Citation Nr: 21064063 Decision Date: 10/18/21 Archive Date: 10/18/21 DOCKET NO. 20-17 593 DATE: October 18, 2021 ORDER Entitlement to service connection for residuals of a miscarriage is denied. Entitlement to service connection for a right knee disability is granted. Entitlement to a rating of 70 percent, but no higher, for PTSD from September 10, 2015 through January 15, 2019 is granted. Entitlement to a rating in excess of 70 percent for PTSD from January 16, 2019 is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted effective September 10, 2015. REMANDED Entitlement to service connection for a right hand injury to include osteoarthritis as secondary to posttraumatic stress disorder (PTSD) is remanded. FINDINGS OF FACT 1. The Veteran's miscarriage does not constitute a current disability and the Veteran has failed to demonstrate that any residuals are related to service at Camp LeJeune or otherwise related to active duty service. 2. Resolving reasonable doubt in favor of the Veteran, it is as likely as not that the Veteran's current right knee disability is related to active service. 3. Throughout the pendency of this appeal, the Veteran's PTSD has manifested with occupational and social impairment, with deficiencies in most areas, but not total occupational and social impairment. 4. Since September 10, 2015, the Veteran's service-connected PTSD and headaches have rendered her unable to obtain or maintain substantially gainful employment consistent with her educational and vocational background. CONCLUSIONS OF LAW 1. The criteria for service connection for residuals of a miscarriage have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for a right knee disability have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. § 3.102, 3.303. 3. The criteria for an initial increased rating of 70 percent, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.130, Diagnostic Code 9411. 4. The criteria for an initial rating in excess of 70 percent for PTSD have not been met at any time during the periods on appeal. 38 U.S.C. §§ 1155, 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.130, Diagnostic Code 9411. 5. The criteria for a TDIU based on service-connected disabilities have been met effective September 10, 2015. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.341, 4.16, 4.19, 4.25, 4.26. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from July 1989 to July 1993 and from January 1995 to January 2001. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2018 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a Board videoconference hearing before the undersigned in February 2021. A transcript of that hearing is associated with the claims file. The Board notes that at the February 2021 hearing, the undersigned VLJ granted the Veteran's representative's request for a 60-day extension to submit additional evidence supporting the Veteran's claims. In April 2021 and in June 2021, the Veteran's representative requested an additional 60 days to submit additional evidence. In a July 2021 Board letter, the Board granted the Veteran's representative's request for an additional 60 days to submit evidence. The Veteran's representative submitted new evidence in August 2021. See Medical Treatment record received August 2021; see also third party correspondence received August 2021. As new evidence was associated with the claims file and the 60-day extension period has expired, the Board may proceed with adjudication of the Veteran's claims on appeal. Service Connection Service connection generally requires (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) competent evidence of a causal relationship, or nexus, between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Additionally, VA acknowledges that veterans who served at the U.S. Marine Corps Base Camp Lejeune between August 1953 and December 1987 were presumptively exposed to drinking water contaminated with volatile organic compounds. These contaminants include trichloroethylene (TCE) (a metal degreaser), perchloroethylene (PCE) (a dry-cleaning agent), benzene, vinyl chloride, and other VOCs. The National Academy of Sciences' National Research Council (NRC) published its report, "Contaminated Water Supplies at Camp Lejeune, Assessing Potential Health Effects," in 2009. This report included a review of studies addressing exposure to TCE and PCE, as well as a mixture of the two, and a discussion of disease manifestations potentially associated with such exposure. Effective March 14, 2017, VA amended its adjudication regulations regarding presumptive service connection, adding certain diseases associated with contaminants present in the base water supply at U.S. Marine Corps Base Camp Lejeune, North Carolina from August 1, 1953, to December 31, 1987. The final rule establishes that Veterans who served at Camp Lejeune for no less than 30 days during this period, and who have been diagnosed with any of eight associated diseases (adult leukemia, aplastic anemia and other myelodysplastic syndromes, bladder cancer, liver cancer, multiple myeloma, Non-Hodgkin's lymphoma, and Parkinson's disease) are presumed to have incurred or aggravated the disease in service for purposes of entitlement to VA benefits. See 38 C.F.R. § 3.309 (f). Service personnel and medical records confirm that the Veteran was not stationed at Camp Lejeune during the presumptive period, and none of her claimed disabilities are on the list of presumptive diseases that are enumerated above. Nonetheless, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that when a claimed disorder is not one of the diseases in the enumerated list, as a statutory presumptive disorder, service connection may alternatively be established, on a direct basis, if the Veteran's disability was incurred in, aggravated by, or was a result of active service, without regard to the statutory presumptions. See Combee v. Brown, 34 F.3d 1039, 1043 44 (Fed. Cir. 1994). Service connection may also be established on a secondary basis for a disability if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing 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) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Id. Temporary or intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence of aggravation unless the underlying condition worsened. Cf. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). 1. Entitlement to service connection for residuals of a miscarriage. The Veteran asserts that she is entitled to service connection for a miscarriage that she experienced during active duty service. See Third Party Correspondence Received August 2021. During the February 2021 Board hearing, the Veteran testified that she took a pregnancy test during service and "it came out very faintly positive." She testified that her lieutenant (who has a medical background) looked at it and said that if the Veteran were actually pregnant it would be dark positive and told her that she was not actually pregnant. The Veteran further noted that she believed that because the lieutenant wanted everyone in the unit deployed, he emphasized that the test was not a true positive particularly since it was very faint. The Veteran stated that while stationed in Croatia, she was sweating badly and experienced bad cramps and heavy bleeding which she believed to be a miscarriage; however, her captain at the time told her that it was just a very heavy period. The Veteran stated that the nurse allowed her to stay in patient hold for one day and gave her maternity pads and she was subsequently assigned back to full duty. The Veteran testified that this impacts her because she thinks about it every day. When asked for clarification, the Veteran indicated that she does not have residuals including pain from the miscarriage and instead indicated that it was a reminder of her husband having an affair. See Hearing Transcript Dated February 2021. The Veteran's service treatment records contain reports from the Veteran of a possible miscarriage. Specifically, an August 1999 treatment note states that the Veteran complained of a possible miscarriage and was concerned. It was noted that the Veteran did a test in June and reported that it was positive and very faint. It was noted that this was not a true positive. Other records note that the Veteran had a positive pregnancy test in April 2000 and a negative pregnancy test in June 2000. See treatment records received November 2017. The Veteran's personnel records do not indicate she performed active duty service at Camp Lejeune during the presumptive period from August 1953, to December 1987, for contaminated water exposure. Her period first period of active service began in July 1989 and indicate she performed duties as a prisoner escort at Camp Lejeune in April 1991. The Veteran's post service treatment records do not contain any information related to a current miscarriage disability or related residuals. A private medical opinion received August 2021 was provided by Dr. FG to address the Veteran's assertions of a miscarriage. Dr. FG reviewed the record including the Veteran's statements about having a miscarriage in service and provided a detailed report. Dr. FG stated that the Veteran in her training at Camp Lejeune was exposed to groundwater and food and airborne pollutants. Dr. FG noted that from 1950 to 1985 the base had two drinking water systems that were contaminated with solvents by the use of an on base landfill used for chemical dumping and leaking storage tanks. Additionally, the examiner noted that trichloroethylene tetrachloroethylene and benzene and vinyl chloride and breakdown products were found in the water. He stated that all of these chemicals are classified as carcinogenic and causal to endocrine disruption. Moreover, the examiner stated that these toxicant exposures at Camp Lejeune are causal to endocrine disruption which was experienced by the Veteran through disruption of menstrual cycles and a probable spontaneous miscarriage. Furthermore, Dr. FG stated that these substances entered the Veteran's body through particular matter which are extremely small particles that are inhalants. Dr. FG further stated that the Veteran was exposed to contaminants on the clothes and bodies of military service personnel that she was responsible for. He also stated that a 40 percent impairment is present by reason of endocrine disruption. In Romanowsky v. Shinseki, 26 Vet. App. 289 (2013), the United States Court of Appeals for Veterans Claims (Court) held that when the record contains a recent diagnosis of disability prior to a claimant filing a claim for benefits, based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. In this case, however, the Veteran filed her claim decades after the occurrence of her miscarriage, and thus, the Board finds that her miscarriage does not constitute a recent diagnosis. Thus, as the evidence has not reflected a current disability and/or a current occurrence of miscarriages during the pendency of this claim, service connection must be denied. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (holding that "[i]n the absence of proof of a present disability there can be no valid claim."). Furthermore, although private examiner Dr. FG relates the Veteran's miscarriage to exposures to toxins at Camp LeJeune, the Veteran was not stationed there at the time that such hazardous toxins and contaminants were present. Moreover, the evidence of record does not support that the Veteran came into contact with any contaminants during her active duty service at Camp LeJeune. Furthermore, there is no current diagnosis of any residuals related to the asserted miscarriage. In fact, during the February 2021 Board hearing, the Veteran herself stated that that she does not currently experience residuals, including any remaining pain from the miscarriage, but instead indicated that the miscarriage in service was a reminder of her husband's infidelity. Based on the foregoing, the Veteran's claim of service connection for miscarriage is denied. The benefit of the doubt doctrine is not applicable, and the claim must be denied. 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 2. Entitlement to service connection for a right knee disability. The Veteran through her representative asserts that she should be granted service connection for a right knee injury incurred while running in service. See medical opinion provided by Dr. FG. During the February 2021 Board hearing, the Veteran testified that while in the service she was running and put her foot into a gopher hole and as a result, twisted her right knee. She testified that she continued running despite the injury and she made it worse as a result, but she did not want to go to sick bay because she felt that she had a reputation to uphold. She testified that the injury in service messed up her knee and experiences sharp pain when going up and down steps. She stated that as a result of the pain, she has to wear a brace and applies Ben Gay to her knee. Additionally, the Veteran testified that she is treated by a doctor at the VA for her knee condition. See Hearing Transcript Dated February 2021. The Veteran's service treatment notes do not contain any specific complaints or treatment for right knee pain, although an April 2000 treatment note indicates that the Veteran was involved in a motor vehicle accident. Although most of the treatment notes from the accident are not legible, the examiner appeared to indicate that the Veteran's right side was affected. The Veteran's post service treatment records include numerous complaints of chronic right knee pain. A treatment record dated April 2018 states that the Veteran experienced ongoing chronic pain in the right knee with clicks and pain around the kneecap which caused limping. Additionally, the treatment note states that the Veteran reported that the pain has been ongoing since active duty service. Moreover, it was noted that the Veteran wears a knee brace and uses absorbine or bengay topicals and takes naprosen or ibuprofen to treat her knee injury. See CAPRI treatment records received April 2018. In an April 2021 opinion, Dr. FG noted that the Veteran had military experience that included orthopedic injuries to the right knee with twisting and torsional injury as she was running and stepped into a hole. Dr. FG stated that as a consequence of that incident, she has developed intraarticular changes with progressive degenerative osteoarthritic change initiated by patellofemoral and femoral tibial cartilage surfacing changes including meniscal changes. Additionally, Dr. FG stated that the Veteran experienced two motor vehicle accidents during military service, both of which took place with a lap belt only and with direct impact injuries to the Veteran's face and head against the interior of the Humvee. See Medical Treatment Record Received August 2021. Resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran's right knee injury was incurred in and related to active duty service. The Board assigns significant probative value to the opinion provided by Dr. FG which relates the Veteran's injury from running in service directly to a current disability of progressive degenerative osteoarthritic change. The Board finds that the Veteran's statements regarding the onset of the injury in service to be credible and consistent with what she reported to a medical professional when seeking treatment. The Board has no reason to doubt the veracity of her reports. Although the service treatment records do not include information regarding the particular running incident in service, the Veteran provided a plausible explanation for why she did not report it. Based on the foregoing, the Veteran's claim of service connection for a right knee injury is granted. Increased Rating Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38U.S.C. §1155; 38C.F.R. §§3.321 (a), 4.1. Where, as here, 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 a "staged" rating are required. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). VA adjudicators must consider whether to assign different ratings at different times during the rating period to compensate the Veteran for times when the disability may have been more severe than at others. The Court of Appeals for Veterans' Claims (the Court) since has extended this practice even to established ratings, so not just initial ratings. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The Veteran's PTSD is currently rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. The Veteran was assigned a rating of 30 percent, effective September 10, 2015 which was increased to 70 percent effective January 16, 2019. Ratings are assigned according to the manifestation of particular symptoms. A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal). This may be due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and/or mild memory loss (such as forgetting names, directions, recent events). The rating criteria provide that a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for 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; memory loss for names of close relatives, own occupation, or own name. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. The "such symptoms as" language of the diagnostic codes for mental disorders in 38 C.F.R. § 4.130 means "for example" and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). However, as the Court also pointed out in that case, "[w]ithout those examples, differentiating a 30% evaluation from a 50% evaluation would be extremely ambiguous." Id. The Court went on to state that the list of examples "provides guidance as to the severity of symptoms contemplated for each rating." Id. Accordingly, while each of the examples needs not be proven in any one case, the particular symptoms must be analyzed in light of those given examples. Put another way, the severity represented by those examples may not be ignored. 3. Entitlement to an initial rating of 70 percent for PTSD prior to January 16, 2019. 4. Entitlement to a rating in excess of 70 percent for PTSD from January 16, 2019. The Veteran through her representative asserts that the record including the Veteran's Board testimony and the medical report from Dr. AS supports a change in the previous initial rating of 30 percent for PTSD effective September 10, 2015 and an increase to 70 percent effective January 16, 2018. Additionally, it is stated that Dr. AS has detailed that the Veteran met the criteria for a 70 percent rating, effective September 10, 2015, and demonstrated that this rating reflects an accurate characterization of the evidence of record, based on Dr. AS's medical expertise. See Third Party Correspondence Received August 2021. During the February 2021 Board hearing, the Veteran stated that she is entitled to a rating of at least 70 percent for the entire appeal period. The Veteran testified that her PTSD symptoms include suspicion of everyone, detachment, fear of being alone, difficulty in personal relationships, avoidance of crowds, hiding in the attic, violent dreams, and difficulty sleeping. The Veteran stated that her husband's infidelity led to a suicide attempt; however, she stated that she does not currently have any thoughts or plans of harming herself. The Veteran also testified that her drinking has increased and also stated that she has migraines and does not want people including her children to touch or hug her. See Hearing Transcript dated February 2021. A September 2015 treatment record states that the Veteran had sudden onsets of headaches that are caused by a stressful event. A May 2016 treatment note indicates that the Veteran experienced issues with episode of moderate migraines. See Medical Treatment Record received July 2017. A July 2016 treatment note states that the Veteran was seen for concerns about emotional status and was having problems with her memory. The Veteran stated that at times her boss will tell her things and she will write them down and forget what she is writing. It is noted that the Veteran was concerned about her ability to maintain her job. Additionally it was noted that she was not sleeping well and feels overwhelmed .The Veteran did not experience suicidal or homicidal ideations but did experience moderate anxiety starting a month ago, difficulty concentrating, excessive worry, and fatigue. See Medical Treatment Record received July 2017. An August 2016 treatment note indicates that the Veteran was seen by Dr. NH for depression. It was noted that the Veteran was having significant problems at work in which she could not retain her memory. It was noted that the Veteran was getting overwhelmed in her workplace and her anxiety was causing her problems. It was noted that she was struggling with forming any new memory and unable to retain information. It was also noted that she forgot simple things like making laundry detergent which she was taught to do by her mom. Additionally, it is noted that she faced additional stressors in the workplace. It was also stated that the Veteran was extremely worried about the memory loss. Dr. NH noted that he was sure that the memory was not related to what the Veteran perceived as ADD and stated that it is stress from her job that is triggering the worry and memory loss. See Medical Treatment Record received July 2017. The Veteran was afforded a VA examination to evaluate her PTSD disorder in January 2018. The Veteran's level of impairment was characterized as occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The Veteran's symptoms were stated to include depressed mood, problems with concentration, and chronic sleep impairment. It was noted that her speech was normal and her thought content was free of any delusions and she displayed adequate insight into her symptoms and the impact that they have upon her day to day functioning. The examiner noted that the Veteran has nightmares about being deployed a couple times a week, avoids crowds, experiences daily depression, lacks motivation, lack emotional attachment to her children, has anger issues, and issues with concentration. The examiner also noted that the Veteran "goes through bouts of drinking." The Veteran denied past and current thoughts, feelings and preparatory behaviors toward suicide and homicide. She described her marriage as "not good", had not recent contact with either of her parents, and described a "very bad relationship" with her two brothers. She did not relate having friends. The Veteran was afforded another examination in February 2020 to assess her PTSD disability. The Veteran's impairment was characterized as occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgement, thinking and/or mood. The examiner noted that the Veteran experienced the following symptoms: depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, impairment of short and long term memory, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including work or a work like setting, inability to establish and maintain effective relationships, and impaired impulse control, such as unprovoked irritability with periods of violence. Additionally, it was noted that the Veteran did not want anyone standing behind her while at the examiner's office and she initially seemed hesitant and uncomfortable. Further, it was stated that the Veteran cried occasionally when she spoke about her difficulties and also became angry while recalling specific stories. It was noted that the Veteran appeared somewhat aggressive at times and there was some evidence of paranoia, but she did not experience hallucinations or delusions. The Veteran was also evaluated for her PTSD by private examiner, Dr. QAS in April 2021. Dr. QAS took extensive notes on the history of the Veteran's lengthy PTSD disability. Dr. QAS noted that throughout the appeal period, the Veteran has suffered from issues with attention, concentration, focus, memory loss due to anxiety, depression, internal preoccupation, impulse control, feelings of detachment, hypervigilance, and paranoia. Additionally, it was noted that the Veteran experienced chronic sleep impairment, marked diminished interest in activities, high levels of feelings of detachment and estrangement from others, significant trouble in her interpersonal relationships, and difficulties with motivation and mood during the appeal period. Upon review of the record, the Board finds that a disability rating of 70 percent and no higher for the Veteran's service-connected PTSD is warranted throughout the period on appeal. Although the Veteran's service-connected PTSD was characterized by the January 2018 examiner as occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication, there are several factors and numerous symptoms all detailed above that reflect that a rating of 70 percent is warranted. As such, when considering the frequency, severity, and duration of the Veteran's impairment to assess her disability picture and when resolving the benefit of the doubt in favor of the Veteran and the Board finds that a rating of 70 percent for PTSD is granted for both periods on appeal. The Board finds the above evidence including the Veteran's testimony, lay statements, medical records, and examinations persuasive, as it shows a history of treatment for severe anxiety and depression, which causes the Veteran to experience difficulty adapting to occupational and stressful situations, as well as maintaining effective relationships. Thus, the foregoing evidence holds the most probative weight, and the Board finds that a 70 percent rating, but no higher, is warranted for the Veteran's service-connected PTSD for the entire period on appeal. The Board has considered whether a 100 percent disability rating is warranted for the Veteran's PTSD disability from September 10, 2015 through January 16, 2019 and from January 16, 2019 and thereafter. Here, after assessing the symptoms displayed during both periods on appeal, the Veteran's overall symptoms simply do not demonstrate total occupational and social impairment, as the evidence of record during the period on appeal shows no gross impairment in thought process or communication, no delusions or hallucinations, no grossly inappropriate behavior, no intermittent inability to perform activities of daily living, no disorientation to time or place, and no memory loss for names of close relatives, own occupation, or own name, and although the Veteran has had thoughts of suicide, she has never acted on any suicidal or homicidal plans. Furthermore, the evidence does not reflect any acts of violence suggestive of the Veteran being a persistent danger of hurting self or others as contemplated by a 100 percent rating. While the Veteran injuring her right hand from punching walls to cope with her anger, the Board does not find this behavior to be persistent or of a frequency or severity as contemplated by the criteria for a 100 percent rating. As such, the Veteran's 70 percent rating is the better assessment of overall impaired functioning due to her PTSD disability. Accordingly, for the entire period on appeal, a disability rating of 70 percent and no higher for the Veteran's service-connected PTSD is appropriate. 5. Entitlement to a total disability rating based on individual unemployability (TDIU). The Veteran asserts, in substance, that her service-connected disabilities prevent substantial employment since at least September 10, 2015. See Third Party Correspondence Received August 2021. A total rating for compensation may be assigned where the schedular rating is less than total when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340 (a). A Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. Age may not be considered as a factor in evaluating service-connected disability; and unemployability, in service-connected claims, associated with advancing age or intercurrent disability, may not be used as a basis for a total disability rating. 38 C.F.R. § 4.19. The applicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner. Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). TDIU is to be awarded based on the judgment of the rating agency. Floore v. Shinseki, 26 Vet. App. 376, 381 (2013). The Veteran contends that she is unemployable due to her service-connected disabilities. The above decision has increased the rating assigned for the Veteran's PTSD to 70 percent, effective from September 10, 2015 (original date of claim). Accordingly, the schedular criteria for a TDIU have also been met from September 10, 2015. See 38 C.F.R. § 4.16 (a). The Veteran is currently in receipt of a 70 percent rating for PTSD from September 10, 2015 and a 30 percent rating for migraines from September 2015. See Rating Decision Code sheet Received March 2020. The Veteran indicated that she graduated from high school on time and that she attained her Associates Degree in 2005. See PTSD DBQ received January 2018. The Veteran also reported that she had been working a contractor position part time for Alaska Airlines for about one year and stated that prior to this she worked for three months for a police department and could not learn the job. Prior to that, the Veteran worked part time at Jackson Hewitt doing taxes and prior to that she worked in Public Safety at McKendree College. Id. The Board received VA Forms 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, in June 2017 and April 2021, which provide more specific details on the Veteran's work history. The Veteran's work history is noted to include a security worker at McKendree University from July 2008 through January 2013, tax preparer at Jackson Hewitt from January 2014 through April 2014, deputy clerk at Collinsville Police Department from July 2016 to September 2016, and ticket assistant for Alaska Airlines from February 2017 until November 2018. The Board observes that while the record reveals that the Veteran was employed at several places, she did not maintain consistent employment for more than a few months after her job as McKendree University which when coupled with the medical evidence of record summarized below, is indicative of the fact that subsequent to her employment at the University, her service-connected conditions directly impacted her ability to maintain substantially gainful employment. The Veteran most recently worked for at a ski facility as a tow rope operator from January to March 2020, during which time she lost time at work due to illness and earned less than $140 a month. A VA DBQ examination dated January 2018 which assessed the Veteran's headache condition states that the Veteran's headache condition impacts her ability to work and it was reported that the Veteran feels dysfunctional when she gets a very intense migraine and experiences nausea and has to lay on the floor. The December 2018 VA examiner noted that after being named employee of the month in February 2018, the Veteran's work environment worsened such that she reduced her workdays from 5 to 3 days due to worsening stress and anxiety symptoms. She also relayed that she was no longer on the work schedule. The February 2020 VA examiner noted the Veteran reported she is easily provoked to anger with coworkers and customers. She reported that she becomes so anxious and panics at times that she does not go into work at all. She acknowledged that she has been fired for not being able to learn her job due to her memory problems as well as interpersonal conflicts. She reported her memory is so poor that she cannot learn new material and then remember to apply it. The Board finds the Veteran is not capable of substantially gainful employment due to her service-connected disabilities. In a very thorough and detailed assessment dated April 2021, vocational expert LP opined that it is more likely than not that the Veteran has been unable to secure and maintain substantially gainful employment, even at the sedentary level, as a result of her service-connected PTSD and migraine headaches since at least September 2015. LP stated that the Veteran's symptoms have continued to progress since she last worked, and she would likely be absent from work more than one day per month and be unable to maintain attention and concentration to complete an 8 hour workday. LP explained that the basis for her vocational opinion is that the Veteran attempted to work for years in spite of significant symptoms and limitations and finally gave up because of those symptoms. Moreover, LP noted that when the Veteran was last employed full-time as a jailer, she was unable to maintain employer-required standards and regularly missed at least four days ber month of work due to her service-connected conditions. Additionally, it was noted that the Veteran had the desire to remain a productive wage earner despite the difficulties, but was unable to do so. LP noted that the opinion provided was based on her training, experience, and review of the Veteran's records. See Medical Treatment Record Received August 2021. Overall, the available medical opinions and evidence of record demonstrate that the Veteran's service-connected disabilities preclude gainful employment. Therefore, entitlement to a TDIU effective from September 10, 2015, is granted. Finally, in an August 2021 correspondence, the Veteran's attorney indicated that the benefit being sought was a 100 percent rating for PTSD or a 70 percent rating for PTSD and the award of TDIU, effective from September 10, 2015. The decision herein has assigned a 70 percent rating for PTSD and granted TDIU from September 10, 2015. Stated in the alternative, this decision represents a complete grant of the issues on appeal. REASONS FOR REMAND Entitlement to service connection for a right hand injury to include arthritis as secondary to posttraumatic stress disorder (PTSD). The Veteran through her representative asserts that her right hand arthritis is due to her service-connected PTSD. The Veteran's representative reiterated the Veteran's Board testimony and stated that her anger and outrage from her PTSD which is related to a sexual assault in service, causes her to punch walls and consequently the Veteran has sustained an injury and experiences pain in her right hand. See Third Party Correspondence Received August 2021. During the February 2021 Board hearing, the Veteran testified that she has a very violent temper and that she punches hard surfaces to get her rage out. The Veteran indicated that she punches cinder block walls to avoid using her anger to hurt people. She testified that she began punching walls to deal with her anger and rage while in service as a coping mechanism. See Hearing Transcript Dated February 2021. The Veteran's VA treatment records dated April 2018 and May 2018 indicate that the Veteran has osteoarthritis of the joint of the right hand. See CAPRI treatment records received May 2018. A treatment record dated April 2018 states that the Veteran's arthritis in the right hand is intermittent and flares at times with grip issues. It was further noted that she treats it with motrin and hot packs. Further, the treatment note states that the Veteran has a history of losing her temper and punching walls. See CAPRI treatment records received April 2018. In a treatment note dated June 2016 it is stated that the Veteran complained of right hand numbness, pain, weakness, and tingling. See Medical Treatment Record received July 2017. A medical report was submitted by Dr. QAS (licensed psychologist) dated May 2021. Dr. QAS stated that the Veteran has high levels of anger and poor impulse control which is related to her PTSD and those symptoms cause her to engage in behavior that make her a risk to herself and others. Dr. QAS also included a note that the Veteran's medical history included reports of a hand injury when she punched a wall in with her hand. See Medical Treatment Record Received August 2021. Although the evidence of record suggests that there may be a correlation of the Veteran's right hand injury and her service-connected PTSD, the record does not contain evidence of an official diagnosis of a right hand injury. Although the Board notes the diagnosis of osteoarthritis of the right hand, it is unclear if osteoarthritis or any other potential right hand diagnosis is at least as likely as not related to the Veteran's service connected PTSD. VA's duty to assist "includes providing an adequate medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim." Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). As such, remand is required to examine the Veteran in order to clarify the Veteran's right hand disabilities and whether such disability is caused or aggravated by PTSD. This matter is REMANDED for the following action: 1. Obtain a medical opinion from an appropriate clinician regarding the nature and etiology of the Veteran's right hand injury/disability. Prior to reaching an opinion, the examiner should review this remand decision and the case file in its entirety, including all of the medical evidence of record. The examiner must address the following: a. Please identify any right hand disability by either (i) diagnosis or (ii) functional impairment. The examiner must address the 2018 VA treatment records indicating the Veteran has been diagnosed with osteoarthritis of the right hand. b. For each diagnosed right hand disability, is it at least as likely as not (a 50 percent or greater probability) caused by the Veteran's service connected PTSD disability? c. For each diagnosed right hand disability, is it at least as likely as not (a 50 percent or greater probability) aggravated by the Veteran's service connected PTSD disability? In responding to the above, the examiner must specifically address the following evidence: (1) Veteran's testimony during the February 2021 that she has a very violent temper and that she punches hard surfaces to get her rage out, to include during service; (2) Veteran's VA treatment records dated April 2018 and May 2018 that indicate that the Veteran has osteoarthritis of the joint of the right hand. See CAPRI treatment records received May 2018; (3) A treatment note dated April 2018 that states that the Veteran has a history of losing her temper and punching walls. (4) A medical report was submitted by Dr. QAS (licensed psychologist) dated May 2021 which states that the Veteran has a history of high levels of anger and poor impulse control related to her PTSD and those symptoms cause her to engage in behavior that make her a risk to herself and others, and which include medical treatment for a right hand injury See Medical Treatment Record Received August 2021. (5) What type of symptoms would have been caused by the Veteran hitting a cinder block wall and/or hard surface with her hand (during and after service)? (6) Is there any medical reason to accept or reject the proposition that the Veteran hitting a wall could have led to the current right hand disability, to include osteoarthritis? Why or why not? The examiner is reminded that caselaw states that there is nothing in the statute or regulation that requires that secondary service connection under 38 C.F.R. § 3.310 be the result of a "permanent" worsening of a condition. Put differently, the question instead is whether the Veteran's right hand disability was aggravated beyond its natural progression as a result of her service-connected PTSD. The examiner is advised that causation and aggravation are separate questions, and therefore both theories must be addressed in the opinion. The examiner must provide a detailed rationale for any opinion expressed. If an opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). Tiffany Dawson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Dorsey-Kwansa, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.