Citation Nr: 21007796 Decision Date: 02/10/21 Archive Date: 02/10/21 DOCKET NO. 14-14 435 DATE: February 10, 2021 ORDER Service connection for hypertension, to include as secondary to service-connected diabetes mellitus, type II (DM), is denied. Service connection for right upper extremity peripheral neuropathy, to include as secondary to service-connected DM, is denied. Service connection for left upper extremity peripheral neuropathy, to include as secondary to service-connected DM, is denied. Service connection for right lower extremity peripheral neuropathy, to include as secondary to service-connected DM, is denied. Service connection for left lower extremity peripheral neuropathy, to include as secondary to service-connected DM, is denied. An initial rating in excess of 30 percent, for an acquired psychiatric disability, to include post-traumatic stress disorder (PTSD), major depressive disorder, anxiety, and somatoform disorder, is denied. FINDINGS OF FACT 1. The probative evidence of record demonstrates that the Veteran's hypertension did not originate in service or for many years thereafter, is not related to any incident during active service and is not caused or aggravated by his service-connected DM. 2. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of right upper extremity peripheral neuropathy. 3. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of left upper extremity peripheral neuropathy. 4. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of right lower extremity peripheral neuropathy. 5. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of left lower extremity peripheral neuropathy. 6. For the entire period on appeal, the Veteran’s symptoms have manifested as occupational and social impairment with occasional decrease in work efficiency. CONCLUSIONS OF LAW 1. The criteria to establish entitlement to service connection for hypertension, to include as secondary to service-connected DM, have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.310(a), 3.303, 3.304. 2. The criteria to establish entitlement to service connection for right upper extremity peripheral neuropathy, to include as secondary to service-connected DM, have not been met. 38 U.S.C. §§ 1110, 1154; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria to establish entitlement to service connection for left upper extremity peripheral neuropathy, to include as secondary to service-connected DM, have not been met. 38 U.S.C. §§ 1110, 1154; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria to establish entitlement to service connection for right lower extremity peripheral neuropathy, to include as secondary to service-connected DM, have not been met. 38 U.S.C. §§ 1110, 1154; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria to establish entitlement to service connection for left lower extremity peripheral neuropathy, to include as secondary to service-connected DM, have not been met. 38 U.S.C. §§ 1110, 1154; 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. For the entire period on appeal, the criteria for an initial rating in excess of 30 percent for an acquired psychiatric disability, to include PTSD, major depressive disorder, anxiety, and somatoform disorder, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.125, 4.126(a), 4.130, Diagnostic Code (DC) 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from June 1963 to July 1975. This matter was previously before the Board of Veterans’ Appeals (Board) in July 2020 when the issues were remanded for further development. In particular, the issues of service connection for bilateral lower extremity peripheral neuropathy and an initial rating in excess of 30 percent for an acquired psychiatric disability were remanded for compliance with the February 2020 Court of Appeals for Veterans Claims (CAVC) joint motion for partial remand (JMPR), which vacated the Board’s February 2019 decision that denied the claims for entitlement to service connection for bilateral lower extremity peripheral neuropathy and an initial rating in excess of 30 percent for an acquired psychiatric disability. The issues of service connection for hypertension and bilateral upper extremity peripheral neuropathy were remanded by the Board in February 2019 in order to obtain VA examinations. The issues were again remanded by the Board in July 2020, along with those discussed above, for further development. Further development having been completed in accordance with the February 2020 JMPR and as instructed in the July 2020 Board remand; the matter is once again before the Board. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). “To establish a right to compensation for a present disability, a veteran must show: ‘(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service’ -the so-called ‘nexus’ requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38C.F.R. §3.303(d); see Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Service connection may also be granted for a disability that is proximately due to, or the result of, a service-connected disability. See 38 C.F.R. § 3.310(a). To prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for a disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of anon-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In deciding an appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether a veteran’s disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465, 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr, 21 Vet. App. 303. Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d 1372, 1377. In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Service connection for hypertension, to include as secondary to service-connected DM, is denied. The Veteran contends that his hypertension is related to his service. Alternatively, he contends that his hypertension is related to his service-connected DM. For the reasons set forth below, service connection for hypertension, to include as secondary to service-connected DM, is not warranted. As hypertension is defined as a chronic disease in 38 C.F.R. § 3.309(a), the provisions of subsection 3.303(b) for chronic disabilities apply, and service connection for hypertension may be established by evidence of a continuity of symptomatology after service. See Walker v. Shinseki, 708 F.3d 1331, 1338-39. As noted above, service connection may also be established on a secondary basis for a disability which is proximately due to or the result of a service connected disease or injury; or, for any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progression of the nonservice-connected disease. 38 C.F.R. § 3.310(a)-(b); Allen, 7 Vet. App. 439. A September 1965 report of medical history indicates normal clinical evaluations of the heart and vascular system. A blood pressure reading of 118/60 was recorded at the time. There was no indication of high blood pressure or hypertension. A September 1965 report of medical examination indicates normal clinical evaluations of the heart and vascular system. A blood pressure reading of 128/84 was recorded at the time. There was no indication of high blood pressure or hypertension. A May 1967 report of medical examination indicates normal clinical evaluations of the heart and vascular system. A blood pressure reading of 128/84 was recorded at the time. There was no indication of high blood pressure or hypertension. A June 1968 report of medical examination indicates normal clinical evaluations of the heart and vascular system. There was no indication of high blood pressure or hypertension. A June 1969 report of medical examination indicates normal clinical evaluations of the heart and vascular system. A blood pressure reading of 116/72 was recorded at the time. There was no indication of high blood pressure or hypertension. A January 1970 report of medical examination indicates normal clinical evaluations of the heart and vascular system. There was no indication of high blood pressure or hypertension. A July 1971 report of medical examination indicates normal clinical evaluations of the heart and vascular system. A blood pressure reading of 124/62 was recorded at the time. There was no indication of high blood pressure or hypertension. A May 1973 report of medical examination indicates normal clinical evaluations of the heart and vascular system. A blood pressure reading of 130/68 was recorded at the time. There was no indication of high blood pressure or hypertension. Service treatment records (STRs) indicate that high blood pressure was noted on a flight physical in 1974. However, there is no indication that the Veteran was diagnosed with or treated for high blood pressure or hypertension in-service. The Veteran’s March 1975 separation examination indicates normal clinical evaluations of the heart and vascular system. A blood pressure reading of 120/78 was recorded at the time. There was no indication of high blood pressure or hypertension. VA medical records indicate a diagnosis of hypertension as early as 2006, more than 30 years after the Veteran’s discharge from service. In a March 2011 VA examination, the examiner noted a diagnosis of hypertension, but opined that it was not caused by service-connected DM. A January 2020 VA Disability Benefits Questionnaire is of record. The examiner noted that a review of available evidence, to include the Veteran’s VA e-folder and VA electronic health records, was completed in conjunction with the evaluation. The examiner noted a diagnosis of hypertension with a date of diagnosis of 2006. The examiner remarked that, after a review of the Veteran's STRs, there is no objective evidence of a diagnosis of hypertension or elevated blood pressure readings to suggest a diagnosis of hypertension during the Veteran’s service. The examiner noted that the Veteran began to show signs of diabetic kidney disease in April 2017 with elevated microalbumin levels. Also, in April 2017, the Veteran was treated with the same medication for his hypertension as he is today. The examiner opined that it would be less likely than not that the Veteran’s hypertension was aggravated beyond it's normal progression by his service-connected DM. Further, the examiner stated that the diagnosis of hypertension predated the diagnosis of DM, and opined that it would be less likely than not that his hypertension was caused by his service-connected DM. Although the Veteran believes that his hypertension is related to his service, to include as secondary to his service-connected DM, he is not competent to provide an etiological opinion in this case. The issue is medically complex, as it requires specialized medical education. Jandreau, 492 F.3d 1372, 1377. The probative evidence of record demonstrates a current diagnosis of hypertension. Although a 1974 STR indicates that high blood pressure was noted on a flight physical, there is no other evidence in the STRs that the Veteran was diagnosed with or treated for high blood pressure or hypertension in-service, no evidence indicating that hypertension is related to the Veteran's service, no evidence of continuity of symptomatology after service, and no evidence indicating that his hypertension was caused or aggravated by his service-connected DM. The post-service medical evidence of record demonstrates that the Veteran is diagnosed with hypertension, which was diagnosed more than 30 years after the Veteran's discharge from service. In particular, VA medical record indicate that the Veteran's hypertension was diagnosed in 2006. The applicability of the benefit of the doubt doctrine has been considered, however, as the preponderance of the evidence is against the Veteran's claim for service connection for hypertension, to include as secondary to service-connected DM, that doctrine is not applicable. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Therefore, the Veteran's claim for service connection for hypertension is denied. 2. Service connection for right upper extremity peripheral neuropathy, to include as secondary to service-connected DM, is denied. 3. Service connection for left upper extremity peripheral neuropathy, to include as secondary to service-connected DM, is denied. 4. Service connection for right lower extremity peripheral neuropathy, to include as secondary to service-connected DM, is denied. 5. Service connection for left lower extremity peripheral neuropathy, to include as secondary to service-connected DM, is denied. The Veteran contends that he has bilateral upper and lower extremity peripheral neuropathy that is related to his service. Alternatively, he contends that his bilateral upper and lower extremity peripheral neuropathy is related to his service-connected DM. The pertinent question 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. The Veteran can also establish service connection if he has a current disability that is proximately due to or the result of service-connected disability. For the reasons set forth below, service connection for bilateral upper and lower extremity peripheral neuropathy is not warranted. In a March 2011 VA Examination, the examiner stated that while the Veteran has experienced subjective symptoms of intermittent numbness in his hands and pain in his feet, he did not have a diagnosis of bilateral lower peripheral neuropathy. The examiner opined that the Veteran had a normal peripheral nerve examination and no peripheral neuropathy was noted. The examiner stated that the Veteran’s foot pain interferes with prolonged standing, walking, wakes him up at night, and keeps him from sleeping. The examiner noted that the Veteran’s hand symptoms cause him to drop things more frequently. However, the examiner noted that the Veteran is able to accomplish his daily activities. No muscle wasting or atrophy was noted, and the joints were noted as not affected. In a February 2014 VA examination, the examiner noted that the Veteran did not have and had never been diagnosed with diabetic peripheral neuropathy. The examiner evaluated the Veteran and determined that, while he experienced subjective symptoms of bilateral leg pain, he did not have a diagnosis of diabetic peripheral neuropathy. The examiner noted that the Veteran’s neurological examination was normal. In an August 2015 Agent Orange Peripheral Neuropathy Review Checklist, it was noted that peripheral neuropathy was not identified. The Veteran was afforded a VA examination in February 2020. The examiner noted that an in-person examination was conducted and that a review of the Veteran’s VA e-folder and CPRS file was completed in conjunction with the examination. The examiner stated that the Veteran does not have a peripheral nerve condition or peripheral neuropathy. However, the examiner noted that the Veteran has symptoms attributable to a peripheral nerve condition. Specifically, the examiner noted that the Veteran has symptoms of mild paresthesias and/or dysesthesias of the bilateral upper extremity. Nonetheless, all nerves of the bilateral upper extremity were noted as normal. The examiner stated that the Veteran does not report symptoms consistent with right upper extremity peripheral neuropathy and stated that his examination is unremarkable with regard to sensory findings, reflex findings, and motor findings. The examiner noted that the Veteran reported intermittent tingling to the third and fourth fingers of the left hand, but stated that the examination shows no sensory deficit, and normal vibration findings, normal reflexes, and normal motor findings were noted. The Veteran denied pain to his upper extremities and denied numbness to his hands, fingers, and arms. All nerves of the bilateral lower extremity were noted as normal. No impact on the functionality of the bilateral upper or lower extremities were noted. No other pertinent findings were indicated. The examiner stated that the condition of left upper extremity peripheral neuropathy is not sufficiently substantiated. The examiner opined that it is less likely than not that bilateral upper extremity peripheral neuropathy was incurred or caused by nerves during service or caused by service-connected DM. Although an April 2016 VA medical record notes a history of peripheral neuropathy, specifically right upper extremity ulnar neuropathy, another April 2016 VA medical record notes that neuropathy of the right upper extremity was ruled out after clinical testing. No other treatment records indicate a diagnosis of bilateral upper or lower extremity peripheral neuropathy. While the Veteran believes he has a current diagnosis of bilateral upper and lower extremity peripheral neuropathy, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education. Jandreau, 492 F.3d 1372, 1377. Consequently, the Board gives more probative weight to the competent medical evidence. The Veteran does not have a current diagnosis of bilateral upper or lower extremity peripheral neuropathy and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). As the Veteran does not have a current disability of bilateral upper or lower extremity peripheral neuropathy, service connection under a direct and secondary theory is not warranted. The Board has considered the ruling in Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), in which the Federal Circuit held that "pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability" if it "reaches the level of a functional impairment of earning capacity." Id. at 1367-69. Although the Veteran has reported pain in his hands, feet, and legs during the period on appeal, there is no indication of functional impairment of earning capacity. In the March 2011 VA examination, the examiner stated that the Veteran’s foot pain interferes with prolonged standing, walking, wakes him up at night, and keeps him from sleeping. The examiner noted that the Veteran’s hand symptoms cause him to drop things more frequently. However, the examiner noted that the Veteran is able to accomplish his daily activities. No muscle wasting or atrophy was noted, and the joints were noted as not affected. The examiner opined that the Veteran had a normal peripheral nerve examination and no peripheral neuropathy was noted. In the February 2014 VA examination, the examiner noted that the Veteran did not have and had never been diagnosed with diabetic peripheral neuropathy. It was determined that even though the Veteran experienced subjective symptoms of bilateral leg pain, he did not have a diagnosis of diabetic peripheral neuropathy and his neurological examination was normal. The February 2020 examiner opined that it is less likely than not that bilateral upper extremity peripheral neuropathy was incurred or caused by nerves during service or caused by service-connected DM. In fact, the examiner stated that the Veteran does not have a peripheral nerve condition or peripheral neuropathy. The examiner stated that the Veteran did not report symptoms consistent with right upper extremity peripheral neuropathy and stated that his examination is unremarkable with regard to sensory findings, reflex findings, and motor findings. The examiner noted that the Veteran reported intermittent tingling to the third and fourth fingers of the left hand, but stated that the examination shows no sensory deficit, and normal vibration findings, normal reflexes, and normal motor findings were noted. The Veteran denied pain to his bilateral upper extremity and denied numbness to his hands, fingers, and arms. No impact on the functionality of the bilateral upper or lower extremities was noted. As the VA examiners reviewed the record, physically examined the Veteran, and conducted appropriate testing, their assessments are probative. Lacking a current bilateral upper or lower extremity disability, the cornerstone element of service connection has not been met. Brammer v. Derwinski, 3 Vet. App. at 225. As such, service connection for bilateral upper or lower extremity disabilities are not warranted on any basis. Aside from the Veteran's statements, a review of the claims file contains no bilateral upper or lower extremity peripheral neuropathy disability. It is acknowledged that pain alone can be a disability, where there is functional impairment. See Saunders v. Wilke, 886 F.3d 1356 (Fed. Cir. 2018). The Federal Circuit clarified that it was not holding that a veteran could demonstrate service connection simply by asserting subjective pain to establish a disability, as the Veteran's pain must amount to functional impairment of earning capacity. However, there is no indication of functional impairment that rises to the level of impairment of earning capacity. Instead, the evidence shows that the Veteran is able to accomplish his daily activities. As there is no evidence of functional impairment, bilateral upper or lower extremity pain do not reach the level of present disabilities. Therefore, beyond the Veteran's assertions, there is no competent evidence that he has bilateral upper or lower extremity peripheral neuropathy disabilities. The existence of a current disability is the cornerstone of a claim for VA disability compensation. Degmetich v. Brown, 104 F.3d 1328 (1997). Because there are no current disabilities upon which benefits could be granted, his appeal for service connection for bilateral upper and lower extremity peripheral neuropathy is denied. See 38 C.F.R. §§ 3.102, 3.303; Brammer v. Derwinski, 3 Vet. App. 223 (1995) (Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents had resulted in a disability). Increased Ratings Disability ratings are determined by applying criteria set forth in VA’s Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations should 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. See 38 C.F.R. § 4.7. In disability rating cases, VA assesses the level of disability from the initial grant of service connection or a year prior to the date of application for an increased rating and determines whether the level of disability warrants the assignment of different disability ratings at different times over the course of the claim, a practice known as “staged ratings.” See Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007) (holding that staged ratings may be warranted in increased rating claims). Additionally, the evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). In assigning a higher disability rating, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 6. An initial rating in excess of 30 percent, for an acquired psychiatric disability, to include PTSD, major depressive disorder, anxiety, and somatoform disorder, is denied. The Veteran contends that his acquired psychiatric disability, to include PTSD, major depressive disorder, anxiety, and somatoform disorder, is worse than that which is contemplated by his current 30 percent rating under 38 C.F.R. § 4.130, DC 9411. For the reasons set forth below, a rating in excess of 30 percent is not warranted at any time during the period on appeal. Under the General Rating Formula for Mental Disorders, a 30 percent evaluation is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned 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 rating is assigned 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 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; memory loss for names of close relatives, own occupation, or own name. The symptoms associated with each rating in 38 C.F.R. § 4.130 are not intended to constitute an exhaustive list; rather, they serve as examples of the type and degree of the symptoms, or their effects, that would justify a rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Thus, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the DCs. See Id. VA must consider all symptoms of a claimant’s disorder that affect his or her occupational and social impairment. See Id. at 443. If the evidence demonstrates that a claimant has symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the DC, the appropriate, equivalent rating will be assigned. Id. In this regard, VA shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant’s capacity for adjustment during periods of remission. 38 C.F.R. § 4.126. Although VA considers the level of social impairment, it does not assign an evaluation based solely on social impairment. Id. VA must consider all the claimant’s symptoms and resulting functional impairment as shown by the evidence in assigning the appropriate rating, and will not rely solely on the examiner’s assessment of the level of disability at the moment of examination. See Id. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is for application as this appeal was pending before the AOJ on August 4, 2014. 38 C.F.R. §§ 4.125, 4.130; 79 Fed. Reg. 45093, 45099 (effective date provisions); 80 Fed. Reg. 53, 14308 (March 19, 2015) (adopting the final rule recognizing that the DSM-IV was rendered obsolete by the publication of the DSM-5 in May 2013). “Given that the DSM-5 abandoned the GAF scale and that VA has formally adopted the DSM-5, the Court holds that the Board errs when it uses GAF scores to assign a psychiatric rating in cases where the DSM-5 applies... [t]he Board should not use such evidence at all when assigning a psychiatric rating in cases where the DSM-5 applies.” Golden v. Shulkin, 29 Vet. App. 221, 225 (2018). In the March 2011 VA examination, the examiner noted that the Veteran has the following symptoms: recurrent and intrusive distressing recollections; recurrent nightmares or distressing dreams; intense psychological distress at exposure to cues that symbolize or resemble an aspect of the event; physiological reactivity on exposure to such cues; efforts to avoid trauma associated thoughts, feelings, or conversations; efforts to avoid activities, places, or people that arouse recollections; difficulty falling or staying asleep; irritability or outbursts of anger; hypervigilance; and exaggerated startle response. The Veteran self-reported symptoms of depression, anxiety, and PTSD symptoms. The examiner explained the Veteran’s reported hypervigilance appears to be limited to situations where he is in a neighborhood where there is higher crime and he feels unsafe. The Veteran reported that he participates in regular social activities and has good relationships with family and friends. The examiner noted that the Veteran experiences mild mental health symptoms. The examiner further stated the Veteran has a long work history that was impacted by his substance abuse, but not by other mental health symptoms. An April 2013 VA medical record indicates that the Veteran reported that he is tired of being angry all of the time. He stated that since his retirement in 2007, he has had increasing problems with managing his anxiety, and reported that he is on edge and angry most of the time. He stated that he wanted to seek counseling in order to learn to manage his thoughts and emotions more appropriately. The Veteran denied sleep disturbance, irritability or aggression, anxiety, depression, apathy of lack of spontaneity, speech difficulty, changes in personality, and slowed thinking. His appearance was noted as neat, his manner was noted as friendly and cooperative, his intelligence was noted as average, his speech was noted as appropriate, he had orientation to time, place, and person, his memory function was noted as normal, his affect was noted as appropriate, his associations were noted as within normal limits, and his judgment was noted as fair. Delusions, disorganized thinking, hallucinations, and grossly disorganized catatonic behaviour were all denied. The examiner noted that the Veteran has a long history of being unable to express his emotions and being angry all the time. The examiner also noted that the Veteran experiences ongoing nightmares, difficulty sleeping, social isolation, hypervigilance, a feeling as if his life will be cut short, and maladaptive behaviour. A May 2013 VA medical record indicates that the Veteran reported that he has been able to manage his anger well over the previous week and reported that he believes that he is not angry in general. He reported that he is able to prepare himself for unpleasant encounters. He reported social support in his church, A.A., prayer group, and his personal relationship with a female friend. He reported that he has been more aware of his thoughts and emotions, which has helped him manage both more effectively. The examiner observed the Veteran to be oriented and cooperative, his thinking was noted as organized and goal directed, his speech was noted as within normal limits, and his judgement and insight were noted as good. The examiner noted that the Veteran had no risk of suicide or homicide. A June 2013 VA medical record indicates that the Veteran reported feeling bad when others died or otherwise would lose contact with him. He reported feeling good about himself and his ability to remain sober over the past 20, plus years. The examiner observed the Veteran to be oriented and cooperative, his thinking was noted as organized and goal directed, his speech was noted as within normal limits, and his judgement and insight were noted as good. The examiner noted that the Veteran had no risk of suicide or homicide. A July 2013 VA medical record indicates that the Veteran reported that he is less angry and more able to engage with others. He reported that he is finding it easier every day to be calm and personable. He reported that for the most part, he is happy with his life. He reported that he has personal relationships and he enjoys his church. The examiner observed the Veteran to be oriented and cooperative, his thinking was noted as organized and goal directed, his speech was noted as within normal limits, and his judgement and insight were noted as good. The examiner noted that the Veteran had no risk of suicide or homicide. An August 2013 VA medical note indicates that the Veteran presented with PTSD, anxiety, and anger. In the February 2014 VA examination, the Veteran reported the following symptoms: recurrent, involuntary, intrusive distressing memories of the traumatic event(s); avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely related with the traumatic event(s); persistent and exaggerated negative beliefs or expectations about oneself, others, or the world; persistent negative emotional state; feelings of detachment or estrangement from others; irritable behavior and angry outbursts; hypervigilance; problems with concentration; symptoms lasting longer than one month; symptoms causing significant distress or impairment in social, occupational, or other important areas of functioning; and that the disturbance is not attributable to the physiological effects of a substance or another medical condition. The examiner noted symptoms of suspiciousness and an inability to establish and maintain effective relationships. The examiner noted that the Veteran has occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with routine behavior, self-care, and conversation. In the March 2016 VA examination, the Veteran stated that his symptoms had worsened since his 2014 VA examination. Specifically, he reported hearing noises that were not there. However, he did not report any other reasons for his belief that his PTSD symptoms were worse than in 2014. In fact, he specifically denied depressive symptoms, anger issues, anxiety, psychotic symptoms, panic symptoms, and memory problems. The examiner noted the Veteran’s appearance and grooming were unremarkable, he had flattened affect, but his statements were logical, coherent, rational, and organized. The examiner did not observe, and the Veteran did not report any psychotic symptoms. The examiner noted that the Veteran no longer endorses symptoms meeting diagnostic criteria for PTSD and that the condition does not appear to be a current disability. The examiner stated there is no evidence supporting a contention that the Veteran’s symptoms have worsened since the prior examination, in fact, a comparison of the symptoms endorsed then versus this examination indicated improvement to the point that PTSD could not be diagnosed at that time. The examiner stated that the Veteran did not have occupational or social impairment due to PTSD or any other mental condition. There is no evidence that the VA examiners are not competent and credible. As all reports noted the Veteran’s subjective reports of his symptoms and their effect on his social and occupational functioning and were based on objective psychiatric evaluations, each examination is entitled to significant probative weight concerning the type and severity of the Veteran’s symptoms, as well as his overall level of social and occupational impairment, at the time they were conducted. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). VA treatment records are silent regarding additional symptoms of PTSD or any other acquired psychiatric disorder. In the Veteran’s June 2018 Board hearing, he described symptoms of weekly anxiety attacks and memory loss, such as forgetting where he placed mail and which tasks he planned to do. He denied mood swings. The Veteran is competent to report symptomatology. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Given the facts as discussed above, the preponderance of the evidence is against the claim for a rating in excess of 30 percent during the entire period on appeal. Therefore, an increased rating in excess of 30 percent is not warranted under DC 9411, at any time during the period on appeal, for the Veteran’s acquired psychiatric disorder and, the claim is denied. A higher, 50 percent rating, is not warranted. Throughout the entire period on appeal, the record indicates that the Veteran participates in regular social activities and has good relationships with family and friends. The Veteran reported social support in his church, A.A., prayer group, and his personal relationship with a female friend. He reported that he has personal relationships and he enjoys his church. He reported feeling good about himself and his ability to remain sober over the past 20, plus years. He reported that for the most part, he is happy with his life. Throughout the entire period on appeal, the Veteran’s appearance has been noted as neat, his manner noted as friendly and cooperative, his speech noted as within normal limits, his judgement and insight noted as good, his thinking noted as organized and goal directed, and he has had orientation to time, place, and person. He has denied delusions and hallucinations, and he has been assessed as having no risk of suicide or homicide. Staged ratings are not warranted during the period on appeal, as the Veteran has had a relatively stable level of symptomatology throughout the entire period on appeal. Any other increases in severity were not sufficient for a higher rating. See Fenderson, 12 Vet. App. at 126–27. Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Timothy T. Emmart 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.