POSTTRAUMATIC STRESS DISORDER (PTSD)

H. SEESEL · 2026 · Case ID: 26004175

MIXED

Summary

The veteran, who served in the U.S. Army from February 1968 to February 1971, appeals decisions regarding his post-traumatic stress disorder (PTSD) and related conditions. The Board granted a 70% disability rating for PTSD prior to December 12, 2019, finding that the veteran's symptoms, including persistent flashbacks, distressing memories, avoidance behaviors, irritability, anger outbursts, and difficulty adapting to stressful circumstances, met the criteria for this rating. However, the Board denied an increased rating above 70% for PTSD from December 12, 2019, forward, concluding that while symptoms persisted, they did not rise to the level of total occupational and social impairment, citing the veteran's maintained social relationships and lack of gross cognitive deficits. The Board also granted service connection for erectile dysfunction as secondary to the medication prescribed for his PTSD, finding the evidence in equipoise regarding the link between the medication and the condition. Consequently, special monthly compensation for the loss of use of a creative organ was also granted. The decision details extensive efforts by the VA to obtain private medical records from a chiropractor, K.S., which were ultimately unsuccessful due to incomplete information and the provider's retirement, leading the Board to find the duty to assist was satisfied.

Rationale

Symptoms approximated near continuous panic or depression affecting ability to function independently.; Difficulty interacting with others and adapting to stressful circumstances contributed to significant social and occupational impairment.; Impaired impulse control, such as unprovoked irritability with periods of violence, was noted.

Service Branch

ARMY

Special Benefit

SMC

Docket No.

13-00 421

Full Decision Text

Citation Nr: 26004175
Decision Date: 04/03/26 Archive Date: 04/03/26

DOCKET NO. 13-00 421
DATE: April 3, 2026

ORDER

Entitlement to a disability rating of 70 percent, but not higher for post traumatic stress disorder (PTSD) prior to December 12, 2019, is granted.

Entitlement to a disability rating in excess of 70 percent for PTSD from December 12, 2019, is denied.

Entitlement to service connection for erectile dysfunction as secondary to medication prescribed for service-connected PTSD is granted.

Entitlement to special monthly compensation based on the loss of use of a creative organ is granted.

FINDINGS OF FACT

1. Prior to December 12, 2019, the Veteran's PTSD manifested as occupational and social impairment with deficiencies in most areas.

2. Prior to and from December 12, 2019, the Veteran's PTSD did not manifest as total social and occupational impairment.

3. The evidence is at least in equipoise as to whether the Veteran's erectile dysfunction has been shown to be related to the medication prescribed for the service-connected PTSD.

4. The loss of use of a creative organ is due to the service-connected erectile dysfunction.

CONCLUSIONS OF LAW

1. The criteria for entitlement to a disability rating of 70 percent, but no higher, for PTSD prior to December 12, 2019, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.126, 4.130, Diagnostic Code 9411.

2. The criteria for entitlement to a disability rating in excess of 70 percent for PTSD from December 12, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.126, 4.130, Diagnostic Code 9411.

3. The criteria for service connection for erectile dysfunction secondary to medication prescribed for service-connected PTSD have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310(a).

4. The criteria for entitlement to special monthly compensation based on the loss of use of a creative organ have been met. 38 U.S.C. §§ 1114(k); 38 C.F.R. § 3.350(a).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran, who is the Appellant in this case, had active service in the United States Army from February 1968 to February 1971. The Board of Veterans' Appeals (Board) is grateful to the Veteran for his honorable service.

This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. §20.900(c). 38 U.S.C. § 7107(a)(2).

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2010 rating decision issued by a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ)

The Veteran testified before the undersigned at a hearing held in June 2016; a transcript of that hearing is of record.

These matters were first before the Board in September 2016 and again in November 2019. In March 2022, the Board denied the Veteran's PTSD claims for increased ratings. The Veteran appealed the Board decision to the United States Court of Appeals for Veterans Claims (Court). In February 2023, the Court granted a Joint Motion for Partial Remand (JMPR), vacating and remanding the Veteran's PTSD claims for increased ratings.

In March 2022, the Board issued a decision denying the Veteran's claims for increased ratings for PTSD. The Veteran appealed the March 2022 Board decision to the United States Court of Appeals for Veterans Claims (Court). In February 2023, the Court granted a Joint Motion for Partial Remand (JMPR), vacating and remanding the issues.

Following the February 2023 JMPR, in May 2023, the Board remanded the Veteran's PTSD claims for increased ratings, in order to obtain outstanding private medical records from the Portland Vet Center. The Board notes that in June 2023 the outstanding private medical records were associated with the claims file. Therefore, substantial compliance with the Board's May 2023 Remand directives has occurred. See Stegall v. West, 11 Vet. App. 268, 271 (1998).

In February
decision to the United States Court of Appeals for Veterans Claims (Court). In February 2023, the Court granted a Joint Motion for Partial Remand (JMPR), vacating and remanding the issues.

In February 2024, the Board granted an increased rating of 50 percent prior to September 17, 2014, denied an increased rating over 50 percent from September 17, 2014, to December 12, 2019, and denied a rating over 70 percent thereafter.

The Veteran appealed the Board's February 2024 rating decision to the Court, and in November 2024, the Court vacated the Board decision and remanded (1) a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to September 17, 2014; (2) a rating in excess of 50 percent for PTSD from September 17, 2014, to December 12, 2019; and (3) a rating in excess of 70 percent for PTSD from December 12, 2019, for action consistent with the directives of a joint motion for partial remand (JMPR).

The portion of the Board's decision granting entitlement to a 50 percent rating for PTSD prior to September 17, 2014, is a favorable finding and was not disturbed by the Court. Roberson v. Principi, 17 Vet. App. 135, 139 (2003) (per curiam order) (the Court lacks authority to disturb favorable findings).

Following the November 2024 JMPR, in April 2025, the Board remanded the increased ratings for PTSD claims to obtain private medical records, including from K.S. and to obtain a VA medical opinion to determine the nature and etiology of the Veteran's sexual dysfunction, including any erectile disfunction. The record reflects that VA asked the Veteran and his representative for additional identifying information regarding private treatment records from K.S. due to insufficient information, made several attempts to obtain the missing private treatment records from K.S., and informed the Veteran that it had not received the records, that he may submit relevant private treatment records, or complete a VA Form 21-4142, Authorization and Consent to Release Information so that VA may obtain these records. Also, a VA opinion was obtained in December 2025 regarding the nature and etiology of the Veteran's sexual dysfunction. Upon review, the Board finds there has been substantial compliance with the April 2025 remand directives, and the terms of the parties' JMPR have been met for the reasons discussed below regarding increased ratings for PTSD. See Stegall v. West, 11 Vet. App. 268, 271 (1998).

Duty to Assist Medical Records

VA has a duty to assist veterans in the procurement of various records in developing their claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. This duty includes obtaining relevant records not in the custody of a federal department or agency, such as private medical care providers. 38 C.F.R. § 3.159(c)(1); 38 U.S.C. § 5103A(b)(1). This obligation is contingent upon a claimant providing sufficient information to facilitate VA's attempt to obtain such evidence. 38 U.S.C. § 5103A(b)(1); 38 C.F.R. § 3.159(c)(1)(i). Thus, although VA has a duty to assist claimants in developing their claims, claimants have ultimate responsibility to locate and secure records; VA has no duty to obtain records that claimants have not adequately identified. See Loving v. Nicholson, 19 Vet. App. 96, 10203 (2005).

Once the duty to assist is triggered, VA will make reasonable efforts to obtain relevant records not in the custody of a federal department or agency. 38 U.S.C. § 5103A(b)(2); 38 C.F.R. § 3.159(c)(1). VA "shall make not less than two requests to a custodian of a private record in order for an effort to obtain relevant private records to be treated as reasonable under this section, unless it is made evident by the first request that a second request would be futile
secure records; VA has no duty to obtain records that claimants have not adequately identified. See Loving v. Nicholson, 19 Vet. App. 96, 10203 (2005).

Once the duty to assist is triggered, VA will make reasonable efforts to obtain relevant records not in the custody of a federal department or agency. 38 U.S.C. § 5103A(b)(2); 38 C.F.R. § 3.159(c)(1). VA "shall make not less than two requests to a custodian of a private record in order for an effort to obtain relevant private records to be treated as reasonable under this section, unless it is made evident by the first request that a second request would be futile in obtaining such records." 38 U.S.C. § 5103A(b)(2)(B) (emphasis added); see also 38 C.F.R. § 3.159(c)(1). VA will refrain from providing assistance in obtaining evidence if there is "no reasonable possibility" that any further VA assistance would aid in substantiating the claim. 38 C.F.R. § 3.159(d).

On review of the record, in April 2023, the Veteran submitted a VA 21-4142, Authorization for Release of Information, and identified K.S. as a provider. VA notified the Veteran in May 2023 correspondence private medical records from K.S. were requested and that it was his responsibility to see that VA received it. A May 2023 report of contact, a VA employee noted that research was performed and contact information for the listed provider was incomplete and unable to be located. The request was closed as the information provided was deemed invalid.

In March 2024 correspondence, the Veteran was informed that information for K.S. did not contain an address or had an incorrect address on the authorization and release form. The Veteran was asked to tell VA the correct address of K.S. so that the medical records could be requested or the Veteran may obtain and send VA the information himself.

In response, the Veteran submitted a completed VA Form 21-4142, in March 2024, and noted that K.S. was a chiropractor who was no longer practicing as she closed the office over two years ago. The Veteran reported that he did not know how to contact her.

In March 2024, a private medical records (PMR) contractor indicated that the request for medical records was rejected due to incomplete information.

In November 2024, the Veteran appealed the February 2024 Board decision denying increased ratings for his PTSD to the Court. The Veteran's representative argued that the Board erred by failing to provide adequate reasons or bases addressing whether or not the duty assist was satisfied regarding private treatment records from K.S. in Kingman, AZ, which were identified by the Veteran. In November 2024, the Parties to the JMPR agreed and the Court stated that although VA informed the Veteran that it had "requested copies of your private medical records from: KS[,]", a subsequent May 2023 Report of Contact indicated that VA was not able to request those records because the information provided by the Veteran was incomplete. See May 9, 2023, VA Notification Letter and May 16, 2023, Report of Contact. As there was no indication that VA later notified the Veteran that it could not obtain those private treatment records from K.S. due to incomplete information, the Board, on remand, was directed to discuss whether VA satisfied its duty to assist in obtaining these private treatment records. See 38 C.F.R. §§ 3.159(c)(1), (e)(1).

In a March 2025 Informal Hearing Presentation, the Veteran's attorney recited the findings in the JMPR, and stated that the Board on remand must discuss whether VA satisfied its duty to assist in obtaining private treatment records from K.S.

In April 2025, the Board remanded the increased ratings for PTSD issues consistent with the November 2024 JMPR and instructed the AOJ to contact the Veteran and his representative and inform them that VA was unable to obtain private medical records from K.S. due to insufficient information to identify and locate the private doctor and the identified records. The remand directed the AOJ ask the Veteran and his representative for additional identifying information, and if provided make and document additional attempts at obtaining the records, unless further attempts would be futile. The remand further noted that the AOJ should request that the Veteran submit relevant private treatment records, including those from K.S., or complete a VA Form 21-4142, Authorization and Consent to Release Information to VA, so that VA may obtain these records.

In May 2025 correspondence, VA notified the Veteran that it was unable to obtain private medical records from K.S. due to insufficient
them that VA was unable to obtain private medical records from K.S. due to insufficient information to identify and locate the private doctor and the identified records. The remand directed the AOJ ask the Veteran and his representative for additional identifying information, and if provided make and document additional attempts at obtaining the records, unless further attempts would be futile. The remand further noted that the AOJ should request that the Veteran submit relevant private treatment records, including those from K.S., or complete a VA Form 21-4142, Authorization and Consent to Release Information to VA, so that VA may obtain these records.

In May 2025 correspondence, VA notified the Veteran that it was unable to obtain private medical records from K.S. due to insufficient information necessary to identify and locate the private doctor and the identified records. The Veteran was advised to provide additional identifying information on the enclosed VA-Form 21-4138 Statement in Support of Claim; submit relevant private treatment records, including those from K.S.; or complete VA Form 21-4142, Authorization and Consent to Release Information and VA Form 21-4142a, General Release for Medical Provider Information, so that VA may obtain these records.

Then the Veteran submitted a completed VA Form 21-4142, in May 2025, identifying K.S. as retired with the office permanently closed. The Veteran reported that K.S. treated him for his right shoulder and lower back conditions.

In May 2025, VA attempted to obtain medical records from Dr. K.S. The Veteran was notified on the same day that VA asked for the private treatment records from Dr. K.S. and that it was the Veteran's responsibility to see that VA received the records. The Veteran was advised to send medical records from the provider as well.

The Veteran subsequently submitted a VA Form 21-4142a, in May 2025, and identified Aspire Medical for treatment for his chest and back. He did not know the street address. He identified K.S. as working for Aspire Medical. He added that he was unable to get a reply from the provider, but a former employee informed him that VA had to contact the medical board.

The evidence reflects that the medical record request was rejected as the request was incomplete in May 2025.

The Veteran was advised that the VA form 21-4142 that he previously submitted was being returned and he was asked to resubmit both VA Forms 21-4142 and 20-4142a so that VA may process his request for medical records.

A June 2025 VA Form 27-0820, Report of General Information, noted that the Veteran advised VA that he did not have additional records from Dr. K.S. as she retired a number of years ago and the office was no longer open.

In June 2025, VA again attempted to obtain the records from Dr. K.S.

VA sent a separate letter in June 2025 to advise the Veteran that VA sent an additional records request to Dr. K.S., still had not received a response from the provider, and that it was the Veteran's responsibility to see that VA received the records.

A June 2025 VA Form 27-0820, Report of General Information noted that the Private Medical Records (PMR) Retrieval Program called the number obtained online for Dr. K.S. and reached a recording that did not confirm the facility and/or doctor. The PMR Retrieval Program performed additional research and was unable to locate alternative contact information for the provider.

A July 2025 VA Form 27-0820, Report of General Information documented the Veteran's call in response to the June 2025 VA letter. He notified VA that Dr. K.S.'s clinical office was closed, the medical records were not able to be obtained, and the medical records had nothing to do with his claim. The Veteran requested VA to move on with his claim.

In an October 2025 letter, VA advised the Veteran that it was unable to obtain private medical records from K.S. due to insufficient information to identify and locate the private doctor and the identified records. VA asked the Veteran to submit relevant private treatment records, including those from K.S., or complete a VA Form 21-4142, Authorization and Consent to Release Information to VA and VA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs (VA), so that VA may obtain these records.

In October 2025 VA Form 27-0820, Report of General Information, the Veteran called in response to the October 2025 letter and advised VA that Dr. K.S.'s clinical office had been closed, the medical records were not able to be obtained, and these medical records had nothing to do with his current claim.
and locate the private doctor and the identified records. VA asked the Veteran to submit relevant private treatment records, including those from K.S., or complete a VA Form 21-4142, Authorization and Consent to Release Information to VA and VA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs (VA), so that VA may obtain these records.

In October 2025, the medical records request was rejected and in October 2025 correspondence, VA asked the Veteran to resubmit both VA Forms 21-4142 and 20-4142a.

The Veteran submitted a VA Form 21-4142a and noted that K.S. was a chiropractor working for Aspire Medical before the office closed. He indicated that neither he nor the doctors were able to get information.

In November 2025, VA asked the Veteran to resubmit both VA Forms 21-4142 and 20-4142a.

In November 2025, the Veteran submitted a partially completed VA Form 21-4142 and responded that regarding the information that VA sought for K.S., a chiropractor from Aspire, she no longer worked there and approximately 3-3 12 years ago the office was closed. The Veteran stated that no one, not even the doctors that worked there, could get records of their patients. The Veteran added that the records had no connection to his claim.

In a January 2026 Informal Hearing Presentation, the Veteran's representative noted that the Board remanded the claim in April 2025, restated the remand directives, and reported that the remanded tasks were completed.

The Board finds VA has satisfied the duty to assist in accordance with 38 C.F.R. § 3.159 and the terms of the parties' November 2024 JMPR as it pertains to outstanding records from K.S. VA made necessary and reasonable attempts to obtain outstanding medical records from K.S. VA sent at least two requests to the identified medical professional, K.S., seeking outstanding medical records. VA informed the Veteran that it had not received the records, that he may submit relevant private treatment records, including those from K.S., or complete a VA Form 21-4142, Authorization and Consent to Release Information and VA Form 21-4142a, General Release for Medical Provider Information, so that VA may obtain these records.

VA's duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Veteran must cooperate with VA's efforts to obtain evidence necessary to adjudicate his claims. The Board notes that the Veteran's representative argued in the November 2024 appeal to the Court that the Board failed to satisfy the duty to assist in the February 2024 decision when it did not ensure that VA made reasonable efforts to obtain private treatment records from K.S. However, only after the Court vacated the February 2024 Board decision and VA repeatedly attempted to obtain medical records from K.S. consistent with the November 2024 JMPR and Board's remand in April 2025, the Veteran informed VA that K.S. treated his right shoulder and back conditions and had nothing to do with his claim for increased ratings for PTSD.

Accordingly, the terms of the parties' November 2024 JMPR regarding the duty to assist to make reasonable efforts to obtain relevant private treatment records have been satisfied, and there is no further action to be taken.

Disability Ratings

Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1.

The Veteran's PTSD is rated under the General Rating Formula for Mental Disorders (General Rating Formula), 38 C.F.R. § 4.130, Diagnostic Code 9411. In relevant part, a 30 percent rating is warranted 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). A 50 percent 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 such as, retention of only highly learned material, forgetting to complete tasks; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to symptoms, such 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, 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. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behaviour; 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; and memory loss for names of close relatives, own occupation, or own name. Id.

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 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.

When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a).

The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b).

Under the General Formula for Mental Disorders, 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).

Entitlement to a disability rating of 70 percent, but not higher for PTSD prior to December 12, 2019, is granted.

Entitlement to a disability rating in excess of 70 percent for PTSD from December 12, 2019, is denied.

The Veteran is seeking an increased rating for his PTSD.

On review of the record, an October 2009 VA treatment note indicated that the Veteran was going through current treatment for his PTSD symptoms. He reported a triggering event
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).

Entitlement to a disability rating of 70 percent, but not higher for PTSD prior to December 12, 2019, is granted.

Entitlement to a disability rating in excess of 70 percent for PTSD from December 12, 2019, is denied.

The Veteran is seeking an increased rating for his PTSD.

On review of the record, an October 2009 VA treatment note indicated that the Veteran was going through current treatment for his PTSD symptoms. He reported a triggering event for his PTSD stressors while watching television. He noted increased sleep problems, seeing intrusive images, feeling withdrawn, avoidance, and becoming more irritable and angrier. He reported nightmares and avoiding his family, staying to himself, and not going to VFW meetings. He also stated he "may have a fleeting thought" about suicide but that it "is not an option" and "does not stay with thought nor was a plan." See October 2009 VA treatment note.

The Veteran underwent a VA PTSD examination in May 2010. This examination found the Veteran living alone, but also in a relationship with his girlfriend of four years. He worked part-time due to a lack of construction projects, as an inspector, for an engineering firm for the past three years. He kept busy with hobbies, including gardening, fishing, and hunting. He had one close friend from the Army, with whom he went hunting and fishing. He went to functions and volunteered at the local VFW and attended family birthday parties. He reported that he was currently working to secure bids to complete the building of the new VFW. He described this, "as a somewhat frustrating process and that he walked out of the building on Sunday due to difficulties interacting with another person."

During the examination, the Veteran was dressed casually and his mood was euthymic and cheerful. He answered questions easily and his thought processes were logical and linear. He did not appear to be suffering any psychological distress or any gross cognitive deficits. He did not have suicidal or homicidal thoughts and there were no signs of psychosis. His judgment was grossly intact with no difficulties communicating. He had nightmares and took medication for it and insomnia. According to the Veteran, since his last examination, he was more easily aggravated with people and had more sleep problems. He described symptoms such as temper issues, memory problems, hypervigilance, and exaggerated startle response. He reported that he continued to suffer from distressing memories from Vietnam. Sounds, like tailgates slamming, and the smell of burning grass took him back to Vietnam. He tried to avoid environmental stressors and had decreased interest in activities that he previously enjoyed. The examiner reported that the Veteran's sleep difficulties were positively impacted by his medication and therapy. The examiner specifically stated that there was no indication that the Veteran suffered any significant work-related difficulties. He did have social dysfunction, which included social isolation, avoidance of social situations, and interacting with people on a very limited basis only.

A September 2010 VA treatment record noted the Veteran's reports of trying to keep his mind occupied and stay busy in order to avoid intrusive thoughts that would take him back to Vietnam. He was unable to relax and had to actively work in order to stay present. He also had to work at being able to be with friends and family. He had been more socially isolated and no longer went to the VFW to avoid talking about Vietnam. He had nightmares and awakened multiple times a night. His assessment was chronic and severe PTSD with restricted life.

A January 2011 VA Mental Health note reported that the Veteran was neatly and casually dressed, polite, and pleasant. He felt that his medications were helpful and his sleep was better and his PTSD symptoms were softened. He added that he thought about Vietnam multiple times an hour, but did so quietly. He stated that he was, "Thinking he will stop work - stressful - focused on safety." He did not have any suicidal thoughts."

In December 2012, he was reported as neatly groomed and had plans to spend time with his family during the holidays. He remained committed to his family and responsibilities despite his PTSD symptoms. He reported having anxiety 4-5 times a week. Loud noises could trigger his PTSD and he would not watch television in order to avoid triggers. He reported that when he recently was at the VFW, someone popped a paper bag and he, "hit the floor." He stated that after an episode like this, he would remain anxious for a few hours followed by nightmares about Vietnam. He has only worked two days since May 2011 because working around loud noises became increasingly difficult for him. He also had memory problems described as forgetting a lot and being unable to finish things that he started due to having intrusive thoughts that would set him off. The assessment reflected that he had intrusive images and nightmares in the daytime. Also, if he was startled in the daytime, then nightmares would follow for a few nights. The provider noted that the Veteran's symptoms for his major depression improved and despite his PTSD symptoms, he attempted to live a purposeful life. The provider documented that she supported the Veteran for applying for an increased rating for his PTSD. Additionally, the provider noted the rating board needed to address the effort and energy the Veteran used to manage his significant PTSD symptoms to live what others defined as a normal life.

An August 2014 VA mental health treatment record noted the Veteran's frustration with intrusive images and thoughts, which distracted him from tasks and impacted his concentration and attention. He reported that he thought about Vietnam many times a day and certain noises took him back to Vietnam. He startled often and felt alone and misunderstood in public. He had a very hard time allowing himself to have fun and being involved with activities outside of his home. Even with his medications, he still had nightmares of combat.

At the September 2014 VA PTSD examination, the Veteran was diagnosed with PTSD and depression. The VA examiner opined that the Veteran had occupational and social impairment with reduced reliability and productivity. The Veteran was still with his girlfriend of the last eight years. He spent winters in Arizona where it was warmer and more relaxing. He continued to take medications prescribed for his PTSD management. He also reported increased alcohol use which was probably contributing to his depression. He had recurrent involuntary memories of events in Vietnam and distress when exposed to cues that reminded him of those events. He reported irritable behavior and angry outbursts with little provocation, hypervigilance, startle response to noise, and problems concentrating. PTSD symptoms of anxiety, chronic sleep impairment, disturbance of motivation and mood, difficulty adapting to stressful circumstances, including work contributed to significant social and occupational impairment. Additionally, the VA reported that the Veteran experienced irritable behavior and angry outbursts. Behavioral observations revealed that he was alert, cooperative, and oriented times three. He reported that there was some increase in his symptoms of PTSD in the last several years with increased depression, more social isolation, and ongoing sleep issues. He reported intrusive thoughts leading to a level of distractibility, startle response, and flashback experiences. He reported that he had an intense flashback a month ago. He reported that it took him a long time to recover after he experienced a flashback or other incident involving hyperarousal.

A May 2015 VA treatment record included a suicide risk questionnaire on which the Veteran indicated that he felt hopeless about the present and future, but he did not have thoughts about taking his life and never had a suicide attempt.

In June 2015, objectively, the Veteran was polite, pleasant, and tearful as he talked about the unexpected passing of one of his daughters. The therapist noted that the Veteran had connections with family and friends, enjoyed traveling, and had a good relationship with his significant other. His PTSD symptoms impacted him with needing to have things correctly done, sudden noises, guilt, sleep and arousal. He did not have suicidal thoughts.

A July 2015 VA treatment record noted the Veteran's reports that he was doing much better on the new medication sertraline. He stated that he felt calmer during the day and that he slept much better on sertraline.

At the Board June 2016 hearing, the Veteran testified that he retired in 2011 due to his PTSD symptoms. The loud noises at construction sites kept him startled and his ability to concentrate was diminished due to PTSD. He was no longer able to keep notes he needed to properly do his job as an inspector. Rattle guns, air guns, and other common construction site noises distracted and irritated him and made his report writing more and more difficult with time. Eventually, he felt he could no longer work around construction sites. His irritability also resulted in physical confrontations with other workers on the job. Both his concentration and memory needed for construction inspection work were negatively impacted by PTSD. He stated that he, "retired because, uh, I wasn't functioning like I should be and the jobs I had . . . so it just got more and more irritating . . . I just didn't like being around what was happening . . ." and described altercations with employees "maybe about three times." He also described how his social life was getting less and less as he went out to places like the VFW and local bars less often, due to increased PTSD symptoms. His increased startle response landed him underneath a pool table at the VFW, when a fellow Veteran popped a bag as a prank. He also described how he could not watch the news, war movies on TV, and had a hard time on the 4th of July due to all the fireworks. He described how his monthly sessions with his therapist before she left her position kept him adjusted, and without them this last half year, his PTSD symptoms had worsened. The Veteran also described a pattern of sleepless nights, due to tossing and turning, and flashbacks that persisted since Vietnam. Loss of sleep at night made it hard for him to function during the day. He recalled how he kicked his wife out of bed with both feet one night during a flash back, and how he also kicked his current girlfriend out of bed during a similar more recent flashback.

During the hearing, the Veteran's representative indicated that the Veteran's PTSD symptoms increased in severity and frequency since his last VA examination in 2014. He recalled an incident from the week prior to the hearing, where the Veteran was confronted by a young man on the street while the Veteran was in his truck. The young man walked over and reached for the truck door handle, and the Veteran opened his truck door himself, knocking the man down with it. The Veteran then got out of his truck and asked the young man if he had had enough. He recounted this story as an example of his recent diminishing temper control.

A July 2016 VA treatment record noted that the Veterans relationship with his female partner remained good and they were going on 10 years together. He had residual PTSD triggers to flashbacks and recollections daily. Objectively he was overweight, casually dressed, adequately groomed, and engaging. His mood was euthymic, his affect was in good range, and his speech was appropriate, fluent, coherent, relevant, and spontaneous. There was no evidence of psychosis and he was oriented times three. His memory and judgment were good and his insight was fair. He did not have any suicidal or homicidal ideations.

A new VA examination was conducted in October 2016. The VA examiner opined that the Veteran had occupational and social impairment with reduced reliability and productivity. The Veteran reported being irritable and rigid with subordinates when he worked. He described having periodic difficulties with anger control and reported having a physical confrontation in a store parking lot in July 2016. He described himself as having increasing difficulty coping with large crowds and noise. He indicated he withdraws at these times.

The Veteran reported periodic depressed mood related to PTSD but denied suicidal ideation or intent. At this examination, he was still with his girlfriend, then ten years. He said they lived in an RV and traveled out of the area from December to June each year, and that they have friends in Arizona they see regularly. He said his relationship with his girlfriend was going well and that they never argued. The Veteran lost one of his daughters in 2014, but had a close relationship with his surviving daughter. He reported having difficulty socializing in large groups, which caused him to withdraw, and he had a physical confrontation earlier that summer. The Veteran reported that he was no longer working. He stopped after bypass surgery which made raising his right arm difficult. Before he stopped working, he was irritable and strict with subordinates, but he never missed work due to mental health issues. He reported taking medication regularly to control his anger, and prior to taking medication in 2006, he regularly got
each year, and that they have friends in Arizona they see regularly. He said his relationship with his girlfriend was going well and that they never argued. The Veteran lost one of his daughters in 2014, but had a close relationship with his surviving daughter. He reported having difficulty socializing in large groups, which caused him to withdraw, and he had a physical confrontation earlier that summer. The Veteran reported that he was no longer working. He stopped after bypass surgery which made raising his right arm difficult. Before he stopped working, he was irritable and strict with subordinates, but he never missed work due to mental health issues. He reported taking medication regularly to control his anger, and prior to taking medication in 2006, he regularly got into physical fights.

The Veteran reported the following PTSD symptoms in October 2016: depressed mood, anxiety, chronic sleep impairment, impaired judgment, disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. He also reported irritable behavior and angry outbursts, hypervigilance, problems concentrating, and difficulty falling and staying asleep or restless sleep. The Veteran also reported avoiding reminders of events in Vietnam to include thoughts of Vietnam, and sounds, images, and smells that brought back those memories. During the examination, the examiner found the Veteran was casually dressed and well groomed, spoke freely, was correctly oriented to person, place, time, and purpose. His thoughts were logical, and goal directed. There were no signs of major psychopathology such as hallucinations or delusions. The Veteran's affect was within normal limits and mood was neutral to happy. Several times he laughed and smiled during the examination. His attention and memory were grossly intact.

A November 2016 VA mental health treatment record noted that the Veteran was casually and neatly dressed. His speech was fluent and regular in rate and rhythm. His thoughts were forward focused. His affect was even and his mood was described as, "good". He did not currently experience any urges, plans, or intentions to commit suicide or self-harm or harm others. In December 2016, he reported that the increased dose of sertraline was helping him. The medicine helped him slow down and complete a project. He still was easily distracted. A mental status examination revealed that he was causally dressed, pleasant and relaxed and smiling. His mood was euthymic and his thought process was clear.

In May 2017 correspondence, the Veteran reported that his PTSD was getting worse. He reported that his nightmares occurred more often, his concentration was worse, and he was unable to finish projects that he started. He added that he was not suicidal or homicidal, but his social life, "sucks". He asserted that he went to Arizona to get away from people, crowds, loud noises, and a rushed routine.

Records for the Portland Vet Center included various progress notes in 2017. In June 2017, the Veteran requested help with hypervigilance and sleeping issues. The readjustment counselor who evaluated the Veteran stated that the Veteran seemed relaxed and was not in a crisis. In August 2017, the Veteran endorsed grief, feeling numb, and angry. No suicidal or homicidal ideation were reported. In September 2017, the Veteran reported increased depression, few nightmares, sleeping well, and managing triggers towards his PTSD symptoms. No suicidal or homicidal ideation were reported. In November 2017, a progress note indicated that ongoing treatment for PTSD was recommended.

During an August 2018 VA psycho-social pain evaluation, the Veteran reported that he had a few friends, got along well with others, lived in his own home with his girlfriend, and traveled to a home in Arizona every winter. He liked outdoor activities such as hunting, fishing and gardening. He also exercised regularly, ate well, and lost weight (15 lbs.) in the last year. He enjoyed keeping busy and staying active, denied the presence of abnormal stressors, reported being moderately social and doing things every week, and met financial obligations with little effort. He had nightmares and no suicidal or homicidal ideations. On mental status examination, his appearance showed that he was casually dressed and had adequate grooming. There was no evidence of any psychomotor abnormalities noted, his eye contact was appropriate, and his speech was fluent with normal rate, rhythm, and volume. His mood was pleasant and congruent with mood. His thought process was linear. There were no apparent auditory or visual hallucinations or delusions. His cognition appeared to be grossly intact. His insight and judgment appeared to be limited regarding the bio-psycho-social model of pain.

In September 2018, the Veteran reported that he had a "Bad month". He was easily irritated, impulsively snapping at people (including
homicidal ideations. On mental status examination, his appearance showed that he was casually dressed and had adequate grooming. There was no evidence of any psychomotor abnormalities noted, his eye contact was appropriate, and his speech was fluent with normal rate, rhythm, and volume. His mood was pleasant and congruent with mood. His thought process was linear. There were no apparent auditory or visual hallucinations or delusions. His cognition appeared to be grossly intact. His insight and judgment appeared to be limited regarding the bio-psycho-social model of pain.

In September 2018, the Veteran reported that he had a "Bad month". He was easily irritated, impulsively snapping at people (including his girlfriend and also strangers). He had increased anxious tension. His sleep was hit or miss and some nights he could not quiet his thoughts to be able to fall asleep. He was remembering and waking up from his nightmares more often. When exploring his symptoms, in general when he spent his summers in Washington, he encountered more stimuli and unpleasant interactions with people, traffic, and loud noises. His symptoms fairly reliably improve when he was in Arizona, where he stayed most of the year.

In June 2019, the Veteran reported that he has had waxing and waning symptoms of PTSD and his average has been around his chronic baseline. He had an uptick in nightmares. On mental status examination, he had good grooming and hygiene and appeared his stated age. He was cooperative with no abnormal movements. His speech was normal rate and rhythm. His mood was "OK" and his affect was non-labile and euthymic. He denied suicidal and homicidal ideations. His insight and judgment were grossly intact.

A July 2019 VA treatment record noted the Veteran's reports of having a "rough" July 4th week. Despite being prepared for the detonation of the fireworks, it "sounded just like the mortar that blew up 20 feet behind me..." His neighbors set off fireworks in the middle of the night. He reported that it took him a week to calm down. He denied feelings of hopelessness or having suicidal ideations. On mental status examination, his grooming and hygiene were good. He appeared his stated age. He was cooperative with no abnormal movements. His speech was normal rate and rhythm. His mood was "OK" and his affect was non-labile and euthymic. He denied suicidal and homicidal ideations. His insight and judgment were grossly intact.

In September 2019, the Veteran had complaints of increased irritability since August 20, 2019 when he drove by a truck and the tire blew out, which "Sounded like an incoming round." He stated that he was anxious and jumpy for the rest of the day. This has since settled, but his irritability has persisted. A mental status examination showed that his grooming and hygiene were good. He appeared his stated age. He was cooperative with no abnormal movements. His speech was normal rate and rhythm. His mood was "OK" and his affect was non-labile and euthymic. He denied suicidal and homicidal ideations. His insight and judgment were grossly intact.

Overall, and giving the Veteran the benefit of the doubt, the Board finds that a 70 percent rating is warranted for the appeal period prior to December 12, 2019. Specifically, prior to December 12, 2019, the Veteran had such symptoms as persistent flashbacks and distressing recurrent involuntary memories from Vietnam, which occurred multiple times a day and distracted him from completing tasks and impacted his concentration and attention. He also experienced distress when exposed to cues, such as loud noises and television programs, that reminded him of Vietnam and led to a level of distractibility, which would last for hours and was followed by nightmares. These symptoms approximated symptoms of near continuous panic or depression affecting the ability to function independently, appropriately, and effectively under the 70 percent rating criteria. During his May 2010 VA Examination, he described working voluntarily on a bid for the VFW "as a somewhat frustrating process and that he walked out of the building on Sunday due to difficulties interacting with another person." While seeking VA treatment in June 2011, he reported that he was, "Thinking he will stop work - stressful - focused on safety." The September 2014 VA examiner documented that the Veteran had difficulty adapting to stressful circumstances, including work. During his June 2016 hearing, the Veteran stated that he "retired because, uh, I wasn't functioning like I should be and the jobs I had . . . so it just got more and more irritating . . . I just didn't like being around what was
May 2010 VA Examination, he described working voluntarily on a bid for the VFW "as a somewhat frustrating process and that he walked out of the building on Sunday due to difficulties interacting with another person." While seeking VA treatment in June 2011, he reported that he was, "Thinking he will stop work - stressful - focused on safety." The September 2014 VA examiner documented that the Veteran had difficulty adapting to stressful circumstances, including work. During his June 2016 hearing, the Veteran stated that he "retired because, uh, I wasn't functioning like I should be and the jobs I had . . . so it just got more and more irritating . . . I just didn't like being around what was happening . . ." and describing altercations with employees "maybe about three times." The evidence reflected that he had difficulty interacting with other people and adapting to stressful circumstances, including work which contributed to significant social and occupational impairment consistent with the 70 percent rating criteria. He was easily aggravated, was increasingly irritable, had temper issues, and had angry outbursts with little provocation, which resulted in physical confrontations at times and was consistent with having impaired impulse control (such as unprovoked irritability with periods of violence) under the 70 percent rating criteria.

Additionally, the Veteran also exhibited feelings of hopelessness, hyperarousal, hypervigilance, an exaggerated startle response that occurred often, chronic sleep impairment, guilt, disturbance of motivation and mood, decreased interest in activities that he previously enjoyed, memory problems described as forgetting a lot and being unable to finish things that he started, nightmares and awakening multiple times a night, avoidance of his family and environmental stressors, isolating behaviors, feelings of being misunderstood, anxiety 4-5 times a week, difficulty in establishing and maintaining effective work and social relationships. The Board acknowledges the effort and energy the Veteran used to manage his significant PTSD symptoms and that he chose to live in Arizona for at least part of the year to avoid more stimuli and unpleasant interactions with people, traffic, and loud noises. Collectively, these symptoms are of the type, extent, severity, and/or frequency that more nearly approximate occupational and social impairment with deficiencies in most areas of the Veteran's life, including work, school, family relations, judgment, thinking, and mood for the appeal period prior to December 19, 2019. See Mauerhan, 16 Vet. App. 436 (2002).

The Court has held that the presence of suicidal ideation alone may cause occupational and social impairment with deficiencies in most areas (a 70 percent disability rating under 38 C.F.R. § 4.130). See Bankhead v. Shulkin, 29 Vet. App. 10 (2017). The Court specified that VA must not require more than thought or thoughts to establish the symptom of suicidal ideation, and may not require that the Veteran have been hospitalized or treated on an inpatient basis to establish suicidal ideation. Id. Although the Veteran denied having suicidal ideations on multiple occasions during this period, he indicated that he had, fleeting thoughts of suicide and feelings of hopelessness on at least one occasion during the appeal period. Here, the Veteran's social and occupational impairment as demonstrated by the symptoms discussed in the above paragraph show that when viewed holistically, looking at social and occupational impairment and the Veteran's history of ongoing symptoms, the Veteran's disability picture more nearly approximates a severity level warranting the 70 percent rating in the General Rating Formula for Mental Disorders prior to December 12, 2019. 38 C.F.R. § 4.130.

As the Veteran is now in receipt of a 70 percent disability rating for the appeal periods both prior to and from December 19, 2019, the Board now turns to the question as to whether or not a rating in excess of 70 percent is warranted at any point throughout the appeal both prior to and from December 19, 2019.

First, the Board will review the remaining evidence of record. The Veteran was afforded a VA PTSD examination in December 2019, where the VA examiner described the Veteran's level of occupational and social impairment as occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking and/ or mood. The Veteran reportedly still lived with his girlfriend now for 13 years. He was still close with his remaining daughter and two grandchildren. He retired in 2011 and has not worked since his open-heart surgery. In the last year, the Veteran's girlfriend noted that he became agitated easier, was "snippy," had poorer concentration, had more trouble socializing, stayed at home most days, and showed declining memory. She also noticed that he was unable to sleep when he became agitated. The Veteran reported having recurrent distress
2019, where the VA examiner described the Veteran's level of occupational and social impairment as occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking and/ or mood. The Veteran reportedly still lived with his girlfriend now for 13 years. He was still close with his remaining daughter and two grandchildren. He retired in 2011 and has not worked since his open-heart surgery. In the last year, the Veteran's girlfriend noted that he became agitated easier, was "snippy," had poorer concentration, had more trouble socializing, stayed at home most days, and showed declining memory. She also noticed that he was unable to sleep when he became agitated. The Veteran reported having recurrent distressing dreams of Vietnam as well as flashbacks and experienced prolonged psychological distress at exposure to cues that symbolize or resemble events from Vietnam. The Veteran avoided reminders, smells, tastes, sounds, people, places, and thoughts that reminded him of Vietnam. He reported feeling angry, guilty, responsible for, horror at events from Vietnam. He experienced hypervigilance, problems with concentration, sleep disturbance, and reckless or self-destructive behavior as a result of events in Vietnam.

The December 2019 VA examiner reported that the Veteran experienced the following PTSD symptoms: depressed mood, anxiety, panic attacks, chronic sleep impairment, mild memory loss, impairment of short and longterm memory, flattened affect, stereotyped speech, speech intermittently illogical, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances. Behavioral observations revealed that he arrived on time for his appointment and was casually dressed. He appeared his stated age. He ambulated without assistance, and no psychomotor difficulties were noted. He was oriented to all spheres and made adequate eye contact, but he appeared confused at times. His mood was euthymic. He reciprocated conversation and was forthcoming with information. His speech was slurred, however, and was circumstantial, non-linear, and rambling. He denied any suicidal or homicidal ideation. He did not appear to be attuned to any perceptual disturbances during the evaluation.

Regarding worsening symptoms, the examiner noted that since the Veteran's last review in 2016, he experienced additional symptoms of panic attacks that occur weekly or less often; mild memory loss and impairment of short- and long-term memory; flattened affect; circumstantial, circumlocutory or stereotyped speech; speech intermittently illogical, obscure, or irrelevant; and difficulty adapting to stressful conditions. The examiner stated that the severity and frequency of his symptoms appeared to have worsened, and his impaired judgment resulted in him becoming the victim of a scam in September 2019. The examiner added that these symptoms would make it extremely difficult for the Veteran to work given his cognitive symptoms of memory loss and poor judgment. Further, he evidenced confusion and slurred speech while in the examination such that the examiner assessed whether he had been drinking. He had not been drinking, but seemed confused and illogical in his thought processes.

VA treatment records dated in September 2022, noted that the Veteran no longer desired mental health services, but rather desired to just get refills of his psychotropic medications. In March and November 2023, he denied having mood swings, anxiety, and depression. He did not have suicidal or homicidal ideations.

In July 2025, the Veteran reported that he had some sleepless nights and occasional episodes of agitation without known triggers. He denied having any persistent exacerbation of PTSD. He continued to take his medication as prescribed. He was future oriented. There was no evidence of mania or psychosis and he denied having any suicidal or homicidal ideations, plan, or intent. On mental status examination, he was in no acute distress. He was alert and oriented times three. He appeared his stated age, gender, and race. His grooming and hygiene were fair. He was dressed appropriately in casual clothes. His behavior was calm, cooperative, and with good eye contact. No psychomotor agitation or retardation was noted. His speech had an appropriate rate, volume, and rhythm. His mood was described as, "Good". His affect was euthymic and congruent mood. He denied suicidal and homicidal ideations. There were no paranoid or delusional thoughts present. He denied auditory and visual hallucinations. His judgment, insight, and impulse control were fair.

On review of the evidence, the Board finds that a rating higher than 70 percent for PTSD is not warranted at any point during the appeal period both prior to and from December 12, 2019, as the weight of the evidence does not more nearly approximate total social and occupational impairment to warrant a 100 percent disability rating at
or retardation was noted. His speech had an appropriate rate, volume, and rhythm. His mood was described as, "Good". His affect was euthymic and congruent mood. He denied suicidal and homicidal ideations. There were no paranoid or delusional thoughts present. He denied auditory and visual hallucinations. His judgment, insight, and impulse control were fair.

On review of the evidence, the Board finds that a rating higher than 70 percent for PTSD is not warranted at any point during the appeal period both prior to and from December 12, 2019, as the weight of the evidence does not more nearly approximate total social and occupational impairment to warrant a 100 percent disability rating at any time during the pendency of the appeal. The Board acknowledges that there was an increase in the Veteran's symptoms of PTSD reported during the December 2019 examination and that he has not worked since 2011. However, the Veteran has maintained a longstanding relationship with his girlfriend and remained close with his daughter and grandchildren. Therefore, the Board finds that while the Veteran may well have difficulty with establishing and maintaining relationships, the overall weight of the evidence shows that his PTSD does not cause total social impairment.

Moreover, there is no evidence in the record showing that his service-connected PTSD has manifested in symptoms such as gross impairment in thought processes or communication; grossly inappropriate behavior; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. Although he appeared confused at times during the December 2019 VA examination, when performing a mental status examination, the examiner noted that the Veteran was alert and oriented in all spheres. Furthermore, VA treatment records as well as his VA examination reports consistently reported that the Veteran was alert and oriented to person, time, and place; casually and appropriately dressed; his thought processes were intact; and he denied delusions or hallucinations.

The Board has not overlooked the Veteran reporting that he had fleeting thoughts of suicide and impaired impulse control, such as unprovoked irritability with periods of violence. However, the Board finds these symptoms are accounted for in the currently assigned 70 percent rating and did not rise to the level of persistent danger of hurting self or others. Also, the VA treatment records and VA examination reports documented the Veteran repeatedly denying having suicidal or homicidal ideations.

Overall, the Board finds that the record does not show that the Veteran had both total occupational and social impairment at any time during the pendency of the appeal because it shows he had long-standing social relationships.

Given the medical history discussed above, the Board finds that that the weight of the evidence of record persuasively shows that the Veteran's service-connected PTSD does not cause both total occupational and social impairment as contemplated by the rating criteria for a 100 percent rating at any time during the pendency of the appeal prior to or from December 12, 2019. Therefore, the Board finds that the criteria for a higher, 100 percent, rating are not met at any time prior to or from December 12, 2019, and a rating in excess of 70 percent is denied. See 38 C.F.R. § 4.130; Fenderson, supra; Hart, supra.

Entitlement to service connection for erectile dysfunction as secondary to medication prescribed for service-connected PTSD is granted.

Entitlement to special monthly compensation based on the loss of use of a creative organ is granted.

In the November 2024 JMPR, the Court directed the Board to address whether entitlement to special monthly compensation (SMC) for loss of use of a creative organ (SMC(k)) was reasonably raised by the evidence of record. See Robinson v. Peake, 21 Vet. App. 545, 552 (2008), aff'd sub. nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir.).

The Board is required to consider all theories of entitlement to VA benefits that are either raised by the claimant or reasonably raised by the record. Schroeder v. West, 212 F.3d 1265, 1271 (Fed. Cir. 2000); Robinson v. Mansfield, 21 Vet. App. 545, 552 (2008), aff'd sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009). Based on review of the record, the Board finds that entitlement to service connection for erectile dysfunction as secondary to medication used to treat PTSD as well as entitlement to special monthly compensation (SMC) for loss of use of a creative organ (SMC(k)) were reasonably raised by the evidence of record. See Robinson v. Peake, 21 Vet. App. 545, 552 (2008), aff'd sub
5, 1271 (Fed. Cir. 2000); Robinson v. Mansfield, 21 Vet. App. 545, 552 (2008), aff'd sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009). Based on review of the record, the Board finds that entitlement to service connection for erectile dysfunction as secondary to medication used to treat PTSD as well as entitlement to special monthly compensation (SMC) for loss of use of a creative organ (SMC(k)) were reasonably raised by the evidence of record. See Robinson v. Peake, 21 Vet. App. 545, 552 (2008), aff'd sub. nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir.).

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.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). Secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected condition. 38 C.F.R. § 3.310.

Special monthly compensation for the loss of use of a creative organ is payable where a veteran, as a result of service-connected disability, has suffered the anatomical loss or the loss of use of one or more creative organs. 38 U.S.C. § 1114(k); 38 C.F.R. § 3.350(a).

The Court added that the Board must address an October 2017 VA Mental Health Medication Management Note recording that the Veteran's depression was well-controlled and his PTSD was present but at baseline on 150mg of sertraline. Unfortunately, he had sexual side effects (difficulty obtaining erection, anorgasmia). Also in a May 2017 Statement, the Veteran reported that his "sexual life is very consortium. It is getting to be very displeasing for my partner. She keeps trying to work with me and gets very frustrated." A Sept. 29, 2010, VA Mental Health Note noted that the Veteran's "antidepressant impacts his ability to be sexually active...not being able to have sex really bothers [him]."

In addition to the records discussed in the JMPR, treatment records from Dr. S.A.H. showed that the Veteran was being treated for depression. A January 2007 record noted that the Veteran had erectile dysfunction and was given samples of Viagra. An April 2010 record indicated that the Veteran had sexual problems when taking SRI's.

VA treatment records dated in January and February 2010 noted that the Veteran could not take or was not tolerating Citalopram due to sexual side effects or difficulty with sexual function.

VA treatment records dated in July 2017 noted that the Veteran's mood/PTSD symptoms did not change with a decrease of sertraline from 150 mg to 100 mg; however neither did the sexual side effects (delayed ejaculation). His sertraline dosage was then further reduced from 100 mg to 50 mg due to sexual side effects.

An August 2017 urology consult noted the Veteran's complaints of having difficulty with erection degree and holding along with loss of any ejaculation as well as infrequent and diminished climax. He has used Viagra and Cialis for the condition. The provider noted that the Veteran took prazosin at bedtime for the past 10 years for his PTSD. He also took trazodone at bedtime along with other medications. He was provided with an assessment of having difficulty with erections, probably both drug and vascular disease related. The provider added that the lack of climax and lack of ejaculation was probably secondary to medications because prazosin was an alpha-blocker. The provider noted that he explained to the Veteran that the lack of ejaculation was drug related and he was restarted on Viagra (sildenafil citrate).

Additional treatment records dated in August 2017 noted that the Veteran reported a benefit in his mood from sertraline in
for the condition. The provider noted that the Veteran took prazosin at bedtime for the past 10 years for his PTSD. He also took trazodone at bedtime along with other medications. He was provided with an assessment of having difficulty with erections, probably both drug and vascular disease related. The provider added that the lack of climax and lack of ejaculation was probably secondary to medications because prazosin was an alpha-blocker. The provider noted that he explained to the Veteran that the lack of ejaculation was drug related and he was restarted on Viagra (sildenafil citrate).

Additional treatment records dated in August 2017 noted that the Veteran reported a benefit in his mood from sertraline in the midst of his bereavement versus depression following the death of his daughter. He stated that his mood was stable. His PTSD symptoms were chronic but did not worsen with tapering of sertraline from 150 to 50 mg. Sexual side effects persisted and he had delayed orgasm/doesn't experience the full sensation of orgasm. He showed mild improvement, but not enough. The provider planned to decrease the sertraline dose from 50 mg to 25 mg in hopes of ongoing maintenance treatment for the Veteran's PTSD and to address the ongoing sexual side effects that negatively interacted with intimacy with his girlfriend. The provider planned to titrate prazosin upwards in hopes of systematic treatment of hyperarousal symptoms of PTSD. The Veteran was advised to pay attention to changes in mood, PTSD symptoms, and sexual side effects of the new dose or prazosin and reduced sertraline. In September 2017, it was noted that the Veteran began to experience dysphoria with the tapering of sertraline and ongoing sexual side effects (difficulty obtaining erection, anorgasmia), so buspirone was added in hopes that it could augment antidepressant, lessen anxiety, and reduce sexual side effects. An October 2017 record noted that the Veteran misunderstood the directions and stopped taking sertraline. He was pleased that his sexual side effects remitted off the sertraline. VA treatment records continued to list erectile dysfunction as a problem and records showed that he has been continuously prescribed Viagra.

The Board remanded the claim in April 2025 and instructed the AOJ to obtain a VA medical opinion to determine the nature and etiology of the Veteran's sexual dysfunction, including any erectile disfunction.

In December 2025, a VA examiner opined that the Veteran's erectile dysfunction, with or without penile deformity condition was less likely than not proximately due to/ the result of or aggravated beyond its natural progression by the service-connected PTSD condition, to include any treatment or medications for this condition. The examiner reasoned that erectile dysfunction could be due to genetic problems, age, hormonal changes, anatomic problems, smoking, obesity, neural/circulatory issues or idiopathic etc. The examiner added that since there were multiple known potential causes of erectile dysfunction (such as their advanced age of 77, smoking history, obesity (BMI: 37.0), hypertension, hyperlipidemia, sleep apnea and prediabetes) as well as idiopathic erectile dysfunction, there was no way to determine the cause or the aggravating factors of the problem as it would not be supported by objective evidence. The examiner also noted that the Veteran had not undergone sufficient medical work-up to explore and explain the underlying etiology of his erectile dysfunction. The examiner reported that attributing the Veteran's erectile dysfunction to PTSD, to include medication, was not supported by any objective evidence whatsoever. There was no evidence in the entire e-file of any "aggravation", nor had any evidence "aggravation" ever been objectively verified. There was not any evidence to attribute "aggravation" of the erectile dysfunction, with or without penile deformity to PTSD to include any treatment or medications for this condition. The examiner stated that the determination of aggravation was not objectively supported by the evidence.

The examiner also opined that the Veteran's erectile dysfunction, with or without penile deformity condition was less likely than not (likelihood is less than approximately balanced or nearly equal) caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the veteran and the synergistic, combined effect of all toxic exposure risk activities of the veteran to include Herbicide in Vietnam.

The examiner noted that the Veteran had claimed exposure(s) to Herbicide Agent - 2,3,7,8 - Tetrachlorodibenzodioxin (TCDD) while serving in Vietnam theater of activities. The frequency of exposure was reported as daily. The route of exposure was described as inhalation. The duration of exposure was described as from February
, with or without penile deformity condition was less likely than not (likelihood is less than approximately balanced or nearly equal) caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the veteran and the synergistic, combined effect of all toxic exposure risk activities of the veteran to include Herbicide in Vietnam.

The examiner explained that records reviewed indicated the following risk factors outside of military service: advanced age of 77, smoking history, obesity (BMI: 37.0), hypertension, hyperlipidemia, sleep apnea and prediabetes.

The examiner added that erectile dysfunction could be due to genetic problems, age, hormonal changes, anatomic problems, smoking, obesity, neural/circulatory issues or idiopathic etc. Since there were multiple known potential causes of their erectile dysfunction as well as idiopathic erectile dysfunction, there was no way to determine the cause of the problem in an objective manner. The examiner found no objective evidence that would allow for a determination of any connection to Herbicide or other toxic exposure during the service. The job aids and medical literature as well as the e-file were reviewed and no evidence was found to make such a determination. The job aids and literature did not support such a link. The non-TERA risk factors far outweigh the TERA risk factors.

The Board finds that the evidence is in at least equipoise as to whether the diagnosed erectile dysfunction is related to the medication prescribed for the service-connected PTSD. The VA treatment records clearly reflect the treating physicians noted the erectile dysfunction as a side effect of the medication used for the PTSD and changed medications and dosages to try to address it. Therefore, service connection for erectile dysfunction is warranted. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102.

Considering the establishment of service connection for erectile dysfunction, special monthly compensation for the loss of use of a creative organ is warranted. 38 U.S.C. §§ 1114(k); 38 C.F.R. § 3.350(a).

H. SEESEL

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Crohe, L.

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.

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