Citation Nr: 21011420 Decision Date: 03/01/21 Archive Date: 03/01/21 DOCKET NO. 14-30 388 DATE: March 1, 2021 ORDER An initial 70 percent disability rating for service-connected panic disorder without agoraphobia is granted. REMANDED Entitlement to service connection for a gastrointestinal disorder is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for a low back disorder is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDING OF FACT The evidence is at least evenly balanced as to whether the Veteran’s service-connected panic disorder without agoraphobia symptoms and overall impairment more nearly approximated occupational and social impairment with deficiencies in most areas; however, they have not more nearly approximated total occupational and social impairment. CONCLUSION OF LAW The criteria for an initial 70 percent disability rating for service-connected panic disorder without agoraphobia have been met. 38 U.S.C. §§ 1155, 5103, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.126, 4.130, Diagnostic Code 9412. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from July 1968 to July 1970. His decorations include the Combat Infantryman Badge and the Bronze Star Medal. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2012 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO), in Nashville, Tennessee. In February 2019, the Veteran and his daughter, A. N., a mental health therapist, testified at a personal hearing over which the undersigned presided while at the RO. A transcript of the hearing is of record. Following the Board hearing, the Veteran submitted additional evidence pertinent to his claims on appeal. This evidence was accompanied by a waiver of agency of original jurisdiction consideration. See 38 C.F.R. § 20.1304. A TDIU claim is part of an increased disability rating claim when such claim is raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). When evidence of unemployability is submitted at the same time that a Veteran is appealing the rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. As the issue of unemployability has been raised by the record, the issue of entitlement to a TDIU is before the Board. 1. Entitlement to an initial disability rating greater than 30 percent for service-connected panic disorder without agoraphobia. The Veteran asserts that his service-connected panic disorder without agoraphobia is more disabling than reflected by currently assigned 30 percent disability rating. Service connection was established by rating action dated in July 2012 at which time an initial 30 percent disability rating was assigned effective as of October 28, 2011. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C. § 1155. Separate diagnostic codes identify the various disabilities. It is necessary to rate the disability from the point of view of the Veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any reasonable doubt regarding the extent of the disability in the Veteran’s favor. 38 C.F.R. § 4.3. If there is a question as to which disability rating to apply to the Veteran’s disability, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the Veteran’s entire history is reviewed when assigning a disability rating, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, where the Veteran is appealing the initial assignment of a disability rating, the severity of the disability is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). Additionally, in determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. It is possible for a Veteran to have separate and distinct manifestations from the same injury that would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); 38 C.F.R. § 4.14. The Veteran’s service-connected panic disorder is rated pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9412. This disability is rated under the General Rating Formula for Mental Disorders, which provides as follows: A 100 percent disability rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross 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. A 70 percent disability rating is warranted when there is 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 50 percent disability rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 30 percent disability rating is assigned for 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). The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are “not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating.” Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased disability rating, the adjudicator must consider all symptoms of a claimant’s service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. Effective August 4, 2014, VA amended the regulations regarding the evaluation of mental disorders by removing outdated references to the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The amendments replace those references with references to the recently updated Fifth Edition (DSM-V). As the Veteran’s claim was received prior to August 4, 2014, but had not yet been certified to the Board, the DSM-IV is applicable to this case. However, according to the new DSM-V, clinicians do not typically assess Global Assessment of Functioning (GAF) scores. The DSM-V introduction states that it was recommended that the GAF be dropped from DSM-V for several reasons, including its conceptual lack of clarity (i.e., including symptoms, suicide risk, and disabilities in its descriptors) and questionable psychometrics in routine practice. In reviewing the evidence of record, the Board will consider any assigned GAF score; however, the Board is cognizant that GAF scores are not, in and of themselves, the dispositive element in rating a disability. Rather, GAF scores must be considered in light of the actual symptoms of the Veteran’s disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126 (a). The GAF is a scale reflecting psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV). According to the DSM-IV, which VA had adopted pursuant to 38 C.F.R. §§ 4.125 and 4.130, a GAF score of 41 to 50 is reflective of serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). During the February 2019 Board hearing, the Veteran and his daughter, a mental health therapist, endorsed that he had a history of experiencing avoidance of reminders of active service, isolation, sleep disturbance, nightmares, difficulty concentrating, disorientation, hallucinations, paranoia, increased startle response, anxiety, and memory loss. A VA examination report dated in December 2011 shows that the Veteran did not meet the criteria for a diagnosis of posttraumatic stress disorder (PTSD). However, he was diagnosed with panic disorder without agoraphobia. A GAF score of 60 was assigned. His level of occupational and social impairment with regard to all mental diagnoses was described as occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The Veteran reported that prior to service, he had never been fired from any job, but that since service, he had been fired from three, one of which was from a business he had with his father. The Veteran reported experienced sleep disturbance, depression, panic attacks, and suicidal thoughts. Symptoms that applied to the Veteran’s diagnosis were said to include anxiety, panic attacks more than once a week, chronic sleep impairment, and mild memory loss. VA outpatient treatment records dated from May 2011 to April 2013 show that the Veteran had reported anxiety, mood disorder, panic attacks, sleep disturbance, and occasional nightmares, with a history of a strained relationship with his father for which he had been charged with aggravated assault against his father. Mental status examination during this period revealed appropriate hygiene and grooming. He was alert and oriented to person, place and time. He had no abnormal motor movements. He maintained good attention and focus on the interviewer. Speech had regular rate, rhythm, and tone. Mood was euthymic. Affect was slightly restricted. There were no hallucinations or delusions noted. Thought process was logical and goal-directed. There were no suicidal or homicidal ideations. Cognition and memory were intact. Judgment and insight were good. The assessment was anxiety disorder, not otherwise specified; depressive disorder, not otherwise specified; and a history of alcohol abuse. GAF scores ranged from 55 to 60. A private psychiatric evaluation report from S. Moragne, M.D., dated in June 2016, shows that the Veteran reported having last worked in 2012 where he worked as a forklift operator in a family run business. He job ended because of his mental health problems, having difficulty maintaining focus and concentration. He was said to be very forgetful. He had difficulty handling stress and would experience frequent panic attacks. He would have memory issues, anxiety attacks, and depressive symptoms. He would panic in crowded and enclosed areas, as well as in social situations. He would have flashbacks, nightmares, sleep disturbance, and poor impulse control, becoming assaultive, threatening, and verbally abusive. A history of assaulting his father in 2012 was noted. He was said to have an explosive temper, management issues, impulsivity, and poor judgment. Mental status examination revealed he was well dressed with good hygiene, but only oriented times two, having gotten the date wrong. He appeared euthymic with a normal affect. He had continued sleep problems but had a good appetite. He did not have social outlets or support. He would isolate himself with his wife and dog. Speech was normal with no flight of ideas. He reported occasional auditory and visual hallucinations. He did not endorse any paranoid delusions. He was a good historian. He endorsed having panic attacks triggered by crowds which would be stressful to him. He did not endorse obsessive compulsive disorder or intrusive thoughts. He reported decreased memory. Insight and judgment seemed fair. The diagnosis was PTSD (secondary to Vietnam War experiences), panic disorder with agoraphobia, recurrent major depressive disorder, and mild to moderate dementia. Dr. Moragne opined that the Veteran’s symptoms most closely approximated occupational and social impairment, with deficiencies in most areas. Panic was said to affect functionality, an inability to function independently, difficulty in adapting to stressful circumstances including work, and problems with relationships. He would also experience some hallucinations, disorientation, memory issues, and difficulty in stressful work, family, and social situations. It was concluded that his disability more nearly approximated the criteria for at least a 70 percent disability rating. A private medical record from Dr. E. Davis, dated in February 2019, shows that the Veteran was said to meet the criteria for a diagnosis of PTSD. The disability was said to be manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Symptoms that applied to the Veteran’s diagnosis were said to include depressed mood; anxiety; suspiciousness; panic attacks more than once a week; chronic sleep impairment; mild memory loss; impairment of short-and long-term memory; flattened affect; circumstantial, circumlocutory or stereotyped speech; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work like setting; inability to establish and maintain effective relationships; impaired impulse control, such as unprovoked irritability with periods of violence; persistent delusions or hallucinations (minor); and disorientation to time or place. Dr. Davis added that during the examination, the Veteran frequently demonstrated tangential thinking, generating random statements on different subjects. He endorsed that it was hard for him to think straight. He was said to, in the past and currently, experience the symptoms consistent with chronic PTSD. The Veteran’s GAF scores have ranged from 55 to 60. These findings are indicative of a description of symptoms that have ranged from moderate to serious with moderate to serious impairment in social and occupational functioning. In light of the broad range of GAF scores provided, the Board will place greater weight on the objective facts than on the subjective GAF scores. In this regard, it is the impact of the Veteran’s psychiatric symptomatology on his occupational and social functioning that is the ultimate consideration. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). Here, the range of GAF scores cannot, in and of themselves, establish the precise level of occupational and social impairment. The overall evidence of record has demonstrated that the Veteran has consistently experienced ongoing depression, anxiety, sleep disturbance, nightmares, irritability, avoidant behavior, impaired memory, impaired impulse control, disorientation, difficulty concentrating, regular panic attacks, and anxiety. He has also endorsed visual and auditory hallucinations. In order to meet the criteria for a 70 percent disability rating, the Veteran’s disability would have to be manifested primarily by occupational and social impairment, with deficiencies in most areas due to symptoms such as suicidal ideation; obsessional rituals; intermittently illogical speech; near-continuous panic or depression; 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; and an inability to establish and maintain effective relationships. In this regard, the Veteran has exhibited near-continuous panic and depression, impaired impulse control, difficulty in adapting to stressful circumstances, disorientation, and difficulty establishing and maintaining effective relationships. Additionally, he has endorsed intermittent hallucinations which are included among the criteria for a 100 percent disability rating. Although he did not exhibit all of the symptomatology consistent with a 70 percent disability rating, resolving all doubt in favor of the Veteran, the Board finds that overall, his disability picture over the entire course of the appeal meets the criteria for a 70 percent disability rating. See Mauerhan, 16 Vet. App. at 442. The Board has additionally reviewed the evidence to determine if a disability rating in excess of 70 percent may be assigned. A 100 percent disability rating requires symptoms more nearly approximating total occupational and social impairment. The preponderance of the evidence of record demonstrates that while the Veteran exhibited hallucinations and some disorientation, he has not exhibited gross impairment in thought processes or communication; persistent delusions; gross inappropriate behavior; or persistent danger of hurting self or others. Moreover, the Veteran has apparently maintained a good relationship with his wife and daughter. Thus, total impairment is not demonstrated. In sum, considering all applicable rating criteria, the Board finds that the level of impairment presented by the Veteran’s service-connected psychiatric disorder over the course of this appeal warrants a 70 percent disability rating, and no higher. As such, overall disability picture most closely approximates the criteria for an initial 70 percent disability rating. Consideration has been given to additional staged ratings since the date of the Veteran’s claim (i.e., different percentage ratings for different periods of time). See Fenderson, 12 Vet. App. at 119. There, however, appears to be no identifiable period of time since the date of claim during which an additional staged rating for the psychiatric disorder would be warranted. The Board has considered the statements of the Veteran as to the extent of his current symptoms. He is certainly competent to report that his symptoms are worse. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, in evaluating a claim for an increased schedular rating, VA must consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. REASONS FOR REMAND 1. Entitlement to service connection for a gastrointestinal disorder, to include gastroesophageal reflux disease and gastric ulcers. The Veteran asserts that he has a gastrointestinal disorder that was first manifested during his period of active service. During the February 2019 Board hearing, the Veteran described that he began having stomach trouble during his combat service overseas. He indicated that he was given a chalky liquid to drink in the field to treat his stomach pain, nausea, and vomiting. He added that upon returning home, he had ongoing burning and pain for which he has taken medication ever since. Service treatment records dated in August 1969 show that the Veteran reported a three week history of burning pain in the stomach coupled with diarrhea and nausea. Physical examination revealed gastrointestinal tenderness. The impression was probable functional gastrointestinal syndrome. In December 1969, he was treated for reported epigastric pain. He indicated that he had experienced similar symptoms prior to service, but had never had X-rays. Symptoms were said to have returned after three months in Vietnam. An upper gastrointestinal series was conducted, but was negative. He was prescribed Famotidine and Maalox. It was also noted that the Veteran was very nervous. Post-service outpatient treatment records show that the Veteran has been intermittently treated for symptoms associated with a gastrointestinal disorder, to include gastroesophageal reflux disease. If the Veteran engaged in combat with the enemy, and it is claimed that a disease or injury was incurred in such combat, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(d). To establish service connection, however, there must be medical evidence of a nexus between the current disability and the combat injury. See Dalton v. Nicholson, 21 Vet. App. 23 (2007); Libertine v. Brown, 9 Vet. App. 521, 523-24 (1996). In such cases, not only is the combat injury presumed, but so are the consequences of that injury at least in service. See Reeves v Shinseki, 682 F.3d 988 (Fed. Cir. 2012). In considering the foregoing, it is again noted that the Veteran is in receipt of the Combat Infantryman Badge and the Bronze Star Medal which establish that the he engaged in combat. He is competent to report symptoms of his disability. His service treatment records show in-service manifestation, and post-service treatment records show ongoing treatment. Additionally, the service connection has been established for a psychiatric disorder. The Veteran’s service treatment records suggested that in being treated for his gastrointestinal symptoms, he was noted to be very nervous. The Board is required to consider all theories of entitlement raised either by the claimant or by the evidence of record as part of the non-adversarial administrative adjudication process. See Robinson v. Peake, 21 Vet. App. 545, 553 (2008), aff’d sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009); see also Schroeder v. West, 212 F.3d 1265, 1271 (Fed. Cir. 2000). As such, on remand, an opinion should be obtained addressing whether the Veteran has a current gastrointestinal secondary to his service-connected psychiatric disorder. Given this evidence, a remand is warranted to afford the Veteran a VA examination to obtain the necessary etiology opinions. See 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159; McLendon v. Nicholson, 20 Vet. App. 79 (2006). 2. Entitlement to service connection for bilateral hearing loss. The Veteran asserts that he has a bilateral hearing loss disability that is a result of exposure to excessive artillery fire, bombing, and other acoustic trauma experienced during his combat service in the Republic of Vietnam. Service connection for tinnitus as a result of combat service has already been established. During the February 2019 Board hearing, the Veteran reiterated that his hearing loss symptoms began at the same time as his tinnitus. He added that he had not been given the benefit of ear protection. He stated that his symptoms had become progressively worse ever since. A VA examination report dated in March 2012 shows that the Veteran was diagnosed with left and right ear sensorineural hearing loss. The examiner concluded that the Veteran had no evidence of hearing loss during service, and that while he did have noise exposure sufficient to lead to tinnitus, it was less likely than not that the hearing loss was related to service. In this instance, while the VA examiner noted the Veteran’s reported history, in offering an opinion regarding etiology, the examiner did not afford the Veteran’s lay statements any weight and instead relied on the absence of evidence in the service treatment records in providing a negative nexus opinion. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (examination was inadequate where the examiner did not comment on the appellant’s report of in-service injury and instead relied on the absence of evidence in the service medical records to provide a negative opinion). Additionally, it is conceded that the Veteran sustained acoustic trauma as a result of in-service combat, and that not only is the combat injury presumed, but so are the consequences of that injury at least in service. See Reeves v Shinseki, 682 F.3d 988 (Fed. Cir. 2012). As such, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992); see also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 3. Entitlement to service connection for a low back disorder. The Veteran asserts that he has a low back disorder that his manifested as a result of his period of active service. During the February 2019 Board hearing, he described that the rigors of being in an infantry unit, to specifically include jumping as a parachutist, resulted in the onset of low back symptoms. He described injuring his back on his fourth jump when he was impacted by wind causing him to hit the ground backwards. The Veteran added that he has experienced low back symptoms ever since and has been diagnosed with spinal stenosis. The Veteran’s service personnel records confirm that he served in an infantry unit, that he engaged in combat with the enemy, and that he earned the parachutist’s badge. A private medical record from S. J. Chung, D.O., dated in March 2019, shows that the Veteran was diagnosed with intervertebral disc syndrome, foraminal lumbar spine stenosis, and bilateral lumbar radiculopathy. Dr. Chung opined that the spinal conditions were causally related and aggravated by the events which occurred in active service. However, Dr. Chung did not provide a rationale for the opinion that he provided. Nonetheless, the Veteran has not been afforded a VA examination addressing the etiology of the asserted low back disability. Given this evidence above, coupled with the Veteran’s combat service, a remand is warranted to afford him a VA examination to obtain the necessary etiology opinion. See 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159; McLendon, 20 Vet. App. at 79. 4. Entitlement to a TDIU. The claims file does not contain a VA Form 21-8940, Application for Increased Compensation based on Unemployability, and the record does not otherwise indicate if/when the Veteran was last gainfully employed, or, the Veteran’s level of education and work history. This information is necessary to decide the claim. Moreover, in light of the grant of an increased disability rating for the service-connected psychiatric disorder, and given the additional development required for the remaining issued being remanded, the issue of entitlement to a TDIU must be deferred. The claims are inextricably intertwined and, before the issue of entitlement to TDIU can be addressed on appeal, the foregoing development and implementation of the grant of an increased disability rating must be undertaken. See Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. Request from the Veteran a completed VA Form 21-8940, Application for Increased Compensation Based on Unemployability, to ascertain the Veteran’s last date of employment, level of education, and work history. 2. Schedule the Veteran for a VA examination for his asserted gastrointestinal disability. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion(s) below. The examiner should answer all of the following questions: (a) Is it at least as likely as not that the Veteran's diagnosed gastrointestinal disorder had its onset in service, was manifested by peptic ulcer disease in the year immediately following any period of service, or is otherwise the result of a disease or injury in service, to specifically include the 1969 treatments for gastrointestinal symptoms? (b) Is it at least as likely as not that the Veteran's diagnosed gastrointestinal disorder was caused (in whole or in part) by a service-connected disability, to specifically include the service-connected psychiatric disability? (c) Is it at least as likely as not that the Veteran's diagnosed gastrointestinal disorder is aggravated (made worse as shown by comparing the current disability to medical evidence created prior to any aggravation) by a service-connected disability, to specifically include the service-connected psychiatric disability? If the Veteran's current gastrointestinal is aggravated by a service-connected disability, the examiner should also indicate, to the extent possible, the level of such aggravation by identifying the baseline level of disability. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptomatology, he or she must provide a reason for doing so. The examiner is instructed to concede that the Veteran experienced gastrointestinal symptoms during his period of combat service, and that not only are such symptoms presumed, but so are the consequences. If the examiner is unable to provide an opinion without resort to speculation, a reason must be provided, and what additional evidence would be necessary before an opinion could be rendered must be given. The examiner must provide a rationale for each opinion given. 2. Schedule the Veteran for a VA examination for his asserted bilateral hearing loss disability. The examiner must review the claims file. The examiner is directed to opine as to whether it is at least as likely as not that the current bilateral hearing loss had onset in service or is causally related to active service, to include as due to acoustic trauma experienced therein. The examiner is instructed to concede that the Veteran sustained acoustic trauma as a result of in-service combat, and that not only is the combat injury presumed, but so are the consequences of that injury at least in service. In providing this rationale, the examiner must comment on the likelihood that the incidents of loud noise experienced during service resulted in damage to auditory hair cells even though findings may or may not suggest a recovered temporary threshold shift during service. If the examiner finds auditory hair cell damage to be a likely result of in-service noise exposure, then he/she should comment on the likelihood that such damaged auditory hair cells would result in a greater permanent hearing loss than otherwise would be manifested. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran’s reports of symptomatology, he or she must provide a reason for doing so. The absence of evidence of treatment for a hearing loss disability in the service treatment records cannot, standing alone, serve as the basis for a negative opinion. If the examiner is unable to provide an opinion without resort to speculation, a reason must be provided, and what additional evidence would be necessary before an opinion could be rendered must be given. The examiner must provide a rationale for each opinion given. 3. Schedule the Veteran for a VA examination for his asserted low back disorder. The examiner must review the claims file. The examiner is directed to opine as to whether it is at least as likely as not that the currently diagnosed low back disability had onset in service or is causally related to active service, to include as due to infantry service as a parachutist. The examiner is instructed to concede that the Veteran’s combat service, and that not only is the combat injury presumed, but so are the consequences of that injury at least in service. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran’s reports of symptomatology, he or she must provide a reason for doing so. The absence of evidence of treatment for a back injury in the service treatment records cannot, standing alone, serve as the basis for a negative opinion. If the examiner is unable to provide an opinion without resort to speculation, a reason must be provided, and what additional evidence would be necessary before an opinion could be rendered must be given. The examiner must provide a rationale for each opinion given. (Continued on the next page)   4. Following the above development and the implementation of the increased disability rating granted herein, readjudicate the claim for a TDIU. L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Orfanoudis, 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.