Citation Nr: 21062238 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 17-10 612 DATE: October 6, 2021 ORDER Service connection for obstructive sleep apnea (OSA), to include secondary to the service-connected posttraumatic stress disorder (PTSD) is denied. A disability rating in excess of 50 percent for the service-connected PTSD is denied. FINDINGS OF FACT 1. The preponderance of the most probative evidence shows that the Veteran's OSA did not have its onset in service and is not causally related to service, to include his service-connected PTSD. 2. For the entire period on appeal, the Veteran's service-connected PTSD has been manifested by symptoms of anxiety, sleeplessness, hopelessness, sadness, flashbacks, nightmares, isolation, reports of rage and violent outbursts, detachment from others, avoidance of triggers, hypervigilance, suspiciousness, daytime fatigue, intrusive thoughts, irritability, anger towards others, and some suicidal ideation, but no plan. 3. For the entire period on appeal, the Veteran's service-connected PTSD did not more nearly approximate occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for OSA, to include secondary to the service-connected PTSD have not been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 2. The criteria for a disability rating in excess of 50 percent for the service-connected PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.125, 4.126, 4.130, Diagnostic Code (DC) 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from October 1970 to October 1974 and from December 1990 to April 1991. This matter is before the Board of Veterans' Appeals (the Board) on appeal from a February 2015 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. The rating decision, inter alia, denied service connection for OSA and confirmed and continued the 50 percent disability rating for the service-connected PTSD. The Veteran's Notice of Disagreement (NOD) was received in June 2015. The Statement of the Case was issued in February 2017, and the Veteran's VA Form 9, substantive appeal to the Board, was received the same month. In July 2021, the Veteran and his representative appeared before the undersigned Veterans Law Judge (VLJ) for a Board hearing. The transcript is of record. 1. Entitlement to service connection for OSA, to include secondary to the service-connected PTSD. During the July 2021 Board hearing, the Veteran contended that his OSA symptoms began in 2010 and included daytime fatigue and waking up at night. There were no reports of snoring. The Veteran contended that his service-connected PTSD caused or aggravated his OSA. He submitted medical studies in support of his contention. Alternatively, the Veteran contended that his OSA is a result of in-service exposure to Agent Orange. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). "To establish a right to compensation for a present disability, a Veteran 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"- the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Establishing a service connection on a secondary basis requires evidence sufficient to show: (1) that a current disability exists; and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). It is the Board's responsibility to determine whether a preponderance of the evidence supports the claim or whether the evidence is in relative equipoise, with the veteran prevailing in either event, or whether there is a preponderance of evidence against the claim, in which case the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The Veteran's service treatment records (STRs) do not contain complaints or treatments for OSA. The Veteran's VA treatment records indicate that the Veteran was diagnosed with OSA pursuant to a January 2014 study. In May 2018, the Veteran underwent a VA examination for his claim. A January 2014 diagnosis of OSA was noted. Under history, it was noted that the Veteran had a history of symptoms consistent with OSA pursuant reported in a September 2013 VA treatment note. It was also noted that the Veteran was diagnosed pursuant to a January 2014 sleep study. The VA examiner indicated that the Veteran's OSA required continuous use of CPAP and did not require continuous medication. The VA examiner concluded that it is less likely than not that the Veteran's OSA was incurred in or caused by the claimed in-service injury, event or illness. The VA examiner indicated that OSA is a breathing disorder that occurs due to passive collapse of the oro- and/or nasopharynx during inspiration while sleeping. The VA examiner also indicated that OSA is caused by anatomical abnormalities, including obesity, redundant tissue in the soft palate, enlarged tonsils or uvula, low soft palate, large or posteriorly located tongue, as well as neuromuscular disorders, and alcohol or other sedative use before bedtime. The VA examiner noted that risk factors include being overweight, large neck side, a narrowed airway, smoking and alcohol use. The VA examiner also noted that there is no pathophysiology or causative effect of PTSD on OSA, and that there are no physical or emotional factors that influence OSA. The VA examiner also concluded that the Veteran's OSA was not aggravated beyond its natural progression by the Veteran's PTSD. The Veteran submitted medical literature in support of his claim. There is 2005 published study titled "Association of Psychiatric Disorders and Sleep Apnea in a Large Cohort." Under objectives, it is noted that the study was conducted to determine whether psychiatric disorders are commonly associated with sleep apnea in Veteran Health Administration Beneficiaries. The conclusions indicate that OSA is associated with a higher prevalence of psychiatric comorbid conditions in Veterans Health Beneficiaries, and that this association suggests that patients with psychiatric disorders and coincident symptoms suggesting sleep-disordered breathing should be evaluated for sleep apnea. There is an October 2010 slide presentation titled "Prevalence of Sleep Disorders Among Soldiers With Combat-Related Posttraumatic Stress Disorder." The authors are listed as doctors, but there is no indication of what the source of this record is. Under purpose, the presentation states that poor sleep quality, insomnia, and daytime somnolence are common among recently deployed soldiers and those with PTSD and that the presenters sought to determine the prevalence of sleep complaints and sleep disorders among recently deployed soldiers with PTSD. Under methods, it is noted that records of 80 consecutive soldiers returning from combat and diagnosed with PTSD were analyzed, and that the rate of sleep complaints and prevalence of insomnia and OSA were determined. It was further noted that demographic data, psychoactive medication use, psychiatric disorders and concomitant traumatic brain injury (TBI) were compared to determine any variables correlated with increased sleep complaints or disorders. Under results, it was noted that 61 percent of patients were diagnosed with OSA, and those with OSA had less use of narcotics and benzodiazepines and a lower prevalence of TBI than those without OSA. The conclusion indicates that sleep complaints were almost universal among soldiers with PTSD and that majority were diagnosed with insomnia and/or OSA. Under clinical implications, it was noted that given the common occurrence of sleep complaints and their potential clinical impact, patients with PTSD should be screened for sleep disorders. There is a 2013 publication of a study called Sleep Disorders and Associated Medical Comorbidities in Active Duty Military Personnel. The study objective is listed as describe the prevalence of sleep disorders in military personnel referred for polysomnography and identify relationships between demographic characteristics, comorbid diagnoses, and specific sleep disorders. The conclusion indicates that the service-related illnesses are prevalent in military personnel who undergo polysomnography with significant associations between PTSD, pain syndrome, and insomnia. The study notes that despite having sleep disorders, almost half reported short sleep duration, and goes on to state that multidisciplinary assessment and treatment of military personnel with sleep disorders and service-related illnesses are required. With respect to claims of in-service exposure to Agent Orange, the RO undertook development to determine whether the Veteran had requisite service in Republic of Vietnam, or in its inland waterways, or in the offshore eligible waters as defined in the Blue Water Navy Vietnam Veterans Act of 2019, Public Law 116-23. An April 2021 Memorandum contains a formal finding that exposure to herbicides cannot be conceded as the evidence of record does not show that the Veteran had duty or visitation in the Republic of Vietnam, or on its inland or in its inland waterways, or in the offshore eligible waters as defined in the Blue Water Navy Vietnam Veterans Act of 2019. Based on the review of the entire record, the preponderance of the evidence supports the finding that the Veteran's OSA did not have its onset in service, and is not otherwise causally related to the Veteran's service, to include secondary to his service-connected PTSD. As such, service connection is not warranted. The Veteran's OSA did not have its onset in service. The Veteran's STRs and VA treatment records indicate that the Veteran's OSA was not diagnosed until the January 2014 sleep study. Moreover, the Veteran does not claim that his OSA had its onset in service. Indeed, he reported that he did not begin experiencing symptoms until 2010. As such, the remaining question is whether OSA is otherwise causally related to the Veteran's service. With respect to a nexus, the Veteran presented two distinct theories. First, he indicated that OSA is related to his in-service exposure to herbicides. Second, the Veteran indicated that his service-connected PTSD causes or aggravates his OSA. While the Veteran is competent to report observable symptoms, such as daytime fatigue and trouble sleeping, he does not possess the medical expertise to provide a nexus opinion in this case. In other words, he is not competent to state that his observable symptoms of daytime fatigue and sleep disruption, for example, are due to OSA, and he is not competent to provide a medical opinion on whether the OSA is caused or aggravated by the PTSD. The two issues are medically complex, as they require knowledge and interpretation of complicated diagnostic medical testing, records, and studies. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). As such, the Veteran's contentions with respect to a nexus in this case cannot serve as the basis for an award of service connection. The Veteran claims that his OSA is caused by in-service exposure to herbicides. However, the record does not contain evidence of in-service herbicide exposure. For veterans who are presumed to have been exposed to certain herbicide agents, including Agent Orange; or, for those veterans who are not entitled to the presumption of exposure, but who have otherwise established exposure to herbicide agents on a direct basis, certain diseases are presumed to be due to that exposure. OSA is not one of the diseases covered under the presumption. See 38 C.F.R. §§ 3.307 (a)(6); 3.309(e). Although the OSA is not one of the diseases enumerated under the herbicide exposure presumption, the Veteran is not precluded from establishing service connection due to herbicide exposure on a direct basis. See 38 U.S.C. § 1113 (b); 38 C.F.R. § 3.303 (d) (the availability of service connection on a presumptive basis does not preclude consideration of service connection on a direct basis); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994) (Radiation Compensation Act does not preclude a veteran from establishing service connection with proof of actual direct causation). In this case, the evidence does not show that the Veteran has requisite service in the Republic of Vietnam, or inland or offshore waterways as required by the herbicide exposure presumption. The April 2021 memorandum from the RO contains a formal finding that the Veteran did not have requisite service in the Republic of Vietnam. The formal finding was a result of the requisite development performed by the RO, including a review of the Veteran's service records. As the Veteran's records do not indicate that he had requite service in the Republic of Vietnam or inland or offshore waterways as required by the presumption, in-service exposure to herbicides is not conceded. Given that the Veteran's records do not corroborate in-service exposure to herbicides, and the Veteran's service does not warrant a finding of exposure on a presumptive basis, there is no finding of in-service herbicide exposure. Moreover, there is no evidence of any in-service event, injury or disease as to which OSA may be related. As such, service connection may not be established on a direct basis. In other words, a nexus to service may not be established without a finding of an in-service injury. Here, the evidence is against the finding that the Veteran was exposed to herbicides in service. The evidence also does not contain, and the Veteran has not identified, another in-service event or injury, which could have caused OSA. As there is no evidence of an in-service injury, there is no need to obtain an additional medical opinion, and service connection is not warranted. McLendon v. Nicholson, 20 Vet. App. 79 (2006). With respect to the secondary service connection claim, the most probative evidence of record shows that the Veteran's PTSD did not cause or aggravate his OSA. The medical literature that the Veteran provided in support of his claim at best suggests that some Veterans suffer from both PTSD and OSA. However, these studies do not specifically indicate that there is a causal relationship between the two, and they are too general to serve as a nexus in this case without any supportive medical opinion specific to this Veteran. In other words, just because there is a prevalence of sleeping disorders amongst Veterans with PTSD, does not mean that PTSD causes OSA. Further, the medical literature that the Veteran provided does not address the Veteran's specific medical history, diagnosis, and etiology, including presence of other risk factors. While medical articles or treatises can provide important support when combined with an opinion of a medical professional, such medical article or treatise evidence must nevertheless discuss generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222 (1999); Wallin v. West, 11 Vet. App. 509 (1998); Sacks v. West, 11 Vet. App. 314 (1998). The Court held that, "generally, an attempt to establish a medical nexus to a disease or injury solely by generic information in a medical journal or treatise is too general and inconclusive." Mattern at 228 (citing Sacks v. West, 11 Vet. App. 314, 317 (1998). By contrast, the May 2018 VA medical opinion indicates that there is no pathophysiology or causative effect of PTSD on OSA. The medical opinion also indicates that PTSD did not aggravate OSA. Given that the VA examiner provided sound medical rationale and cited appropriate medical literature, the May 2018 VA medical opinion is assigned probative value. On the other hand, the Board does not assign the medical literature provided by the Veteran probative value because it does not take into consideration the Veteran's medical history and does not provide conclusive results with respect to the relationship between PTSD and OSA. Thus, the preponderance of the medical evidence does not support a finding that the Veteran's OSA was causally related to service, to include his service-connected PTSD. The Veteran was diagnosed with OSA over twenty years after service and the record in this case does not support a nexus between OSA and service, to include service-connected PTSD. Accordingly, the preponderance of the evidence is against the claim for service connection for OSA, to include secondary to service-connected PTSD, and it is, therefore, denied. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt rule enunciated in 38 U.S.C. § 5107(b). However, as there is not an approximate balance of evidence, that rule is not helpful to the Veteran. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). 2. Entitlement to a disability rating in excess of 50 percent for the service-connected PTSD. During the July 2021 Board hearing, the Veteran testified that his service-connected PTSD is worse than what is contemplated by the current 50 percent disability rating. He indicated that his symptoms are anxiety, sleeplessness, hopelessness, sadness, flashbacks, nightmares, isolation, keeping tabs on people, and daytime fatigue. He also indicated that he experiences daytime intrusive thoughts about his time during Desert Storm. He also indicated that he stays inside the house all of the time and has recently had a confrontation with the neighbors. The Veteran testified that he threatened to bash his neighbor's head in, and that his neighbors avoid him. He also testified that he is easily irritable, easily angered, cannot be around kids, and experiences road rage. He also testified that he has not worked since 2008, during which time he was a mail carrier for united healthcare. He testified that he took his breaks in his car because he could not be around people. He indicated that he was laid off due to anger mismanagement. He also testified that he avoids his wife as much as possible, has two adult sons that rarely call, and avoids places like the grocery store. The Veteran testified that he forgets where he parked his car. He also testified that he received mental health treatment through the VA and sees his provider every three months and takes medication for his PTSD symptoms. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's PTSD is rated pursuant to DC 9411 as 50 percent disabling from June 30, 2005. As with other psychiatric disorders, the criteria for rating PTSD are based on the General Formula for Mental Disorders, found at 38 C.F.R. § 4.130. Pursuant to the General Rating Formula, a 30 percent rating is assigned where there is 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, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation 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; disturbance of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation 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 evaluation 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. Ratings assigned under the General Formula for Mental Disorders must be based on a holistic analysis that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10 (2017); 38 C.F.R. § 4.130. The symptoms listed in the General Rating Formula are examples, not an exhaustive list and it is not required to find the presence of all, most, or even some of the enumerated symptoms. Mauerhan v. Principi, 16 Vet. App. 436 (2002). When determining the appropriate rating to be assigned for a service-connected mental disorder, the focus is on how the frequency, severity, and duration of the symptoms affect the Veteran's occupational and social impairment, rather than on an absence of particular symptoms listed in the schedular criteria. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The Board must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126. While VA considers the level of social impairment, it shall not assign an evaluation based solely on social impairment. Id. A February 2014 statement from the Veteran's wife indicates that she observed the Veteran complain about not being able to sleep, waking up several times in the middle of the night, having panic attacks, flashbacks, and anxiety attacks. In October 2014, the Veteran underwent a VA examination for his claim. He was diagnosed with chronic moderate PTSD and alcohol abuse in full sustained remission. The VA examiner differentiated PTSD symptoms as rage, violent outbursts, detachment from others, avoidance of triggers, hypervigilance, flashbacks, nightmares, insomnia, and negative affect and noted that the Veteran used alcohol to medicate his moods but has been in remission for 21 years. The VA examiner concluded that the Veteran's PTSD manifests in occupational and social impairment with reduced reliability and productivity and noted that the Veteran has a history of violent outbursts, negative affect, cognitive distortions, and avoidance of triggers amongst other symptoms. On examination, the Veteran was alert and fully oriented. He was dressed casually, neatly and appropriately. The Veteran was pleasant and cooperative, and he appeared to be a reliable historian. Rapport was easily established. Mood was anxious with congruent affect. The Veteran denied auditory, olfactory, or visual hallucinations. There was no evidence of paranoia or loose associations. The Veteran reported speech disturbance. Speech was logical and delivered in a rhythmic rate and flow. He had a clinically clear sensorium. Cognitive parameters, including attention, recent/remote memory, and judgement/insight were intact. Fund of knowledge was commensurate with the Veteran's level of education. Although intelligence was not formally assessed, it appeared to the examiner to be in the average range. There was no evidence of psychomotor retardation or agitation. Kinetic activity revealed no tics, dyskinesias, or abnormal patterns. Eye contact was maintained. According to the Veteran, his PTSD symptoms preclude the Veteran's ability to function appropriately at work and in social life. The VA examiner recorded the Veteran's self-reported history of exhibiting work behaviors years ago as a bus driver, that would now be considered punishable offenses, such as throwing individuals off busses, assaulting attackers, and man-handling individuals. The Veteran also reported that he used alcohol for many years to medicate his moods and was laid off from his last job due to anger mismanagement. The Veteran also reported to the VA examiner that he cannot handle being around children as he is triggered to engage in angry outbursts; and, that his 32-year marriage is tumultuous. It was also noted that the Veteran is under VA psychiatric care for PTSD and took daily medications. The Veteran denied psychiatric admissions but reported passive suicidal ideation with no gestures. He denied homicidal ideations but endorsed violent behavior. History of violent behavior with first wife and former brother-in-law. The Veteran's symptoms for VA rating purposes were listed as anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, difficulty establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, inability to establish and maintain effective relationships, suicidal ideation, and impaired impulse control, such as unprovoked irritability with periods of violence. The Veteran reported, "No one wants to be around me because I am so anxious and angry." The Veteran also reported road rage; however, examiner indicated that during the interview, the Veteran was pleasant and cooperative. The Veteran was found capable of managing his own financial affairs. An April 2015 VA psychiatry note indicates that the Veteran was seen for a follow up appointment. He reported waking up twice almost every night and having trouble falling back asleep. He reported daytime flashbacks and hearing explosions, leading him to want to stay inside. It was noted that he had generalized anxiety disorder (GAD) and major depressive disorder (MDD) secondary to PTSD. It was noted that his depressive symptoms variably improved, such as having depressed mood less frequently. He was noted to have infrequent crying spells, insomnia, variable appetite, anhedonia, fatigability, decreased concentration, and variable productivity. He was not noted to have any suicidal ideations. He was noted to have infrequent irritability, but no impulsivity and no recent reported episodes of poor judgment. He did not report racing thoughts, pressured speech, or other manic symptoms. He did report some PTSD-type symptoms, including thoughts of combat, recurrent dreams and nightmares, insomnia, anger problems, hypervigilance, startle reaction, distrust of others, avoidance, trouble socializing outside of family, and decreased recreational activities. It was noted that he neither admitted nor denied flashbacks and other dissociative symptoms apart from nightmares. The Veteran denied hallucinations. He was noted to be appropriately dressed, memory intact, concentration impaired, mood euthymic, with no inappropriate affect. It was noted that his thought process was coherent, logical and goal oriented. He was recommended to continue his medications and follow up in approximately three and a half months. His October 2015, January 2016, May 2016, September 2016, January 2017, and May 2017 follow up treatment notes contained similar reports. In September 2016 the Veteran reported flashbacks, and in January 2017, the Veteran reported more PTSD symptoms. A May 2015 statement from the Veteran's son indicates that his son has been an active witness to the Veteran's medical issues, severe symptoms, and social disorder due to PTSD, with occasional outburst of rage, irritability, and horror. The Veteran's son indicated that the Veteran reported that no one understands the crisis that he is going through and that his symptoms are increasing daily. The Veteran's son indicated that the Veteran was constantly on high alert with deep arousal, that he did not sleep normally, was really jumpy, did not function socially with people, did not have friends, and has a high distrust of others. The Veteran's son indicated that the Veteran suffers from headaches, nausea, disturbing dreams, panic attacks, flashbacks, and memory loss. The Veteran's son also indicated that the Veteran does not like to watch tv as it makes him agitated and angry, forgets what to buy when he goes to the store, forgets to pay certain bills, stays in a room by himself until late hours, and often talks about hurting someone. A May 2015 letter from the Veteran's father indicates that he has observed the Veteran's PTSD symptoms including occasional outbursts of anger and irritability. This language of this letter is nearly identical to the May 2015 letter from the Veteran's son. A May 2015 statement from the Veteran's wife indicates that the Veteran often wakes up from severe nightmares, and has several mood changes and suicidal thoughts throughout the day. The Veteran's wife also indicates that the Veteran does not take showers some days or take care of his personal hygiene. An October 2017 VA psychiatry telehealth note indicates that the Veteran was not medication compliant and that it was difficult to have a logical discussion with him. In May 2018, the Veteran underwent a VA examination for his claim. The Veteran reported being married for 39 years and not sleeping in the same bed as his wife due to his nightmares and hitting her in his sleep. The Veteran described his marriage as fair, noting that he hardly sees his wife. The Veteran denied suicide attempts and psychiatric hospitalizations. It was noted that the Veteran has been receiving mental health treatment through VA since January 2009 and is currently on medications. It was also noted that the Veteran finished group PTSD therapy two weeks ago. The Veteran's symptoms were listed as anxiety, suspiciousness, chronic sleep impairment, and disturbances of motivation and mood. It was noted that the Veteran avoided crowds, isolated, and reported getting irritable. He also reported that he likes to go finishing as he gets to be alone. He reported arguing with his wife, being distant very distant from his sons and other relatives, being vigilant in public, being reminded of Vietnam when seeing kids and babies (which causes anxiety), disliking baby stores/cribs/strollers/ baby wipes, and avoiding traffic due to road rage. Under behavioral observations, it was noted that the Veteran was well groomed and made eye contact. His speech was noted to be normal in volume and rate. His mood was euthymic and affect normal. He was noted to be coherent, logical, with good insight and judgment. The Veteran denied suicidal ideations, homicidal ideations, and hallucinations. The Veteran was found capable of managing is own finances. Under remarks, the VA examiner noted that there has been no increase in PTSD symptoms. The VA examiner concluded that the Veteran's PTSD manifests in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. A May 2018 VA psychiatry telehealth note indicates that the Veteran had a history of PTSD, recurrent MDD of mild severity, and GAD, and was seen for medication management. It was noted that the Veteran was last seen in October 2017 at which time medication noncompliance was noted along with ongoing PTSD symptoms and difficulty to engage in logical discussion. The Veteran reported his mood being ok and endorsing depression every two days, lasting minutes to hours. He endorsed anger, irritability, particularly around children. He also endorsed daily intrusive thoughts (triggered by the news), hypervigilance, panic attacks lasting 10 minutes every 3 days, and flashbacks. He endorsed frequent feelings of stillness, hopelessness, nervousness, anxiety, depression, poor sleep, waking up 3-4 times per night, nightmares once per week, low energy, and poor concentration. The Veteran also endorsed suicidal thoughts once per week and denied current suicidal or homicidal ideations. The Veteran reported adhering to his medications. A safety plan was drafted, and the Veteran's medications were adjusted. It was noted that the Veteran was participating in group PTSD therapy and that he will be closely followed by mental health. The Veteran was ordered follow up in 6 weeks. A July 2018 VA psychiatry telehealth note indicates that the Veteran reported his mood being the same, with daily depression, anger, and irritability. He also reported anhedonia, difficulty sleeping, waking up 3 times per night, noise flashbacks, intrusive thoughts and memories, hypervigilance and having to check his house perimeters nightly, and feelings of guilt. The Veteran reported spending his time watching TV and going on walks. He endorsed daily suicidal thinking but denied intent or a plan. He reported going to group PTSD therapy. The Veteran's July 2018, January 2019, March 2019, and April 2019 VA psychiatry notes had similar reports. A May 2019 VA psychiatry note indicates that the Veteran was seen for supportive therapy and medication management. It was noted that the Veteran's doses were increased since his last visit due to sleep, mood, and possible psychosis. The Veteran reported medications helping with nightmares and other symptoms but still hearing sirens. He reported getting 6 hours of sleep per night. He was noted to have vague suicidal thoughts with no plan or intent. He was noted to live with his wife who is really supportive but did not understand what was going on. It was noted that higher dose medications helped with depression and anxiety and that further therapy was recommended. However, the Veteran refused therapy, indicating that he prefers to isolate. An October 2019 VA telehealth psychiatry note indicates that the Veteran completed a medication management appointment and reported having less drowsiness with slightly improved mood. There was no acute safety concern. There was follow up in November 2019 with similar reports. A December 2019 VA telehealth psychiatry note indicates that the Veteran participated in a medication management follow up. He reported similar symptoms as before, indicating that he has nightmares once per week and gets 6 to 7 hours of sleep per night. He reported medication helping with anxiety. He was noted to have unrested sleep and excessive drowsiness. He did not wish to change his medications and was ordered follow up in two months. A February 2020 VA psychiatry note indicated that the Veteran was seen for medication management and supportive therapy. He reported feeling ok, episodes of sadness, decreased motivation, memories/images recollections, feeling very anxious and restless when has to leave the house. He also reported using his medications. It was noted that he continues to have chronic PTSD symptoms, such as episodes of marked anxiety/restlessness when has to go out, preference to stay at home, episodes of hypervigilant behavior, checks perimeters of the house every night, being startled by noises/firecrackers/fireworks, recurrent thoughts, with symptoms being worse during the holidays. He was noted to have chronic flashbacks which decreased with medications, His overall sleeping was noted to be better, and he was feeling less sedated. It was noted that he continues to have 1 nightmare per week and that he sleeps in another bedroom as not scare his wife. The Veteran denied irritability, aggressive behavior, self-harm, hallucinations, or delusional thinking. The Veteran was noted to be well groomed, well developed, pleasant, and cooperative. His affect was depressed. His thought process coherent. His insight and judgment were noted to be good. He was ordered follow up in 3 months. The Veteran's July 2020 VA psychiatry note contained similar contentions as the February 2020 VA psychiatry note. In addition, the Veteran reported waking up 3 to 4 times per night and staying at home due to triggers, such as gasoline. Based on a careful review of the record, the Veteran's overall disability picture is manifested by symptoms which more nearly approximate the criteria for the assignment of a 50 percent rating for the entire period on appeal. The Veteran's VA mental health treatment records as well as the VA examination reports are highly probative, as the VA examiners and the Veteran's VA therapists are trained in the mental health field and are competent to report the overall state of the Veteran's mental health. Throughout the period on appeal, the Veteran's symptoms included depression, anxiety, panic attacks, sleep disturbance, suspiciousness, disturbances of motivation and mood, hypervigilance, flashbacks, intrusive thoughts, nightmares, isolation, avoidance, anger, and irritability. The Veteran's VA treatment records also contain a period of time during which the Veteran endorsed suicidal ideations without a plan or intent (discussed below). The evidence does not show that the Veteran's symptoms are of the type and degree contemplated by the criteria for a 70 percent disability rating at any time during the appeal period. The record does not show that the Veteran has sustained suicidal ideations unresponsive to treatment. There is no evidence of obsessional rituals, illogical speech, near-continuous panic or depression, memory problems, spatial disorientation, or an inability to establish and maintain effective relationships; or, symptoms of a similar type and severity. At no time has the evidence shown that the Veteran's PTSD symptoms result in disorientation to time, place, or person. He is not out of touch with reality or shown to experience persistent delusions or hallucinations, and he has consistently denied homicidal ideations. While the Veteran endorses violent outbursts, there is no indication that he has been arrested or has had physical altercations with others on any kind of consistent basis. Thus, the extent of his impairment has not been shown by the competent medical evidence of record to be that required for a 70 percent or higher rating at any time during the appeal period. In short, the Veteran's overall disability picture is not manifested by occupational and social impairment with deficiencies in most areas. Accordingly, the assignment of the next higher 70 percent rating is not warranted. With respect to suicidal ideations, the Veteran's VA treatment records contain a period of time during which the Veteran endorsed suicidal ideations without a plan or intent. Specifically, in March 2018 a safety plan was completed. However, the record also indicates that prior to reporting suicidal ideations, the Veteran stopped taking his medications. Moreover, after being back on medication and having an increase in dosage, the Veteran's symptoms improved. In other words, the evidence shows that the Veteran's period of time during which suicidal ideations were reported was an isolated period of time and not sustained. This was followed by improvement after treatment compliance. This also indicates that the Veteran's symptoms are largely responsive to treatment. In this case, the criteria for rating mental disorders contemplates the ameliorative effects of medication. See 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. Generally, when assigning a disability rating, that rating may not consider the ameliorative effects of medication where those effects are not explicitly contemplated by the rating criteria. See generally Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). "Thus, if [the applicable DC] does not specifically contemplate the effects of medication, the Board is required pursuant to Jones to discount the ameliorative effects of medication when evaluating [the disability]. Conversely, if [the applicable DC] does specifically contemplate the effects of medication, then Jones is inapplicable." McCarroll v. McDonald, 28 Vet. App. 267, 271 (2016) (en banc). Diagnostic Code 9411 provides for a noncompensable disability rating when symptoms of a mental disorder do not require continuous medication for control; a 10 percent disability rating when symptoms are controlled by continuous medication; and, by implication, higher disability ratings when psychiatric symptoms of greater severity are not controlled by continuous medication. Therefore, DC 9411 does contemplate the effects of medication. As noted above, the outpatient mental health records reflect that the Veteran is noncompliant with his medication; yet, his mood and other symptoms improve while he is on the medication. Thus, while the Veteran's symptoms are shown to wax and wane at times, the probative evidence indicates that medication improves his symptoms. Moreover, while the Veteran's self-report of symptoms has been relatively consistent throughout the appeal period, so to are the behavioral observations by VA mental health providers. These reports consistently show an overall disability picture that is quite different than what the Veteran reports. The Veteran is consistently pleasant and cooperative with intact insight, judgment, and thinking. The Veteran's overall disability picture and other symptoms are not of such severity and frequency as to warrant a higher disability rating. Thus, the evidence showing a period of time during which the Veteran reported suicidal ideations without a plan or intent does not warrant a higher 70 percent disability rating. While the Veteran and his witnesses contend that his PTSD symptoms are of such severity and frequency as to warrant a higher rating, his VA treatment records and the VA examination reports do not support these contentions. For example, the Veteran's son reported the Veteran often talking about hurting someone, and the Veteran reports history of violent outbursts. However, the Veteran's VA treatment records indicate that he consistently denied homicidal ideations and do not contain any reports of confrontations. While the Veteran reported a history of physical confrontations at his job as a bus driver and a domestic violence incident during his previous marriage, there are no reports of such confrontations during the period on appeal. The Veteran's story regarding a confrontation with his neighbor is not corroborated in his VA treatment records. His reports of being laid off from his last job due to anger mismanagement are not corroborated by the record and are based on his own self-reported history. Additionally, the Veteran's wife reports in her May 2015 letter that the Veteran talks about suicide multiple times per day and on occasionally does not take care of his hygiene. To the contrary, the Veteran's VA treatment records for that time period indicate that he denied suicidal ideations until May 2018. There is also no evidence of the Veteran having any problems with his personal hygiene as he was routinely observed by his providers. To this extent, the Veteran's son's May 2015 letter, his father's May 2015 letter, and his wife's May 2015 letter are not afforded probative value, as they are contradicted by the Veteran's VA treatment records and other probative medical evidence, such as the VA examination reports. The VA treatment records are afforded higher probative value because they were made in the process of providing the Veteran mental health treatment. The above-mentioned letters contain numerous other contradictions. The Veteran's son indicates that he observed the Veteran's PTSD symptoms. However, the Veteran reported that his sons live in another state and that he rarely calls. The Veteran's son also reported that the Veteran does not like to watch TV. However, the Veteran reported that he spends his days watching TV. The Veteran's son reported the Veteran having memory problems and forgetting to pay bills, while the VA examination reports and the Veteran's VA treatment records indicate that the Veteran did not have memory problems and was capable of managing his financial affairs. There are also noted contradictions in the Veteran's reports. For example, the Veteran reported that he spends most of his time alone and does not leave the house. However, the record indicates that the Veteran goes to the grocery store, goes fishing, goes for walks, and reported taking his wife to dinner. Thus, while it is true that the Veteran's symptoms include isolation and strained relationships with family members, the severity of these symptoms is contemplated in the criteria for a 50 percent rating. While the Veteran does report that he is unable to be around others and does have problems with work and personal relationships, he also has been in a successful marriage for several decades. Moreover, the Veteran's VA providers and VA examiners consistently described the Veteran as pleasant and cooperative. In other words, the totality of the evidence illustrates a difficulty with relationships, rather than an inability to establish or maintain relationships. The Veteran and his son also contended that his symptoms are near-continuous. However, his VA treatment records indicate that there has been improvement with treatment. For example, a May 2018 VA psychiatry note nightmares once per week, and panic attacks every 3 days lasting 10 minutes. A May 2019 VA treatment note indicates that the Veteran's symptoms improved with medication, including nightmares, depression, and anxiety. Thus, the evidence shows that the Veteran's symptoms improved with treatment and medication. In general, the credibility of the Veteran's self-reported history is questionable, and as such, the medical evidence in this case outweighs the Veteran's statements regarding the severity of his disability. Certainly, the Veteran may very well perceive that his symptoms are of such severity to warrant a 70 percent disability rating; however, more weight is accorded to the medical evidence in this case than the lay statements provided by the Veteran and his family. Notably, however, the denial of this claim does not discount that the Veteran has PTSD symptoms which cause occupational and social impairments. Rather, with all symptoms and their severity and frequency acknowledged, the Veteran's overall disability picture does not more nearly approximate occupational and social impairment with deficiencies in most areas, as contemplated by the 70 percent disability rating. Overall, the evidence shows that there are certainly isolated points in time where the Veteran's symptoms escalated, but as noted above, they improved with treatment and the escalation was not shown on a consistent basis. In other words, the Veteran's symptoms may have waxed and waned, but the overall disability picture throughout the period on appeal does not more nearly approximate occupational and social impairment with deficiencies in most areas. In sum, the preponderance of the evidence does not show that the Veteran's PTSD symptoms rise to such severity or frequency as to warrant a 70 percent disability rating. The Veteran's overall disability picture does not more nearly approximate occupational and social impairment with deficiencies in most areas. As the preponderance of the evidence is against the claim for a rating in excess of 50 percent thereafter, the benefit-of-the-doubt doctrine is not applicable, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). L. B. CRYAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Kuksova, Kseniya 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.