Citation Nr: 21001820 Decision Date: 01/11/21 Archive Date: 01/11/21 DOCKET NO. 19-10 201 DATE: January 11, 2021 ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for paroxysmal atrial fibrillation is denied. Entitlement to service connection for anemia with bleeding ulcers is denied. Entitlement to an initial rating in excess of 50 percent for PTSD is denied. Entitlement to a rating of total disability based on individual unemployability (TDIU) is granted. FINDINGS OF FACT 1. The Veteran’s bilateral hearing loss did not onset in service, nor are they etiologically related to service. 2. The Veteran’s tinnitus did not onset in service, nor is it related to service. 3. The Veteran’s paroxysmal atrial fibrillation did not onset in service, nor is it etiologically related to service, to include presumed Agent Orange exposure. 4. The Veteran’s anemia with bleeding ulcers did not onset in service, nor is it etiologically related to service. 5. During the period on appeal, the frequency, severity. and duration of the Veteran’s PTSD symptoms did not more closely approximate occupational and social impairment with deficiencies in most areas. 6. The evidence of record shows that the Veteran is unable to secure and follow a substantially gainful occupation due to service connected disabilities. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 1131, 5103(a), 5103A (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309. 2. The criteria for entitlement to service connection for tinnitus have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for paroxysmal atrial fibrillation have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for anemia have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for an initial rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 6. The criteria for a rating of total disability based on individual unemployability (TDIU) have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1970 to January 1972. The issues on appeal were remanded by the Board in September 2019 and September 2020. The Board is now satisfied there was substantial compliance with this Remand. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Specifically, additional medical records were obtained and associated with the claims file, and new VA opinions were obtained, which the Board finds adequate for adjudication purposes. After the required development was completed, this issue was readjudicated and the Veteran was sent two supplemental statements of the case in October 2020. Accordingly, the Board finds that the Remand directives were substantially complied with and, thus, there is no Stegall violation in this case. The Board notes that, in November 2020, the Veteran the Veteran submitted a request (via Form 20-0996) to move the issues of entitlement to an increased rating for PTSD and for TDIU into the Appeals Modernization Act procedures, and specifically to seek “higher-level review.” The RO did not accept this form as an adequate request. Therefore, these issues remain on appeal and are addressed here. Service Connection The Veteran seeks service connection for bilateral hearing loss and tinnitus. He also seeks service connection for paroxysmal atrial fibrillation, as well as anemia and bleeding ulcer secondary to a gastric bypass. He further seeks an initial rating in excess of 50 percent for PTSD and a rating of TDIU. Unfortunately, the Board is unable to grant the benefits sought at this time. 1. Entitlement to service connection for bilateral hearing loss 2. Entitlement to service connection for tinnitus The Veteran asserts that he developed hearing loss and tinnitus as a result of exposure to noise. In a July 2020 affidavit, the Veteran states that his tinnitus is less noticeable in a busy environment, but is more noticeable since he retired. At its worst, the tinnitus can last several days and is overwhelming. He also reports that it “aggravates [him] to death.” In cases where a hearing loss disability is claimed, impaired hearing is considered a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz (Hz) is 40 decibels (dB) or greater; or when the auditory thresholds for at least three of the above frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. 38 C.F.R. § 3.385 does not preclude service connection for a current hearing loss disability where hearing was within normal limits on audiometric testing at separation from service. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Rather, when audiometric test results at a veteran’s separation from service do not meet the requirements of 38 C.F.R. § 3.385, a veteran may nevertheless establish service connection for current hearing disability by submitting medical evidence that the current disability is causally related to service. Hensley v. Brown, 5 Vet. App. 155 (1993). Where the requirements for hearing loss disability pursuant to 38 C.F.R. § 3.385 are not met until several years after separation from service, the record must include evidence of exposure to disease or injury in service that would adversely affect the auditory system and post-service test results meeting the criteria of 38 C.F.R. § 3.385; Hensley, 5 Vet. App at 155. If the record shows (a) acoustic trauma due to significant noise exposure in service and audiometric test results reflect an upward shift in tested thresholds while in service, though still not meeting the requirements for “disability” under 38 C.F.R. § 3.385, and (b) post service audiometric testing produces findings which meet the requirements of 38 C.F.R. § 3.385 ; then the rating authorities must consider whether there is a medically sound basis to attribute the post service findings to the injury in service, or whether these findings are more properly attributable to intervening causes. Id. at 159. If the Veteran engaged in combat with the enemy, and it is claimed that a disease or injury was incurred in such combat, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C. § 1154 (b); 38 C.F.R. § 3.304 (d). To establish service connection, however, there must be medical evidence of a nexus between the current disability and the combat injury. See Dalton v. Nicholson, 21 Vet. App. 23 (2007); Libertine v. Brown, 9 Vet. App. 521, 523-24 (1996). Most recently, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that in such cases, not only is the combat injury presumed, but so are the consequences of that injury at least in service. See Reeves v Shinseki, 682 F.3d 988 (Fed. Cir. 2012). The Federal Circuit explained that “[e]ven when the statutory combat presumption applies, a veteran seeking compensation must still show the existence of a present disability and that there is a causal relationship between the present disability and the injury, disease, or aggravation of a preexisting injury or disease incurred during active duty.” Id. at 999 n. 9. Thus, the evidence must show that the “disability [the veteran] incurred in service was a chronic condition that persisted in the years following his active duty.” Id. at 1000. In this case, based on the evidence of record, the Board determines that service connection is not warranted for the Veteran’s bilateral hearing loss or tinnitus. As an initial matter, the Board finds the Veteran’s May 2020 and June 2016 statements regarding his in-service acoustic trauma credible; according to his DD-214 and his written, the Veteran experienced noise from artillery, heavy gunfire, and helicopter rotor blades. Further, the nature of his service as a chaplain’s assistant deployed with the 101st Airborne Division in the Vietnam era is consistent with a military occupation where significant noise exposure over a prolonged period is likely. Thus, the Board concedes exposure to hazardous noise for purposes of establishing an in-service event. However, while the Veteran has current diagnoses of bilateral hearing loss and tinnitus per his June 2020 examination report, the preponderance of the evidence weighs against finding that his hearing loss was a result of such exposure. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. §§ 3.303 (a), (d), 3.304, 3.307, 3.309. First, the Veteran did not report symptoms of hearing loss or tinnitus during any of his in-service treatment, despite credibly reporting to his C&P examiners that he was exposed to weapons fire and helicopter noise. While he mentions temporarily losing his hearing on at least two distinct occasions, the Veteran’s in-service treatment records, and his January 1972 separation examination report do not mention chronic hearing loss or tinnitus. Notably, the puretone thresholds up to 4,000 Hz show some increase at separation, compared to those at induction. However, as pointed out by the Veteran’s June 2020 C&P examiner, no permanent threshold shift in the Veteran’s puretone measurements was observed. Therefore, there is not only no indication of chronic hearing loss in service, but also no indication that the Veteran had more than transitory, isolated incidents of hearing loss in service. Next, the post-service evidence does not reflect symptoms related to sensorineural hearing loss for many years after the Veteran left active duty service. The first clinical indication of hearing loss was not until July 2011. In fact, a January 2002 record shows a negative report for hearing loss. Moreover, while the Veteran’s claim indicates two untreated in-service episodes following noise exposure, the rest of his statements rest his claim on application of Hensley v. Brown, 5 Vet. App. 155 (1993). As for tinnitus, the Veteran did not report tinnitus until his 2016 claim. Thus, continuity of symptomatology is not warranted based on the medical evidence, or in the case of hearing loss, the Veteran’s statements. The Veteran contends that his tinnitus has persisted since the in-service acoustic trauma, and became permanent in about 2008. The Board is, unfortunately, unable to grant service connection based on the Veteran’s statement alone, as it is inconsistent with the other evidence of record. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (Lance, J., concurring) (discussing the distinction between cases in which there is a complete absence of any evidence to corroborate or contradict the testimony, and cases in which there is evidence that is relevant either because it speaks directly to the issue or allows the Board as factfinder to draw a reasonable inference). Despite his specific statements regarding the circumstances of the event, the Veteran’s testimony is inconsistent with the available evidence of record. Notably, the Veteran states that his tinnitus has been present in one form or another since service, and only became permanent in 2008. However, the Veteran also mentioned to his June 2016 examiner that his tinnitus began approximately 5-10 years prior. This means that the tinnitus onset, at the earliest, in 2006. Further, if the Veteran had symptoms since service, it seems that he would have sought service connection along with his 2011 claims for diabetes, neuropathy, hypertension and SMC. The fact that the Veteran knew to apply for service connection for disorders, and did not apply for tinnitus until 2016, conflicts with his statement of continuity, even since 2008. Thus, service connection cannot be awarded based on continuity of symptoms or the Veteran’s statements. Finally, service connection may also be granted when the evidence establishes a medical nexus between active duty service and current complaints. In this case, the weight of the competent evidence does not attribute the Veteran’s bilateral hearing loss or tinnitus to active duty. In so deciding, the Board places significant value on the opinions C&P examiners who evaluated the Veteran’s symptoms in November 2016 and in June 2020. The November 2016 examiner stated that the results were invalid for rating purposes. Indeed, the Veteran’s Maryland CNC and speech discrimination results showed he was deaf, though he was able to follow conversation prior to the examination and his speech was not distorted, as would be expected from a deaf patient. Nonetheless, the June 2020 examiner provided an adequate negative nexus opinion. Specifically, the June 2020 C&P examiner acknowledged the Veteran’s reported exposure to howitzer fire and satchel charges while providing chaplain services. The Board notes that this examination was rendered without the benefit of elaboration provided in a July 2020 statement. The Veteran narrates the details of two instances in which his hearing was temporarily affected by noise exposure in service. He recounts frequent attacks at Forward Operating Bases, including gunfire and 122 mm rockets. He describes 155mm howitzers that would bounce a person off the ground, rendering them unable to hear for minutes. During one FOB attack, the Veteran notes, a satchel charge detonated 30 feet away from him, momentarily deafening him. He was also fired upon and a bullet came so close that it deafened his right ear. Nonetheless, the evidence weighs against finding a nexus to service. The June 2020 C&P examiner noted that the Veteran’s hearing was normal at entrance and at separation, and that there was no in-service threshold shift beyond normal variations. The July 2020 descriptions of momentary hearing loss in service does not change the Board’s analysis. The C&P the examiner noted the lack of chronic hearing loss symptoms in service. However, given the lack of a permanent threshold shift in service, and given that the disability did not persist in the years since active duty, the combat presumption of Section 1154(b) cannot be used to presume that the Veteran’s hearing loss has a medical nexus to service. The Board finds that Veteran’s hearing loss is less likely caused or aggravated in or by service. Accordingly, service connection must be denied based on the medical and lay evidence. A medical nexus is not of record for tinnitus either. Specifically, the June 2020 C&P examiner re-emphasized that the Veteran’s tinnitus, according to his own testimony, began 10 years prior to his first C&P examination for tinnitus. In so doing, the Board observes that if the Veteran’s hearing loss had had a nexus to service, service-connection for tinnitus would likely be warranted as secondary to hearing loss. However, the evidence does not indicate a possible nexus to service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran cites the Federal Circuit’s holding in Reeves v. Shinseki, asserting that if the Board concedes in-service noise exposure, the cause should be presumed. This conclusion is a misapplication of the Federal Circuit’s holding in Reeves. While the Board can concede in-service noise exposure, the Veteran must still show a causal relationship between the present disability and the in-service injury. Unfortunately, the June 2020 C&P examiner was unable to establish a nexus, as there was no permanent shift in the Veteran’s hearing thresholds. Further, as was the case in Reeves, the Veteran’s June 2020 C&P examiner opined that the Veteran’s tinnitus is more consistent with a hearing loss-induced pathology. Since the Veteran’s hearing loss is not shown to be service connected, this makes it less likely that tinnitus has a nexus to the Veteran’s conceded in-service noise exposure. Given the denial of service connection for hearing loss, and given the inconsistency in the Veteran’s statements regarding continuity of tinnitus, the Board finds that remand for an adequate examination would only delay adjudication. Unfortunately, the Board is unable to resolve reasonable doubt in favor of the Veteran. Service connection for hearing loss and tinnitus must be denied. 3. Entitlement to service connection for paroxysmal atrial fibrillation The Veteran seeks service connection for atrial fibrillation, to include as secondary to Agent Orange exposure, service-connected PTSD, and/or service-connected diabetes. Specifically, he asserts that stress, nightmares, and panic from PTSD caused frequent rapid heartbeats, which developed into atrial fibrillation. Also, in a May 2020 statement, the Veteran states that his atrial fibrillation may have been aggravated by PTSD or diabetes. Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Certain chronic diseases, including prostate cancer, are subject to presumptive service connection if manifested to a compensable degree within one year from separation from service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307 (a)(3) (2014), 3.309(a). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology for diseases that qualify as a chronic disease listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection is warranted for a veteran who has been exposed to a toxic herbicide agent during active military service (subject to the requirements of 38 C.F.R. § 3.307 (a)) for diseases such as chloracne or other acneform diseases consistent with Type 2 diabetes, Hodgkin’s disease, non-Hodgkin’s lymphoma, porphyria cutanea tarda, multiple myeloma, B-cell leukemias, soft-tissue sarcomas, early-onset peripheral neuropathy, Parkinson’s disease, chloracne and respiratory cancers, ischemic heart disease and as potentially relevant here, prostate cancer. 38 C.F.R. § 3.309(e). In this case, after reviewing all evidence currently of record, the Board determines that service connection for atrial fibrillation is not warranted. The Veteran’s medical records, including an August 2017 treatment record and the Veteran’s June 2020 C&P examination report, show that the Veteran currently takes metoprolol after undergoing electrocardioversion therapy for a 2017 episode of atrial fibrillation. However, the evidence does not show that the Veteran’s condition is related to or had its onset during his service or within a year after separation, service-connected diabetes or PTSD, or a presumptive or etiological relationship to in-service exposure to toxic herbicide agents. First, the Veteran’s disease cannot be attributed to herbicide agent exposure on a presumptive basis. While the Veteran served in Vietnam during the period from 1962 to 1975, atrial fibrillation is not one of the heart disorders that may be presumed related to toxic herbicide agent exposure under §3.309. Thus, service connection for atrial fibrillation is not warranted on a presumptive basis. Next, although though his primary assertions have been addressed above, the Veteran is not precluded from establishing service connection with proof of actual direct causation as due to active duty service. See Combee v. Brown, 34 F.3d 1039, 1041-42 (Fed. Cir. 1994). However, service connection is also not warranted on this basis, or secondary to diabetes or PTSD. Specifically, the Veteran’s service treatment records show no treatment for or symptoms of atrial fibrillation in service, or at any of his medical examinations at or near the end of his active service, or within the presumptive one-year period after separation. In fact, the post-service evidence does not reflect symptoms related to this claim until September 2016. While a September 2016 record indicates extremely rapid heartbeat and chest pains with shortness of breath for “several years,” the Veteran has never truly asserted that such symptoms have existed since service. Therefore, based on the clinical evidence of record, service connection cannot be established through continuity of symptomatology or the Veteran’s statements. See Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007). Despite the lack of continuous symptoms, service connection may still be warranted if the evidence otherwise indicates a relationship between his current disorder and his active duty service. However, there is no medical nexus between the Veteran’s active duty and current diagnosis. Indeed, atrial fibrillation was less likely caused or aggravated by the Veteran’s PTSD or diabetes. The Veteran’s June 2020 C&P examiner observed that the Veteran’s paroxysmal atrial fibrillation onset due to an aberrant conduction pathway in his heart. Accordingly, the evidence of record does not sufficiently indicate a relationship between the Veteran’s atrial fibrillation and active duty service or service-connected diabetes or PTSD, nor has any treating medical professional opined that this disorder may be related to active duty. Moreover, the examiner observed that the Veteran’s symptoms receded with treatment in 2018, making it less likely related to the Veteran’s ongoing PTSD or diabetes. These disorders, which have not gone into remission, less likely induced the Veteran’s atrial fibrillation. Therefore, obtaining further medical examinations and opinions to more exhaustively explore secondary etiologies would not assist the Veteran. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 4. Entitlement to service connection for anemia with bleeding ulcer The Veteran takes iron for iron deficiency anemia and the resulting bleeding ulcers. While the Veteran’s June 2020 examiner observes that symptoms have stopped with treatment, this is still a current disability. See McClain v. Nicholson, 21 Vet. App. 319 (2007). The Veteran asserts that his anemia and bleeding ulcers were caused or aggravated by his 2008 gastric bypass surgery, which was performed to reduce obesity. The Veteran thus attributes the gastric bypass to service-connected diabetes. The evidence shows that the Veteran’s anemia began some time before his September 2011 statement. As he puts it, the anemia had lasted for “many years.” However, he does not truly assert that this disability has persisted since service. Thus, he does not assert that his anemia onset in or is directly related to service. The lay and medical evidence also does not indicate a direct nexus to any in-service event. Unfortunately, the evidence of record also does not warrant a grant of service connection on a secondary basis. The medical evidence of record does not show that the Veteran’s anemia was caused or aggravated by service-connected disabilities, to include diabetes. Specifically, the Veteran appears to have conflated which disabilities were caused by which physical conditions. Rather than his obesity being caused or aggravated by diabetes, the Veteran’s June 2020 C&P examiner clarified that the Veteran developed obesity, which resulted in his developing diabetes as well as treatment with gastric bypass. The Veteran’s diabetes developed from his non-service-connected obesity. He also underwent a gastric bypass to control his obesity, and by extension, his diabetes. However, the medical evidence does not indicate a causal relation between the Veteran’s anemia and his diabetes. Diabetes and anemia each have their roots in the Veteran’s non-service-connected obesity. Without further information linking anemia to diabetes, and given the evidence to the contrary, the record does not indicate a relation between anemia and any of the Veteran’s service-connected disabilities. Accordingly, further examinations and opinions would not assist the Veteran’s claim. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Because his anemia is the result of a gastric bypass, which is correlated with obesity and not diabetes, service connection for anemia secondary to either disability is not warranted. The Board notes that the Veteran is not arguing that his obesity is a connector between anemia and service-connected diabetes. Thus, unlike Walsh v. Wilkie, No. 18-0495 (2020), in service connection was awarded using obesity as a connector between the service-connected disability and the one on appeal, the Board is unable to award service-connection based on this Veteran’s obesity-induced gastric bypass. In arriving at these conclusions, the Board recognizes the statements of the Veteran relating his disabilities to his service and/or service-connected disabilities. Of note, the Veteran ascribes his atrial fibrillation to panic attacks from PTSD, as suggested by the Veteran’s doctor. The Federal Circuit has held that “[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.” Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (quoting Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In this case, however, the Veteran is not competent to testify regarding the etiology of heart arrythmia, hearing loss, tinnitus, anemia, or gastric ulcers. See Jandreau, 492 F.3d 1372 at 1377, n.4. Because such disorders are not diagnosed by unique and readily identifiable features, they do not have a simple identification that a layperson is competent to make. In this case, the Veteran’s trained medical examiners found that the Veteran’s disabilities were unrelated to service (to include Agent Orange), service-connected disabilities. Therefore, the lay statements of belief that the Veteran’s disabilities are related to his time in service, especially the use of Agent Orange in Vietnam, are found to lack competency. Unfortunately, based on the evidence of record, the Veteran’s claims must be denied. 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. 5. Entitlement to an initial rating in excess of 50 percent for PTSD The Veteran is presently service connected for post-traumatic stress disorder (PTSD), rated at 50 percent disabling. In a June 2016 statement and his March 2019 Form 9, the Veteran claims that his symptoms reflect a 70 percent rating. Thus, while the period on appeal begins in June 2016, a fair analysis of the Veteran’s symptoms requires discussion of some evidence prior to this date. See 38. C.F.R. §3.400. Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Veteran’s entire history is reviewed when making disability evaluations. See generally, Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of staged ratings are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Further, “[w]here there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned.” 38 C.F.R. § 4.7. The Veteran’s psychiatric disorder is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. Under the applicable diagnostic criteria, a 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to symptoms such as, but not limited to, 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, resulting in a difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9411. The next higher 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school family relations, judgment, thinking or mood, due to symptoms such as, but again not limited to, suicidal ideations; 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 the veteran’s personal appearance and hygiene; difficulty in adapting to stressful circumstances (including in work or work like settings), thereby resulting in the inability to establish and maintain effective relationships. Id. Unfortunately, based on the evidence of record, the Board determines that the next-highest 70 percent rating for the period on appeal is not warranted. Specifically, the record indicates that the Veteran’s symptoms do not produce occupational and social impairment with deficiencies in most areas. While the Veteran has significant occupational impairment over the appeal period, his social impairment is not sufficiently affected to warrant a rating increase. As an initial matter, the Veteran’s general presentation and appearance during the period on appeal did not reflect deficiencies in “most areas.” The evidence of record, including examinations dated October 2016 and May 2019, demonstrates that the Veteran was alert and oriented in all spheres with appropriate behavior and goal directed thoughts. During the period on appeal, the Veteran’s speech was of normal tone, rate, rhythm and volume, and his affect was generally euthymic and appropriate. The Veteran’s June 2020 C&P examiner noted appropriate grooming and that his personal hygiene was not neglected. Of note, the Veteran was consistently able to communicate appropriately. These symptoms over the appeal period do not reflect deficiencies in most areas. The Veteran asserts entitlement to a 70 percent rating based on mood symptoms including asserted unpredictable anger and panic, and per a March 2019 Affidavit, the inability to feel good about anything. However, his symptoms, as described in the lay and medical evidence of record, represent at most, reduced reliability and productivity. Indeed, the Veteran’s mood did not approximate a state of “near-continuous panic,” one of the main indicia of a 70 percent rating. While the Veteran takes prazosin, and competently recounts that without it, he wakes up in a panic, the Veteran’s panic attacks mostly occur at night. The Veteran stated to his June 2020 C&P examiner that these panic attacks will often cause a noticeably palpitating/racing heart. Conversely, the evidence does not mention panic attacks during the daytime, but rather a fear of them. The Board finds that a fear of panic attacks, compared to actually having them, does not cause deficiencies in most areas. Moreover, the Veteran described a persistently negative outlook, severe irritability, sudden rage episodes, and often wishing he could go to sleep and never wake up. The Veteran’s wife, in a March 2019 buddy statement, related that he seemingly had panic attacks every week, almost daily, and sometimes more than once a day. He was on constant guard, keeping his back to a wall whenever he did visit restaurants. The Veteran, according to his and his wife’s 2019 Affidavits, could sometimes smell gunpowder and burning hydraulic fluid at times. The Board notes that the Veteran and his wife are not competent to diagnose psychiatric phenomena such as panic attacks. Despite the seemingly near-continuous nature of the Veteran’s panic, the occupational and social his impairment was not frequent or severe enough to be considered “in most areas.” Accordingly, the Veteran’s mood symptoms were not productive of deficiencies in most areas. Next, a June 2016 record, the Veteran’s April 2018 statement, and the Veteran’s January 2017 and June 2020 C&P examiners noted exaggerated startle, hypervigilance, nightmares, intrusive memories, poor sleep, disrupted focus, irritability, and avoidance of triggers. Such symptoms are significant. However, in the Board’s view, the Veteran’s mood and motivational disturbances are adequately reflected in his current 50 percent rating for this period. While the Veteran experienced sleep disturbances such as nightmares during the period on appeal, these symptoms are contemplated his current disability rating under DC 9411. The Veteran complained of worsened nighttime sleep symptoms in June 2016, requesting sleep medications. He also reported daytime symptoms including easy startle, avoidance of crowds, and general depressed mood. He was prescribed prazosin and three months later, noted an improvement in a September 2016 record. In April 2018, the Veteran reported that he could not remember the last time he slept all night. He also mentioned yelling in his sleep, jumping out of bed, and waking up with his heart racing. According to a March 2019 Affidavit, this occurred almost every night. Fatigue, concentration, and impaired focus ensued, resulting in his struggling to finish tasks. At a C&P Examination in June 2020, the Veteran reported difficulty falling and staying asleep due to intrusive thoughts and nightmares of being shot down. Night terrors almost every night resulted in his getting two to three hours of sleep nightly, and he repeated his struggling to finish tasks due to concentration, difficulty with focus, and both short-term and long-term memory. Disjointed sleep and nightmares occur in most cases of PTSD; unless they cause deficiencies in most areas, they do not warrant a 70 percent rating. While the Veteran had difficulty with concentration, focus, and memory, the Board finds that these symptoms intrinsically did not produce deficiencies in most areas. While they cause occupational impairment, they do not cause occupational and social impairment, with deficiencies in most areas of both fields. Finally, the Board notes the presence of survivor’s guilt and suicidal thoughts during the period on appeal. Specifically, the Veteran, in October 2019, reported over the past month, wishing he were dead or that he could go to sleep and never wake up. Nearly every day, he had experienced little interest or pleasure in activities, and feeling down and depressed. Indeed, he reported having no consistent hobbies to his June 2020 examiner. The May 2019 standardized depression screen noted that these symptoms made social and occupational functioning “very difficult.” The Veteran’s occupational impairment, while significant is balanced by his relatively fair social functioning. The Veteran does have some social impairment. Notably, he went from withholding his combat experiences from his friends in 2016, to not having friends from 2019 onward. The Veteran describes a rocky relationship with his wife, and an “okay” relationship with his two adult children. Despite their rocky relationship, the Veteran cites his wife as a good source of support. The Veteran’s symptoms, as described, do not rise to a level where his occupational and social functioning is mostly impaired. Accordingly, the Veteran’s current 50 percent rating is adequate to address his symptoms; a 70 percent rating is not warranted. Based on the symptoms clinically observed, the Veteran has experienced some of the relevant symptoms that might support a rating in excess of 50 percent. For example, the Veteran experienced suicidal thoughts and wishes, obsessional rituals, and a constant fear of panic or a sudden outburst of anger. Significantly, in a March 2019 affidavit, the Veteran asserted that his 2016 C&P examination did not reflect the “full severity, depth, or persistence of [his] long standing symptoms.” The Veteran attested that his unpredictable anger caused problems with relationships. However, his symptoms, as described in his lay statements, do not reach the degree required to demonstrate occupational and social impairment with deficiencies in most areas. The criteria for the next-higher 70 percent rating depict a level of impairment, when viewed as a whole, that is more severe than the symptoms displayed by the Veteran. In so deciding, the Board notes that there are no “tripwire” symptoms that automatically trigger a higher rating. Even in cases where suicidal ideations are present, if the Veteran’s social or occupational functioning does not reflect deficiencies in most areas, a 70 percent rating is unwarranted. Next, although the general rating formula provides specific examples of symptoms that may result from various acquired psychiatric disorders, the Board emphasizes that its analysis should not be limited to only these symptoms, but should also consider any other relevant criteria outside of the rating code in order to determine the level of occupational and social impairment. Mauerhan v. Principi, 16 Vet. App. 436, 444 (2002). As such, the Board has also considered the extent to which there are other indications of total occupational and social impairment, such as grossly inappropriate behavior and memory loss, to include social and occupational inadaptability. In this regard, the Veteran’s disorder clearly impacts his social and occupational functioning. Nevertheless, the evidence does not indicate that a rating in excess of 50 percent is warranted. As mentioned above, the Veteran has a rocky relationship with his wife of 48 years. He also has an okay relationship with both of his adult children. The Veteran appears to no longer trust people outside of his family, and as such, does not have friendships. Nonetheless, the Board finds that the Veteran’s impairment is balanced by his adequate social functioning, and therefore does not merit an increase in rating. The Veteran is retired, and the medical evidence indicates that he would have difficulty with employment due to his service-connected PTSD. Nonetheless, this difficulty does not warrant a rating increase. As early as October 2011, the Veteran had been engaged in occupational activities with his wife. Further, the Veteran reported to his January 2017 examiner that he engaged in reading and providing pastoral services to retirement community, even after no longer working. The Board recognizes the Veteran’s statements of daily flashbacks, anxiety, depression, guarding, unpredictable outbursts, and lack of motivation. He also endorses sleeping difficulties resulting in diminished focus. Nonetheless, the medical evidence does not show a significant enough occupational impact to warrant an increased rating for “deficiencies in most areas.” Given this evidence, the Board determines that the Veteran’s psychiatric symptoms most nearly approximate the symptoms listed for a 50 percent rating. Specifically, his psychiatric disability was primarily manifested by disturbances of motivation mood and focus, and sleep disturbances. As the frequency, duration and severity of the Veteran’s psychiatric symptoms demonstrate occupational and social impairment with reduced reliability and productivity for the period on appeal, a 50 percent evaluation is warranted for the Veteran’s acquired psychiatric disorders. 38 C.F.R. § 4.130, Diagnostic Code 9411. In considering the appropriate disability ratings, the Board has also considered the Veteran’s statements that his PTSD is worse than the ratings he currently receives. 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 evidence favorable to the claimant. See 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. While the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of disability of his acquired psychiatric disability according to the appropriate diagnostic codes. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). On the other hand, such competent evidence concerning the nature and extent of the Veteran’s and PTSD has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which these disabilities are evaluated. Therefore, based on the evidence of record, the Board determines that the ratings awarded for this period are appropriate. The Board also finds that consideration for an extraschedular evaluation, a component of a claim for an increased rating, is not warranted. Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). In considering whether an extraschedular rating may be warranted, VA must first determine whether the available applicable schedular rating criteria are inadequate because they do not contemplate the Veteran’s level of disability and symptomatology. If the rating criteria are inadequate, VA must then determine whether the Veteran exhibits an exceptional disability picture indicated by other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for extraschedular consideration. See Thun v. Peake, 22 Vet. App. 111 (2008). In this case, the evidence does not indicate that Veteran’s disability picture could not be adequately contemplated by the applicable schedular rating criteria discussed above. Specifically, the Board has reviewed all relevant symptoms related to the issues on appeal, and concludes that there are no symptoms that were not able to be addressed by the applicable diagnostic codes. See Mittleider v. West, 11 Vet. App. 181 (1998). Moreover, as was established in Mauerhan, 16 Vet. App. at 444, a schedular rating for psychiatric disorders is not necessarily limited to the enumerated symptoms in the general rating formula, and no relevant symptoms have been excluded in the Board’s analysis. As such, the Veteran’s symptoms are not which are so unusual that they are outside the schedular criteria. Therefore, given that the applicable schedular rating criteria are more than adequate in this case, the Board need not consider whether the Veteran’s disability picture includes exceptional factors, and referral for consideration of the assignment of a disability evaluation on an extraschedular basis is not warranted. See Thun, 22 Vet. App. at 111; see also Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Therefore, the Board must deny an initial rating in excess of 50 percent for PTSD. 6. Entitlement to a rating of total disability based on individual unemployability The Veteran and his representative argue that his service-connected PTSD symptoms, as well as the effects of diabetes, render him unemployable. Total disability is considered to exist when there is any impairment which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340(a)(1). A total disability rating for compensation purposes may be assigned on the basis of “individual unemployability,” or when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). In such an instance, if there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Id. The Board must evaluate whether there are circumstances in the Veteran’s case, apart from any non-service-connected conditions and advancing age, which would justify TDIU. 38 C.F.R. §§ 3.341(a), 4.19; See Van Hoose v. Brown, 4 Vet. App. 361 (1993); see also Hodges v. Brown, 5 Vet. App. 375 (1993); Blackburn v. Brown, 4 Vet. App. 395 (1993). The Veteran’s service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16(b). In this case, the Board determines that TDIU should be granted for the period on appeal. As an initial matter, the Board notes that the Veteran did not meet the schedular requirements for TDIU during the period on appeal. Specifically, the Veteran is service connected for PTSD, rated at 50 percent from June 16, 2016; diabetes at 20 percent from August 16, 2011; peripheral neuropathy of the right and left lower extremities, at 20 percent each from August 16, 2011; hypertension at 10 percent from August 16, 2011; loss of a portion of the mandible, rated at 0 percent from June 16, 2016; and loss of left lower posterior mandibular teeth, rated at 0 percent from June 16, 2016. Under his current ratings, therefore, the Veteran’s current combined rating is 60 percent from August 16, 2011, and 80 percent from June 16, 2016. He only meets the schedular criteria from June 16, 2016. Nevertheless, consideration for extraschedular TDIU is warranted as the evidence demonstrates that the Veteran was unable to obtain gainful employment from 2011. In making this determination, the Board places significant probative value on lay statements from the Veteran and his wife, indicating that his PTSD symptoms caused severe inability to focus, as well as mood symptoms, that precluded him from substantially gainful employment. Post-service, the Veteran had 32 jobs in 40 years, the latest of which was management of a retirement community. However, the record shows that in the years prior to 2011, the Veteran’s wife had increasingly needed to cover for him because of his inability to focus on tasks and remember to complete them. Indeed, the Veteran’s June 2020 C&P examiner noted that the Veteran’s difficulty with focus, concentration, and memory may make it difficult to complete tasks or follow directions effectively. Further, the Veteran noted to his examiner that he had nightmares almost nightly, that he got about 3 hours of sleep nightly, requiring napping or dozing off during the day. Finally, in a November 2020 affidavit, the Veteran competently asserts that because of his sleep and mood difficulties, he has no mental ability to concentrate, follow directions, or be amenable to supervision. He has constant fatigue due to poor sleep and recurrent nightmares. His depression interferes with motivation, as does his frequent and unexpected panic. For these reasons, the examiner confirmed the Veteran’s statements that his sleep difficulty and memory symptoms could make it difficult to work in stressful environments such as managing a retirement community. Indeed, this is the only employment the Veteran has had for several decades. While the frequency and severity of the Veteran’s sleep difficulties and memory and cognitive disability do not cause occupational and social impairment with difficulties in most areas of both, the Board nonetheless finds him unable to secure and follow substantially gainful employment. See 38 C.F.R. § 4.16(a). In making this determination, the Board is aware that, generally, the Board does not assign an extraschedular evaluation in the first instance under 38 C.F.R. § 4.16(b). However, the Board notes that 38 C.F.R. § 4.16(b) merely states that rating boards “should” refer to the Director of Compensation Service for extraschedular consideration all cases where the Veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disability. In any event, remanding for this evaluation would serve only to unnecessarily delay the Veteran’s claim. See Jarrell v. Nicholson, 20 Vet. App. 326, 332 (2006) (The Board may exercise authority with regard to questions or issues not previously addressed by an AOJ in the first instance if it determines that there would be no prejudice to the claimant); See also Scott v. McDonald, 789 F.3rd 1375 (Fed. Cir. 2015). Given the unique facts of the present case, the Board has determined that consideration of the Veteran’s extraschedular TDIU claim in the first instance under § 4.16(b) is appropriate. Given that the Board is granting the full benefits on appeal for which the Board has jurisdiction, there is no prejudice to the Veteran in the Board’s consideration of this issue in the first instance. Accordingly, entitlement to TDIU is granted. B.T. KNOPE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Z. Maskatia