Citation Nr: 21061976 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 17-10 391 DATE: October 6, 2021 ORDERZ Service connection for posttraumatic stress disorder (PTSD) is granted. Entitlement to a 70 percent rating for an anxiety disorder is granted. REMANDED Entitlement to more than a 70 percent rating for an anxiety disorder is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran's PTSD is related to his combat service in Vietnam. 2. The Veteran's anxiety disorder results in occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 50 percent for an anxiety disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9400. 2. The criteria for service connection of PTSD have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from May 1968 to May 1970, including combat service in the Republic of Vietnam, where he served from October 1968 to October 1969. The Veteran's decorations include the Combat Infantryman Badge and the Air Medal. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2013 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran presented sworn testimony at a hearing before the undersigned Veterans Law Judge (VLJ) in September 2021. Service Connection The Veteran seeks service connection for PTSD. Service connection may be granted for a disability resulting in a disease or injury that is incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 U.S.C. § 3.303. To establish service connection for the claimed disorder, the following criteria must be met: (1) evidence of a current disability; (2) evidence of an in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and current disability. See 38 C.F.R. § 3.303; see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999). The Veteran has a diagnosis of PTSD. See October 2020 and November 2009 VA treatment records. He relates his PTSD diagnosis to his combat service in Vietnam, which is consistent with combat decorations. The Veteran reports that he experienced PTSD symptoms since his service. His symptoms worsened after his retirement and after the news began covering the "War on Terror." Several VA treating physicians opine that the Veteran's PTSD is the result of his active-duty service. More specifically, the November 2009 treating physician opined that the Veteran's PTSD is clearly associated with trauma that occurred on active duty. As a result, the Board finds that service connection for the Veteran's PTSD is warranted. Increased Rating The Veteran seeks an increased rating for his anxiety disorder. The period on appeal begins on May 14, 2012, when the Veteran filed this claim. Throughout the appeal, he receives a 30 percent rating for his anxiety disorder under DC 9400. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause 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 normal conversation). A 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. The records shows that the Veteran's anxiety disorder results in chronic sleep impairment, depressed mood, anxiety and suicidal ideation He has mood swings and reports that his anxiety makes him withdraw from others. His wife describes him as obsessive compulsive and controlling. He reports having few relationships outside of his familial relationship with his wife and daughter. Given the Veteran and his wife's lay statements and the medical evidence, the Board finds the Veteran's anxiety disorder was manifested by symptoms associated with a 50 percent resulting in occupational and social impairment with reduced reliability and productivity. Thus, entitlement to at least a 70 percent rating for an anxiety disorder is established. Bankhead. REASONS FOR REMAND Anxiety Disorder The Veteran reports that his anxiety disorder symptoms worsened since his last medical evaluation. In order to determine whether a rating in excess of 70 percent is warranted, further medical information is required. As a result, VA is required to afford him a contemporaneous VA examination to assess the current nature, extent, and severity of his anxiety disorder. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). TDIU The Veteran asserts that his service-connected disabilities result in his inability to obtain and maintain employment. Rice v. Shinseki, 22 Vet. App. 447 (2009). Additional information regarding the Veteran's work history is needed to determine his entitlement to TDIU. The Board notes that a failure of the Veteran to provide the necessary information may result in the denial of his claim. As a result, remand is necessary for the Veteran to complete a VA Form 21-8940 in connection with his TDIU claim. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records. 2. Schedule a VA examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) to assess the current nature and severity of his anxiety disorder. 3. Furnish the Veteran a VA Form 21-8940 and request that he complete and submit it in connection with the TDIU claim. STEVEN D. REISS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Ijitimehin, Kemi D. 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.