MAJOR DEPRESSIVE DISORDER

Summary

The Veteran, a Veteran who served from August 1991 to August 1995, appeals the denial of service connection for occipital neuralgia and an increased rating for PTSD. The Board granted service connection for depression as a manifestation of PTSD and awarded a 70% rating for PTSD, effective January 22, 2019. The Board found the Veteran's acquired psychiatric disability, including depressed mood, chronic sleep impairment, disturbances in motivation, difficulty with social relationships, and suicidal ideation, warranted the 70% rating. While the Veteran reported daily suicidal ideation in 2018, decreasing to weekly by 2019, and experienced nightmares, the Board found this did not meet the criteria for a 100% rating due to a lack of total occupational and social impairment and no persistent danger of self-harm. The Board also noted that while a private psychologist provided a diagnosis and noted symptom overlap, the outdated DBQ form and lack of DSM-5 diagnosis limited its weight. The Board remanded claims for occipital neuralgia, surgical scars, spinal pacemaker, and TDIU. The occipital neuralgia claim was remanded for a new VA examination to determine its etiology and service connection, as the existing private opinion was deemed inadequate and the RO failed to provide an examination. The secondary claims for a spinal pacemaker and surgical scars were remanded as they were inextricably intertwined with the occipital neuralgia claim. The TDIU claim was remanded due to the Veteran's reported unemployment and symptoms related to occipital neuralgia and mental health conditions.

Rationale

Depression symptoms could not be disassociated from PTSD; Symptom overlap between PTSD and depression noted; Service connection warranted as a manifestation of PTSD

Full Decision Text

Citation Nr: A26037759
Decision Date: 04/22/26	Archive Date: 04/22/26

DOCKET NO. 210602-163489
DATE: April 22, 2026

ORDER

Service connection for depression as a manifestation of posttraumatic stress disorder (PTSD) is granted.

Entitlement to an initial rating of 70 percent from January 22, 2019, but no higher and no earlier, for service-connected PTSD is granted.

REMANDED

Entitlement to service connection for occipital neuralgia is remanded.

Entitlement to service connection for implementation of a spinal pacemaker as secondary to occipital neuralgia is remanded.

Entitlement to service connection for surgical scars as secondary to occipital neuralgia is remanded.

Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded.

FINDINGS OF FACT

1. The record reflects that the Veteran suffers from depression in conjunction with his PTSD and such cannot be disassociated from the symptoms associated with his service-connected PTSD.

2. From January 22, 2019, the Veteran's service-connected PTSD with other specified trauma and stressor related disorder and alcohol use disorder, mild, in sustained remission, was manifested by occupational and social impairment, with deficiencies in most areas.

CONCLUSIONS OF LAW

1. The criteria for service connection for depression as a manifestation of PTSD are met.  38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310.

2. From January 22, 2019, the criteria for an initial rating of 70 percent, but no higher, for PTSD with other specified trauma and stressor related disorder and alcohol use disorder, mild, in sustained remission have been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400, 4.126, 4.130, Diagnostic Code 9411.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from August 1991 to August 1995.

These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 22, 2020, and March 10, 2021, rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO).

By way of background, the Veteran filed for entitlement to service connection for occipital neuralgia and depressive disorder secondary to a traumatic brain injury (TBI) in May 2011.  The RO denied his claims in an October 2012 rating decision.

The Veteran filed a VA Form 21-526EZ in January 2019 and sought entitlement to service connection for occipital neuralgia and depressive disorder.  The RO denied his claims in an April 2019 rating decision and found no new and material evidence had been submitted.

The Veteran filed a VA Form 21-526EZ in July 2019 and sought entitlement to service connection for TBI, depressive disorder, severe headaches, posttraumatic stress disorder (PTSD), and surgical scars/spinal pacemaker.  

In July 2019, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of the April 2019 decision.  The Board notes that the agency of original jurisdiction (AOJ) sent the Veteran correspondence on July 26, 2019, which stated the Veteran's HLR request for the headache and depression claims was premature.  However, in August 2019, the AOJ issued a HLR decision, which considered the evidence of record at the time of the prior April 2019 decision, and denied the Veteran's claims.

The RO mailed the Veteran correspondence in August 2019 and advised he needed to file a VA Form 21-0995, Supplemental Claim Application for his claim for entitlement to service connection for a traumatic brain injury.

In September 2019, the Veteran submitted a subsequent VA Form 20-0996, HLR Request, and requested review of an August 16, 2019, decision.  The Board notes that no such rating decision exists in the Veteran's claims file, and the RO liberally construed the request as appealing the August 14, 2019, rating decision.  In addition, the Veteran sought review of his claims for entitlement to service connection for PTSD, surgical scars, and a TBI.  The RO mailed the Veteran correspondence that explained he could not request Higher-Level Review of a HLR decision; his HLR request for his PTSD and surgical scars claims
 his claim for entitlement to service connection for a traumatic brain injury.

In September 2019, the Veteran submitted a subsequent VA Form 20-0996, HLR Request, and requested review of an August 16, 2019, decision.  The Board notes that no such rating decision exists in the Veteran's claims file, and the RO liberally construed the request as appealing the August 14, 2019, rating decision.  In addition, the Veteran sought review of his claims for entitlement to service connection for PTSD, surgical scars, and a TBI.  The RO mailed the Veteran correspondence that explained he could not request Higher-Level Review of a HLR decision; his HLR request for his PTSD and surgical scars claims was premature; and, that the AOJ could not accept a HLR request for his TBI claim.

Meanwhile, the RO granted entitlement to service connection for the Veteran's PTSD claim in a January 2020 rating decision.  The RO evaluated his PTSD as 30 percent disabling and assigned an effective date of July 15, 2019.  The RO denied the Veteran's claim for service connection for surgical scars.

In November 2020, the Veteran submitted a VA Form 20-0995, Decision Review Request: Supplemental Claim, and requested readjudication of entitlement to service connection for depressive disorder and occipital neuralgia most recently addressed in an August 16, 2019 rating decision.  Again, the Board notes that no such rating decision exists in the Veteran's claims file, and the RO liberally construed the request as appealing the August 14, 2019, rating decision.  In addition, the Veteran, through his representative, filed a COVID-19 extension request for his untimely appeal of the August 2019 decision. In December 2020, the agency of original jurisdiction (AOJ) issued the supplemental claim decision on appeal, which found that new and relevant evidence had been received and denied the claim based on the evidence of record at the time of that decision.  

In January 2021, the Veteran submitted a Supplemental Claim, and requested readjudication of entitlement to service connection for surgical scars and sought an increased rating for his service-connected PTSD most recently addressed in a January 9, 2020 rating decision.  The Board notes that no such rating decision exists in the Veteran's claims file, and the RO liberally construed the request as appealing the January 7, 2020, rating decision, for which the RO mailed notice on January 9, 2020.  Accordingly, the appeal was timely.  In March 2021, the AOJ issued the supplemental claim decision on appeal, which found that new and relevant evidence had been received with regard to the Veteran's increased rating claim and assigned a 50 precent evaluation for his PTSD effective January 8, 2021.  The RO denied the Veteran's claim for surgical scars.  

In the June 2, 2021, VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. The Veteran identified December 24, 2020 and March 12, 2021 rating decision as the decisions being appealed.  The Board notes no such rating decisions exist in the Veteran's claims file, but has liberally construed the 10182 as appealing the December 22, 2020 (depressive disorder and occipital neuralgia) and March 10, 2021 (PTSD and surgical scars/spinal pacemaker) rating decisions.  

The Board has bifurcated the surgical scars and pacemaker claims.

A Board hearing was held on April 8, 2025, before the undersigned Veterans Law Judge.  A transcript of the hearing is associated with the Veteran's electronic claims file.  Therefore, the Board may only consider the evidence of record at the time of the December 22, 2020 and March 12, 2021 agency of original jurisdiction (AOJ) supplemental claim decisions on appeal, as well as any evidence submitted by the Veteran or his representative at the hearing or within 90 days following the hearing. 38 C.F.R. §?20.302. If evidence was submitted either (1) during the period after the AOJ issued the supplemental claim decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 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.
 or within 90 days following the hearing. 38 C.F.R. §?20.302. If evidence was submitted either (1) during the period after the AOJ issued the supplemental claim decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 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. 

However, because the Board is remanding the claims of entitlement to service connection for occipital neuralgia and a TDIU, any evidence the Board could not consider will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii).

Service Connection for Depression

Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service.  38 U.S.C. § 1110; 38 C.F.R. § 3.303.  Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).

Service connection on a secondary basis requires (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) evidence establishing that the service-connected disability either (a) caused, or (b) aggravated, the nonservice-connected disability. 38 C.F.R. § 3.310; Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (invalidating the requirement of "proximate cause" and instead held a "but for" causation or aggravation is enough to show entitlement to secondary service connection).

A VA PTSD examination conducted in March 2021 diagnosed PTSD and other specified trauma and stressor related disorder. The examiner noted that "military-related PTSD may increase susceptibility to developing depression symptoms to new stressors." The Veteran's relevant PTSD history included "psychological distress: increased irritability, depression (including crying), loneliness, anxious, fear." The examiner found it was not possible to differentiate the symptoms of each mental health disorder, noting that there was symptom overlap between PTSD and depressed mood of the other specified trauma and stressor related disorder. As such, the undersigned finds depression cannot be disassociated from the symptoms associated with his service connected PTSD, and that service connection for depression as a manifestation of PTSD is thus warranted. See Mittleider v. West, 11 Vet. App. 181 (1998).  

Increased rating

Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) in 38 C.F.R. Part 4.  The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations.  38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1.  Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation.  Otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7.

In evaluating the severity of a particular disability, it is essential to consider its history.  38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991).  In cases where the original rating assigned is appealed, consideration must be given to whether a higher rating is warranted at any point during the pendency of the claim.  Fenderson v. West, 12 Vet. App. 119 (1999).  Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made.  Hart v. Mansfield, 21 Vet. App. 505 (2007).  The analysis in the
  38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991).  In cases where the original rating assigned is appealed, consideration must be given to whether a higher rating is warranted at any point during the pendency of the claim.  Fenderson v. West, 12 Vet. App. 119 (1999).  Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made.  Hart v. Mansfield, 21 Vet. App. 505 (2007).  The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods.

If the evidence for and against a claim is approximately balanced, the claim will be granted.  38 C.F.R. § 4.3.  A claim will be denied only if the record persuasively weighs against the claim.  38 U.S.C. § 5107; 38 C.F.R. § 3.102; see Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).  Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant.  38 C.F.R. § 4.3.

Earlier effective dates

Generally, the effective date of compensation based on an original claim, a claim for increase, or a claim reopened after final disallowance, will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400.   An effective date for a claim for increase may be granted prior to the date of claim if it is factually ascertainable that an increase in disability had occurred within one year from the date of claim. 38 U.S.C. § 5110 (b)(3); 38 C.F.R. §§ 3.400(o)(1), (2).

Under the AMA, an appellant can preserve an effective date by continuously pursuing a claim. This is accomplished by filing an appropriate administrative review option to an AMA decision as specified in 38 C.F.R. § 3.2500(c) within one year of the issuance of the decision. If a claim is continuously pursued, it will be considered filed as of the date of the first claim in the continuously pursued chain, not the date the most recent request for review was received. 38 C.F.R. §§ 3.400, 3.2500(c). In other words, the period under review for the purposes of an increased rating and effective date is the date of receipt of initial claim, if there has been continuous pursuit of the initial claim.

1. Entitlement to an initial rating higher than 50 percent prior to January 22, 8, 2021, for service-connected PTSD.

The Board will next address whether the Veteran has continuously pursued his claim for entitlement to service connection for depressive disorder, which the Board herein finds to be a manifestation of the Veteran's service-connected PTSD.  

Here, the Veteran filed for entitlement to service connection for a psychiatric disability in May 2011 and the RO denied his claim in an October 2012 rating decision.  VA received no timely communication from the Veteran expressing notice of disagreement with the October 2012 rating decision, and no new and material evidence was received within one year of issuance of the decision. Accordingly, the October 2012 rating decision became final.  See 38 C.F.R. § 3.2500(c). 

The Veteran subsequently filed a VA Form 21-526EZ on January 22, 2019, and sought service connection for a psychiatric disability.  The RO denied his claim in an April 2019 rating decision and found no new and material evidence had been submitted.  The Veteran filed a VA Form 21-526EZ for entitlement to service connection for PTSD in July 2019 and a HLR request of the April 2019 rating decision.  The RO found new and relevant evidence had been submitted but denied the Veteran's claim for a psychiatric disability in an August 2019 rating decision.  The RO granted entitlement to service connection for PTSD in a January 2020 rating decision and assigned an effective date of July 15, 2019.  

In November 2020, the Veteran filed a Supplemental Claim regarding service connection for his psychiatric disability denied in the August 2019 rating decision.  He also filed a COVID-19 extension request, which the RO accepted but denied his claim for service connection in a December 2020 rating decision.  In January 
 connection for PTSD in July 2019 and a HLR request of the April 2019 rating decision.  The RO found new and relevant evidence had been submitted but denied the Veteran's claim for a psychiatric disability in an August 2019 rating decision.  The RO granted entitlement to service connection for PTSD in a January 2020 rating decision and assigned an effective date of July 15, 2019.  

In November 2020, the Veteran filed a Supplemental Claim regarding service connection for his psychiatric disability denied in the August 2019 rating decision.  He also filed a COVID-19 extension request, which the RO accepted but denied his claim for service connection in a December 2020 rating decision.  In January 2021, the Veteran sought an earlier effective date and increased rating for his service-connected PTSD.  A March 2021 rating decision granted an increased rating effective January 8, 2021.

The Board finds the Veteran has continuously pursued his claim for an increased rating for his service-connected acquired psychiatric disability since his date of claim for service connection, January 22, 2019.  The Board notes the date of claim is the effective date that the Veteran's representative requested during the April 2025 Board hearing.  See Transcript at 15.

Thus, the issue on appeal is whether the Veteran is entitled to an increased rating for his service-connected acquired psychiatric disability from the date of his claim for service connection, January 22, 2019.  The Veteran is currently in receipt of a 30 percent rating from July 15, 2019, and a 50 percent rating from January 8, 2021.

The Veteran's acquired psychiatric disability is evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411.  

Psychiatric impairment is evaluated under the General Rating Formula for Mental Disorders (General Formula).  

Under the General Formula, a 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause 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 normal conversation).

A 50 percent rating is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9400.

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

A 100 percent rating is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id.

As the United States Court of Appeals for the Federal Circuit has held, evaluation under 38 C.F.R. § 4.130 is "symptom driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under the regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms, but also that those symptoms have caused occupational
130 is "symptom driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under the regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms, but also that those symptoms have caused occupational and social impairment in most of the referenced areas," i.e., "the regulation... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-118; 38 C.F.R. § 4.130.

VA must engage in a holistic analysis that assesses the severity, frequency, and duration of the signs and symptoms of the psychiatric disability; quantifies the level of occupational and social impairment caused by those symptoms; and assigns an evaluation that most nearly approximates the level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017).

Factual background

The Veteran contends he is entitled to a higher initial rating for his service-connected psychiatric disability because he has suffered from frequent suicidal ideation since 2018.  See Transcript at 22.   

The Veteran testified that he was denied surgical intervention to treat his chronic pain in December 2018 which "led [him] down a horrible path."  See Transcript at 22.  He described feeling angry, depressed, and suicidal.  See id.  He had a reoccurring nightmare.  See id.  His medications were increased and he described everything "went downhill."  See id.

In a February 2019 VA treatment note, the Veteran endorsed daily thoughts of suicidal intent and described a plan.  He exhibited warning signs, to include direct communication, anger, feeling trapped, mood changes, and sleep disturbance.

The Veteran attended a VA Initial PTSD examination in December 2019. He was diagnosed with PTSD.  The Veteran was not taking any psychiatric medications at the time of his examination.  His symptoms included depressed mood, anxiety, panic attacks that occurred weekly or less often, and chronic sleep impairment.  The Veteran also reported depressed mood and low motivation which he attributed to his pain.  He shared that he had a fleeting thought of suicide when he was denied surgical intervention for his pain. The examiner found the Veteran's psychiatric disability caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care, and conversation.  The VA examiner stated that the Veteran worked in commercial aviation as an aircraft maintenance supervisor, and he owned a food truck which he operated on his days off. 

Regarding his social functioning, the VA examiner reported the Veteran had been married for 21 years and had two children.  The Veteran had few close friends but he socialized with his wife and other couples.  He had coached his son's teams in the past and had an accomodation to sit on the floor level at his daughter's gymnastic competitions rather than sit in the bleachers.  The Veteran shared that his family liked to vacation at Disney World and the beach.  When the Veteran visited the beach with his family, he watched his children and avoided the water.

In February 2020, the Veteran sought mental health treatment at the VA.  He reported he had stopped psychiatric treatment about one year earlier but complained of increasing depression and suicidal ideation.  At April and May 2020 visits, the Veteran shared that he was not sleeping and not working. He reported he lost his job because of COVID-19.  See CAPRI (receipt date January 12, 2021).  He endorsed sleeping during the day.  He stated that he was feeling down.

In August 2020, the Veteran had an increase in PTSD symptoms and reported decreased sleep.  In September 2020, the Veteran described a severe, angry outburst at his son, and noted a decrease in restful sleep.  The Veteran felt frustrated and his mood was low.  He described "ups and downs."  He was on unemployment benefits and reported a reoccurring feeling that he was being punished.  See CAPRI (receipt date January 12, 2021).  

An October 2020 VA treatment note reflects diagnoses of depression, anxiety, PTSD, and a recent history of suicidal intent.

In January 2021, the Veteran described
 sleeping during the day.  He stated that he was feeling down.

In August 2020, the Veteran had an increase in PTSD symptoms and reported decreased sleep.  In September 2020, the Veteran described a severe, angry outburst at his son, and noted a decrease in restful sleep.  The Veteran felt frustrated and his mood was low.  He described "ups and downs."  He was on unemployment benefits and reported a reoccurring feeling that he was being punished.  See CAPRI (receipt date January 12, 2021).  

An October 2020 VA treatment note reflects diagnoses of depression, anxiety, PTSD, and a recent history of suicidal intent.

In January 2021, the Veteran described feeling very depressed.  He reported a one-day-at-a-time mentality and was prescribed four psychiatric medications.  He was attempting to reduce his medication usage.  He denied self-harm.  In February 2021, the Veteran felt short-fused, jittery, and slept 2 - 3 nonconsecutive hours per night.  He had frequent dreams that were often nightmares.  

The Veteran submitted a PTSD Disability Benefits Questionnaire from a private psychologist, Dr. H.H.  It is unclear whether the Veteran attended an examination, but Dr. H.H. noted she reviewed the claims file and conducted a psychological interview.  The Veteran was diagnosed with PTSD and severe major depressive disorder; however, the Board notes it appears Dr. H.H. utilized an outdated DBQ form from May 2018 and did not diagnose the Veteran using the DSM-5.  Dr. H.H. noted the Veteran's psychiatric symptoms had considerable overlap and interplay between diagnoses.  She found that his psychiatric disabilities caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgement, thinking and/or mood.  The Veteran reported he was prescribed three psychiatric medications.

The Veteran reported many psychiatric symptoms.  He reported panic attacks more than once a week, near-continuous panic or depression, chronic sleep impairment, memory loss, disturbances in mood and motivation, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, and suicidal ideation.  Other symptoms included persistent delusions or hallucinations, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living.  Finally, Dr. H.H. noted his symptoms had affected the Veteran since at least July 2019.

The Veteran attended a VA PTSD examination in March 2021 and was diagnosed with PTSD, other specified trauma and stressor related disorder, and alcohol use disorder.  The VA examiner found that the Veteran's psychiatric disabilities caused occupational and social impairment with reduced reliability and productivity. The Veteran was not employed. The Veteran was prescribed two medications for his psychiatric symptoms at the time of his examination.  

Regarding his depression symptoms, the Veteran reported an onset of October 2020, and shared that once or twice a month he will have low motivation for a few days to a week.  He felt sad and experienced increased crying and feelings of worthlessness during the periods.  He also had difficulty concentrating and making decisions.  He had passive suicidal ideation 3 - 4 times per month and reported the onset as 10 - 12 years ago.  His last suicidal ideation was three weeks prior to his examination.  

The Veteran reported numerous PTSD symptoms.  He shared he experienced intrusive memories and nightmares during the week, sometimes even throughout the day.  He had flashbacks about 5 times per month, and experienced psychological and physiological distress.  He had increased irritability, depression, felt jittery, his heart rate increased, and he would sweat.  Other symptoms included avoidance, guilt, reduced interest, difficulty sleeping, detachment, difficulty concentrating or remembering certain things, hypervigilance, and a startle response.  He reported suicidal ideation, but denied any current ideation, plan, or intent.

At his April 2025 Board hearing, the Veteran testified that he often views life as a punishment.  See Transcript at 26.  He testified that in 2019 he thought about suicide daily because of his chronic pain, but that his current suicidal thoughts were weekly.  See Transcript at 25 - 26.  He described that nightmares lead to his suicidal ideation and that he told his kids goodbye while they were sleeping multiple times.  See Transcript at 21, 26.  The Veteran testified about his avoidant tendencies, specifically how he does not look at or get in the ocean or engage with crowds of people.  See Transcript at 28.  He described he had panic attacks around crowds.  See Transcript at 29.  The Veteran reported that he tolerated crowds at Disney World and sporting events for his family.  See id. at 30 - 31. He was working a full-time job
 daily because of his chronic pain, but that his current suicidal thoughts were weekly.  See Transcript at 25 - 26.  He described that nightmares lead to his suicidal ideation and that he told his kids goodbye while they were sleeping multiple times.  See Transcript at 21, 26.  The Veteran testified about his avoidant tendencies, specifically how he does not look at or get in the ocean or engage with crowds of people.  See Transcript at 28.  He described he had panic attacks around crowds.  See Transcript at 29.  The Veteran reported that he tolerated crowds at Disney World and sporting events for his family.  See id. at 30 - 31. He was working a full-time job.  See Transcript at 32.

Analysis

The Board has considered the Veteran's statements, the relevant treatment records, the private DBQ from Dr. H.H., and the VA examinations. After engaging in a "holistic analysis," that assesses the severity, frequency, and duration of the signs and symptoms of the Veteran's acquired psychiatric disability, the Board finds the criteria for a 70 percent rating, but no higher, is warranted from the date of claim, January 22, 2019.

The Board finds the Veteran's acquired psychiatric disability most closely resembles a 70 percent disability rating.  Specifically, the Board has considered the Veteran's depressed mood, chronic sleep impairment, disturbances in motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, and suicidal ideation.

At his March 2021 VA examination, the Veteran reported intrusive memories and nightmares throughout the week, sometimes even throughout the day. He had flashbacks, psychological distress, and physiological distress.  Other symptoms included avoidance, guilt, reduced interest, difficulty sleeping, detachment, difficulty concentrating or remembering certain things, hypervigilance, and a startle response.  

At his April 2025 Board hearing, the Veteran testified that nightmares caused weekly suicidal ideation.  The Veteran testified that his suicidal ideation and worsening symptoms began in December 2018. He testified that he had suicidal thoughts on a daily basis at that time, which decreased to once or twice a week in 2019 after his surgery because his chronic pain was more bearable. He also testified that nightmares got worse in 2019, and at his March 2021 VA examination he reported he had nightmares throughout the week.

The Veteran's daily nightmares and intrusive thoughts, in addition to his weekly suicidal ideation, reflect that the severity, frequency, and duration consistent with occupational and social impairment, with deficiencies in most areas, or the 70 percent rating criteria. Particularly, with regard to suicidal ideation, the Board recognizes that this symptom is contemplated by the 70 percent criteria, and is similar to persistent danger of self-harm, which is contemplated by the 100 percent criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). However, the severity, frequency, and duration of the Veteran's suicidal ideation has not risen to the level such that a higher rating is warranted. The Veteran was able to manage his symptoms and continue to work up until the pandemic.  Moreover, the most probative and competent credible evidence is against a finding that the Veteran has been in persistent danger of hurting himself or others.   He has been seen by several clinicians on numerous occasions and none has found that he needed to be hospitalized to prevent a suicide or assault on another.  In addition, the evidence does not reflect that he has ever been arrested for such, or attempted such, or that a clinician has felt that he was a danger to others.  The Veteran himself has stated that he would not harm himself despite thoughts of death. See Hearing Transcript at 26-27.

However, the Board finds that the Veteran's acquired psychiatric disability does not meet the next higher rating of 100 percent.  The Board acknowledges that the January 2021 private DBQ from Dr. H.H. reflects some symptoms listed in the rating criteria for a 100 percent rating.  Specifically, persistent delusions or hallucinations, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living.  The Board notes that neither the December 2019 nor the March 2021 in-person VA examinations noted those criteria, and the Veteran's VA treatment records do not reflect delusions, neglect of hygiene, or inability to perform daily living activities.  The Veteran was not noted to have gross impairment in thought processes or communication, intermittent inability to perform activities of daily living, or memory loss to the level contemplated by a 100 percent rating.  

In addition, the evidence does not reflect total social impairment.  At his December 2019 VA examination, the Veteran reported he had a few close friends but he socialized with his wife and other couples
inations, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living.  The Board notes that neither the December 2019 nor the March 2021 in-person VA examinations noted those criteria, and the Veteran's VA treatment records do not reflect delusions, neglect of hygiene, or inability to perform daily living activities.  The Veteran was not noted to have gross impairment in thought processes or communication, intermittent inability to perform activities of daily living, or memory loss to the level contemplated by a 100 percent rating.  

In addition, the evidence does not reflect total social impairment.  At his December 2019 VA examination, the Veteran reported he had a few close friends but he socialized with his wife and other couples.  He coached his son's teams and attended his daughter's gymnastic competitions albeit with an accommodation.  The Veteran vacationed at Disney World and the beach with his family.  He testified that he tolerated these vacations for his family at the April 2025 Board hearing.  The Board finds that the Veteran's PTSD manifestations do not rise to the level of total social impairment contemplated by the 100 percent criteria.    

In sum, the evidence of record does not reflect that the severity, frequency, and duration of the Veteran's symptoms result in total occupational and social impairment.

For the above reasons, the Board finds that an initial increased rating of 70 percent, from January 22, 2019, but no higher and no earlier, is warranted for the Veteran's service-connected acquired psychiatric disability.  

REASONS FOR REMAND

1. Entitlement to service connection for occipital neuralgia, to include as secondary to service-connected PTSD.

The Veteran contends entitlement to service connection for occipital neuralgia.  He contends his occipital neuralgia was caused by a blow to the head during service. See July 2019 VA Form 21-526EZ.  In addition, the Veteran and his representative contend that the occipital neuralgia is secondary to the Veteran's service-connected PTSD.  

The RO found the Veteran had a current diagnosis and an in-service event.  These are favorable findings and binding on the Board absent clear and unmistakable error. See 38 C.F.R. § 3.104(c).

The Veteran's service treatment records reflect a complaint of a headache for 11 days in October 1994.  On the Veteran's May 1995 separation examination, the Veteran complained of frequent and severe headaches. The examiner noted that the Veteran reported a severe headache above his right eye 6 months prior to the examination. In July 1995, the Veteran was struck in the jaw by a high pressure hose and knocked unconscious.  He was diagnosed with a concussion.  

The Veteran's post service treatment records reflect extensive treatment for occipital neuralgia. 

The Veteran's wife and mother submitted statements that the Veteran has painful headaches.  See Statements in Support of Claim (receipt date July 7, 2025).

The Veteran submitted medical literature which addresses possible etiologies of occipital neuralgia and chronic pain and depression.  See Correspondence (receipt date July 7, 2025); STR - Medical (receipt date July 7, 2025).

The Veteran submitted a private nexus letter from Dr. R.M. in October 2020. Dr. R.M. opined that the Veteran's occipital neuralgia at least as likely as not began in service.  

The Board finds this opinion inadequate for adjudicative purposes because the opinion is conclusory and not supported by an adequate rationale.  See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (an adequate medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record).

Here, the RO did not obtain a medical examination. The Board finds that the failure to obtain an examination constitutes a pre-decisional duty to assist error. There is a current diagnosis, an in-service event, and an indication that the Veteran's occipital neuralgia began in service or is related to a service-connected disability. Therefore a remand is warranted so that an addendum medical examination may be obtained. 38 C.F.R. §§ 3.159(c), 20.802(a); McLendon v. Nicholson, 20 Vet. App. 79 (2006).

2. Entitlement to service connection for implementation of a spinal pacemaker as secondary to occipital neuralgia.

3. Entitlement to service connection for surgical scars as secondary to occipital neuralgia.

The Veteran contends entitlement to service connection for a spinal pacemaker and the associated surgical scars.  See Transcript at 9.

The Board finds that these claims are inextricably intertwined with the occipital neuralgia claim that is being remanded.
-connected disability. Therefore a remand is warranted so that an addendum medical examination may be obtained. 38 C.F.R. §§ 3.159(c), 20.802(a); McLendon v. Nicholson, 20 Vet. App. 79 (2006).

2. Entitlement to service connection for implementation of a spinal pacemaker as secondary to occipital neuralgia.

3. Entitlement to service connection for surgical scars as secondary to occipital neuralgia.

The Veteran contends entitlement to service connection for a spinal pacemaker and the associated surgical scars.  See Transcript at 9.

The Board finds that these claims are inextricably intertwined with the occipital neuralgia claim that is being remanded. Thus, these claims must also be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when the adjudication of one issue could have "significant impact" on the other issue).

4. Entitlement to a total disability rating based on individual unemployability (TDIU).

The Board finds the issue of entitlement to a total disability rating based on individual unemployability (TDIU) has been raised by the record.  See Rice v. Shinseki, 22 Vet. App. 447 (2009). Specifically, VA treatment notes reflect the Veteran reported that he was unemployed around April 2020.  See CAPRI (receipt date January 12, 2021).  

The Board notes that the Veteran filed a VA Form 21-8940 in July 2025 and claimed he could not work because of his occipital neuralgia and mental health disability. 

In the remarks section of the July 2025 VA Form 21-8940, the Veteran reported several surgeries and procedures, including procedures to treat his chronic pain associated with occipital neuralgia.  He stated he lost about five months of work and used short term disability benefits.  He also reported that the spinal pacemaker caused pain and interference with his ability to sit at work.

Accordingly, a claim for entitlement to a TDIU for the period on appeal (since January 2019 until March 2021), is inextricably intertwined with the initial adjudication of the claim for entitlement to service connection for occipital neuralgia and associated secondary claims.  Thus, this claim must be remanded.  See Harris, 1 Vet. App. 180.

The matter is REMANDED for the following action:

1. Schedule the Veteran for a VA examination, with an appropriate clinician, to determine the nature and etiology of the Veteran's occipital neuralgia.  The claims file must be reviewed.  The examiner should address the following:

(a.) Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that occipital neuralgia had its onset during active service or is otherwise etiologically related to it. 

The examiner must address the following:

"	The Veteran's complaint of frequent, severe headaches on his May 1995 separation examination (see STR - Medical, receipt date May 23, 2011); 

"	The Veteran's July 1995 head injury (see id.); and

"	Veteran's lay statement that he has experienced symptoms since service (Transcript at 4).

(b.) Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's occipital neuralgia is caused by his service-connected PTSD with other specified trauma and stressor related disorder, and alcohol use disorder.

(c.) If the answer to (b.) is no, then is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's occipital neuralgia is aggravated (any worsening) by his service-connected psychiatric disability?

Specifically, would the occipital neuralgia have been less severe but for the service-connected psychiatric disability, either because there is an etiological link or because the psychiatric disability resulted in the inability to treat the occipital neuralgia?

Separate causation and aggravation opinions should be provided.

It should be noted that the Veteran is competent to report his symptoms and history.  Such reports must be acknowledged and considered in formulating any opinion.  If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation.  The examiner is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions.   

The examiner must provide a complete rationale for his or her opinion(s).  If the requested opinion cannot be provided without resorting to mere speculation,