Citation Nr: 21070571 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 18-34 572 DATE: November 24, 2021 ORDER The issue of entitlement to an evaluation of 50 percent disabling for service-connected posttraumatic stress disorder (PTSD) for the period prior to March 29, 2017, is granted. REMANDED The issue of entitlement to an evaluation in excess of 50 percent disabling for service-connected PTSD is remanded. The issue of entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDING OF FACT The current record shows that throughout the period on appeal, the Veteran's symptoms have been consistently severe. CONCLUSION OF LAW For the entire period on appeal, including the period prior to March 29, 2017, the criteria for a 50 percent disability rating for the Veteran's service-connected PTSD are met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2021). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from March 1968 to January 1970, to include service in the Republic of Vietnam from August 1968 to August 1969. The Veteran is a recipient of a Bronze Star Medal, Air Medal, Silver Star, Purple Heart, Combat Infantryman Badge, and Vietnam Cross of Gallantry with Palm, among other decorations. In November 2021, the Veteran testified before the undersigned Veterans Law Judge at a virtual hearing. The issue of entitlement to a TDIU has been added to the issues on appeal pursuant to Rice v. Shinseki, 22 Vet. App. 447, 454 (2009). See Veteran's Application for Increased Compensation Based on Unemployability, August 2015. Entitlement to an evaluation of 50 percent disabling for service-connected PTSD for the period prior to March 29, 2017. The Board finds that the Veteran is entitled to a 50 percent disability evaluation for the period prior to March 29, 2017. Legal Criteria A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. See 38 C.F.R. § 4.130. However, under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). Evidence and Analysis During the course of his appeal for an increased evaluation for his service-connected PTSD, the Veteran's disability rating was raised from 30 percent disabling to 50 percent disabling, effective March 29, 2017. See Rating decision, April 2018. However, this increase does not apply to the entire period on appeal. The March 29, 2017 date appears to derive from the date of the most recent VA examination. At the November 2021 virtual hearing, the Veteran indicated that the symptoms that merited the increased evaluation were present during the earlier period on appeal. The Veteran is competent to describe symptoms he has observed and are "within the realm of his personal knowledge." Layno v. Brown, 6 Vet. App. 465, 469-470 (1994). In addition, the Veteran's contentions are supported by the record. For example, at the earlier September 2015 VA examination it was reported that the Veteran experiences: anxiety; suspiciousness; panic attacks that occur weekly or less often; and chronic sleep impairment. At the March 2017 VA examination it was reported that Veteran experiences: depressed mood; anxiety; suspiciousness; chronic sleep impairment; and disturbances of motivation and mood. Similarly, both examinations noted the following: hypervigilance; persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame); markedly diminished interest or participation in significant activities; and feelings of detachment or estrangement from others. The Board also notes that the September 2015 VA examination states that "[t]he veteran would frequently become silent and have difficulty formulating his thoughts whenever the content of the examination [came] close to having to directly assess/discuss his Vietnam experiences." Similar difficulties were reported at the March 2017 VA examination: "The veteran was guarded throughout the evaluation and had difficulty articulating his responses to the majority of the questions. There was a significant pause between the questions being asked and his responses." The Board observed similar behavior at the November 2021 virtual hearing. To the extent that discrepancies in the examination reports can be attributable to the Veteran's difficultly expressing his symptoms and experiences, the Board will resolve reasonable doubt in the Veteran's favor. Accordingly, affording the Veteran the full benefit-of-the-doubt, the Board finds that an increase in his disability rating for the period prior to March 29, 2017, is appropriate. To this extent, the issue is granted. The appeal for a disability evaluation above 50 percent remains on appeal and is addressed in the remand portion of this decision. REASONS FOR REMAND 1. Entitlement to an evaluation in excess of 50 percent disabling for service-connected PTSD. 2. Entitlement to a TDIU. The Board finds that a new VA examination is needed in order to adequately address the severity of the Veteran's symptoms. At the November 2021virtual hearing, the Veteran's testimony suggested a worsening of his PTSD symptoms. Accordingly, a new VA examination is needed. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). In addition, the Board notes that there are documents pertaining to vocational rehabilitation contained in the claim file. See, e.g., Correspondence, May 2018. To the extent that this indicates that there are outstanding vocational rehabilitation records, the Board asks that such records be obtained an associated with the claim file. The matters are REMANDED for the following action: 1. After securing any necessary consent forms from the Veteran, obtain any outstanding records, to include any VA and/or private treatment records, as well as any vocational rehabilitation records, pertaining to the issue on appeal. All efforts should be documented in the claim file. If any records could not be obtained, this should be noted in the claim file. 2. Upon completion of the above, schedule the Veteran for a VA examination to address the current severity of the service-connected PTSD disability on appeal. Please also address the impact of the Veteran's service-connected PTSD on his employability. The VA examiner should be given access to the claim file. The examiner should state that a review of the claim file was completed. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. A detailed rationale is requested for all opinions provided. 3. If upon completion of the above action the issue is denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. F., 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.