Citation Nr: 21041759 Decision Date: 07/10/21 Archive Date: 07/10/21 DOCKET NO. 14-34 124 DATE: July 10, 2021 ORDER New and material evidence has been received and the request to reopen a claim for service connection for residuals of pneumothorax is granted. Entitlement to an initial rating in excess of 70 percent for posttraumatic stress disorder (PTSD) before October 29, 2020 is denied. REMANDED Entitlement to service connection for service connection for residuals of pneumothorax is remanded. Entitlement to service connection for a right eye disability (claimed as right eye damage) is remanded. FINDINGS OF FACT 1. In a February 2009 rating decision, the Department of Veterans Affairs (VA) Regional Office (RO) denied service connection for residuals from a pneumothorax (pneumothorax); the Veteran did not appeal the decision and new and material evidence was not received within the one-year appeal period. 2. Evidence associated with the record since the February 2009 rating decision relates to unestablished facts and raises a reasonable possibility of substantiating the claim of entitlement to service connection for pneumothorax. 3. The severity, frequency, and duration of the Veteran's PTSD symptoms did not more closely approximate total occupational and social impairment before October 29, 2020. CONCLUSIONS OF LAW 1. The criteria for reopening the previously denied claim for service connection for pneumothorax have been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156(a). 2. The criteria for an initial rating in excess of 70 percent for PTSD before October 29, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 2004 to December 2008. His service included duty in Iraq which included combat. In addition, the Veteran served in the United States Army Reserves from March 2009 to August 2010. In June 2018, the Veteran appeared at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is in the record. In October 2018, the Board issued a decision denying the Veteran's claim to reopen the claim for service connection for pneumothorax. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In a February 2018 Order, the Court vacated and remanded the Board's decision for compliance with the instructions in the Joint Motion. In October 2018, the Board remanded the case to the RO for additional development as to the claims for service connection for a right eye disability and a higher rating for PTSD. In September 2020, the Board remanded all claims. With respect to the issues decided herein, the requested development has been completed. Thus, no further action is necessary to comply with the Board's remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). Service Connection 1. Whether new and material evidence has been received to reopen a claim for service connection for residuals of pneumothorax If a claim of entitlement to service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 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 credibility of the evidence is presumed for purposes of reopening the claim. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). The threshold for reopening is low. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Service treatment records demonstrate the Veteran was treated for a spontaneous pneumothorax in December 2007. The RO denied the Veteran's claim of service connection for pneumothorax in a February 2009 rating decision, finding that the medical evidence of record did not show a current disability from the pneumothorax. The Veteran was provided notice of this decision and his appellate rights but did not appeal the decision or submit new and material evidence within one year of the decision. Therefore, the decision is final. See 38 C.F.R. §§ 3.156, 20.302, 20.1103 (2009). The evidence received since the February 2009 rating decision includes evidence that is both new and material to the claim. See 38 C.F.R. § 3.156. For example, the Veteran reports that in cold weather or with some exertion, he experiences chest pain. Since the original denial, there has been a significant change in VA law. In Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), 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. Further, the Veteran has submitted evidence and medical literature that suggested that having developed one spontaneous pneumothorax in service, he is susceptible to another. In addition, service treatment records noted a lower thoracic scoliosis while treating the pneumothorax. The medical literature submitted by the Veteran indicates a relationship between scoliosis and spontaneous pneumothorax. This new evidence addresses the reason for the previous denial; that is, a current disability (a symptom possibly causing functional limitation), a nexus to service, and raises a reasonable possibility of substantiating the claim. The credibility of this evidence is presumed for purposes of reopening the claim. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). Accordingly, the claim is reopened and will be considered on the merits. Before the Board addresses the merits, further development is required. 2. Entitlement to an initial rating in excess of 70 percent for posttraumatic stress disorder (PTSD) before October 29, 2020 Disability ratings are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Different ratings may be assigned for different periods of time for the same disorder if the facts show distinct time periods with different levels of disability. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. See 38 C.F.R. § 4.3. The evidentiary record does not reasonably raise the prospect that the Veteran's disability is not and cannot be adequately rated under the Rating Schedule. The Veteran is currently assigned a 70 percent disability rating pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, for PTSD since the effective date, February 29, 2012, which is the date he filed for service connection. Effective October 29, 2020, PTSD has been rated at 100 percent. The Veteran asserts he is entitled to a 100 percent rating from February 29, 2012 to October 29, 2020. The Veteran's PTSD is evaluated under Diagnostic Code 9411, which assigns ratings based upon the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. A 70 percent 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 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, or 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; and the inability to establish and maintain effective relationships. Id. A maximum 100 percent rating is warranted when there is 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 and place; memory loss for names of close relatives, own occupation, or own name. Id. The symptoms listed in the General Rating Formula for Mental Disorders are not intended to constitute an exhaustive list. Rather, the symptoms serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). The record includes Global Assessment of Functioning (GAF) scores that clinicians have assigned. The GAF was a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV); Carpenter v. Brown, 8 Vet. App. 240 (1995). Clinicians dealing with mental health issues currently use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Given the procedural posture of this appeal, the DSM-5 applies. See 80 Fed. Reg. 14308 (Mar. 19, 2015) (DSM-5 applies to claims received by VA or pending before the agency of original jurisdiction on or after August 4, 2014). The United States Court of Appeals for Veterans Claims (Court) noted that the DSM-5 eliminated GAF scores because of their conceptual lack of clarity and questionable psychometrics in routine practice, and further stated that an adjudicator is not permitted to rely on evidence that the American Psychiatric Association itself finds lacking in clarity and usefulness. The Court explained symptoms should be the primary focus when assigning a rating for a psychiatric disorder and clarified that the use of numerical GAF scores as a shortcut for gauging psychiatric impairment would be error. Further noted was that the adequacy of medical examinations has never depended upon the use or inclusion of GAF scores. Golden v. Shulkin, 29 Vet. App. 221, 224-26 (2018). Accordingly, the Board has ignored any GAF scores in the record as part of its analysis. In March 2012, a mental health provider diagnosed the Veteran with PTSD. He reported poor sleep, constant alertness, hypervigilance, anger, and drinking to calm himself. The Veteran asserted he could not to hold a job because he cannot deal with civilians. He finds his concentration is poor. He has intrusive thoughts about his service in Iraq and gets upset with the news. The Veteran did not display overt depression, anxiety, or report a history of mania, hypomania, hallucinations, or paranoia. He denied suicidal or violent thoughts. During the evaluation, the Veteran was alert, oriented, pleasant, cooperative, and maintained eye contact. He had a euthymic mood with an appropriate and congruent affect. The Veteran, however, described his mood as unmotivated wanting to isolate all day. Thought processes and memory appeared intact. Speech was coherent. Thoughts were logical with some slight rumination on "all the problems in the world" and the current political environment. The Veteran had fair insight and judgment. The Veteran also underwent a VA examination in March 2012. Again, the VA examiner diagnosed PTSD which resulted in occupational and social impairment with reduced reliability and productivity. Since separation, the Veteran reported he no longer spends time with his former friends. He has difficulty expressing his feelings to others and often feels irritable. He has panic attacks in social settings. He has not dated in over a year and feels too anxious and depressed to start dating. Nevertheless, the Veteran hoped to start dating again in the near future. He lives with his step- father but they rarely speak and spend most of their time in separate parts of the house. Currently unemployed, the Veteran plans to move out once he has a job. He has an associate degree but has worked odd jobs. He never got along with people at work. In one instance, he worked at a job for three weeks but got into an argument with his supervisor and did not like the job. The Veteran slept only a few hours a night due to nightmares. He also has intrusive thoughts. He was easily distracted and lost his train of thought. He often scanned his environment. He was agitated by loud noises. The Veteran experienced intense psychological or physiological distress at reminders of his stressors. The Veteran tried to avoid thoughts, feelings, conversations, activities, places, or people that are associated with his trauma. The Veteran also reported markedly diminished interest or participation in significant activities, experienced feelings of detachment or estrangement from others, and a restricted range of effect. The Veteran characterized his symptoms as severe and occur daily. The examiner noted the Veteran had symptoms of a depressed mood, suspiciousness, weekly or more frequent panic attacks, mild memory loss, a flattened effect, and disturbances in motivation and mood. He also had difficulty in adapting to stressful circumstances and intermittent inability to perform activities of daily living. On the other hand, the Veteran did not have circumstantial, intermittently illogical, obscure, or irrelevant speech problems. He had no difficulty in understanding complex commands. Judgment and abstract thinking were not impaired. There was not a gross impairment in thought process or communication. He has not been assaultive or suicidal. The VA examiner concluded the Veteran displayed a severe deficit in social functioning and has become a very socially isolated individual with little emotional connection to others. The examiner also concluded the Veteran displayed a moderate deficit in vocational functioning. He has difficulty in maintaining employment due to high levels of anxiety and irritability in the workplace. The examiner had a cautiously optimistic prognosis for the Veteran. While the Veteran continued to struggle with high levels of anxiety, depression, and irritability, the Veteran had some strengths. He is a highly intelligent individual and just beginning to utilize mental health service. The examiner hoped the Veteran could develop the skills necessary to effectively control his trauma related symptoms. In August 2012, the Veteran was noted to be very future oriented and believed in a higher power. He had, however, feelings of hopelessness, negativity about world events, and questionable prospects about making a life for himself. The Veteran also reported sleep problems, flashbacks, and nightmares. The Veteran did not have any hallucinations, suicidal ideations, or homicidal ideations. He is bright and high functioning. In a November 2012 mental health evaluation, the Veteran stated he drank alcohol to get numb. He felt depressed, irritable, and frustrated that he did not know where he fit in since returning from deployment. The Veteran denied suicidal ideations but reported anger outbursts at strangers and his roommate; he avoids socializing when possible. He has problems falling and staying asleep due to nightmares and night sweats. While he does go to clubs "to escape reality," he does not talk to anyone. He is concerned about the country's financial system, the wars around the world, and the division that exists among people. He thinks and dreams about his experiences in the military and becomes hypervigilant when he hears noises. He had reduced appetite and feelings of guilt or hopelessness. Nearly every day he has trouble concentrating. Quite often, he re-experienced events, becomes upset, and then had physical symptoms. He made extreme efforts to avoid thoughts and activities. The Veteran described a moderate loss of interest but extreme feelings of distance and numbness. He did not have any trouble with recall but felt he had extreme difficulty concentrating. The Veteran also felt extremely nervous. He was not easily startled. He had a moderate feeling his life is foreshortened. A month later, the Veteran in December 2012 reported that he stays up all night watching CNN or BBC or reading history books. In January 2013, the Veteran reported he was "addicted to current events," but also interested in conspiracy groups and history. Others do not share the intensity of his interests, and this is isolating. He was in school. He has chronic insomnia, sleeps only 4 hours, then is wide awake and active. Every month, the Veteran has one to two days in a row where he does not sleep at all. He has had depression and anxiety at times. Religion is important to him- he reads the Bible every morning to look for direction. He has continued difficulty relating to peers in his age demographic and relates more to people in their 50's or 60's. His mood has been stable but dependent or reliant to his feelings about current events. When he feels depressed about events he will listen to music, go on a walk, or pick up the Bible. The Veteran stated he would like to look for a stable job that makes him happy and get in touch with his faith. The Veteran, in April 2013 identified symptoms of social anxiety, obsessive focus on certain topics, and an inability to get and keep a job. Nevertheless, he continued to try finding work and is motivated to do so. His goal is to establish financial stability. Interviewers have told him that he is all over the map, tangential, and rambling. Others tell him they are unable to follow him in conversation. He wakes after 4 hours of sleep with high energy and must get out of bed. He feels little need for sleep or food and forces himself to eat once a day. Occasionally does not eat for 24 hrs. He is often irritable, easily angered over small things. The Veteran also experienced racing thoughts. He is more aware of how mood symptoms effect his life. The Veteran has been focused on reading the Bible daily. His providers suggested medication, but the Veteran wanted to continue thinking about it and do research into the pros and cons. The Veteran had logical thoughts with fair organization. The Veteran endorsed multiple symptoms of hypomania. He had hyperverbal, tangential speech. He denied suicidal or homicidal ideation. In July 2014, the Veteran was cooperative, well oriented, related appropriately, and established good eye contact. He gave relevant replies to questions, but the replies were over inclusive and hyperverbal. He reported being in a "just like going with the motion" mood and his affect is appropriate. He believed that certain people do not like the things that he says. He also believed they might eventually harm him, but he placed his faith in the Lord. He did not believe anyone is following him. He denied any intent or plan to retaliate. He also denied suicidal or homicidal ideation, intent, or plan. The mental provider did not find any referential thinking, thought insertion, or diffusion. The Veteran endorsed feeling depressed stating he is in captivity or slavery, but this applied to everyone if one does not believe in the Lord. Currently, his sole interest is in the Bible and appeared upbeat when talking about his Bible/religious beliefs. The Veteran displayed over productive, pressured speech but sufficient insight and judgment The Veteran continued to have nightmares occurring irregularly at weekly intervals. He did not report flashbacks. He tries to avoid crowded settings and does not like talking about his military experience, preferring to keep it to himself. Occasionally he is startled if a door is slammed. The Veteran had no friends and no longer goes to clubs. Once in a blue moon, he will walk to the beach and watch the ocean. He called himself a hermit. He denies ever being too happy or even happy. He endorsed rapid thinking but denied hyperactivity and grandiosity. He reported good, intensive concentration. He endorsed mood fluctuations. On these occasions, he may read something and become agitated, have an outburst of cursing using profanities then he just sits and tears up that this place (the world) is hopeless. He denied having phobias, obsessions, or compulsions. He denied panic attacks and denied ever hearing any voices when alone or seeing visions but later spoke of an experience he had with a spirit. By November 2014, the Veteran participated in the VA vocational rehabilitation program. He stated he needed a job and had good coping skills. As part of the rehabilitation program, he worked in the VA compensated work therapy program and is pleased with it overall. He had an anxious mood, broad affect, good judgement and was talkative. There was no change in risk factors as he had no suicidal or homicidal ideations. He continued to enjoy reading the Bible and keeping up with politics. He had pressured speech but good eye contact. He had a tangential thought process with some paranoia elicited. The Veteran had fair judgement and insight. By January 2015, the Veteran reported he is not as hyper and learned to let things go. He is happy with his job and recently had been offered a permanent full-time position. (The Veteran worked for VA in an administrative/clerical position). He endorsed some underlying depression but had an overall more positive outlook. Outside of work he spends time educating himself about current events, reads the Bible, and preaches. He recently went to a restaurant/bar with a friend, drinking a glass of wine, and talking with some females. He was able to keep the conversation light and avoided getting into politics or sharing his views. He still had fragmented sleep with sometimes having nightmares about world tragedies and mass chaos. By this point, the Veteran used medications to alleviate his symptoms and was pleased with the effects. The Veteran was alert and oriented with a neutral mood and some underlying anxiety. He had broad affect. He denied any hallucinations, suicidal ideations, or homicidal ideations. His speech was goal-oriented with regular rate, rhythm, and tone and he had good eye contact. The thought process was tangential with a religious and political over tone. The Veteran had some underlying paranoia/suspiciousness but was not a danger to self or others. The Veteran had an adequate and fair insight and judgement. The Veteran in April 2015 reported he finds the medications helps keep him calm, and finds he is less irritable. He does not associate with people he does not agree with. He keeps his beliefs to himself particularly in the workplace. Socially, he meets with a group who read the Bible how he reads it. Says he feels depressed mostly about the future of our country, but he tries to take things one day at a time. In June 2015, the Veteran reports that medication has been working out as he feels calmer and getting sufficient sleep. He states he is less reactive to what goes on in the world since medicated. His mother finds him calmer with the medication. He assessed his work performance as good and has been told he is good in customer service. He did not raise any PTSD symptoms. However, the Veteran stays away from people to avoid dealing with their emotions. The only people he felt are unsafe to him are "the elite," people in big administrative positions, but they are not around him. In October 2015, the Veteran reported increased medication made him feel calmer. Occasionally he speaks louder or so others tell him. However, at work they find him quiet. He reports performing well there and his work is appreciated. He expressed frustration with coworkers from a different shift not doing their work, but he did not indicate this frustration affected his functioning. He only reported anxiety related to world changes, and concern about politics. The Veteran reported some paranoia symptoms. He anticipates marshal law to be instituted and he then will be extracted from home which he will be happy about- a fulfilled prophecy. This excited him because what he predicted is happening in the world. He had clear speech with answers are relevant to the questions asked but his conversations drifted into his beliefs about the world. He continued to read daily the Bible which comforts him. The Veteran had proper insight and judgment. There was no suicidal or homicidal ideation. By December 2015, the Veteran reported he has been mellower, calmer. He gets along with his mother. He remains gainfully employed and works the nightshift which he likes. He assesses that he is a good worker, has been told he is a hard worker, and the staff has given positive feedback about him. He had plans to move up in position. The only paranoia he feels is if he sees someone who does not belong in a specific area, then he becomes suspicious. He does not feel targeted or that anyone is out to harm him specifically. The Veteran listens to music, and watches documentaries and the History Channel. In February 2016, the Veteran reported making a recent trip to the fair with a friend, but he had occasional irritation at work. In May 2016, the Veteran assessed that he performs well in his current position and is now trying his hardest to move up at work. He felt he can deal with people, interact with them, including staff. He has been keeping positive and does not let what is going on in the world affect him too much. He sleeps sufficiently. The Veteran goes to church every Saturday. He brought a finances book with him. He indicates that the medication prevents him from as feeling less depressed then before. Whenever he feels a certain way about something, he is not as reactive as he had been at the beginning of treatment. He has a more passive attitude toward certain issues. He is not constantly focusing on a topic or highly energized about something. The Veteran is able to laugh at certain things. He does not bring up PTSD symptoms. When asked, he says in his sleep he sees combat and faces of people who died. He does not call them nightmares. He does not have flashbacks but has premonitions. He has memories of Iraq, wondering why he went there. Depression symptoms are usually triggered by things on the news, lifestyle of certain members of his family and friends. Motivation is good and he goes out with his girlfriend, friends, or at times by himself. He is talkative but his speech is not pressured. At times, he has racing thoughts/overthinks. He reports having much less fluctuations in his mood than before. The Veteran in October 2016 reported he walks around more and does a few pushups. In March 2017, the Veteran reported that he was doing well, "playing the part," working, paying the bills, and taking his medication. He slept up to five hours and felt okay the next day. He found it hard to socialize, "just my church buddies." He sometimes had nightmares related to service. He also endorsed flashbacks, and memories of past trauma mainly with certain faces, certain noises, helicopters, big trucks. He was pleased with his medication which kept him focused and he copes better. He can brush upsetting things off rather than get involved in them. The Veteran had clear speech which was over productive but not rushed. His thought content had a religious overtone and while he properly answered questions, he then drifted to the Bible and his beliefs. The Veteran noted in July 2017 that his sister died and at her funeral, he saw various family members to whom he is not close. Nevertheless, he stayed peaceful without conflicts. He himself is alright with her death. His perspective is that his sister no longer is in pain and now she is in a better place. Work functioning is good, but his sleep fluctuates. He has been walking more and does push-ups every morning. With medication, he has calmed down to a point that he can articulate himself, able to address his problems easily, and move in the right direction. He sometimes has nightmares especially with what is going on in current events. Flashbacks are infrequent with the last one about three weeks earlier. Memories of past trauma occur at times. The Veteran's answers are proper but then he digresses to the way things are in the world or that the war should not have happened with people who died in vain. He has depression but feels he can manage it. The Veteran also reported feelings of hopelessness/helplessness at times but when he feels this way, he turns to his spirituality. His faith and spirituality sustain him a great deal. The Veteran underwent a VA PTSD examination in August 2017. The VA examiner determined that overall, the PTSD symptom severity resulted in occupational and social impairment with deficiencies in most areas. The Veteran lives with his mother but does not say much to her fearing it will scare her. He has not been in a relationship, i.e., a girlfriend. He lost his sister in June and does not maintain frequent communication with his brother who lives in Alaska. He maintains several acquittances at his church although he does not engage in activities outside of church. He avoids interaction with others. He enjoys researching economics and military movement. He now works at VA social services; his performance appraisals have been good. He currently takes medication for his PTSD symptoms and engages in individual psychotherapy. The Veteran reported symptoms of depressed mood, feelings of hopelessness in relation to world events, irritability/anger, sleep impairment with nightmares, intrusive thoughts, becoming easily startled by loud noises, hypervigilance, social isolation, and suspiciousness of others. Regarding his irritability, the Veteran stated that if he is not doing something, he gets irritable and agitated. He avoided reminders of his trauma stressors. The Veteran reported diminished interest or participation in significant activities and feelings of detachment or estrangement. The Veteran also reported symptoms of depressed mood, anxiety, suspiciousness, panic attacks occurring at most once a week. He had mild memory loss. The Veteran described difficulty in establishing and maintaining effective work and social relationships and difficulty in adapting to stressful circumstances. The Veteran had persistent and exaggerated negative beliefs about himself, others, or the world. The Veteran did not have a history of assault or legal problems. The Veteran was alert, oriented, polite, cooperative, and had normal speech, though content and thought process. He did not have any hallucinations, delusions, or suicidal or homicidal ideation. He had adequate judgment and insight. The examiner noted that he had protective factors such as full- time employment, living with his mother, mental health care, and his religious beliefs. The Veteran could handle his financial affairs. In October 2017, the Veteran reported that besides the then recent mass shooting in Las Vegas, everything was good, and he denied feeling depressed. He still worked. His sleep fluctuated with less sleep if he has things on his mind. At that time, the Veteran considered but not yet decided to study accounting and becoming a certified CPA. He continued good work performance; his boss often tells him she is happy that she hired him. He has occasional nightmares and memories of his deployment in Iraq. Flashbacks are not frequent. The Veteran had clear and talkative speech but without pressure. His answers are relevant although he interprets current happenings in the world through the Bible. In February 2018, the Veteran reported good performance at work, good sleep, and good appetite while remaining adherent to his medication regimens. Sleep fluctuates and some nights he sweats from dreams he is having which he describes as "prophetic stuff." He denies feeling persecuted or unsafe but sometimes he gets unknown calls and does not know if it is from "government control." He also feels that they might watch him when he is on his computer as sometimes it shuts down. He believes he is a prophet as he can tell things that are going to happen such as World War III. The Veteran stated in April 2018 he is doing well got promoted at work three weeks earlier. It is going well. His sleep fluctuates; some nights it is good other times fragmented. He benefits from medication. He listens to music from time to time, walks on the beach, goes to church. He is asked and states he has nightmares seeing nuclear missiles and wakes up from them. At times he has flashbacks of "military stuff, certain events that had happened". Memories of past trauma are always there. In June 2018, the Veteran noted he finds work therapeutic and he had good performance. His sleep and appetite fluctuate. He has nightmares of past trauma and "what is coming," flashbacks, and memories of service time. Nevertheless, his reported mood is "alright, just relaxed." The Veteran had a labile, intense affect when he speaks of his beliefs. The Veteran's thought process was tangential and digresses to how the Iraq war (and his participation) was unnecessary or his religious beliefs. He finds help only in the Bible and he otherwise is just moving through society. He stated his energy is alright and he has been exercising, try to keep himself fit. The Veteran reported in September 2018 that he continued to live with his mother and is getting along with her. He has more responsibility at work and performs well. He also keeps up with current events by watching/reading multiple news outlets. He recent made a trip to the local zoo. The Veteran tries to keep himself active, walks, and goes to the beach. He has nightmares and flashbacks related to war/Iraq and certain sounds remind him of Iraq. Occasionally, he feels depressed over what is going on in the world and sees world events happening in the light of the Bible. By December 2018, the Veteran moved into a new position full time in hospice/palliative care. He reports performing well in the new position. He offers no psychiatric complaints and he is doing well. In April 2019, the Veteran shared that he is looking into moving up the ladder and continues to perform well at work. Medication helps keep the Veteran calm and he can say "I have improved." The Veteran attends church every Saturday. He sometimes has nightmares, flashbacks and past traumatic memories are always there. His mental health provider noted he is over productive, elaborating on his religious/political views. The Veteran displayed some religious preoccupation by digressing to his religious beliefs between answers to questions, his Bible readings, and political observations. He commented that he stays away from people in view things that come out of their mouth. On the other hand, the CIA is not his worry now as they have so much to worry about with what is going on all over the world rather than deal with him. By December 2019, he still works in hospice, assessing that he performs well on the job. He also maintains his activities off hours. He assesses that without the medication, he might be angry, maybe condescending. He also can brush things off when he is medicated. He listens to music, goes to the zoo, goes to church, and reads. He does not bring it up but when he is asked, he endorses still having trauma related nightmares, flashbacks, and memories. In April 2020, the Veteran continued to seek treatment but by phone because of COVID 19. He chose to continue working on site. "I have been good, staying positive to the best of my ability." He sometimes has a hard time sleeping. His mind might be preoccupied with what is going on out there. He has an appetite. He is asked and endorsed that he sometimes experienced flashbacks, nightmares, dreams of being back in Iraq, and has memories of the service. He denied any hallucinations "except for my conscience." As for paranoia, the Veteran stated the government has better things to worry about than "little conspiracy me" and denied fearing for his safety. He expressed belief that what is happening is in the Bible. He believes that he foresaw what is going on. The Veteran does not trust people and goes walking early when others are inside. He feels he might not be safe around people because they may see him working when there is a lot of people out of work. He advises his mother also to stay safe, keep the curtains closed. In June 2020, the Veteran states he is hanging in there and stays active with pullups, sit-ups, and walking. He has been social distancing and maintains function. However, with social distancing it is hard to do things such as going to the zoo. The Veteran does grocery shopping. The Veteran believes everyone should stop playing that everything is okay and not engage in sport, entertainment, etc. If not for medication, he would not be coping as well as he is. He does not sleep well as his mind is racing. The Veteran reported some increase in trauma related symptoms but did not provide any elaboration. He punctuates his comments with laughter over what is going on in the world which he says he anticipated. Answers are proper but then he digresses to elaborate how he is not surprised to see what is going on in the world with the pandemic. Motivation is okay. He can get his work done and there is no depression. In September 2020, the Veteran stated he keeps going, keeps a low profile, does not engage with people, and does his work. His appetite fluctuates. Medication is still beneficial. He walks and keeps up to date with current events. This keeps him going. He still has problems with nightmares, flashbacks, and memories. The Veteran was cooperative and well oriented. The provider noted no evidence of hallucination, delusions, or paranoia. The Veteran had clear, coherent speech and his answers were proper/elaborated. Although the Veteran had feelings of depression at times, he did not have any hopelessness or helplessness. His energy fluctuated but he had enough motivation to do what he must do. There is no suicidal or homicidal ideation, intent, or plan. The Veteran had proper insight and judgment. The mental health provider concluded the Veteran was not acutely symptomatic at present. In the October 22, 2020 treatment note, the Veteran stated he is trying to keep his balance and copes with stress with walking/breathing. He is spending more time at home with his mother. The Veteran has up and down mood and on and off sleep. He continues to stay aware of current events/politics. There is no suicidal or homicidal ideation. The Veteran was talkative, cooperative, and not in acute distress even with a frustrated mood. The Veteran had good judgement and a normal rate of speech. 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). While the Board finds the evidence warrants a 70 percent rating effective February 29, 2012 to October 29, 2020, the Veteran is not entitled to a 100 percent rating for his PTSD during this period. In the Board's view, a 70 percent rating requires a severity of symptoms that rise to a level that inhibits or prevents everyday occupational and social functioning when the symptoms are near continuous (such as near continuous depression or panic attacks), interfere with communication, or present the possibility of harm to the Veteran or others (suicidal ideation or impaired impulse control). A 100 percent rating requires symptoms presenting a higher level of severity such as delusions or gross thought impairment. These are symptoms that are not only near continuous but also evidence of complete or near complete inability to function in everyday life or interact with others, i.e., interpersonal reactions and communications. The Veteran's disability picture does not rise to this level. The Veteran has not reported nor is there evidence of symptoms similar in severity, frequency, and duration to the listed symptoms in the schedular criteria for a 100 percent rating such as an inability to take care of himself, impaired impulse control, judgment or thinking, anger/irritability that presents a threat to others to himself or others, significant memory loss, or loss of concentration that inhibit or prevent work or tasks. The Veteran's symptoms do not rise to such a level of severity and as such, the Board finds that the Veteran's anxiety does not approximate a disability picture as severe as the picture for a 100 percent rating. It may result in occupational and social impairment with deficiencies in most areas but not total impairment. He has not reported symptoms or displayed behavior outside of the norm suggesting a higher rating. It is apparent that the Veteran's symptoms, such as his sleep difficulty, anxiety, depression, social isolation, hypervigilance, obsessions, paranoia, and even anger/irritability, have not essentially totally impaired his social and occupational functioning. First and foremost, the Veteran has demonstrated the ability to maintain occupational functioning. At all relevant times, the Veteran has been employed, actively looking for employment, or undergoing training and/or study. For most of the time, the Veteran has not only been employed, but has apparently been successful. He has assessed his performance as good. Further, the feedback he received from his superiors indicated they are pleased with his performance. He has even been promoted or moved into new positions with more responsibility. While the Veteran has problems with irritability and anger or may at times talk excessively about his beliefs, the Veteran has not done this while at work. To be sure, the Veteran may have difficulty maintaining employment or establishing and maintaining effective work relationships, but the severity of his symptoms does not establish he is unable to maintain occupational functioning or a complete inability to work with others. It is also quite apparent to the Board that anger is a problem for the Veteran. Nevertheless, the Board notes the Veteran has demonstrated impulse control and good judgment regarding his anger. His anger has not resulted in physical assaults of others, breaking objects, or verbal assaults. Instead, he deals with his anger by expressing it in more limited situations such as his statements to the Board or to trusted sources such as his mental health providers. As just indicated, the Veteran can successfully function in his job. Any anger problems have not apparently been directed at his superiors, co-workers, or the public/patients. The Board also notes that the Veteran sometimes displays paranoia and/or an obsessive focus on his beliefs or current events. The Veteran's answers sometimes are more about how he currently sees the world or in relation to his religion. To the extent these behaviors demonstrate paranoia or obsession, they are already incorporated into the 70 percent rating. More importantly, the Board finds that the Veteran's strong spirituality is a strength for him. It allows him to cope and perform in a work like setting. Further, like anger and irritability, the Veteran can exercise judgement and does not raise these beliefs at work so that it interferes with his job performance or interaction with his superiors, co-workers, or the public/patients. As for social impairment and isolation, the evidence demonstrates the Veteran's social impairment and isolation is not as bad as the Veteran believes it is. Although there is evidence of some strain, the Veteran maintains a relationship with his mother and has lived with her for some time. He also apparently has some friends through his church. He also has demonstrated an ability to engage in activities such as walking and exercising, going to the beach or the zoo, watching documentaries and the History Channel, and reading on different subjects such as history, finances, or the Bible. He listens to music. Again, the Board is not saying social isolation and loss of interest is not a problem for the Veteran but the severity of these symptoms along or in combination with his other symptoms do not present a disability picture more nearly approximating the 100 percent rating. The Board also acknowledges he has other symptoms such as sleep impairment and nightmares. However, chronic sleep impairment is already incorporated into the criteria for a lower rating. The evidence also does not establish that any problems with sleep affect his functioning the next day. In a similar manner, the Veteran's functioning has not been affected by his flashbacks, intrusive memories, exaggerated startle response, or hypervigilance. While the Veteran has reported depression, this symptom does not appear to be persistent and the Veteran has never had a problem with suicidal or homicidal ideation. The Board recognizes that the evidence supporting the Veteran's claim for a higher rating for PTSD includes his own statements and the statements from his mother and a friend. In evaluating a claim for an increased schedular disability rating, however, 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. Massey v. Brown, 7 Vet. App. 204, 208 (1994). The objective medical evidence of record is of greater probative value as to the Veteran's level of impairment than his assertions. In any event, the level of impairment described by the Veteran, his mother, and his friend does not rise to that of total occupational and social impairment for the period in question. Further, the Veteran appears to argue he should receive a 100 percent rating because war in Iraq was wrong and he should never have been deployed to Iraq. As a consequence, he developed PTSD. It is unfortunate the Veteran now has PTSD. However, the Veteran is already service connected for PTSD. Thus, VA already acknowledges the PTSD is related to his service. As to the rating during any given period since the effective date of service connection, as noted disability ratings are based upon the schedular criteria of VA regulations. The criteria is based upon how a Veteran's function is affected, not the circumstances that gave rise to the disability. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Board is not free to ignore VA's duly promulgated regulations, which include the Rating Schedule. Franklin v. Brown, 5 Vet. App. 190, 193 (1993). Thus, the Board must assign a rating for the February 2012 -October 2020 period based upon the criteria set forth in the General Formula for psychiatric disabilities. The medical findings (as provided in the examination report and the clinical records) directly address the criteria under which this disability is evaluated and show a disability picture less than total. In sum, the evidence demonstrates the severity of the Veteran's psychiatric symptoms from February 29, 2012 to October 29, 2020 warrant the 70 percent rating. Overall, the evidence is against a finding that the symptoms are near continuous and affect the ability to function independently, appropriately, and effectively, such as contemplated in the criteria for a higher 100 percent rating. The Board finds the severity, frequency, and duration of the Veteran's symptoms, whether listed in the General Formula or unlisted, more closely approximate the symptoms contemplated by a 70 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 100 percent rating. In short, the Board finds the Veteran's symptoms of depression, anxiety, anger/irritability, avoidance behavior, social isolation, intrusive thoughts, and sleep problems including disturbing dreams are already incorporated into the 70 percent rating. A 100 percent rating for his PTSD is not demonstrated and therefore, a rating in excess of 70 percent from February 29, 2012 to October 29, 2020 to the present is denied. REASONS FOR REMAND 1. Entitlement to service connection for service connection for residuals of pneumothorax is remanded. Although the Veteran's claim for service connection for residuals of a pneumothorax is now reopened, the Board has determined that further development is warranted before the Board proceeds to the merits of his claim. As noted, the Veteran reports that in cold weather or with some exertion, he experiences chest pain. It is unclear as to whether this symptom rises to the level of functional impairment of earning capacity, Saunders, supra. First, ongoing medical records should be obtained. Thereafter, once the records development is completed, a VA medical examination and accompanying medical opinion is needed to ascertain whether a disability is present and to ascertain the relationship to service. 38 C.F.R. § 3.159; see also McLendon v. Nicholson, 20 Vet. App. 79, 86 (2006). 2. Entitlement to service connection for a right eye disability (claimed as right eye damage) is remanded. The Veteran asserts that he has suffered a right eye disability related to his service. Specifically, the Veteran contends that any eye disability stems from his exposure to environmental hazards during his service. In the last remand, the Board directed medical opinions addressing whether noted eye diagnoses, papillary/allergic conjunctivitis and corneal opacity are related to service. The Board also directed the examiner to address whether the Veteran's refractive error was aggravated or subject to superimposed service injury during that resulted in additional disability. The Veteran received a December 2020 VA eye examination. The examiner concluded that the papillary/allergic conjunctivitis resulted from contact lens misuse, not service environmental hazards. The examiner, however, did not determine whether the contact lens misuse started in service. The Veteran has stated he had no problems with contact lens before his Iraq deployment. As to the corneal opacity, the examiner noted that the prior diagnosis called the corneal opacity old and it was no longer present by the December 2012 examination. However, the Veteran may be entitled to service connection for the corneal opacity if present during any relevant period or shortly prior to the claim being filed. A Veteran is entitled to service connection for a disability even if it was diagnosed before the filing of the claim and resolves by the time of adjudication. See Brammer v. Derwinski, 3 Vet. App. 223 (1992); McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). The Board also directed the VA examiner to determine whether the Veteran's refractive error was aggravated or subject to superimposed injury during service that resulted in additional disability. While the December 2020 VA examiner stated the Veteran's refractive error had not been aggravated by service, the examiner did not provide a rationale for the opinion. Accordingly, the Board has determined that another VA opinion is required. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all outstanding treatment records relevant to his claims. All identified VA records should be added to the claims file. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of the unavailability of the records. 2. After records development is completed, schedule the Veteran for a VA examination to determine whether it is at least as likely as not (50 percent probability or greater) that any current disability of the respiratory system had its onset during service or is otherwise related to an in-service injury, event, or disease, to include a spontaneous pneumothorax. In offering the opinion, the examiner is asked to consider and discuss the Veteran's evidence that since the spontaneous pneumothorax in service, the Veteran has continued to experience chest pain in cold weather or with exertion. The examiner is advised that a symptom such as pain may be considered a VA disability even without an established diagnosis if the symptom results in functional impairment of earning capacity. The examiner is also asked to discuss the evidence that having developed a spontaneous pneumothorax once, the Veteran is now more likely to develop another one. The examiner should elicit a full history from the Veteran and consider the lay statements of record. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, and if there is a medical basis to support or doubt the history provided by the Veteran the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings. 3. After records development is completed, the claims file should be sent to an appropriate examiner to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current eye disability onset during service or is otherwise related to an in-service injury, event, or disease, to include environmental hazards during Iraq deployment, chemical exposure at any time during active service, and contact lens misuse. With respect to any diagnosed acquired vision/eye disorder, to include papillary/allergic conjunctivitis and corneal opacity, that is not considered a refractive error, the examiner must provide an opinion as to whether it is at least as likely as not that such disorder manifested during service or is otherwise related to any incident of service, to include exposure to environmental hazards or to contact lens misuse. With respect to any diagnosed refractive error, the examiner must provide an opinion as to whether it is at least as likely as not that any such disorder has been aggravated beyond its natural progression or subject to a superimposed injury that resulted in additional disability due to the Veteran's active service If the examiner determines that the Veteran does not have any acquired vision/eye disorder, to include papillary/allergic conjunctivitis and corneal opacity, the examiner must reconcile this finding with the prior diagnoses and explain why. The need for an examination is left to the discretion of the examiner. A rationale for all opinions offered is requested as adjudicators are precluded from making any medical findings. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Russell P. Veldenz, 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.