Citation Nr: 21075255 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 17-37 001 DATE: December 20, 2021 ORDER Entitlement to an initial 100 percent rating for posttraumatic stress disorder (PTSD) with alcohol use disorder and cocaine use disorder is granted. REMANDED Entitlement to service connection for erectile dysfunction, including as secondary to PTSD with alcohol use disorder and cocaine use disorder, is remanded. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, the severity, frequency, and duration of the symptoms associated with his PTSD with alcohol use disorder and cocaine use disorder more closely approximate total occupational and social impairment. CONCLUSION OF LAW The criteria for an initial 100 percent rating for PTSD with alcohol use disorder and cocaine use disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1982 to July 1985 and from October 1985 to September 1989. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision of the Department of Veterans Affairs (VA) agency of original jurisdiction (AOJ). In a July 2017 substantive appeal, the Veteran's attorney requested a Board videoconference hearing on these matters. That request was withdrawn in a May 2021 letter from the attorney. With respect to the claim decided herein, VA has met all statutory and regulatory notice and duty-to-assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. Neither the Veteran nor his attorney has advanced any procedural arguments related to VA's duties to notify and assist. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015) (holding that "absent extraordinary circumstances . . . we think it is appropriate for the Board and the Veterans Court to address only those procedural arguments specifically raised by the veteran . . . ."). Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). A 100 percent rating is assigned 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; or memory loss for names of close relatives, own occupation, or own name. VA medical center (VAMC) records, private treatment records, two 2016 examinations from VAMC clinicians, a May 2019 private examination, lay statements, and the Veteran's history of at least seven periods of hospitalization during the appeal period show that the Veteran's PTSD with alcohol use disorder and cocaine use disorder was manifested by symptoms associated with a 100 percent rating (gross impairment in thought processes; persistent danger of hurting self or others; and intermittent inability to perform activities of daily living). The Veteran also had symptoms that are not listed with a specific rating, such as recurrent recollections of trauma, dissociative episodes, and social isolation These symptoms more nearly approximate total social and occupational impairment because his ability to think, process, and concentrate are affected, as well as his ability to interact in a consistent and safe manner with coworkers and members of the public. As the evidence of record is at least in equipoise that the Veteran experiences total occupational and social impairment, the maximum 100 percent rating is warranted for the entire appeal period. As a final matter, the Board notes that the Veteran's attorney indicated in a July 2017 letter (which accompanied the substantive appeal) that an earlier effective date was warranted for service connection. The attorney did not cite any evidence supporting an earlier effective date, however, or raise any argument beyond the bare statement. The evidence of record does not support an award of an effective date earlier than the date currently assigned, or reasonably raise any theory. Thus, the Board finds that the issue has not been properly raised on appeal. REASONS FOR REMAND Remand is required for the Veteran's service-connection claim for erectile dysfunction, including as secondary to PTSD with alcohol use disorder and cocaine use disorder. A September 2013 VA examination determined that the Veteran's erectile dysfunction was not related to his psychiatric disability medications. The VA examination only noted the relative risks of some of the Veteran's medications, however, and did not mention the risks associated with other medications such as zolpidem, clonazepam, and paroxetine. Furthermore, the VA examination did not address whether the service-connected psychiatric disabilities themselves caused erectile dysfunction. Accordingly, an additional VA medical opinion is necessary. The matter is REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's erectile dysfunction is at least as likely as not proximately due to or aggravated beyond its natural progression by his service-connected psychiatric disabilities, including all medications used to treat those disabilities. Examination is at the discretion of the reviewer. 2. Then, readjudicate the claim. If the benefit sought remains denied, issue a supplemental statement of the case and return the matter to the Board if otherwise in order. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board W. Ripplinger, 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.