Citation Nr: 21006176 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 17-18 293 DATE: February 3, 2021 ORDER New and material evidence has been received to reopen a previously denied claim for service connection for bronchitis; to this extent only, the appeal is granted. Service connection for a left-hand condition is denied. Service connection for a right hand and wrist condition, status post right wrist surgery is denied. Service connection for a left shoulder condition is denied. Service connection for a right shoulder condition is denied. Service connection for a neck condition is denied. Service connection for a left knee condition is denied. Service connection for a right knee condition is denied. Entitlement to an initial evaluation of 50 percent, but no higher, for posttraumatic stress disorder (PTSD) is granted. Entitlement to a total rating based on individual unemployability (TDIU) is denied. REMANDED Service connection for bronchitis is remanded. FINDINGS OF FACT 1. Service connection for bronchitis was denied in an unappealed June 2016 rating decision. 2. Evidence received since the June 2016 rating decision is new, relates to unestablished facts necessary to substantiate the claim, and triggers a duty to assist. 3. The Veteran’s left hand condition is not secondary to service-connected PTSD, and is not otherwise related to an in-service injury or disease. 4. The Veteran’s right hand and wrist condition, status post right wrist surgery is not secondary to service-connected PTSD, and is not otherwise related to an in-service injury or disease. 5. The Veteran’s left shoulder condition is not secondary to service-connected PTSD, and is not otherwise related to an in-service injury or disease. 6. The Veteran’s right shoulder condition is not secondary to service-connected PTSD, and is not otherwise related to an in-service injury or disease. 7. The Veteran’s neck condition is not secondary to service-connected PTSD, and is not otherwise related to an in-service injury or disease. 8. The Veteran’s osteoarthritis was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 9. For the entire appeal period, the severity, frequency, and duration of the Veteran’s PTSD symptoms more closely approximate occupational and social impairment with reduced reliability and productivity. 10. The preponderance of the evidence is against finding that the Veteran is unable to secure and follow a substantially gainful occupation as a result of his service-connected disabilities. CONCLUSIONS OF LAW 1. New and material evidence has been received to reopen the claim for service connection for bronchitis. 38 U.S.C. § 5108 ; 38 C.F.R. § 3.156 (a). 2. The criteria for service connection for a left hand condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. The criteria for service connection for a right hand and wrist condition, status post right wrist surgery have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 4. The criteria for service connection for a left shoulder condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 5. The criteria for service connection for a right shoulder condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 6. The criteria for service connection for a neck condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 7. The criteria for service connection for a bilateral knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 8. The criteria for an initial evaluation of 50 percent, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. 9. The criteria for TDIU have not been met. 38 U.S.C. § 1155 ; 38 C.F.R. § 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1967 to December 1970. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). A hearing was held before the undersigned Veterans Law Judge in August 2019. A copy of the hearing transcript has been associated with the file. In January 2020, the Board remanded the claims for service connection for the Veteran’s left shoulder, right shoulder, left hand, right hand and wrist (status post wrist surgery), and neck disabilities, as well as the claim for an increase evaluation for PTSD and entitlement to individual unemployability. New and Material Evidence 1. The petition to reopen a previously denied claim for service connection for bronchitis is granted. The Secretary must reopen a finally disallowed claim when new and material evidence is presented or secured with respect to that claim. See 38 U.S.C. § 5108; Knightly v. Brown, 6 Vet. App. 200 (1994). New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.” See Shade v. Shinseki, 24 Vet. App. 110 (2010). Moreover, in determining whether this low threshold is met, consideration need not be limited to whether the newly-submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA’s duty to assist or through consideration of an alternative theory of entitlement. For the purpose of determining whether a case should be reopened, the credibility of the evidence added to the record is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Service connection for bronchitis was denied in a June 2016 rating decision on the basis that a causal nexus was not shown. The Veteran was notified of the decision in a July 2016 letter. The Veteran did not initiate an appeal of this decision. Although VA medical records were associated with the claims file within one year of the decision, the records were not material to the claim of bronchitis. As new and material evidence was not received within a year of notice of the June 2016 rating determination it became final based on the evidence then of record. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156 (b), 20.302, 20.1103; see also Bond v. Shinseki, 659 F.3d 1362, 1367 (Fed. Cir. 2011). The Veteran sought to reopen his claim in August 2018. Evidence associated with the file since the June 2016 determination includes the Veteran’s August 2018 statement that his bronchitis is related to herbicide agent exposure in Vietnam. In addition, the Veteran related his condition an in-service hospitalization at Fort Bragg. See April 2020 VA 21-4138. This evidence addresses causal nexus, a previously unestablished fact necessary to substantiate the claim. The Veteran’s statements also raise a reasonable possibility of substantiating the claim by triggering the VA’s duty to assist; thus, it is material. For these reasons, reopening of the previously denied claim of service connection for bronchitis is warranted. The reopened claim is addressed further in the remand section. Service Connection 2. Service connection for a left hand condition is denied. 3. Service connection for a right hand and wrist condition, status post right wrist surgery is denied. 4. Service connection for a left shoulder condition is denied. 5. Service connection for a right shoulder condition is denied. 6. Service connection for a neck condition is denied. The Veteran asserts that his left shoulder, right shoulder, left hand, right hand and wrist (status post wrist surgery), and neck disabilities are related to heavy lifting in service. The Veteran’s military occupational specialty was storage specialist. In addition, at the August 2019 Board hearing, the Veteran testified that a truck bed canopy fell and nicked his back while in Vietnam. The Veteran also testified that he has had pain in his joints since service. See also January 2015 notice of disagreement (indicating that he has been coping with arthritis for over thirty years). In a written statement from August 2013, the Veteran also reported his post-service employment at Wawa involved heavy lifting. He also reported that he injured his right shoulder and hand in his post-service work. The Veteran also acknowledged that his hand, shoulder, wrist and neck disabilities did not have onset within one year of discharge but progressed over the years. See October 2020 correspondence. Alternatively, the Veteran asserts that these disabilities are secondary to service-connected posttraumatic stress disorder (PTSD). See August 2019 Board hearing. Specifically, the Veteran indicated that the constant stress inherent in his PTSD causes chemical problems related to his disabilities and PTSD flare-ups and sleep difficulty aggravate his muscle and joint pain. See e.g. October 2020 correspondence. Generally, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 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). Certain chronic diseases, such as arthritis, will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The dispositive question for the Board is whether the Veteran has a current disability that began during service or within the presumptive period; or is at least as likely as not related to an in-service injury, event, or disease, to include as proximately due to or the result of, or aggravated beyond its natural progression by service-connected PTSD. Initially, the Board notes that the evidence of record includes multiple diagnoses relating to the Veteran’s claims for his hands, shoulders, wrist and neck. Specifically, the March 2020 VA examination report for hand conditions noted a diagnoses of right hand degenerative arthritis and left hand strain. The March 2020 wrist examination also noted a diagnosis of right wrist status post arthrodesis carpal fusion. The March 2020 examination for shoulder conditions noted multiple diagnoses including bilateral shoulder strain, right rotator cuff tendonitis, and bilateral shoulder arthritis. Lastly, the Veteran was noted to have a diagnosis of neck strain, cervical spondylosis, and degenerative arthritis of the spine. See March 2020 VA examination for neck conditions. As to whether any of the listed disabilities began during service or within one year of separation from service, or is at least as likely as not related to an in-service injury, event, or disease, the Board concludes that the preponderance of the evidence weighs against the Veteran’s claims. The Veteran’s service treatment records are silent for diagnosis, complaints or treatment related to the Veteran’s hands, shoulders, neck or wrist. In fact, the Veteran reported good health in the November 1970 report of medical history. He also went on to check “no” to having had arthritis or rheumatism; bone, joint, or other deformity; painful or “trick” shoulder or elbow; back trouble of any kind; and neuritis, swollen, or painful joints. The separation examination in November 1970 did not note any related abnormalities, including of the upper extremities, and spine, other musculoskeletal. The physician’s summary noted foot trouble but no current medical problems. In a subsequent November 1970 statement of medical condition, the Veteran indicated that he had undergone examination more than three days prior to separation from service, but there had been no change in his medical condition since his last examination. Post-service, the Veteran complained of neck and shoulder pain in July 2005. At the time, the Veteran reported a one month history of right shoulder pain, with intermittent tingling in the right upper extremity. See July 2005 treatment records. X-rays showed AC joint arthritis and cervical spine degenerative joint disease. In August 2011 treatment records, a diagnosis of cervical spondylosis was made after radiological imaging. In August 2011, the Veteran was also seen for pain in his hands, wrist, and right shoulder. Pursuant to the Board’s remand, the Veteran was afforded VA examinations in March 2020, with an addendum opinion in August 2020. In rendering medical opinions for each of the claimed disabilities, the VA examiner opined that each of the Veteran’s hands, wrist, shoulders, and neck disabilities is less likely as not related to an in-service injury, event, or disease. The rationale noted that the Veteran’s report of in-service injury at the current examination was inconsistent with the other reports he had made prior to the examination. In addition, the examiner noted that the severity of any injury in-service did not require medical treatment during or soon after service. Thus, the examiner noted that the injury in service would not account for the disabilities that onset many decades later. In the August 2020 addendum, the examiner indicated that for each diagnosis of arthritis, there was no onset within one year of separation from service. Finally, the examiner offered a negative opinion as to secondary service connection. The examiner explained that PTSD is a psychiatric disorder that is distinct from musculoskeletal disabilities. Notably, the examiner indicated that PTSD did not cause or aggravate the Veteran’s hands, wrist, shoulders, or neck disabilities, to include as due to stress produced by PTSD. The medical evidence and rationale did not support such a relationship between his psychiatric disorder and the Veteran’s musculoskeletal disabilities. The Board finds the opinions of the collective March 2020 and August 2020 opinions to be probative because the examiner has the appropriate training, expertise and knowledge to evaluate the claimed disabilities. The examiner provided a thorough and cogent rationale for the report’s findings and opinions, which included consideration of the Veteran’s reported symptoms both during and after service, and the post-service clinical history. Furthermore, the examiner also reviewed the entire claims file. There are no competent opinions to the contrary. To the extent the Veteran contends that his diagnosed arthritis is a chronic disease that had manifested to a compensable degree within the presumptive period, it is not competent or probative evidence in this matter. Initially, the Veteran’s statements on the matter has been inconsistent. In an October 2020 correspondence, the Veteran has reported that his arthritis did not have onset within one year. More importantly, any assertion that the Veteran’s arthritis had onset within one year of service is not supported by the medical evidence. As arthritis is an internal process not capable of lay observation, the diagnosis and determination of whether symptoms are manifestations of arthritis is beyond the scope of lay evidence. In this case, there has not been competent evidence to support the onset within a presumptive period. Moreover, while the Veteran is competent to report having experienced symptoms of pain and limitations of motion since service or that he experiences a higher degree of musculoskeletal pain due to flares up of PTSD, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of his disabilities. As noted, the issue is medically complex and requires knowledge of the interaction and internal progress of the musculoskeletal systems in the body and interpretation of complicated diagnostic medical testing such as radiographs. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). As such, the Board gives more probative weight to the VA examiner’s opinions and findings. Ultimately, the March 2020 and August 2020 VA opinions weigh against a nexus between the Veteran’s hands, wrist, shoulders, and neck disabilities with service, to include as due or aggravated by his service-connected PTSD. The VA examination reports are the only competent evidence in that regard, and they are persuasive. Accordingly, the competent evidence weighs against a nexus between any of the current disability and active service. As such, there is no reasonable doubt to be resolved in this instance. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Service connection is not warranted. 7. Entitlement to service connection for a bilateral knee disability On his April 2020 VA Form 9, the Veteran asserted that during basic training he was required to run and perform physical training with boots on hard surfaces. He asserted this caused a great deal of pounding and stress on his knees, and over time arthritis had developed. He reported that during service, he had times where his knees were twisted, sore or swollen but he endured the pain and kept going. The Veteran’s service treatment records are silent for any diagnosis, complaints or treatment related to his knees. The records show treatment for a few medical problems, unrelated to knee complaints. The Veteran reported being in “good health” in the November 1970 report of medical history completed at separation. He denied having had arthritis or rheumatism; bone, joint, or other deformity; painful or “trick” knees, and swollen, or painful joints. The separation examination in November 1970 did not note any lower extremities abnormalities, including the knees. A physician’s summary shows ‘no current medical problems.’ Post-service VA treatment records beginning in 2010 show complaints of knee pain with reported onset many years ago, and a diagnosis of mild to moderate arthritis in October 2014 following X-rays. The Veteran has not identified any other post-service treatment records. There is no medical opinion or evidence of record to indicate or suggest that the Veteran’s current osteoarthritis of the bilateral knees, first diagnosed in 2014, several decades after service separation, is related to any aspect of military service. Osteoarthritis was not shown as chronic in service, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. The Veteran denied any knee symptoms at discharge, the physical examination was normal, and he has not reported experiencing symptoms of knee pain or other symptoms on a recurrent or continuous basis since service discharge. Rather, he reported to VA medical personnel in 2010 that his knee pain had been present for years. He has not otherwise specifically indicated at any point during this appeal that his knee pain or related symptoms have been present since service discharge. Osteoarthritis of the bilateral knees was first diagnosed several decades after service separation. For these reasons, arthritis is not presumed to have onset in service. The preponderance of the evidence is against finding that a medical nexus exists between the Veteran’s bilateral knee osteoarthritis and his military service. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. The Veteran is not competent to provide an opinion regarding the etiology of his current osteoarthritis, or to determine that any symptoms of knee pain in the years after service were manifestations of his current disability as he has not demonstrated the necessary medical expertise. The issue is medically complex, as it requires knowledge of internal joint pathology and complicated medical testing such as X-ray imaging. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). A VA examination was not provided in conjunction with the Veteran's claim and the evidence of record does not warrant one. See 38 C.F.R. § 3.159(c)(4). VA has a duty to provide an examination when the record lacks evidence to decide the Veteran's claim and there is evidence of (1) a current disability; (2) an in-service event, injury, or disease; and (3) some indication that the claimed disability may be associated with the established event, injury, or disease. Id.; see also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). There is no indication that the current knee disorder had onset in or is otherwise related to service. There is nothing more than the Veteran's vague assertion that he has had knee pain for years, and his conclusory, generalized statement that his bilateral knee osteoarthritis is related to service. Accordingly, the Board finds that the duty to provide an examination has not been triggered. See Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010). Service connection for a bilateral knee disability is not warranted. See 38 C.F.R. § 3.303. Increased Ratings 8. Entitlement to an initial evaluation of 50 percent, but no higher, for PTSD is granted. The Veteran seeks higher initial evaluations for his service-connected PTSD due to depression, sleep disturbances, anger issues, flashbacks, and nightmares. See November 2011 VA 21-4138. The Veteran reported that his psychiatric disorder, in combination with other disabilities, impaired his ability to work at his job. See October 2011 notice of disagreement. Specifically, the Veteran reported symptoms that interfere with employment including sleep difficulties, depression, disturbances of motivation and mood, and difficulty maintaining and establishing effective work and social relationships. In an October 2020 correspondence, the Veteran indicated that he attended numerous psychiatric group and therapy sessions, and had thoughts of suicide at times. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155 ; 38 C.F.R. § 4.1. Initially the Board notes that this appeal stems from the grant of service connection. See March 2011 rating decision. 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. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The assignment of staged ratings is also appropriate. See Hart v. Mansfield, 21 Vet. App. 505 (2007). At present, the Veteran is in receipt of a 30 percent evaluation from September 27, 2010, and a 50 percent evaluation from June 5, 2013 under Diagnostic Code 9411. 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 noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause 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 normal conversation). 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. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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 worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 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. The issue in this appeal is whether the Veteran’s associated symptoms caused the level of impairment required for a disability rating higher than the 30 percent assigned prior to June 5, 2013 and 50 percent thereafter. Based on the following, the Board finds that a rating of 50 percent, and no higher, is warranted for the entire appeal period. During the pendency of the appeal, the Veteran received consistent psychiatric care at VA treatment facilities. Generally, the Veteran reported symptoms of irritability, hypervigilance, social isolation, depression, sleep difficulty, anxiety, and nightmares. At mental status examination, those records generally indicate that the Veteran was well groomed, alert and fully oriented. See e.g. June 2016 VA treatment records; October 2018 VA treatment records. He also exhibited normal motor function without psychomotor agitation or retardation, normal range of mood/affect, normal speech, linear thought process, and intact judgement/insight. Delusional thinking, hallucinations, suicidal ideation and homicidal ideation was absent. Moreover, the Veteran’s PTSD was noted to take a stable course. See October 2019 VA treatment records (noting stable course with chronic symptoms). Treatment records also predominantly show a strong, supportive marriage between the Veteran and his spouse. See April 2016 VA treatment records (noting support relationship and marriage of 10 years). Although the Veteran had a more limited social circle, the Veteran reported some social engagement in that he attended church and sang in the men’s choir. See August 2016 VA treatment records. The Veteran also reported hobbies, such as bowling and rowing. See October 2017 VA treatment records. Occasionally, the Veteran reported suicidal thoughts or wishes, as well as disturbances of motivation and mood. Of note, in November 2010, the Veteran reported loss of pleasure, loss of interest, indecisiveness, loss of energy, and suicidal ideation. In subsequent November 2010 VA treatment records, the Veteran reported that he was emotionally numb and self-isolating; he also had sleep difficulty, intrusive recollections, and increased irritability with co-workers affecting the circumstances of his employment (going to part-time employment). In May 2011, the Veteran continued to report irritability, emotional numbness, and on and off depressed mood. The VA treatment records also show occasions where the Veteran was able to sufficiently cope with stressors in social settings. Of note, the Veteran reported being able to sell his home, handle his late mother’s estate, and being able to walk away from a confrontation without escalating the incident. See January 2019 VA treatment records. The Veteran’s treatment records do not show occasions where he engaged in periods of unprovoked violence or similar behavior. The Veteran has been afforded multiple VA examinations in relations to this claim. The Veteran was initially examined in November 2010. The examiner noted a diagnosis of PTSD, chronic type, in partial remission. The Veteran reported constant hypervigilance, difficulty concentrating, difficulty falling asleep, and nightmares. The Veteran also reported feeling depressed most of every day, hopelessness, helplessness, worthlessness and reduced appetite. These symptoms were noted to be moderate, but constant. The Veteran reported no real friendships and lack of enjoyment from daily things. The Veteran indicated that he was unable to sustain daytime employment because he found it overwhelming. There was no violent behavior or suicidal attempts. Mental status examination revealed normal orientation, thought process, communication, speech, and concentration. His appearance, hygiene, and behavior were appropriate. His affect was somewhat flat and mildly suspicious. There were no panic attacks, delusions, hallucinations, impaired judgment, and impairment in abstract thinking. The examiner noted obsessive-compulsive behavior and mildly abnormal memory in that he forgets names. The examiner indicated that the Veteran’s prognosis is fair, with likely improvement through medication and therapy. At current, the Veteran had no difficulty performing activities of daily living. The Veteran was afforded another examination in August 2013. The examiner concluded that the Veteran suffers occupational and social impairment with reduced reliability and productivity. The examiner noted that the Veteran is married and in a supportive relationship. The examiner also noted a close relationship with the Veteran’s step-children, but that he does not engage in many social activities and has few friends. The Veteran reported bouts of depression, nightmares, flashbacks, hypervigilance, problems with attention and concentration, tendency to isolate, and a preference to work alone. The Veteran also reported some obsessional rituals such as checking and organizing compulsions. However, the examiner noted that it remains unclear if they represent clinically significant obsessive compulsive symptoms. The examiner did endorse symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbance of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, inability to establish and maintain effective relationships, suicidal ideation, obsessional rituals which interfere with routine activities, hypervigilance, avoidance of reminders, exaggerated startle response, and emotional numbing. In the November 2014 VA examination, the examiner indicated that the Veteran’s symptoms produce occupational and social impairment with reduced reliability and productivity. The Veteran reported a good relationship with his spouse. As to symptoms, he reported nightmares, self-isolation with few friends, continued sleep problems, on and off mood, anxiety, intrusive thoughts, and feeling tired. Symptoms endorsed by the examiner included anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Upon observation, the Veteran was noted to be alert and oriented on all spheres, with euthymic mood and congruent affect. He had organized and linear thought process, with normal thought content. Pursuant to the Board’s remand, the Veteran was afforded another VA examination in March 2020. The examiner endorsed occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The Veteran described an understanding marriage where his wife is his best friend, but an otherwise limited social network. As to symptoms, the Veteran reported nightmares, flashbacks, avoidance of large crowds, hypervigilance, persistent anger and anxiety, depression, sleep issues, difficulty with concentration, low energy, low motivation, mild memory issues, and a history of suicidal thoughts without intent or plan. The examiner endorsed symptoms of depressed mood, anxiety, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances. The examiner indicated that the Veteran was oriented, well-groomed, dressed appropriately, and cooperative during mental status examination. The Veteran was also coherent, and logical, with receptive and expressive language skills. The evidence of record also includes a July 2019 letter from Dr. Fox, the Veteran’s VA psychiatrist. In the letter, Dr. Fox indicated that the Veteran has severe PTSD with intrusive recollections, hypervigilance, nightmares, avoidance behaviors, depressed mood, and irritability. Dr. Fox concluded that these symptoms have a severe negative impact on his social and occupational functioning, and that the Veteran’s disorder is totally and permanently disabling. Of note, this letter followed a July 2019 psychiatric consultation where the Veteran reported feeling a little worse, and more depressed. However, mental status examination noted that the Veteran was well-groomed appearance, alert and fully oriented. He was noted to have normal motor functioning, fine/normal range of affect, normal speech, linear and goal directed thought processes, and intact insight/judgement. The clinician noted no suicidal or homicidal ideation, delusional thought content, or hallucinations. Upon review of the evidence, the Board concludes that the Veteran’s symptoms more closely approximated the symptoms associated with a 50 percent rating, and resulted in a level of impairment that most closely approximated the level of impairment associated with a 50 percent rating. As noted, VA treatment records, the VA examinations, and the Veteran’s lay statements show that the Veteran’s PTSD was manifested by symptoms associated with a 50 percent rating including flattened affect, impairment of short and long-term memory, disturbances in motivation and mood, difficulty in establishing and maintaining effective work and social relationships. The August 2013 and November 2014 VA examination also endorsed occupational and social impairment with reduced reliability and productivity, which correlated to a 50 percent rating. The record also shows that the Veteran’s PTSD manifested with symptoms associated with a less than 50 percent rating. Of note, the Veteran had depressed mood, anxiety, suspiciousness, chronic sleep impairment and mild memory loss. The November 2010 and March 2020 VA examiners also endorsed a level of occupational and social impairment consistent with a less than 50 percent rating. Further, the evidence indicates that the Veteran has been able to maintain family and some social relations, showed logical and goal-directed thought processes, and cooperative behavior. He sang in the church choir, and engaged in some hobbies. He is in a supportive and stable marriage, and has occasionally reported good relationships with his step-children. The Veteran was able to manage complex tasks such as managing the estate of his late mother and the sale of his own home. On mental status examinations, he was found to be consistently well dressed, with normal speech, normal thought processes, normal mood, intact insight and judgment, and free of hallucinations and delusions. These are all symptoms and a level of functioning consistent with no more than a 50 percent rating. The Veteran’s overwhelming reported symptoms of nightmares, mood swings, and irritability and short-temperedness are also contemplated by the 50 percent rating. A higher rating of at least 70 percent requires more severe symptoms like those enumerated in the rating criteria, such as deficiencies in work, family relations, judgment; near-continuous panic; depression affecting the ability to function independently; neglect of personal appearance and hygiene; or difficulty in adapting to stressful circumstances. In this case, the evidence reflects that the Veteran has not neglected personal appearances or hygiene. Although the Veteran was noted to have some obsessional rituals in November 2010 and August 2013 VA examination, the August 2013 VA examiner noted that it is unclear if this was clinically significant obsession compulsive symptoms. Moreover, his VA treatment records did not show interference with routine activities due to obsessive rituals. Likewise, the Veteran was noted to have difficulty in adapting to stressful circumstances, and an inability to establish and maintain effective relationships. As noted, he has maintained relationships with family, and some involvement with his church. He did not have the major disturbances of thought process or content that involve delusions or hallucinations. Despite any irritability, the Veteran did not have such impaired impulse control that he exhibited a history of violence. The Board also notes that the assessments offered by the VA examiners, based on their review of the Veteran’s symptoms and clinical presentation, do not support a rating in excess of 50 percent. The Board notes that the Veteran expressed suicidal ideation, which is a symptom contemplated by a 70 percent rating. The Veteran reported suicidal ideation or history of such thought in August 2013 and March 2020 VA examinations, November 2010 VA treatment records, and October 2020 correspondence. The Court has held that suicidal ideation generally rises to the level contemplated in a 70 percent evaluation. See Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). However, the Court in Bankhead also noted that the presence of a single symptom is not dispositive of any particular disability level. VA must engage in a holistic analysis in which it assesses the severity, frequency, and duration of the signs and symptoms, quantifies the level of occupational and social impairment caused by those symptoms, and assigns an evaluation that more nearly approximates that level of occupational and social impairment. In this case, there is no indication that the Veteran’s reported suicidal ideation has had a significant negative impact on his occupational and social functioning. Suicidal ideation was absent from the vast majority of his VA treatment records throughout the 10 plus years during the appeal period, in the July 2019 letter from Dr. Fox, and at the November 2010 and November 2014 VA examination. In evaluating the Veteran’s statement of suicidal ideation, they are infrequent, and he states that they only occur at times. The Veteran has not described this symptom as having had a significant impact on his ability to function. There is no other evidence indicating that these thoughts have been productive of impaired industrial incapacity. Regarding social impairment, the Veteran had meaningful relationships with his mother when she was alive, spouse and was able to participate in some social activities. Moreover, the Board notes that the August 2013 and March 2020 VA examiner considered the Veteran report of suicidal ideation and found that his overall level of impairment was characterized by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. This characterization is consistent with a 50 percent rating, and is not supportive of finding that the Veteran’s overall level of impairment - even considering his report that he considers taking his life- does not support an assignment of a 70 percent rating. The Board has considered the letter of Dr. Fox, the Veteran’s VA psychiatrist. Although Dr. Fox characterizes the Veteran’s disorder as severe and totally disabling, the characterization is at odds with her own observations and clinical notes from VA treatment records. As noted, these treatment records establish a generally chronic and stable disorder which does not produce severe impairment. Moreover, the symptoms cited by Dr. Fox in support of her opinion are the Veteran’s intrusive recollections, hypervigilance, nightmares, avoidance behaviors, depressed mood, and irritability. The majority of the symptoms do not correspond to a totally disabling disability or even a 70 percent rating. Although the Veteran reported irritability, the Veteran is not shown to have any history of violence in relation to this symptom. Finally, Dr. Fox does not support her conclusion with actual manifestations of the severe and total impairment. As the record does not otherwise support such a severe and total impairment, the Board does not accord this opinion much probative weight. The Board recognizes the Veteran’s contentions that his symptoms warrant a higher rating. However, the Board finds the VA examiners’ assessment about his level of social and occupational functioning to be persuasive, and more probative than the Veteran’s lay assertion. Further, using the current rating criteria as a guide, and in consideration of the frequency, severity, and nature of the Veteran’s symptoms as shown by the record, the Board finds that his level of functioning does not more nearly approximate occupational and social impairment with deficiencies in most areas, such that a higher than 50 percent rating is warranted. In sum, while the Veteran experiences some the symptoms seemingly contemplated by a 70 percent rating, the cumulative evidence does not demonstrate the overall level of impairment associated with a 70 percent rating. That is, the severity, frequency, and duration of the Veteran’s PTSD symptoms correspond with the level of impairment required for a 50 percent rating. Accordingly, the Board finds that an initial rating in of 50 percent, but no higher, is warranted. There are no other issues expressly or reasonably raised by the record. 9. Entitlement to a TDIU is denied. The Veteran asserts his service-connected PTSD, in conjunction with other disabilities, preclude substantially gainful employment. See November 2011 VA 21-4138. Specifically, the Veteran asserts that his service-connected PTSD results in difficulty maintaining and establishing effective work relationship, disturbances of motivation and mood, and difficulty trusting co-workers. See September 2011 correspondence. The Veteran has also reported difficulty maintaining a full time schedule and performing work tasks due to stress, time needed for group and individual therapy sessions, and lack of sleep. Finally, the Veteran testified that he was unable to work in positions which required him to deal with people due to irritability. See August 2018 Board Hearing. He also indicated that he suffers occupational impairment due to non-service connected disabilities. See August 2018 Board Hearing; February 2016 VA 21-8940. Notably, the Veteran testified that one of the reasons he stopped working was his right wrist operation, arthritis affecting his bilateral hands and shoulder pain. The Veteran also indicated that symptoms in his hands, wrists, and shoulders prevent him from doing any kind of manual or dexterity work. The Veteran has not reported that his claimed bronchitis condition, which is not yet service-connected, has affected his ability to secure and follow substantially gainful occupation. Initially, the Board notes that the Veteran’s claim for TDIU is part and parcel of the Veteran’s claim for a higher initial evaluation for his PTSD pursuant to Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Thus, the appeal period before the Board begins September 27, 2010, the effective date for service connection for PTSD. It is the established policy of VA that all Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. See 38 C.F.R. § 4.16. A finding of total disability is appropriate “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.” See 38 C.F.R. §§ 3.340 (a)(1), 4.15. TDIU may be assigned where the schedular rating is less than total and it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of either (1) a single service-connected disability ratable at 60 percent or more, or (2) two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is a sufficient additional service-connected disabilities to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16 (a). For the purposes of determining rating level, disabilities resulting from a common etiology or affecting a single body system are considered a single disability. 38 C.F.R. § 4.16 (a). Where these percentage requirements are not met, entitlement to the benefits on an extraschedular basis may be considered when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. See 38 C.F.R. § 4.16 (b). The Veteran’s service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16 (b). For the relevant period, the Veteran is service-connected for PTSD, rated as 50 percent disabling from September 27, 2010; sleep apnea associated with PTSD rated as 50 percent disabling from August 22, 2018; tinnitus rated 10 percent disabling from June 5, 2013; and bilateral hearing loss rated as noncompensable. The Veteran is in receipt of a combined evaluation of 50 percent from September 27, 2010; 60 percent from June 5, 2013; and 80 percent from August 22, 2018. Thus, the Veteran meets the schedular criteria for a TDIU from August 22, 2018, but not prior to that period thereafter. See38 C.F.R. § 4.16 (a). Nevertheless, entitlement to a TDIU still may be granted, instead, on an extra-schedular basis under § 4.16(b). This additional subpart of this governing VA regulation indicates “that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled.” Id. (emphasis added). The Board does not have the authority to assign an extraschedular TDIU in the first instance. Bowling v. Principi, 15 Vet. App. 1(2001). The United States Court of Appeals for Veterans Claims (Court), in Ray v. Wilkie, 31 Vet. App. 58 (2019), interpreted the phrase “unable to secure and follow a substantially gainful occupation” under 38 C.F.R. § 4.16 (b). Court defined the term to have two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component, which is pertinent in this case, includes consideration of: The Veteran’s history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. Based on the following, the Board finds the evidence does not support an award of TDIU. The Veteran’s DD Form 214 shows his military occupational specialty was equipment storage specialist. On the Veteran’s February 2016 VA 21-8940, he did not report information about prior employment. He indicated he had completed three years of college, with no specialized training. The Veteran also reported that he became too disabled to work in June 2013. When the Veteran was examined for PTSD in August 2013, the Veteran reported previously working assembling telephones and in computer application at an engineering company. He also worked as a night auditor at hotel, and eventually did part time work at Wawa, a convenience store. The Veteran reported quitting due to arthritis in shoulder and wrist. At the August 2019 Board hearing, the Veteran clarified that he studied hotel/motel management at college. He also testified that he had training in electronic repair and maintenance. The Veteran reported work history which included contract work for a part of NASA, and work as a convenience store clerk at Wawa. At the March 2020 VA examination for PTSD, the Veteran reported a work history that included deliveryman for papers, packer for an electrician company, truck driving during service, and as a contractor in the electronic department. The Veteran reported that his longest work history was as a contractor from 1989 to 2004. The Veteran reported that he stopped working in 2013 when he hurt his hand and had an operation. Looking at economic considerations, the Veteran had the education, training, skills, and work history to perform substantially gainful work in a wide variety of fields. This included his prior work history in a convenience store, in hotel management or the hospitality industry, in delivery to include as a truck driver, and in skilled electric work as a contractor or building electric equipment such as telephones. With regard to physical and mental disabilities, the medical evidence did show the Veteran had some difficulties due to his service-connected PTSD. Notably, the Veteran reported conflict and irritability with co-workers and his supervisor. Indeed, the August 2013 VA examination reflects he had disturbance of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and inability to establish and maintain effective relationships. However, that disability alone did not preclude the Veteran from obtaining substantially gainful employment consistent with his work history, training, education, and skills. The Board finds that the Veteran could have performed employment consistent with his training, work experience and education. Indeed, the Veteran was able to do contract work until 2004, and later worked as a convenience store clerk until 2013 despite his service-connected PTSD. Rather, the Veteran reported on the VA 21-8940 that he could not work due to the combined impact of his right and left hand, and his right shoulder pain. The Veteran also reported that his shoulder and hand arthritis was the immediate cause of his leaving gainful employment in 2013 at the August 2013 and March 2020 VA examinations. Those disabilities prevented the Veteran from lifting, operating machinery, and caused great pain. See February 2016 VA 21-8940. It is likely that these numerous non-service connected condition predominantly impacted his ability to continue employment. There is no evidence of mental inability to perform gainful employment due to service-connected disabilities alone. The Board has considered the July 2019 assessment provided by Dr. Fox. As noted, the Board has not accorded that evidence much probative weight given its lack of rationale to support the conclusion that the Veteran is totally disabled due to PTSD. As noted, the appropriate standard for the Board when determining whether to remand a claim for TDIU pursuant to §4.16(b) is whether there is sufficient evidence to substantiate a reasonable possibility that a veteran is unemployable by reason of his or her service-connected disabilities. Based on the Board’s review, the evidentiary record fails to demonstrate that the Veteran was unemployable due solely to his service-connected disabilities. Accordingly, there is no basis to refer this matter to the Director of Compensation Services for extraschedular consideration. The preponderance of the competent and probative evidence is against the claim. As such, the benefit of the doubt doctrine does not apply. See Gilbert v. Derwinski,1 Vet. App. 49, 55 (1990). Entitlement to a TDIU is denied. REASONS FOR REMAND 1. Service connection for bronchitis is remanded. The Veteran relates his current condition to a 5-day period of hospitalization for pneumonia during service, while at Fort Bragg. See April 2020 VA 21-4138. Alternatively, the Veteran asserts that his bronchitis is due to herbicide agent exposure in service. See August 2018 VA 21526EZ. Lastly, in his February 2016 claim, the Veteran indicated that his condition was secondary to service-connected PTSD. Although the Veteran was afforded a May 2016 VA examination, the Board cannot make a fully-informed decision on the issue as the examination is not responsive to the enitrety of the Veteran’s contentions and does sufficiently address all prongs of secondary service connection. Notably, the examiner indicated that bronchitis is not proximately due to or the result of PTSD. However, the examiner did not address aggravation by service-connected PTSD. In addtion, the examiner did not offer an opinion on direct service connection. Accordingly, a remand is required for an addendum opinion, and if necessary an examination. The matters are REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician regarding the nature and etiology of the Veteran’s bronchitis. The examiner must review the claims file, including this Remand. It is up to the discretion of the examiner if an in-person VA examination is necessary. a) For the diagnosis of bronchitis or any current respiratory condition, the examiner is to indicate whether it is at least as likely as not that such had onset in service, or is otherwise related to the Veteran’s military service, to include in-service hospitalization for pneumonia in February 1968 or presumed in-service exposure to herbicide agent. The examiner is advised that a negative opinion cannot be based solely on the fact that bronchitis is not on the list of diseases that are presumptively associated with exposure to herbicide agents. b) For the diagnosis of bronchitis or other current respiratory condition, the examiner is to indicate whether it is at least as likely as not aggravated beyond its natural progression by the service-connected PTSD. The examiner should consider the Veteran’s contentions regarding the stress and sleep difficulty produced by PTSD. A complete rationale for the opinions must be provided. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Vuong, 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.