Citation Nr: 21068946 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 16-51 477 DATE: November 17, 2021 ORDER Service connection for hypertension is denied. Service connection for left eye ischemic optic neuropathy is denied. For the period from September 12, 2019, to July 24, 2021 only, a disability rating of 70 percent for posttraumatic stress disorder (PTSD) with marijuana abuse and alcohol abuse in remission is granted. REMANDED Service connection for peripheral vascular disease, left lower extremity, is remanded. Service connection for peripheral vascular disease, right lower extremity, is remanded. Service connection for peripheral vascular disease, right upper extremity, is remanded. Service connection for peripheral vascular disease, left lower extremity, is remanded. Service connection for kidney dysfunction is remanded. FINDINGS OF FACT 1. The weight of the evidence is against a finding that hypertension was manifested during the Veteran's period of active service, manifested due to presumed exposure to herbicides, or that it is otherwise the result of a disease or injury during active service, or that it is proximately due to or aggravated by a service-connected disability. 2. The weight of the evidence is against a finding that left eye ischemic optic neuropathy is proximately due to or aggravated by a service-connected disability. 3. The Veteran's PTSD with marijuana abuse and alcohol abuse in remission is manifested by symptoms resulting in occupational and social impairment with reduced reliability and productivity due to such symptoms as disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships; for the period from September 12, 2019, to July 24, 2021, occupational and social impairment manifesting in deficiencies in most areas have been shown. CONCLUSIONS OF LAW 1. Service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1116, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. Service connection for left eye ischemic optic neuropathy have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for a disability rating of 70 percent for PTSD with marijuana abuse and alcohol abuse in remission have been met from September 12, 2019, to July 24, 2021. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from November 1966 to October 1968. These matters came to the Board of Veterans' Appeals (Board) from an October 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a Board hearing in August 2019; the transcript is of record. These matters were remanded in November 2019. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. Hypertension The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease, to include herbicides, or whether he has a disability that is due to or aggravated by a service-connected disability. Certain diseases, to include cardiovascular-renal disease, including hypertension, may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. A nexus between a current disability and an in-service injury or event may be established by evidence of continuity of symptomatology, if the condition is a chronic disease enumerated under 38 U.S.C. § 1101. Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013). With chronic diseases shown as such in service, or within the presumptive period after service, so as to permit a finding of service connection, subsequent manifestation of the same chronic disease at any later date, however remote, are service connected unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). The Board concludes that, while the Veteran has a current diagnosis of hypertension, the preponderance of the evidence weighs against finding that this began during service or is otherwise related to an in-service injury, event, or disease; that it manifested within a year of separation from service; that it is due to exposure to herbicides; or that the diagnosis is proximately due to or the result of, or aggravated beyond its natural progression by a service-connected disability. 38 U.S.C. § 1110; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). Initially, the Board notes that service treatment records are negative for any complaints, treatment, or diagnosis of hypertension. An October 1968 Report of Medical Examination reflects that he was clinically evaluated as normal with regard to all systems. His blood pressure was 126/72. 06/02/2009 STR-Medical at 32-33. An October 1968 Report of Medical History reflects that he checked the 'No' box for 'high or low blood pressure.' Id. at 40. Thus, the evidence of record does not support a finding that hypertension manifested during active service. VA treatment records reflect that hypertension was diagnosed in or about January 2006, an thus such did not manifest within a year of separation from active service. 06/17/2015 CAPRI at 208. Moreover, an October 2015 C&P examiner reviewed the claims folder and opined that the Veteran's hypertension was not due to service. The examiner indicated that hypertension was diagnosed in 2006. The examiner found no evidence of hypertension while in the military. Likewise, a September 2018 C&P examiner reviewed the claims folder and opined that his hypertension was not due to service. The examiner noted that the Veteran verified that he separated from the military in 1968 and he was diagnosed with high blood pressure in 2008 and started taking medication in 2008. This was the first time he was told of high blood pressure. The examiner stated that a connection to military service has not been established. Thus, the evidence of record does not support a finding that his hypertension manifested during service. A "veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service." 38 U.S.C. § 1116 (f); 38 C.F.R. § 3.307 (a)(6)(iii). The Veteran's DD Form 214 reflects that he served in the United States Army as a Heavy Vehicle Driver. He had 9 months and 9 days of service in Vietnam and is in receipt of the Vietnam Service Medal and Vietnam Campaign Medal. Thus, it is presumed that the Veteran was exposed to herbicides during his period of active service. 38 U.S.C. § 1116 (f). If a veteran was exposed to a herbicide agent during active military, naval, or air service, certain diseases shall be service connected if the requirements of 38 U.S.C. § 1116 and 38 C.F.R. § 3.307 (a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C. § 1113; 38 C.F.R. § 3.307 (d) are also satisfied. 38 C.F.R. § 3.309 (e). The Board notes that VA regulations do not provide hypertension as a presumptive disability associated with herbicide exposure, although the National Academy of Sciences (NAS), in 2006 and 2008 updates, concluded that there was "limited or suggestive evidence of an association" between hypertension and herbicide exposure. See 75 Fed. Reg. 32,540, 32,549 (June 8, 2010); 75 Fed. Reg. 81,332, 81,333 (December 27, 2010). Hypertension was recently moved from the "limited or suggestive" category to the category of "sufficient" evidence of an association. See Veterans and Agent Orange: Update 11 (2018). According to NAS, "[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association" between hypertension and herbicide exposure. In support of his claim, the Veteran has submitted a January 2019 article entitled 'Hypertension, MGUS Associated with Herbicide Exposure in Vietnam Veterans;' an article entitled 'Herbicide Exposure, Vietnam Service, and Hypertension Risk in Army Chemical Corps Veterans;' and, a November 2018 article (authored by Julia Bergman) entitled 'Study finds link between high blood pressure, Agent Orange exposure.' See 09/19/2019 Correspondence. A March 2020 private examiner stated the following: There has been much recent literature linking Agent Orange exposures to coronary artery disease, ischemic heart disease, and hypertension. Among others, Bergman did a review on November 15, 2018 entitled "Study finds link between hypertension and Agent Orange exposure." It was a detailed review of scientific reports dating from 2014 onward and particularly focused on studies done by the National Academy of Science, Engineering, and Medicine. What these studies have shown is that not only is coronary artery disease and other forms of vascular disease associated with Agent Orange, but that when patients develop peripheral vascular disease and ischemic heart disease they both tend to be more severe than the average patient with the above two stated conditions. Given that [the Veteran] spent one (1) full year in Vietnam and had extensive exposure to Agent Orange, it is as least as likely as not that his coronary artery disease, peripheral vascular disease, and hypertension are connected to his service in the U.S. Army. A December 2020 C&P examiner stated the following in opining that hypertension is not due to exposure to herbicides: While recent studies have shown an association with hypertension and veterans assigned to the Chemical corps who had a high exposure to herbicides, there was no association with veterans with other MOS. The prospect of exposure to TCDD from Agent Orange in ground troops in Vietnam seems unlikely in light of the environmental dissipation of TCDD, little bioavailability, and the properties of the herbicides and circumstances of application that occurred. Photochemical degradation of TCDD and limited bioavailability of any residual TCDD present in soil or on vegetation suggest that dioxin concentrations in ground troops who served in Vietnam would have been small and indistinguishable from background levels even if they had been in recently treated areas. Laboratory and field data reported in the literature provide compelling evidence on the fate and dislodgeability of herbicide and TCDD in the environment. This evidence of the environmental fate and poor bioavailability of TCDD from Agent Orange is consistent with the observation of little or no exposure in the veterans who served in Vietnam. Appreciable accumulation of TCDD in veterans would have required repeated long-term direct skin contact of the type experienced by United States (US) Air Force RANCH HAND and US Army Chemical Corps personnel who handled or otherwise had direct contact with liquid herbicide, not from incidental exposure under field conditions where Agent Orange had been sprayed. The Framingham study revealed that 90% of people 55 and over will develop hypertension eventually. Therefore, by definition ALL Vietnam era veterans have a 90% chance of developing hypertension whether they were exposed to agent orange or not. NIH 2018 As detailed above, the March 2020 private examiner proffered a positive etiological opinion regarding hypertension being related to his exposure to herbicides based on the November 2018 article referenced hereinabove and based on the Veteran having spent one full year in Vietnam and having extensive exposure to Agent Orange. The Board notes that while the Veteran served in Vietnam and is presumed to be exposed to herbicides, he spent 9 months and 9 days in Vietnam, rather than a full year. While credence is given to the opinion of the March 2020 private examiner, to include his reliance on the November 2018 article regarding hypertension and Agent Orange, the December 2020 C&P examiner acknowledged and addressed the studies of an association with hypertension and Agent Orange, but provided a negative etiological opinion based on the circumstances of the Veteran's service. As stated by the examiner, "[t]he prospect of exposure to TCDD from Agent Orange in ground troops in Vietnam seems unlikely in light of the environmental dissipation of TCDD, little bioavailability, and the properties of the herbicides and circumstances of application that occurred." Based on these findings, the examiner found that it was less likely than not that his hypertension is due to exposure to herbicides. The Board gives more probative weight to the opinion of the December 2020 C&P examiner as it was based on a review of the record, recent studies regarding hypertension and Agent Orange, and includes consideration of the Veteran's military occupational specialty in formulating a negative etiological opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The December 2020 opinion was provided by a VA medical professional who possesses the necessary education, training, and expertise to provide the requested opinion. Additionally, the opinion is also shown to have been based on a review of the Veteran's record and is accompanied by a sufficient explanation as to why the recent studies and treatise materials do not provide the basis for service connection for hypertension due to exposure to herbicides. Finally, the VA opinion gave deeper consideration as to the circumstances of service beyond the mere fact of exposure. For such reasons, the Board finds that the preponderance of the evidence does not support a finding that his hypertension is due to exposure to herbicides. The Veteran has also asserted that his hypertension is due to or aggravated by his PTSD (50% 01/31/2015) or coronary artery disease/ischemic heart disease (60% 01/31/2015). The March 2020 private examiner stated the following: [The Veteran] additionally suffers from PTSD, for which he is currently service-connected. PTSD has been clearly associated with hypertension. In particular, PTSD has been shown to be both associated with an in fact a major cause of hypertension. This is due to the central nervous system effects (such as hyperarousal and avoidance behavior) which increase catecholamine secretion. There are also other unknown biochemical changes in the brain which are all associated with poor sleep and generalized anxiety disorder. All of these chemicals are associated with PTSD and hypertension. This association has been well documented by Burg et al in the Journal of Psychosomatic Medicine entitled 'Risk for Incident Hypertension Associated with PTSD in Military Veterans, and The Effect of PTSD Treatment.' Therefore, given that [the Veteran's] PTSD is established as being service-connected, it is as least as likely as not that his hypertension condition is secondarily service-connected. The December 2020 C&P examiner opined that the Veteran's PTSD is less likely as not caused by or aggravated by his PTSD. The examiner stated the following: All available medical records were reviewed. While research has shown that stress due to emotional and/or psychological issues (PTSD) can cause temporary elevations in blood pressure there is no scientific basis for the etiology of [hypertension] due to PTSD/stress. [Hypertension] is a vascular condition caused by the restriction of arterial and venous flow and therefore has no medical nexus to PTSD/stress. The examiner cited to articles entitled 'Evaluation of secondary hypertension' and 'Overview of hypertension in adults' in formulating the opinion. With regard to aggravation, the examiner stated that medical records are negative for any signs of aggravation, beyond the natural progression, by the PTSD and a nexus is not established. The December 2020 C&P examiner opined that his hypertension is less likely than not due to or the result of his ischemic heart disease on the basis that his hypertension was diagnosed prior to his ischemic heart disease. The examiner stated that medical records are negative for any signs of aggravation, beyond the natural progression, of the Veteran's hypertension. While the Board assigns credence to the opinion of the March 2020 examiner that the Veteran's hypertension is associated with his PTSD due to the central nervous system effects and other biochemical changes in the brain, the Board assigns greater probative value to the opinion of the December 2020 C&P examiner who acknowledged research that shows that stress due to emotional and/or psychological issues (PTSD) can cause temporary elevations in blood pressure but there is no scientific basis for the etiology of hypertension due to PTSD/stress. The December 2020 examiner also explained that hypertension is a vascular condition caused by the restriction of arterial and venous flow, having no medical nexus to PTSD/stress. The December 2020 opinion was provided by a VA medical professional who possesses the necessary education, training, and expertise to provide the requested opinion. Additionally, the opinion is also shown to have been based on a review of the Veteran's record and is accompanied by a sufficient explanation as to why relevant studies and treatise materials do not provide the basis for a finding of causation and aggravation between hypertension and PTSD. The December 2020 examiner also found no causation or aggravation between hypertension and ischemic heart disease due to hypertension being diagnosed first and no support in the medical records. There is no contrary opinion suggesting a relationship between hypertension and ischemic heart disease. For such reasons, the Board finds that the preponderance of the evidence does not support a finding that his hypertension is due to or aggravated by his PTSD and ischemic heart disease. While the Veteran believes his hypertension is due to service, to include exposure to herbicides, or due to a service-connected disability, the Veteran is not competent to provide a nexus opinion regarding these issues. The issues are medically complex, as it requires knowledge of the interaction between multiple organ systems in the body/anatomical relationships/pathology/interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Based on the Veteran's assertions, medical opinions were sought addressing direct and secondary etiology which were negative. As detailed, a medical diagnosis of hypertension is documented decades after separation from service. The Veteran's contentions are outweighed by the clinical findings documented many years after separation from service, and the lack of diagnosis or complaints reflected in the medical records, and the opinions of trained medical professionals who found no relationship between his hypertension and exposure to herbicides and between hypertension and service-connected disabilities. Left eye ischemic optic neuropathy The Veteran asserts that his left eye ischemic optic neuropathy stems from a stroke, which he asserts is due to his PTSD and hypertension. The Veteran has not asserted that his left eye ischemic optic neuropathy is directly due to service, and service treatment records are negative for any complaints or treatment related to the left eye. Thus, service connection on a direct basis is not warranted. The question for the Board is whether the Veteran has a current disability that is due to or aggravated by a service-connected disability. The Board concludes that, while the Veteran has a current diagnosis of left eye ischemic optic neuropathy, the preponderance of the evidence weighs against finding that the diagnosis is proximately due to or the result of, or aggravated beyond its natural progression by a service-connected disability. 38 U.S.C. § 1110; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). A November 2020 C&P examiner opined that the Veteran's left eye ischemic optic neuropathy is not due to or aggravated by his PTSD, as there is no relationship between non arteritic ischemic optic neuropathy (NAION) and PTSD. The examiner also opined that his left eye ischemic optic neuropathy is not due to or aggravated by his ischemic heart disease. The examiner explained that coronary artery disease is not a widely acknowledged cause of NAION. He has documentation of "crowded disc" due to optic nerve drusen which is unrelated to military service. His hypertension is opined to be the cause of NAION. There is no way to say with certainty what the cause of the Veteran's NAION was. Coronary artery disease is less likely as not the cause of the Veteran's ischemic optic neuropathy and was less likely than not aggravated by coronary artery disease. The examiner explained that hypertension is a known risk factor for NAION and given the above information hypertension is as likely as not the cause of Veteran's ischemic optic neuropathy. As service connection has not been established for hypertension, there is no basis for a grant of service connection for left eye ischemic optic neuropathy. The November 2020 examiner provided negative etiological opinions on a secondary basis in consideration of his PTSD and ischemic heart disease. The opinions are probative as such were based on an accurate medical history, treatise materials, and provide explanations that contain clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There are no contrary opinions of record. While the Veteran believes his left eye ischemic optic neuropathy is due to a service-connected disability, he is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body/anatomical relationships/pathology/interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Based on the Veteran's assertions, medical opinions were sought addressing secondary etiology which were negative. The examiner opined that his left eye ischemic optic neuropathy is due to his hypertension, but service connection has not been established for this disability. The Veteran's contentions are outweighed by the clinical findings and opinion of a trained medical professional. Increased Rating Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The appeal arises from the original assignment of a disability evaluation following an award of service connection, thus the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. The Board has reviewed all the evidence in the Virtual folders, which includes: the lay contentions and post-service treatment records and psychiatric evaluations. Although there is an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). PTSD with marijuana abuse and alcohol abuse in remission has been rated 50 percent disabling pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411 (PTSD). The Board first observes that the symptoms listed in VA's general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). Evaluation under § 4.130 is symptom-driven, meaning that symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). In Vazquez-Claudio, the United States Court of Appeals for the Federal Circuit (Federal Circuit) explained that the frequency, severity and duration of the symptoms also play an important role in determining the rating. Id. at 117. If the evidence shows that the Veteran suffers symptoms listed in the rating criteria or symptoms of similar severity, frequency, and duration, that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443; see also Vazquez-Claudio, 713 F.3d at 117. Indeed, "VA must engage in a holistic analysis" that assess the severity, frequency, and duration of the signs and symptoms of the veteran's service-connected mental disorder; quantifies the level of occupational and social impairment caused by those symptoms; and assigns an evaluation that most nearly approximates the level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). Pursuant to 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders, an evaluation of 50 percent 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. A 70 percent evaluation 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. A 100 percent evaluation is warranted for total occupational and social impairment, due to symptoms such as the following: 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. 38 C.F.R. § 4.130. The Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness." See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (4th ed.1994) (DSM-IV). VA implemented DSM-V, effective August 4, 2014, which no longer considers GAF scores. As the claim was certified after August 4, 2014, the scores assigned under the GAF scale are not necessary. The Board finds that a disability rating in excess of 50 percent is not warranted, except for the period from September 12, 2019, to July 24, 2021, during which a 70 percent rating is supported. An August 2015 C&P examination reflects the examiner's finding that PTSD, with marijuana and alcohol abuse in remission, is manifested by 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. He cited a lot of stress with family and his children. He was treated with Hydroxysine for insomonia. He noted the treatment helped a bit. He also received therapy for his PTSD in the past. The examiner indicated that his PTSD is manifested by depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting. He has had intrusive thoughts, flashbacks, anxiety, depression and sleep disturbance. He has no history of suicide attempts, no history of psychiatric hospitalizations, and he denied any suicidal or homicidal ideation. A September 2019 private psychosocial assessment reflects objective findings of difficulty concentrating, bouts of generalized anxiety with occasional panic attacks, long-term memory loss, flashbacks/intrusive thoughts, insomnia and other sleep disturbance, overwhelming feelings of sorrow with crying spells, withdrawn affect, and bouts of moderate to moderately severe depression. He had trust issues and difficulty in personal relationships. He had a loss of interest in activities such as hunting and fishing, and he had bouts of irritability and anger, with periods of violence. 12/31/2019 Medical Treatment Record-Non-Government Facility. A June 2020 VA treatment record reflects that the Veteran continues to appear motivated and engaged in treatment. His anxiety symptoms are still estimated in the severe range; it is difficult to ascertain currently to what degree this is physiologically attributable to his heart condition and/or amiodarone prescription and how much of it is related to cognitive or behavioral factors. He denied suicidal or homicidal ideation, intent or plan. He was future-oriented and has some social support/reasons for living. His mood/affect was neutral, mildly anxious with affect in appropriate range. His thought process was logical, cohesive and goal directed. There were no auditory/visual hallucinations or delusions. 01/13/2021 CAPRI at 1-3. A July 2021 C&P examination reflects the examiner's finding that the Veteran's PTSD is manifested by occupational and social impairment with reduced reliability and productivity. The Veteran reported that he was divorced and moved in with his significant other of 28 years. He walks a lot on trails, tries to be active and eat healthily. He has two adult children who are supportive and three grandchildren. He goes out frequently to local restaurants and pubs. The examiner indicated that his PTSD is manifested by depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, mild memory loss such as forgetting names, directions or recent events, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner referenced a July 2020 diagnosis of generalized anxiety disorder (GAD). The examiner noted that the GAD-7 is one of the most frequently used diagnostic self-report scales for screening, diagnosis and severity assessment of anxiety disorder. Scores of five, 10, and 15 are taking us to cut off points for mild, moderate, and severe anxiety respectively. On the GAD-7 the Veteran generated a score of 20 suggesting the presence of a severe level of anxiety. The Patient Health Questionnaire (PHQ-9) is a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression. The instrument scores each of the 9 DSM-IV depression criteria as "0" (not at all) to "3" (nearly every day). PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression. On the PHQ-9, the Veteran generated a score of 24, suggesting the presence of severe depressive symptoms. The Clinician Administered PTSD Scale for DSM-5/CAPS-5 is the gold standard for the assessment of PTSD. The CAPS-5 is a 30-item structure interview that can be used for lifetime and current diagnosis of PTSD. In assessing the PTSD symptoms, the CAPS-5 questions target the onset and duration of symptoms, subjective distress, impact of symptoms on social and occupational functioning, and overall PTSD severity. On the CAPS-5, the Veteran endorsed 16 of the possible 20 PTSD related symptoms at clinically significant levels and generated an overall severity score of 32 suggesting a moderate level of severity in global symptomological presentation. The Veteran does continue to meet DSM-5 diagnostic criteria for PTSD. Overall, the severity of the PTSD related symptoms was rated to fall in the moderate range (definite distress or functional impairment but functions satisfactorily with effort). Overall validity of the Veteran's responses was rated "Excellent, no reason to suspect invalid responses." In sum, there is some disparity in the findings demonstrated in the private examination report dated September 12, 2019, when compared to the remainder of the evidence of record. The Board notes that mental health symptoms can fluctuate and therefore it is not necessary to conclude that one set of findings is more accurate than another- they can all be fair representations of the disability picture at the point in time that they are recorded. The September 12, 2019, report tends to show deficiencies in most areas. The report references irritability and occasional violence. The Veteran was described as withdrawn and as having diminished interest in activities that he used to find enjoyable. The Board thus awards a 70 percent evaluation as of the date of this report. A subsequent June 2020 clinical record noted anxiety in the severe range. However, a later VA examination on July 24, 2021 indicated symptoms only approximating the 50 percent rating. For example, the Veteran was noted to have moved in with his significant other of 28 years. He was active, to include walking on trails and had two adult children who are supportive and three grandchildren. He went out frequently to local restaurants and pubs. Thus, the disability is no longer characterized by deficiencies in most areas as of July 24, 2021 and thus the staged rating ends on this date and reverts to 50 percent. Finally, at no time on appeal has the evidence demonstrated total social and occupational impairment, and thus a 100 percent rating is not indicated at any time during the appeal. In sum, outside the period from September 12, 2019, to July 24, 2021, the findings contained in the C&P examination report and VA treatment records reflect that the Veteran is able to function independently and has a support network and he has not been disoriented to time or place. While he has mild memory loss and impairment of long-term memory of in-service trauma, the evaluations do not reflect impairment of his short-term memory, to include no finding of memory loss for names of close relatives, own occupation, or own name. While there are objective findings of the Veteran having difficulty in adapting to stressful circumstances including work or a work-like setting, the Board notes that a total disability rating due to individual unemployability (TDIU) has been established from July 24, 2018 in contemplation of his inability to maintain employment due to his service-connected disabilities. Otherwise, none of the other criteria contemplated by a 70-percent disability rating are shown in the medical evidence of record. Social impairment with deficiencies in most areas is not shown per C&P evaluations and VA treatment records. Based on the foregoing medical and lay evidence, to include the treatment records and examination reports, the Board finds that social and occupational impairment with deficiencies in most areas have not been more nearly approximated over the course of the period on appeal. REASONS FOR REMAND Peripheral vascular disease The Veteran asserts that his peripheral vascular disease affecting the bilateral lower and upper extremities is due to in-service exposure to herbicides. These matters were remanded in November 2019 to obtain an opinion as to whether the peripheral vascular disease has been caused or aggravated by his service-connected PTSD. In November 2020, a C&P examiner opined that the peripheral vascular disease was not due to service. The examiner stated that there is no credible medical evidence to support a causal link between peripheral vascular disease and exposure to herbicides. A nexus is not established. The examiner also opined that the Veteran's peripheral vascular disease is not due to his PTSD or coronary artery disease. The examiner stated that there is no credible medical evidence of a causal link between peripheral vascular disease and PTSD or coronary artery disease. The conditions are distinctly separate and not related. A nexus is not established. The examiner also opined that there is no credible medical evidence to support any mechanism for aggravation, of the Veteran's peripheral vascular disease by his PTSD or coronary artery disease. A nexus is not established. In formulating these opinions, however, the examiner failed to provide a rationale for the negative opinions. Moreover, a March 2020 private examiner stated the following: There has been much recent literature linking Agent Orange exposures to coronary artery disease, ischemic heart disease, and hypertension. Among others, Bergman did a review on November 15, 2018 entitled "Study finds link between hypertension and Agent Orange exposure." It was a detailed review of scientific reports dating from 2014 onward and particularly focused on studies done by the National Academy of Science, Engineering, and Medicine. What these studies have shown is that not only is coronary artery disease and other forms of vascular disease associated with Agent Orange, but that when patients develop peripheral vascular disease and ischemic heart disease they both tend to be more severe than the average patient with the above two stated conditions. Given that [the Veteran] spent one (1) full year in Vietnam and had extensive exposure to Agent Orange, it is as least as likely as not that his coronary artery disease, peripheral vascular disease, and hypertension are connected to his service in the U.S. Army. Further opinions must be sought as to the etiology of the Veteran's peripheral vascular disease, which must include an appropriate rationale that is responsive to the private opinion. Kidney dysfunction The Veteran asserts that his kidney dysfunction, diagnosed as nephrolithiasis, is due to or aggravated by his hypertension. This matter was remanded in November 2019 to obtain an opinion as whether his kidney dysfunction is due to or aggravated by this disability, and/or due to his hypertension. A December 2020 C&P examination reflects the examiner's statement that all available medical records were reviewed. The examiner stated that the only documented diagnosis related to the kidney is status post nephrolithiasis and there is no current diagnosis of kidney disease. In a September 2021 addendum opinion, the examiner opined that kidney dysfunction is not due to or aggravated by his coronary artery disease. The examiner stated that although the Veteran does have a historical diagnosis of status post nephrolithiasis, the examiner is unable to confirm a current chronic diagnosis of kidney dysfunction with current available records. The claims folder evidence does not support kidney dysfunction. Therefore, no nexus or plausible secondary relationship is established. The examiner stated that there is no evidence of flare ups, increased treatment of any renal dysfunction due to the coronary artery disease. The Board is cognizant of McLain v. Nicholson, 21 Vet. App. 319 (2007), in which the United States Court of Appeals for Veterans Claims (Court) held that the requirement that a claimant have a current disability before service connection may be awarded for that disability is also satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even if no disability is present at the time of the claim's adjudication. Thus, while the December 2020 C&P examiner found no chronic kidney disorder, a diagnosis of nephrolithiasis is reflected in the record. In the September 2021 addendum opinion, the basis of the negative etiological opinion appears to be based on an inability to find a chronic diagnosis. An opinion must be sought in which the examiner accounts for the diagnosis of nephrolithiasis contained in treatment records. See McLain v. Nicholson, 21 Vet. App. 319 (2007). The matters are REMANDED for the following actions: 1. Request that a clinician with appropriate expertise review the claims folder and provide opinions as to the following: a) Is peripheral vascular disease of the bilateral lower extremities and/or upper extremities at least as likely as not due to presumed in-service exposure to herbicides; b) Is peripheral vascular disease of the bilateral lower extremities and/or upper extremities at least as likely as not caused by service-connected PTSD or service-connected coronary artery disease? c) If not, has peripheral vascular disease of the bilateral lower extremities and/or upper extremities at least as likely as not been aggravated beyond its natural progression by service-connected PTSD or service-connected coronary artery disease? If aggravation is found, the examiner should identify the baseline level of disability prior to such aggravation. A comprehensive discussion of how the requested opinions were reached would be of assistance to the Board in adjudicating this claim, to include citation to evidence in the record, known medical principles, and medical treatise evidence, where applicable. The examiner must provide a comprehensive rationale for all opinions proffered. 2. Request that a clinician with appropriate expertise review the claims folder and provide opinions as to the following: a) Is kidney dysfunction, specifically nephrolithiasis, at least as likely as not caused by service-connected coronary artery disease? b) If not, has kidney dysfunction, specifically nephrolithiasis, at least as likely as not been aggravated beyond its natural progression by service-connected coronary artery disease? If aggravation is found, the examiner should identify baseline level of disability prior to such aggravation. c) Is kidney dysfunction, specifically nephrolithiasis, at least as likely as not caused by hypertension? d) If not, has kidney dysfunction, specifically nephrolithiasis, at least as likely as not been aggravated beyond its natural progression by hypertension? If aggravation is found, the examiner should identify the baseline level of disability prior to such aggravation. A comprehensive discussion of how the requested opinions were reached would be of assistance to the Board in adjudicating this claim, to include citation to evidence in the record, known medical principles, and medical treatise evidence, where applicable. (Continued on the next page) The examiner must provide a comprehensive rationale for all opinions proffered. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M.W. Kreindler, 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.