MIGRAINE

JOHN J. CROWLEY · 2025 · Case ID: A25021048

DENIED

Summary

The veteran, who served from April 1990 to November 1996, appeals the denial of service connection for migraine headaches, insomnia, and an increased rating for PTSD and sleep apnea. The veteran claimed headaches and insomnia were incurred in or due to service, including Southwest Asia service and TERA participation, and that his sleep apnea and PTSD were improperly rated. The veteran submitted a statement detailing migraines since service, exposure to burn pit smoke and fumes, and medication side effects. He also claimed chronic insomnia and sleep disturbances related to PTSD. However, the veteran's service treatment records were negative for headaches or insomnia during service, and his separation examination showed no diagnosed sleep or headache conditions. A February 2023 PTSD examiner opined that the veteran's insomnia symptoms were subsumed by his PTSD diagnosis and that while migraines can be triggered by stress, no causal link between psychiatric illness and migraines has been established. A May 2023 examiner found no causal connection between TERA and headaches. The Board denied service connection for headaches and insomnia, finding no objective evidence of in-service onset for headaches and that insomnia symptoms were already compensated as part of PTSD. The Board also denied increased ratings for sleep apnea and PTSD, finding the veteran did not meet the criteria for higher ratings based on the evidence, including examinations and treatment records, which did not support chronic respiratory failure for sleep apnea or total occupational/social impairment for PTSD. The Board noted the veteran's employment and ability to manage daily activities, precluding TDIU.

Rationale

No objective evidence of in-service onset; Negative secondary opinion from February 2023 examiner; Medical literature does not support causal link between psychiatric illness and migraines

Special Benefit

NO SPECIAL BENEFIT

Docket No.

240202-413541

Full Decision Text

Citation Nr: A25021048
Decision Date: 03/06/25 Archive Date: 03/06/25

DOCKET NO. 240202-413541
DATE: March 6, 2025

ORDER

Entitlement to service connection for migraine headaches (headaches), to include as proximately due to service connected posttraumatic stress disorder (PTSD), is denied.

Entitlement to service connection for insomnia, to include as proximately due to service connected disabilities, is denied.

Entitlement to an initial rating in excess of 50 percent for sleep apnea is denied.

Entitlement to an increased rating in excess of 70 percent for PTSD is denied.

FINDINGS OF FACT

1. The Veteran's headaches were not incurred in or due to his time in service, to include his service in Southwest Asia or his participation in TERA.

2. The Veteran does not have a separately diagnosed insomnia disability that was incurred in or due to his time inservice or proximately due to a service connected disability.

3. The Veteran's sleep apnea is not manifested by sleep apnea with chronic respiratory failure with carbon dioxide retention or cor pulmonale or requires tracheostomy.

4. The Veteran's PTSD is not manifested by total occupational and social impairment.

CONCLUSIONS OF LAW

1. The criteria for service connection for headaches are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303, 3.307, 3.309, 3.310, 3.317.

2. The criteria for service connection for insomnia are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303, 3.307, 3.309, 3.310, 3.317.

3. The criteria for an initial rating in excess of 50 percent for sleep apnea have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.100, DC 6847.

4. The criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.130, DC 9411.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active service from April 1990 to November 1996.

These matters are on appeal from April and May 2023 rating decisions by a Department of Veterans Affairs (VA) regional office (RO).

In the February 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket.

Therefore, the Board may only consider the evidence of record at the time of the April and May 2023 agency of original jurisdiction (AOJ) decision on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

Service Connection Claims

Generally, to prevail on a claim of service connection on the merits, there must be competent evidence of (1) a current disability, (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury, and (3) medical evidence or other competent evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).

To establish service connection on a secondary basis, the evidence must show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a)(b) (2016), Allen v. Brown, 7 Vet. App. 439 (1995) (
competent evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).

Service connection can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303 (b), 3.309. For chronic diseases shown as such in service or within the applicable presumptive period, subsequent manifestations of the same chronic disease at any later date are service connected unless attributable to an intercurrent cause. 38 C.F.R. § 3.303 (b). For a chronic disease to be considered to have been "shown in service," there must be a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings. When the condition noted in service or within the presumptive period is not a chronic disease, a showing of continuity of symptomatology after discharge is required. Id.

VA will pay compensation to a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability that manifest "during service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War" or to a degree of 10 percent or more before December 31, 2021. 38 U.S.C. § 1117; see 38 C.F.R. § 3.317 (a); 82 Fed. Reg. 49121 (Oct. 24, 2017). A qualifying chronic disability is as a chronic disability that results from an undiagnosed illness or a medically unexplained chronic multisymptom illness (excluding structural gastrointestinal diseases). 38 C.F.R. § 3.317 (a)(2)(i).

A "medically unexplained chronic multisymptom illness" has been defined as a "diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities." 38 C.F.R. § 3.317 (a)(2)(ii). "Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained." Id.

Along with the three examples of a medically unexplained chronic multisymptom illness provided by Section 1117(a)(2)(B), Congress has provided a list of signs or symptoms that may be a manifestation of a medically unexplained chronic multisymptom illness that includes: skin symptoms, headaches, muscle pain, joint pain, neurologic symptoms, neuropsychological symptoms, respiratory system symptoms, sleep disturbances, gastrointestinal symptoms, cardiovascular symptoms, abnormal weight loss, and menstrual disorders. 38 U.S.C. § 1117 (g); 38 C.F.R. § 3.317 (b).

Under the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act), effective from August 10, 2022, Section 303 implemented 38 U.S.C. § 1168, requiring a disability examination and medical opinion be requested for certain non-presumptive conditions involving toxic exposure risk activity (TERA). For such claims, VA is required to provide a disability examination and medical opinion when the Veteran submits a claim for compensation, has evidence of a disability, had evidence of participation in a TERA, and such evidence is not sufficient to establish service connection for the disability. A Veteran can claim participation in a TERA explicitly or implicitly through service in a location presumed associated with toxic exposure, or records showing participation in a TERA; or, if VA has conceded exposure in a prior claim, or the file has a claim attributable to toxic exposure. Other ways to claim or establish participation in a TERA include, when a Veteran's military occupational specialty (MOS) is associated with toxic exposure; when medical records suggest exposure to a toxic substance, chemical, or airborne hazard such as VHA exposure screening; or, with any other relevant evidence of record to include garrison exposures.

Pyramiding, that is the evaluation of the same disability, or the same
evidence is not sufficient to establish service connection for the disability. A Veteran can claim participation in a TERA explicitly or implicitly through service in a location presumed associated with toxic exposure, or records showing participation in a TERA; or, if VA has conceded exposure in a prior claim, or the file has a claim attributable to toxic exposure. Other ways to claim or establish participation in a TERA include, when a Veteran's military occupational specialty (MOS) is associated with toxic exposure; when medical records suggest exposure to a toxic substance, chemical, or airborne hazard such as VHA exposure screening; or, with any other relevant evidence of record to include garrison exposures.

Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § § 4.14 (2016); see Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994).

The Veteran contends he has insomnia and headaches that were incurred in and due to his time in service, to include his time serving in Southwest Asia and participation in TERA.

In a February 2023 statement, the Veteran said he suffered from migraines since returning from Southwest Asia. The Veteran said while in Southwest Asia, he was exposed to burn pit smoke, fumes, and burning oil wells. The Veteran also listed the medication he used to treat his service connected disabilities, which showed side effects as headaches and insomnia. The Veteran said he has had chronic insomnia since October 2009. The Veteran said he suffered from snoring, gasping, excessive sleepiness, morning headaches, and chronic insomnia.

The Veteran has been diagnosed with headaches. The Board notes the Veteran's insomnia has been noted throughout his medical treatment record. However, a February 2023 PTSD examiner opined there was no separate diagnosis of insomnia because the symptoms of insomnia are related and subsumed by his PTSD diagnosis. Per the DSM-5, insomnia is given as a separate diagnosis only when "co-existing mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia."

The examiner confirmed the Veteran's diagnosis of PTSD though has experienced insomnia and disrupted sleep as a part of his PTSD.

Simply stated, the Veteran is having clear problems with his sleep caused by his PTSD.

The Veteran's service treatment records (STRs) are negative for any ongoing treatment or complaint of headaches or insomnia while in service though one record from August 1996 showed the Veteran saying he found himself fatigued. However, in his separation examination, the Veteran was not found to have any diagnosed sleep or headache conditions and the Veteran did not check the box for any ongoing headaches or sleep problems.

The Veteran had a Gulf War examination in October 2017. The examiner did not note any headaches due to his time in Southwest Asia.

The Veteran had an examination for his headaches in February 2023. The examiner saw the Veteran in person, reviewed his file, and reported the Veteran was diagnosed with migraine headaches. The Veteran said the onset was "almost say in service" with 2001 noted on his written exam worksheet. The examiner noted the Veteran denied headaches in his separation examination, though VA treatment records showed occasional headaches in 2009, 2016, 2017, 2018, 2022, 2023. The Veteran described his symptoms.

The February 2023 examiner opined it was less likely than not the Veteran's headaches were proximately due to his service connected PTSD. The examiner explained that research suggested that the primary neuronal dysfunction leads to a sequence of changes intracranially and extracranially that account for migraines. While various stimuli, including emotional stress, hormonal changes, weather, sleep disturbances, and food could trigger migraine headaches, a causal link between psychiatric disorders and migraine headaches have not been established. Studies suggested an association between migraine headaches and a causal link between psychiatric disorders and migraines is due to common genetic and/or environmental risk factors that underlie both. No study had suggested that psychiatric illness is the cause of migraine headaches. Additionally, the examiner said the Veteran was not using any PTSD medication that would result in or predispose him to the development of migraine headaches or aggravate migraine headaches.

The May 2023 examiner opined the Veteran was diagnosed with migraine headaches. The onset was noted to be 2016 with headaches associated with nausea and vomiting. The Veteran had an examination for his headaches in May 2023. The examiner saw the Veteran in person, reviewed his file, and opined it was less likely than not the Veteran's headaches caused by TERA after considering the total potential exposure through all applicable military deployments and the synergistic, combined effect of all TERA of the Veteran. The examiner said the Veteran was diagnosed with migraines.
of migraine headaches. Additionally, the examiner said the Veteran was not using any PTSD medication that would result in or predispose him to the development of migraine headaches or aggravate migraine headaches.

The May 2023 examiner opined the Veteran was diagnosed with migraine headaches. The onset was noted to be 2016 with headaches associated with nausea and vomiting. The Veteran had an examination for his headaches in May 2023. The examiner saw the Veteran in person, reviewed his file, and opined it was less likely than not the Veteran's headaches caused by TERA after considering the total potential exposure through all applicable military deployments and the synergistic, combined effect of all TERA of the Veteran. The examiner said the Veteran was diagnosed with migraines. The examiner noted medical literature reviewed and the Veteran's contention that his headaches were due to exposure to burn pits.

The examiner said the Veteran's STRs did not document headaches and medical literature does not indicate that migraines are triggered by exposure to burn pit smoke.

Here, the Board does not find the Veteran has a separately diagnosed insomnia disability. As discussed above, the same manifestation of a disability cannot permissibly be compensated. The Veteran is already service connected for PTSD and, as is discussed in much greater detail below, the Veteran's sleep disturbances and insomnia are part of his PTSD symptoms and thus, already being compensated. Thus, without a currently separately diagnosed disability, without such being manifested while in service, and with no competent objective link between a separately diagnosed disability and his time in service or proximately due to his time in service, service connection for insomnia is not warranted.

The Board turns next to the Veteran's diagnosed headaches. Here, the Board also finds service connection is not warranted. Because there is no objective evidence showing headaches that began in service, service connection on a direct basis is not warranted. While in one statement, the Veteran said he had headaches "since service," another record shows he reported the onset in 2001 and another noted onset in 2016.

Additionally, the February 2023 examiner offered a negative secondary opinion, thoroughly explaining that while there many things can trigger migraines, there is no causal connection between a psychiatric illness and migraines and that any medication taken would not aggravate the Veteran's headaches. Additionally, a Gulf War examiner did not find any headache condition due to his service in Southwest Asia and there is no objective evidence showing the Veteran's diagnosed migraine headaches constitutes a "medically unexplained chronic multisymptom illness" or a chronic multisymptom illnesses of partially understood etiology and pathophysiology.

Lastly, the May 2023 examiner addressed the Veteran's contention that his headaches are due to his participation in TERA. The examiner noted that the medical literature did not support a causal connection between TERA and headaches. Thus, for these many reasons, service connection is not warranted.

The Board finds the examinations discussed above to be adequate because the examiners reviewed the Veteran's file, considered his statements, and offered opinions supported by explanations.

Increased Rating Claims

Disability evaluations (ratings) are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. §§ 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10.

In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Veteran. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10.

In a claim for a greater original rating after an initial award of service connection, all of the evidence submitted in support of the Veteran's claim is to be considered. See Fenderson v. West, 12 Vet. App. 119 (1999). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994).

The Veteran said due to his sleep apnea, he had day-time sleepiness, morning migraines, and an inability to focus. The Veteran said he had uncontrollable outbursts at his job because of limited sleep. The Veteran said he suffered from snoring
award of service connection, all of the evidence submitted in support of the Veteran's claim is to be considered. See Fenderson v. West, 12 Vet. App. 119 (1999). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994).

The Veteran said due to his sleep apnea, he had day-time sleepiness, morning migraines, and an inability to focus. The Veteran said he had uncontrollable outbursts at his job because of limited sleep. The Veteran said he suffered from snoring, gasping, excessive sleepiness, depression, decreased concentration, and irritability.. (See e.g. February 2023 statement.)

The Veteran contends his sleep apnea is worse than indicated by his 50 percent rating. The Veteran's sleep apnea is rated under DC 6847.

Under DC 6847, a 50 percent rating is warranted for sleep apnea that requires the use of breathing assistance device such as a continuous airway pressure (CPAP) machine. A 100 percent rating is warranted for sleep apnea with chronic respiratory failure with carbon dioxide retention or cor pulmonale or requires tracheostomy.

The Veteran's record shows he uses a CPAP machine. (See e.g. January 2018 treatment records.)

The Veteran had an examination for his sleep apnea in March 2023. The examiner reviewed the Veteran's file and noted several relevant pieces of evidence. The Veteran said he had symptoms of snoring, gasping, witnessed apneas, and daytime sleepiness. The Veteran was using a CPAP machine but did not take continuous medication. The Veteran had persistent daytime hypersomnolence. The Veteran did not have any other signs or symptoms related to his sleep apnea.

The Veteran's file shows he continues to seek treatment for his sleep apnea. However, the record, which includes the Veteran's statements and the objective evidence of record, does not show the Veteran's sleep apnea leads to chronic respiratory failure with carbon dioxide retention or cor pulmonale or requires tracheostomy. Therefore, a higher 100 percent rating is clearly not warranted.

The Board turns next to the Veteran's contention that his PTSD is worse than indicated by his 70 percent rating. The Veteran's PTSD is rated under DC 9411.

Under DC 9411, a 70 percent rating is prescribed when there is evidence of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships.

Important for this case, a 100 percent rating is prescribed when there is evidence of 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 as to time or place; and memory loss for names of close relatives, own occupation, or own name.

The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Veteran. App. 436, 442-3 (2002). However, a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration, and that such symptoms have resulted in the type of occupational and social impairment associated with that percentage. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117-18 (Fed. Cir. 2013).

The Veteran had an examination for his PTSD in February 2023. The examiner saw the Veteran in person and noted the Veteran did not have more than one mental health disorders diagnosed. The examiner said the Veteran's PTSD led to occupational and social impairment with deficiencies in most areas. The Veteran was still married to his wife of 16 years though they were considering separation and divorce, but working to stay together. The Veteran moved in September 2022 and had not established friendships since relocating and his days consisted of going to work and coming home. The Veteran denied participation in leisure or extracurricular activities and was apprehensive about leaving home and avoided social interactions and situations. The Veteran had worked as an assistant chief and then was promoted though the stress was overwhelming. The Veteran said he had several EOO claims at work due to his aggressive communication style, though he denied instances of physical aggression. The Veteran felt angry and hostile at work and therefore, he and his family had relocated to a smaller hospital closer to family. The Veteran was currently employed and had been better able to manage his responsibilities at a smaller hospital. The Veteran endorsed nightmares, insomnia, and sleep apnea. The Veteran also avoided reminders of trauma, avoided eating out, going to social activities, and had a lack in participating in enjoyable activities. The Veteran was fearful of having an instance of anger with his child, endorsed hypervigilance, difficulty concentrating, but denied suicidal ideations or homicidal ideations. The Veteran complied with activities of daily living such as hygiene and self-care, was able to maintain a bank account, and manage his on funds.

The examiner opined the Veteran's symptoms included depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty establishing and maintaining effective relationships, difficulty adapting to stressful situations, and inability to establish and maintain effective relationships. The Veteran was polite and cooperative, though with a depressed mood. The Veteran was tearful in describing his PTSD symptoms and how they affect his daughter. The Veteran had adequate hygiene with normal and logical thoughts. There was no delusional thought or content and not evidence of responding to internal stimuli. Speech was within normal limits with memory, attention, and concentration intact. The Veteran was alert and oriented.

The Board has also reviewed the remainder of the Veteran's file, including his treatment records.

In a June 2022 questionnaire, the Veteran endorsed severe aggressive behaviors, agitation, circumstantial symptoms, depressed mood, dissociative states, elevated mood, emotional trauma perpetrator, emotional trauma victim, generalized anxiety, hyperactivity, irritability, mood swings, panic attacks, sexual dysfunction, and sleep disturbances. The Veteran endorsed moderate emotionality, grief, guilt, hopelessness, loose associations, obsessions, oppositional behavior, paranoid ideation, and social isolation. The Veteran endorsed mild anorexia, appetite disturbance, fatigue, phobias, poor concentration, poor grooming, significant weight gain or loss, substance abuse, and worthlessness. The Veteran was noted to be on medication for anxiety and his insomnia disorder was noted to be related to another mental disorder.

In November 2022, the Veteran said he felt nervous or anxious, worried too much, had trouble relaxing, and was afraid of something awful happening nearly every day. The Veteran said he was not in control of his worrying, felt restless, and became easily annoyed more than half the days. The Veteran also was found to have symptoms consistent with a major depressive episode, with symptoms of little interest, feeling down, trouble sleeping, tired, feelings of guilt, trouble concentrating, but no suicidal ideations. The examiner found the Veteran to be well-groomed with normal psychomotor speed, distinct speech, goal directed content appropriate, no psychotic thoughts, no hallucinations, no suicidal or homicidal ideations, and the Veteran was oriented. The Veteran was also noted to have a fear of going outside with panic attacks.

Pertaining to his occupational impairment, it is clear the Veteran's PTSD may cause difficulty in his ability to work in all situations. However, the Veteran was still gainfully employed and was finding it easier to manage his responsibilities and his behaviors in a smaller setting. The Board notes the Veteran has a history of self-reported claims against him in the workplace for aggressive behavior. The Veteran's lack of sleep and nightmares due to his PTSD leads to problems with concentration. The Veteran's PTSD also leads to difficulty interacting with people at work due to symptoms such as difficulty establishing and maintaining
hallucinations, no suicidal or homicidal ideations, and the Veteran was oriented. The Veteran was also noted to have a fear of going outside with panic attacks.

Pertaining to his occupational impairment, it is clear the Veteran's PTSD may cause difficulty in his ability to work in all situations. However, the Veteran was still gainfully employed and was finding it easier to manage his responsibilities and his behaviors in a smaller setting. The Board notes the Veteran has a history of self-reported claims against him in the workplace for aggressive behavior. The Veteran's lack of sleep and nightmares due to his PTSD leads to problems with concentration. The Veteran's PTSD also leads to difficulty interacting with people at work due to symptoms such as difficulty establishing and maintaining effective relationships, difficulty adapting to stressful situations, and inability to establish and maintain effective relationships.

The Board finds those symptoms also would create social impairment due to his PTSD. However, the Board notes the Veteran did not report having any problems with his co-workers or others while in his new position at the smaller hospital. The Veteran also remained married, and even though he reported a rocky marriage, the Veteran did report he was trying to work on his marriage. The Veteran did report a lot of isolation, having not made friends at his new location and expressing a lack of desire to leave the house. However, the Veteran did seem to have a relationship with his child and was noted to become teary when discussing how his mental health may impact her.

Here, however, the Board also notes the Veteran often denied suicidal and homicidal ideations, was adequately groomed, was coherent in his speech and thoughts, and was oriented. While the Veteran's PTSD is clearly causing him difficulties both socially and occupationally, the Board does not find he is completely impaired due to his PTSD. The Veteran does not exhibit such extreme symptoms approximating persistent delusions or hallucinations, his behavior has not been noted to be grossly inappropriate, he is not a persistent danger to himself or others, and he does not have memory loss so severe as to be unable to remember his own name or own occupation. The Veteran has been able to clearly articulate his feelings, thoughts, and ongoing problems with examiners and has been able to continue to work.

In fact, overall, the Veteran's statements provide evidence against a 100% rating, clearly indicating an ability to function, with problems (as clearly noted above). In this regard, it is very important for the Veteran to understand that 70% rating for PTSD will cause the Veteran many problems, as he has noted.

Overall, the Veteran is clearly having many problems with his PTSD, but simply not the next higher criteria level for this problem.

The Board notes the Veteran does take medication for his condition. See Jones v. Shinseki, 26 Vet. App. 56 (2012) (when a DC is silent as to the effects of medication, VA may not deny entitlement to a higher disability rating based on the relief provided by medication). However, the Board finds that even when not considering the ameliorating effects of his medication, there is no indication that not being on his medication would lead him to have such severe symptoms are having delusions or hallucinations, memory loss so severe that he can't remember his own name, disorientation to time and place, or other such severe symptoms as would warrant a 100 percent rating. Therefore, the Board declines to remand this matter for a speculative opinion regarding the potential symptoms the Veteran may exhibit if he were to be taken off of his medications.

Neither the Veteran nor his representative has identified any other rating criteria that would provide a higher rating or an additional rating. However, the potential applications of various provisions of Title 38 of the Code of Federal Regulations (2016) have been considered as required by the holding of the Court in Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991).

The Court has held that a request for a total disability rating based on individual unemployability (TDIU), whether expressly raised by the Veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, can be part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The Veteran has not explicitly raised this issue and the matter is not raised by the record as the most recent evidence indicates the Veteran is still gainfully employed. Therefore, a TDIU is not warranted.

Regarding the claims above, the Board acknowledges and has considered the Veteran's statements that his conditions impacts him and they are due to his time in service or that his service connected disabilities warrant higher evaluations. However, while the Veteran is competent to report the symptoms of his disabilities, he is not competent to opine
not a separate "claim" for benefits, but rather, can be part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The Veteran has not explicitly raised this issue and the matter is not raised by the record as the most recent evidence indicates the Veteran is still gainfully employed. Therefore, a TDIU is not warranted.

Regarding the claims above, the Board acknowledges and has considered the Veteran's statements that his conditions impacts him and they are due to his time in service or that his service connected disabilities warrant higher evaluations. However, while the Veteran is competent to report the symptoms of his disabilities, he is not competent to opine on matters requiring medical knowledge, such as the nature, etiology, or severity of his complex medical conditions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Thus, while the Board has carefully considered the Veteran's statements about his symptoms, these statements must be weighed against the objective evidence of record, which does not indicate the Veteran has a separately diagnosed insomnia condition, that his headaches are due to his time in service, or that his sleep apnea or PTSD are improperly rated.

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It is important for the Veteran to understand that these medical findings provide highly probative evidence against this claim that the Board cannot, unfortunately, ignore, outweighing the Veteran's beliefs that his conditions warrant service connection or higher disability ratings.

Regarding all the above, the Board has considered the applicability of the benefit of the doubt doctrine. Except as otherwise noted, because the evidence is not in approximate balance or nearly equal, the benefit of the doubt doctrine does not apply. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990), Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

John J. Crowley

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Snoparsky, A.

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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