resulted in some degree of occupational impairment.  For instance, in an October 2003 VA psychiatry admission evaluation note, the Veteran reported he was suspended from work approximately one month prior due to a discussion with his boss, and in an October 2016 lay statement, C.D.A. wrote that in several of the jobs he had, the Veteran would fight with his coworkers and bosses.  Furthermore, the evidence demonstrates that the Veteran’s symptoms resulted in severe social impairment during the entire period on appeal, as discussed above in regard to his impairment in communication.  Notably, in an August 2014 private psychiatric evaluation report, Dr. M.L.C. rendered the following opinion: “A detailed review of his medical record describes extensive deterioration due to mental illness subsequent to his active-duty service present through the current day...The symptoms have been steadily progressive over the course of his life and have prevented him from functioning adequately in either a social or occupational setting. As [he] is barely able to function in the most basic of social settings, his occupational capacity does not exist. He has severe social isolation, significant anger, irritability, altered behavior, unpredictability, volatility, and is completely unsuitable for an occupational environment where he would have to engage coworkers, supervisors, and the public on a day-to-day basis. The extent of his PTSD has led him to have symptoms that are too severe to tolerate the stressors in an occupational setting.”  Additionally, Dr. M.L.C.’s conclusions regarding the Veteran’s occupational and social impairment were corroborated in Dr. N.O.’s August 2009 letter, Dr. J.B.M.’s March 2010 psychiatric evaluation, Dr. L.C.R.’s February 2017 private psychiatric assessment, and Dr. M.L.C.’s own subsequent private psychological evaluation of the Veteran in February 2017.

The Board therefore concludes that, with resolution of any doubt in the Veteran’s favor, the lay and medical evidence supports a finding that the Veteran’s PTSD more nearly approximates total occupational and social impairment, as the rating criteria specifically contemplate the Veteran’s symptoms of persistent hallucinations, intermittent inability to perform activities of daily living, danger of hurting himself or others, and impairment in communication.

For these reasons, the Board finds that the Veteran’s PTSD symptoms more nearly approximate the criteria under the General Rating Formula for a 100 percent initial disability rating for the entire period on appeal.  A 100 percent rating is the maximum schedular rating allowed under the General Rating Formula.

3. Entitlement to a TDIU

As indicated, the RO awarded a TDIU effective July 19, 2019, but because the award was not assigned for the entire period on appeal, the issue remains in appellate status.  

As to the Veteran’s claim for a TDIU, this benefit contemplates a schedular rating less than total for the disability or disabilities on which the TDIU would be based.  See 38 C.F.R. § 4.16(a).  A TDIU is considered a lesser benefit than a 100 percent schedular rating, and the grant of a 100 percent rating generally renders moot the issue of entitlement to a TDIU for the period when the 100 percent rating is in effect.  An exception to this is that a separate award at the housebound rate or a TDIU predicated on a single disability (perhaps not ratable at the schedular 100 percent level) when considered with another disability separately rated at 60 percent or more may warrant payment of special monthly compensation (SMC) under 38 U.S.C. § 1114(s) (2019).  Bradley v. Peake, 22 Vet. App. 280 (2008).

Here, the Veteran has asserted that his unemployability is a result of his PTSD symptoms.  As decided herein, the Veteran has now been awarded a 100 percent rating for PTSD on a schedular basis for the entire period under review.  However, he only has one other service-connected disability (hypertension), and such disability is rated as noncompensable.  As such, entitlement to a TDIU is rendered moot and the issue of entitlement to SMC is not raised by the record.

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Lastly, neither the Veteran nor his attorney has raised any other issues, nor have any other issues been reasonably raised by the record.  See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 

 

S. B. MAYS

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	C. M. Gill, Associate 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.