Citation Nr: A20007327 Decision Date: 04/30/20 Archive Date: 04/30/20 DOCKET NO. 190706-11061 DATE: April 30, 2020 ORDER Service connection for bilateral hearing loss is denied. Service connection for tinnitus is denied. Service connection for other specified depressive disorder (depressive disorder) is denied. Service connection for sinusitis is denied. Service connection for right hand joint pain is denied. Service connection for left hand joint pain is denied. Service connection for chronic fatigue syndrome is denied. Service connection for fibromyalgia is denied. Service connection for irritable bowel syndrome (IBS) is denied. Service connection for restless leg syndrome is denied. Service connection for right arm joint pain is denied. Service connection for left arm joint pain is denied. An initial, increased rating of 50 percent for posttraumatic stress disorder (PTSD) is granted. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran’s current bilateral hearing loss is a result of an in-service injury, illness, or event; and/or that it is otherwise related to his active service. 2. The preponderance of the evidence is against a finding that the Veteran’s tinnitus is the result of an in-service illness, injury, and/or event; and/or that it is otherwise related to his active service. 3. The Veteran’s depressive disorder encompasses the related disability of PTSD, for which he is already service-connected. 4. The Veteran served during the Vietnam Era and did not serve during the Persian Gulf War. 5. There is no competent evidence to establish a causal relationship between the Veteran’s sinusitis and his active service. 6. There is no competent evidence to establish a causal relationship between the Veteran’s right-hand joint pain and his active service. 7. There is no competent evidence to establish a causal relationship between the Veteran’s left-hand joint pain and his active service. 8. There is no competent evidence to establish a causal relationship between the Veteran’s chronic fatigue syndrome and his active service. 9. There is no competent evidence to establish a causal relationship between the Veteran’s fibromyalgia and his active service. 10. There is no competent evidence to establish a causal relationship between the Veteran’s IBS and his active service. 11. There is no competent evidence to establish a causal relationship between the Veteran’s restless legs syndrome and his active service. 12. There is no competent evidence to establish a causal relationship between the Veteran’s right arm joint pain and his active service. 13. There is no competent evidence to establish a causal relationship between the Veteran’s left arm joint pain and his active service. 14. Resolving all reasonable doubt in favor of the Veteran, the severity of his psychiatric symptoms more closely approximate an occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 5107 (West 2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 2. The criteria for service connection for tinnitus have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a separately compensable psychiatric disability, namely, depressive disorder, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for sinusitis have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for right hand joint pain have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for left hand joint pain have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for service connection for chronic fatigue syndrome have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for service connection for fibromyalgia have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 9. The criteria for service connection for IBS have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 10. The criteria for service connection for restless legs syndrome have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 11. The criteria for service connection for right arm joint pain have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 12. The criteria for service connection for left arm joint pain have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 13. The criteria for an initial, increased 50 percent disability rating, for PTSD, have been met. 38 U.S.C. §§ 1155 (West 2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1969 to December 1972. The rating decision on appeal was issued in June 2019. The Veteran selected the “Higher-Level Review” lane when he timely appealed the rating decision in a July 2019 notice of disagreement and requested “direct review” of the evidence considered by the Agency of Original Jurisdiction (AOJ). By selecting “direct review” of the evidence, the Board of Veterans’ Appeal (Board) must base its decision on the evidence that was before the AOJ at the time of the June 2019 rating decision. 84 Fed. Reg. 138, 182 (Jan. 18, 2019) (to be codified at 38 C.F.R. § 20.300). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. § 1110 (West 2012); 38 C.F.R. § 3.303 (2019). That determination requires a finding of a current disability that is related to an injury or disease in service. Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d) (2019). Generally, to establish service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313(Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). With respect to all of his service-connection claims, the Veteran asserts that the RO violated its duty to assist him in the development of his claims, thereby violating the Veterans Claims Assistance Act of 2000 (VCAA), when it overlooked pertinent evidence, namely, an October 2018 private mental evaluation from Dr. W.J.A., and a January 2019 private medical opinion on the Veteran’s disabilities, from Dr. P.J.Y, in the adjudication of his claims in the June 2019 rating decision. See July 2019 NOD; see also July 2019 Statement in Support of Claim. In this regard, the Board notes that it has considered all pertinent evidence, including and not limited to, the above-mentioned private mental evaluation and the January 2019 private medical opinion in the adjudication of the Veteran’s claims on appeal. 1. Bilateral Hearing Loss & Tinnitus In a February 2019 correspondence, the Veteran reported, in pertinent part, while he served aboard the U.S.S. Muliphen, in dry dock, the shipyard itself was a “myriad of loud noises.” At his June 2019 VA examination for hearing loss and tinnitus, he also reported that he was exposed to hazardous noise during service. Although the evidence reflects current diagnoses of bilateral hearing loss and tinnitus, see e.g. June 2019 VA examination Report, service treatment records (STRs) do not show any indication that the Veteran suffered hearing loss in service, complained of, was treated for, and/or was diagnosed with any illnesses, diseases, or injuries that may be associated with acoustic trauma, hearing loss, and or diseases of the ear that may be related to hearing loss. Further, service personnel records do not show that the Veteran was engaged in any activities that were related to the use of equipment, such as firearms, which have impacted his hearing, and/or resulted in the ringing of his ears (tinnitus). In support of his claims, the Veteran has submitted a January 2019 private opinion from a physician, Dr. P.J.Y. In this opinion, Dr. P.Y.J. noted that during his military service, the Veteran was exposed to acoustic trauma of artillery fire, including a Howitzer 105, machine guns, and other weapons of fire, and that he has suffered from progressive bilateral hearing loss and tinnitus. He opined that (1) it is as likely as not that the Veteran’s bilateral hearing loss and tinnitus is directly and causally related to in-service acoustic trauma, and that thus, it is as likely as not that the bilateral hearing loss and tinnitus are directly and causally related to his military service. Although Dr. P.J.Y. stated that the Veteran’s conditions are permanent, he failed to provide a rationale for his opinions. Thus, as these opinions are inadequate for want of a rationale, the Board affords no probative value. Nonetheless, the Veteran was afforded a VA examination for bilateral hearing loss and tinnitus in June 2019. A VA examiner opined that it less likely than not (less than 50 percent probability) the Veteran’s bilateral hearing loss and tinnitus were caused by, and/or a result of an event in military service. As the rationale for the opinion on the right ear, the VA examiner explained that although the Veteran claimed hazardous noise exposure in service, his military occupational specialty (MOS) is considered to have a low probability of hazardous noise exposure; the Veteran’s audiogram data indicates no significant positive threshold shift from enlistment to separation, thereby indicating no evidence of acoustic trauma; and that the Veteran’s hearing was normal throughout service. For the opinion on the left ear, the VA examiner additionally reasoned, in pertinent part, that audiogram date for the left ear indicates that a significant positive threshold shift, from enlistment to separation, was only at 500 Hertz (Hz), in the low frequencies, but that it was not consistent with noise exposure. The VA examiner further explained that this indicates no evidence of acoustic trauma, and that hearing was normal throughout service. As the rationale for the opinion on tinnitus, the VA examiner explained that the Veteran claims hazardous noise exposure and onset of tinnitus in service. He explained that the Veteran denied having combat service, but rather, he indicated that his exposure was due to ship’s canons firing continuously through his military career. However, the VA examiner clarified that the Veteran’s MOS is considered to have a low probability of hazardous noise exposure; audiogram data indicates a significant positive threshold shift, from enlistment to separation, only in the low frequency of 500Hz, which is not consistent with acoustic trauma, and that hearing was normal throughout service. After a review of all pertinent evidence, the Board finds that the preponderance of the evidence is against these claims. Service personnel records do not show that the Veteran was exposed to noise, and/or that he served in any capacity in which he was exposed to acoustic trauma, and/or anything noise-related that may have required the use of hearing protection. As a matter of fact, his DD-214, Certificate of Discharge has listed his “related civilian occupation” as “store managers.” In his service personnel records, a July 1972 “Navy Enlisted Classification Change Recommendation” form indicates that the Veteran was considered “qualified to perform the duties of a ship’s laundryman.” However, his service personnel records have not shown or suggested that his MOS or service duties rendered him the use, and/or placed him in proximity to artillery fire, machine guns, firearms, and/or any other noise-related equipment. The Veteran has not asserted, nor does the record show, that while on board the ship, he might have been placed in close proximity, and/or worked in a loud noise environment, such as, for example, a boiler room that may have a loud, noisy machine or equipment. Thus, as there is no probative evidence of an in-service illness, injury, disease, and/or an event, including and not limited to acoustic trauma, there is no evidence that the Veteran’s bilateral hearing loss and/or tinnitus are related to his active service. 2. Depressive Disorder The Veteran asserts entitlement to service connection for depressive disorder. The medical evidence reflects a current mental disability, including and not limited to, major depression/major depressive disorder and PTSD. See e.g. April 2018 Progress Notes; see also October 2018 Private Medical Opinion from Dr. W.J.A.; see too, January 2019 VA examination for PTSD. In an October 2018 private opinion, which the Veteran submitted in support of his claim, a psychologist, Dr. W.J.A. determined that the Veteran has a diagnosis of PTSD and other specified depressive disorder. In determining that the Veteran has more than one mental disorder diagnosed, however, Dr. W.J.A. indicated that it is not possible to differentiate what symptoms are attributable to each disability, namely, depressive disorder and PTSD. Dr. W.J.A. explained that the Veteran’s symptoms of PTSD and depression, as likely as not, overlap with regards to insomnia and concentration difficulties, and thus, as a result thereof, they cannot be distinguished from one another. Although a June 2019 VA examination indicates that the Veteran only has PTSD, a VA examiner noted that symptoms that are applicable to the Veteran’s PTSD, for VA rating purposes, includes and is not limited to “depressed mood.” In a June 2019 rating decision, the RO granted the Veteran’s PTSD claim for service connection, which the rating decision expressly indicated that the Veteran’s depressed mood was one, out of a limited list of psychiatric symptoms, that was factored into the RO’s assignment of a 10 percent disability rating for PTSD. Thus, after a review of all probative evidence, the Board finds that the Veteran’s diagnosed depressive disorder is encompassed and comprised with the Veteran’s PTSD. As a matter of fact, the Veteran’s claim for depressive disorder is ratable under diagnostic code 9435, which is the rating criteria for “unspecified depressive disorder”, whereas PTSD is ratable under DC 9411, which is the rating criteria for “post-traumatic stress disorder.” Both disabilities and diagnostic codes use the same rating criteria under the General Rating Formula for Mental Disorders, under 38 C.F.R. § 4.130 (2019). Specifically, the United States Court of Appeals for Veterans Claim has held that that the scope of a claim includes any disorder that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and other information of record. See Clemons v. Shinseki, 23 Vet. App. 1, 5 – 6 (2009). Thus, in this regard, the Board finds that the Veteran has already been rated for depressive disorder, which, as indicated above, is a symptom and/or is encompassed with his PTSD, for which he is already service connected. Thus, for these reasons, service connection for depressive disorder must be denied. 3. Sinusitis; Right & Left-Hand Joint Pain (Bilateral Hand Joint Pain); Chronic Fatigue Syndrome; Fibromyalgia; IBS; Restless Legs Syndrome; and Right & Left Arm Joint Pain (Bilateral Arm Joint Pain) The Veteran asserts service connection for sinusitis; bilateral hand joint pain; fibromyalgia; chronic fatigue syndrome; IBS; restless leg syndrome; and bilateral arm joint pain. STRs, however, do not show any evidence of an in-service injury, complaints, treatment, and/or an event associated with the disabilities of sinusitis, bilateral hand joint pain, fibromyalgia, chronic fatigue syndrome, IBS, restless leg syndrome, and bilateral arm joint pain. Although the Veteran’s STRs entail treatment records, including and not limited to, an August 1970 medical record, which reflects that the Veteran had left trapezius pain for approximately two weeks; a February 1972 medical record which reflects that the Veteran had nausea and diarrhea for approximately two days; and a June 1972 medical record which indicates that the Veteran had complaints of laryngitis, productive of coughing, yellowish phlegm, and soreness in the larynx, with a diagnosis of an upper respiratory infection, STRs also suggest that these illnesses resolved as there was no indication of a follow up, recurrence, continuous manifestations of these illnesses during service, and/or that these illnesses were associated with any of the disabilities of sinusitis, bilateral hand joint pain, fibromyalgia, chronic fatigue syndrome, IBS, restless leg syndrome, or bilateral arm joint pain. As a matter of fact, November 1972 and December 1972 medical examination reports for separation from service reflect that no abnormalities or conditions were reported or listed, except for a chest scar. In support of his claims, nonetheless, the Veteran has submitted a January 2019 private opinion from a diagnostic consultant and chiropractor, Dr. P.J.Y. In this opinion, Dr. P.Y.J. stated that the Veteran is diagnosed with respiratory deficiency, to include congestion of the maxillary sinuses with difficulty breathing and facial pain, with coughing noted, and poor aerobic capacity due to this progressive condition, which Dr. P.J.Y. determined that it began with his Gulf War service, and that it is as likely as not that it is directly and causally related to Gulf War Syndrome, per the presumptions (undiagnosed illnesses) published in Gulf War; and that it is as likely as not that this disability is directly and causally related to the Veteran’s military service. As a rationale for this opinion, Dr. P.J.Y. merely stated that this is a permanent condition which had its onset during deployment to the Southwest Asia Theatre of Military Operations that has persisted to the present. With respect to the bilateral hand condition, Dr. P.Y.J. stated that the Veteran suffers from muscle and joint pain of the right and left hands; and it is as likely as not that it is directly and causally related to Gulf War Syndrome per the presumptions (undiagnosed illnesses) published in Gulf War; and that it is as likely as not that this disability is directly and causally related to the Veteran’s military service. As a rationale for this opinion, Dr. P.J.Y. stated that this is a permanent condition which had its onset during deployment to the Southwest Asia Theatre of Military Operations that has persisted to the present. Further, Dr. P.J.Y. also noted, the Veteran is diagnosed with chronic fatigue syndrome; and that it is as likely as not that it is directly and causally related to Gulf War Syndrome per the provisions published in Gulf War; and that it is as likely as not that this disability is directly and causally related to the Veteran’s military service. As a rationale for this opinion, Dr. P.J.Y. stated that this is a permanent condition which had its onset during deployment to the Southwest Asia Theatre of Military Operations that has persisted to the present. Additionally, Dr. P.J.Y. indicated that the Veteran is diagnosed with fibromyalgia; the symptoms are in the arms and legs; and it is as likely as not that it is directly and causally related to Gulf War Syndrome per the presumptions published in Gulf War; and that it is as likely as not that this disability is directly and causally related to the Veteran’s military service. As a rationale for this opinion, Dr. P.J.Y. stated that this is a permanent condition which had its onset during deployment to the Southwest Asia Theatre of Military Operations that has persisted to the present. Dr. P.J.Y. further noted that the Veteran is diagnosed with a condition via intermittent constipation and diarrhea which, he determined that has been present since Gulf War service without hiatus (referring to IBS); and that it is as likely as not that it is directly and causally related to Gulf War Syndrome per the presumptions (undiagnosed illness) published in Gulf War; and that it is as likely as not that this disability is directly and causally related to the Veteran’s military service. As a rationale for this opinion, Dr. P.J.Y. stated that this is a permanent condition which had its onset during deployment to the Southwest Asia Theatre of Military Operations that has persisted to the present. Also, Dr. P.J.Y. diagnosed the Veteran with restless leg syndrome; opined that it is as likely as not that it is directly and causally related to Gulf War Syndrome per the presumptions (neurological) published in Gulf War; and that it is as likely as not that this disability is directly and causally related to the Veteran’s military service. As a rationale for this opinion, Dr. P.J.Y. stated that this is a permanent condition which had its onset during deployment to the Southwest Asia Theatre of Military Operations that has persisted to the present. Further, Dr. P.J.Y. noted that the Veteran suffers from muscle and joint pain of the right and left arms. He opined that it is as likely as not that it is directly and causally related to Gulf War Syndrome per the presumptions (undiagnosed illnesses) published in Gulf War; and that it is as likely as not that this disability is directly and causally related to the Veteran’s military service. As a rationale for this opinion, Dr. P.J.Y. stated that this is a permanent condition which had its onset during deployment to the Southwest Asia Theatre of Military Operations that has persisted to the present. In summary, Dr. P.Y.G, in providing a rationale for these opinions, inaccurately referred to the Veteran’s service as constituting service in Southwest Asia theater of military operations in Bahrain, and then misapplied the law concerning disabilities and presumptions applicable to that class of veterans. As noted above, the Veteran served in active duty from February 1969 to December 1972. Therefore, the Veteran is a Vietnam Veteran, who served during the Vietnam War. Thus, as the Veteran’s period of service is prior to, and outside the scope of the period of the Persian Gulf War, Dr. P.Y.G.’s attempt to apply the law is inapposite and inapplicable to the Veteran’s circumstances. In this regard, the Board finds that these opinions on the disabilities of sinusitis, bilateral hand joint pain, fibromyalgia, chronic fatigue syndrome, IBS, restless leg syndrome, and bilateral arm joint pain are not probative. They are based on an inaccurate factual premise, as the examiner’s opinions are based on an inaccurate understanding of when and where the Veteran served on active duty. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that a medical opinion based on an inaccurate factual premise has no probative value.); see also Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (holding that “[if] the opinion is based on an inaccurate factual premise, then it is correct to discount it entirely.”) (citing Reonal). The Board acknowledges that the Veteran has not been afforded VA examinations for sinusitis, bilateral hand joint pain, fibromyalgia, chronic fatigue syndrome, IBS, restless leg syndrome, and bilateral arm joint pain. However, given the fact that there is no probative evidence that these conditions occurred in service, or that there is no indication that the Veteran’s sinusitis, bilateral hand joint pain, fibromyalgia, chronic fatigue syndrome, IBS, restless leg syndrome, and bilateral arm joint pain may be associated with his service, or another service-connected disability, the Board finds that VA medical examinations are not warranted under the duty to assist. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (holding that an examination and medical nexus opinion is required for a service connection claim when there is evidence of current disability or persistent or recurrent symptoms of a disability, evidence establishing in-service event, injury, or disease, or a disease manifested in accordance with presumptive service connection regulations, and an indication that the current disability may be related to an in-service event, injury, or disease; but insufficient evidence to decide the claim). Moreover, the Secretary is not obligated to grant a claim for benefits simply because there is no evidence disproving it. See 38 U.S.C. § 5107(a) (explaining that “a claimant has the responsibility to present and support a claim for benefits.”); Skoczen v. Shinseki, 564 F.3d 1319, 1323 – 29 (2009) (interpreting section 5107(a) to obligate a claimant to provide an evidentiary basis for his or her benefits claim, consistent with VA’s duty to assist, and recognizing that “[w]hether submitted by the claimant or VA.... the evidence must rise to the requisite level set forth in section 5107(b),” requiring an approximate balance of positive and negative evidence regarding any issue material to the determination); Fagan v. Shinseki, 573 F.3d 1282, 1286 (2009) (stating that the claimant has the burden to “present and support a claim for benefits” and noting that the benefit of the doubt standard in section 5107(b) is not applicable based on pure speculation or remote possibility). Therefore, the preponderance of the evidence is against these claims and service connection for sinusitis, bilateral hand joint pain, fibromyalgia, chronic fatigue syndrome, IBS, restless leg syndrome, and bilateral arm joint pain must be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); 38 U.S.C. § 5107 (West 2012); 38 C.F.R. § 3.102 (2019). Initial Increased Rating for PTSD Disability ratings are determined by application of the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155 (West 2012); 38 C.F.R. Part 4 (2018). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating applies. 38 C.F.R. § 4.7 (2019). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2019). The Veteran’s entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1 (2019); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The criteria for evaluating PTSD is found in the General Rating Formula for Mental Disorders, under 38 C.F.R. § 4.130, Diagnostic Code 9411. A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily), with routine behavior, self-care, and conversation normal, due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). See Id. A 50 percent rating is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands, impairment of short and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and, difficultly in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and, memory loss for names of close relatives, own occupation, or own name. Id. The Veteran has been assigned a 10 percent disability rating for his service-connected PTSD. The medical treatment records reflect that the Veteran complained of, and/or manifested symptoms, including and not limited to, sleep deprivation, anxiety, memory loss, hypervigilance, and depression. Other than an April 2018 progress note, which reflects a diagnosis of major depression and anxiety disorder, no other pertinent, recent treatment records adequately capture a complete assessment of the severity of the Veteran’s psychiatric disability. Nonetheless, the medical evidence reflects psychiatric evaluations, opinions and/or examinations, which assess the current severity of the Veteran’s psychiatric disability. Specifically, in an October 2018 private evaluation, a psychologist, Dr. W.J.A. determined that the Veteran is diagnosed with PTSD and other specified depressive disorder. He also determined that the Veteran’s symptoms of PTSD and depression, as likely as not, overlap with regards to insomnia and concentration difficulties, as a result of which they cannot be distinguished from one another. Dr. W.J.A. summarized the Veteran’s level of occupational and social impairment of his psychiatric disability as an occupational and social impairment with reduced reliability and productivity. He identified symptoms associated with his mental disability, to include anxiety; suspiciousness; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; flattened affect; circumstantial, circumlocutory or stereotyped speech; speech intermittently illogical, obscure, or irrelevant; difficulty in understanding complex commands; and disturbances of motivation and mood. Dr. W.J.A. noted that the Veteran reported that he often feels anxious, although he stated that he is “ok most of the time”; and that insomnia and concentration problems were apparent. He further noted that psychomotor agitation was highly evidence during his interview, during which the Veteran tended to rock his torso; the Veteran reported having significant experiences of fatigue and loss of energy; cognitive difficulties, including the diminished ability to think, as well as indecisiveness. Dr. W.J.A. also stated that the Veteran also described having a history of suicidal ideation, and that most recently, was manifested approximately 13 years prior to this mental assessment, and that although any history of suicidal attempts was denied. He also noted that the Veteran denied having homicidal thoughts, and that overall, the Veteran did not meet the criteria for involuntary hospitalization during his interview. Dr. W.J.A. also noted that a “pattern of worry was noted to have been apparent, although the worry was reported not to have been apparent more often than not. Upon mental status evaluation, Dr. W.J.A. remarked, in pertinent part, that the Veteran’s impulse control appeared to fall within normal limits; speech was normal in terms of manner and content; form of thought was remarkable for circumstantially and frequent tangentiality; thought content fell within normal limits; suicidal ideation, homicidal ideation, and perceptual abnormalities were not apparent; and that the Veteran stated, when asked about his mood at the time of the interview, that he felt “very tired.” Dr. W. J.A. further remarked that the Veteran’s affect was blunted, but stable, during his evaluation, but that it was appropriate for the discussion at all times. He also observed that the Veteran was oriented to all spheres, and that he had no difficulties with measures of visual set shifting, visual motor precision, naming common animals, auditory recall and reversal, auditory motor integration, verbal fluency, or abstract verbal reasoning. In the assessment of his personality, Dr. W.J.A. explained that individuals with similar profiles as the Veteran have intrusive and obsessive thoughts and bizarre sensory, perceptual, or bodily disturbances that they find to be distressing and disturbing; they have marked difficulties with their memory and concentration, as well as their decision making and problem-solving abilities; they tend to be impulsive and risk-taking, and exhibit a low frustration tolerance at times; and that these concerns can prompt them to feel like there is something wrong with their mind or as if they are losing touch with reality. In a January 2019 private opinion for PTSD, a physician, Dr. P.J.Y., noted that the Veteran has supporting military history and symptoms of PTSD, which includes, but are not limited to insomnia, sleep deprivation, anxiety, isolation, memory loss, hypervigilance, depression, and agoraphobia, although no violent ideations were noted. Although it appears that Dr. P.J.Y.’s opinion is primarily based on the lay statements of the Veteran, the Board will afford this opinion limited probative value, to the extent of the reported, documented symptoms are consistent with the reported, documented symptoms noted by other medical evidence, which includes sleep deprivation, anxiety, memory loss, hypervigilance, and depression. In a June 2019 VA examination report, a VA examiner summarized the Veteran’s level of occupational and social impairment of his psychiatric disability as one in which a mental condition has been formally diagnosed, but that the symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. The VA examiner reported that the Veteran has been married twice, in which the first marriage lasted for four years, and ended due to his sleep problems, to include nightmares; and his second marriage, which is has current marriage, has lasted for twenty-seven years. He further noted that the Veteran has not been able to sleep in the same bedroom with his current wife, due to his recurrent nightmares. Additionally, the VA examiner indicated that the symptoms that are applicable to his PTSD, for VA rating purposes, include depressed mood; anxiety; and chronic sleep impairment. In summary, and based on an overall, collective, review of the October 2018 comprehensive evaluation undertaken by Dr. W.J.A., the January 2019 private opinion from Dr. P.Y.J., and the June 2019 VA examination report, the Board finds that the evidence is in at least relative equipoise and that the severity of the Veteran’s PTSD more closely approximates occupational and social impairment with reduced reliability and productivity, which warrants an increased, 50 percent rating for PTSD. However, a 70 percent rating is not warranted for his service-connected PTSD. The evidence fails to show deficiencies in most areas due to symptoms similar or equivalent in severity to those listed in the rating criteria for a 70 percent rating, such as, for example, impaired judgment; impaired abstract thinking; spatial disorientation; grossly inappropriate behavior; persistent danger of hurting himself or others; neglect of personal appearance or hygiene; intermittent inability to perform activities of daily living; or disorientation to place or time. See Vazquez-Claudio v. Shinseki, 713 F. 3d 112, 118 (Fed. Cir. 2013) (holding that a 70 percent disability rating requires sufficient symptoms of the kind listed in the 70 percent requirements, or others of similar severity, frequency or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation). Moreover, deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood was not shown. Specifically, for example, the evidence, as indicated above, reflects that the Veteran has been able to maintain his marriage for over twenty-seven years, and this thus, this is not suggestive or evidence of an impairment with family relations, and/or an inability to establish or maintain effective relationships. Although he reported having suicidal ideation approximately thirteen years prior to his October 2018 evaluation, he has consistently denied having any recent suicidal or homicidal ideation. See e.g. April 2018 Primary Care Attending Note; see also October 2018 Psychiatric Evaluation from Dr. W.J.A. Although the Veteran asserts that the RO overlooked pertinent evidence, and specifically, a private medical evaluation from Dr. W.J.A., and a private medical opinion from Dr. P.J.Y, in the assignment of his service-connected PTSD disability rating, see July 2019 NOD; see also July 2019 Statement in Support of Claim, the Board notes that it has evaluated and addressed all pertinent evidence, including and not limited to, Dr. P.J.Y. and Dr. W.J.A.’s medical opinions, in the assessment and assignment of the Veteran’s disability ratings for PTSD. No other outstanding issues have been raised by the Veteran and/or the record, with respect to the increased rating claim for PTSD. Therefore, based on the foregoing, an increased rating of no higher than 50 percent for the service-connected PTSD is granted. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Vanessa-Nola Pratt 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.