SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

DELYVONNE M. WHITEHEAD · 2026 · Case ID: A26040554

DENIED

Summary

The Veteran, who served from November 1978 to December 1992, appealed the denial of service connection for sleep apnea, testicular hernia, and an increased rating for PTSD. The Board denied service connection for sleep apnea, finding that the evidence did not establish it was caused or aggravated by service-connected PTSD, nor was it incurred in service. The VA examiner's opinions, which found sleep apnea less likely than not related to PTSD and multifactorial in nature, were found to be probative and outweighed the Veteran's lay testimony and the Appellant's belief that PTSD contributed to the condition. The Board also denied service connection for a testicular hernia, finding the weight of the evidence against its existence during service or the appeal period. While the Veteran had in-service epididymitis and later small epididymal cysts were service-connected, no diagnosis of a hernia was found in service treatment or VA records. The Board noted the Veteran's claims for hiatal and umbilical hernias were not encompassed by the testicular hernia claim. Finally, the Board denied an increased rating for PTSD, finding the Veteran's symptoms, while present, did not rise to the level of occupational and social impairment with reduced reliability and productivity required for a higher rating. The evidence showed the Veteran generally functioned satisfactorily, managed his symptoms with medication and therapy, and maintained relationships and some employment.

Rationale

Weight of evidence against service connection; VA examiner found sleep apnea less likely than not related to PTSD; Sleep apnea multifactorial, not directly caused by PTSD

Special Benefit

NO SPECIAL BENEFIT

Docket No.

200228-71508

Full Decision Text

Citation Nr: A26040554
Decision Date: 04/30/26 Archive Date: 04/30/26

DOCKET NO. 200228-71508
DATE: April 30, 2026

ORDER

Entitlement to service connection for a sleep disorder, to include sleep apnea, is denied.

Entitlement to service connection for a testicular hernia is denied.

Entitlement to a rating higher than 30 percent for posttraumatic stress disorder (PTSD) is denied.

FINDINGS OF FACT

1. The weight of the probative evidence does not indicate that the Veteran's sleep apnea was incurred in or related to his active duty service, or that it has been caused or aggravated by PTSD. The Veteran's additional symptoms of difficulty sleeping are encompassed by the award of service connection for PTSD.

2. The weight of the persuasive evidence is against finding that the Veteran had a left-side testicular hernia or other testicular disorder.?

3. The weight of the persuasive evidence is against finding that the Veteran's PTSD manifested by occupational and social impairment with reduced reliability and productivity.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for a sleep disorder, to include sleep apnea, have not been met. ?38?U.S.C. §§?1110, 1131, 5107;?38?C.F.R. §§?3.102, 3.303, 3.304, 3.310.????

2. The criteria for entitlement to service connection for a testicular hernia have not been met.? 38?U.S.C. §§?1110, 1131, 5107;?38?C.F.R. §§?3.102, 3.303, 3.304.

3. The criteria for a rating higher than 30 percent for PTSD have not been met. 38?U.S.C. §§?1110, 1131, 1155, 5107; 38?C.F.R. §?4.130, Diagnostic Code 9411.?

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from November 1978 to December 1992. He passed away in March 2023. The Veteran's surviving spouse has been substituted as the Appellant.

This case comes to the Board of Veterans' Appeals (Board) from May 2019 and August 2019 rating decisions of the Department of Veterans Affairs (VA) Regional Office, which is the Agency of Original Jurisdiction (AOJ).

In the February 2020 VA Forms 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held on January 7, 2025.

The Board may only consider the evidence of record at the time of the May 2019 and August 2019 AOJ decisions on appeal, as well as any evidence submitted by the Appellant or her representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the 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 Appellant would like VA to consider any evidence that was submitted that the Board could not consider, she 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.

Sleep Impairment

In June 2019, the Veteran submitted a claim for service connection for sleep apnea as secondary to PTSD.

At the January 2025 Board hearing, the Appellant testified that she knew the Veteran since 2003, had witnessed the Veteran struggle with sleep apnea at night, including heavy snoring and pauses in breathing. She said that having to stay up late for long periods of time in the military may have added to his sleep problems. Her son-in-law also testified that in the military, you have to work strenuous hours and become mentally trained to survive off of only four hours of sleep a night.

Generally, service connection may be granted for a disability resulting from disease or injury incurred coincident with or aggravated
In June 2019, the Veteran submitted a claim for service connection for sleep apnea as secondary to PTSD.

Generally, service connection may be granted for a disability resulting from disease or injury incurred coincident with or aggravated by service.??38?U.S.C. §§?1110. 1131;?38?C.F.R. §?3.303(a).? Service connection requires evidence satisfying three criteria: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the present disability and the disease or injury incurred or aggravated during service.??Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).??

Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury.? 38?C.F.R. §?3.310(a).? This permits service connection not only for a disability caused by a service-connected disability, but also for the degree of disability resulting from aggravation of a disability by a service-connected disability.? See Allen v. Brown, 7?Vet. App.?439, 448 (1995).

The evidence shows that the Veteran did have a diagnosis of obstructive sleep apnea. He attended a VA examination in July 2019, where he was found to have a diagnosis of obstructive sleep apnea since 2000. At this examination, he reported that his condition started in 1991, although a sleep study was not performed until 2000.

The evidence does not indicate, however, that the Veteran's sleep apnea was caused or aggravated by his service-connected PTSD.

The VA examiner who performed the July 2019 VA examination provided VA opinions addressing the relationship between the Veteran's sleep apnea and PTSD. He found that sleep apnea was less likely than not proximately due to or the result of PTSD. He explained that sleep apnea tends to be multifactorial in nature, including genetic factors, environmental factors, drug abuse, lifestyles, body habitus, sinus conditions, upper respiratory conditions, and neurological deficits, and it can be idiopathic. He wrote that there was no direct causality of PTSD causing or leading to sleep apnea. He also wrote that although sleeping difficulty is one of the many symptoms of PTSD, PTSD is not a contributing factor to sleep apnea and is not associated with sleep apnea.

The examiner was also asked to address obesity, and he wrote that it was at least as likely as not that the Veteran sleep apnea was proximately due to or caused by obesity, because this has been linked as a risk factor for sleep apnea due to the extra fat in the neck, decreasing the airway and causing obstruction. The examiner did not, however, address the relationship between PTSD and obesity, so an addendum opinion was requested in August 2019. The same examiner reviewed the records and revised his opinion, stating that the sleep apnea was not directly caused by obesity, because sleep apnea was multifactorial in nature. He also wrote that it was less likely as not that the Veteran's obesity was proximately due to or the result of PTSD since there was no medical literature that directly linked PTSD causing or leading to obesity since they are both anatomically and different physiological system.

The Board finds these medical opinions to be probative evidence which weighs against the claim.? They were based on an in-person examination of the Veteran and an accurate understanding of his medical history, and the examiner provided adequate rationale to support his findings.? See Prejean v. West, 13?Vet. App.?444, 448-49 (2000).? The Board recognizes that the VA examiner did not provide separate questionnaires for causation and for aggravation, but in this case, it is clear that his opinion was meant to encompass both whether PTSD had caused or had aggravated sleep apnea, as he included in his rationale sentences addressing both causation but also it had contributed to or been associated with sleep apnea, and the Board finds that the opinion is adequate. See El-Amin v. Shinseki, 26 Vet. App. 136, 140
accurate understanding of his medical history, and the examiner provided adequate rationale to support his findings.? See Prejean v. West, 13?Vet. App.?444, 448-49 (2000).? The Board recognizes that the VA examiner did not provide separate questionnaires for causation and for aggravation, but in this case, it is clear that his opinion was meant to encompass both whether PTSD had caused or had aggravated sleep apnea, as he included in his rationale sentences addressing both causation but also it had contributed to or been associated with sleep apnea, and the Board finds that the opinion is adequate. See El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). There are no other medical opinions which contradict with these findings, so even to the extent that the examiner's failure to provide clearly separate opinions lessens the probative weight of the opinion, there are no conflicting opinions which come to any different conclusions.?

The Appellant has not submitted any other medical evidence regarding whether PTSD could have caused or aggravated sleep apnea. At the January 2025 Board hearing, when asked whether she believed PTSD could have contributed to developing sleep apnea, she stated that his job and training caused extra stress, but did not actually indicate that she believed PTSD had caused or contributed to his sleep apnea. The Board recognizes that the Veteran believed his PTSD may have caused or aggravated his sleep apnea, but as a lay person, he was not competent to opine on the etiology of a complex condition like sleep apnea.? See?Jandreau?v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis).? His assertions are outweighed by the more probative findings of the VA examiner.

The Board therefore finds that the evidence is persuasively in favor of finding that the Veteran's sleep apnea was not related to his military service and was not caused or aggravated by his service-connected PTSD. The Veteran's other sleep impairment symptoms, including difficulty falling and staying asleep, are symptoms that are encompassed by the award of service connection for PTSD. The claim of entitlement to service connection for a sleep disorder, to include sleep apnea, is denied.? The evidence is not in approximate balance, and the benefit-of-the-doubt rule does not apply.? See Lynch v. McDonough, 21 F. 4th 776 (2021).?

Testicular Hernia

The Veteran also submitted a claim for service connection for left-side testicular hernia. The Veteran wrote that he had a severely swollen testicle in service which he believed led to his inability to have more children.

After reviewing all of the evidence, the Board finds that the weight of the persuasive evidence is against finding that the Veteran had a diagnosis of a testicular hernia or other testicular disorder, and service connection is not warranted.

At the January 2025 Board hearing, the Appellant's representative stated that although the claim had been for a "left-side" testicular hernia, she thought that could be in error, and that the claim was actually for a right-side testicular hernia. The Board accepts that this may be the case, and will consider whether service connection can be granted for a hernia affecting either testicle. Also at that hearing, the Veteran's daughter stated that repetitive strain, combat, and training can cause stress in the testicular area and can cause a hernia. The Appellant stated that the Veteran had told her that he had an injury to the testicular area in service, that the condition did not resolve, and that he had to continue taking medication for it. She said that he did complain a little bit about pain in that area.

The Veteran asserted several times to VA that he believed he had a testicular hernia in 1977 which required antibiotics and bedrest. However, a review of the service treatment records show that the Veteran was mistaken about the cause of his testicular pain in service. His service treatment records show that in November 1977, he was seen for a swollen testicle that had occurred for two weeks. He was diagnosed with right epididymitis and placed on bed rest and given medication. Three days later, he was seen again for right testicle pain, which he reported was getting better, and the swelling had gone down. The right testicle still had a firm mass that was tender to compression. The diagnosis was still epididymitis. Five days after this, in December 1977, he was noted to be doing better with his right testicle, with no pain or swelling. The teste had no mass, edema
of his testicular pain in service. His service treatment records show that in November 1977, he was seen for a swollen testicle that had occurred for two weeks. He was diagnosed with right epididymitis and placed on bed rest and given medication. Three days later, he was seen again for right testicle pain, which he reported was getting better, and the swelling had gone down. The right testicle still had a firm mass that was tender to compression. The diagnosis was still epididymitis. Five days after this, in December 1977, he was noted to be doing better with his right testicle, with no pain or swelling. The teste had no mass, edema, or tenderness. He was found to have resolved epididymitis, but was advised to continue scrotal support for two more weeks.

There are no other reports of recurring problems with the right testicle. His December 1992 retirement examination. The abdomen and viscera, including hernia, and the genitourinary system were found to be normal. On the Report of Medical History, he checked "No" for any rupture or hernia.

The Veteran did previously submit a claim for injury to the right testicle which occurred in November 1977, in January 1992.

At a February 1993 VA examination, he reported that in the late 1970s, he had swelling and pain in the right side of his scrotum. He was not sent to the hospital, but was put to bed in quarters for 72 hours and given an antibiotic. The swelling subsided and he returned to duty. He thought that it could have led to sterility, and the examiner found possible sterility resulting from testicular infection. He then attended a VA urology examination, where he reported that while he was in the service, he was doing physical training exercises and noted some discomfort in the right testicle which gradually became quite swollen, painful, and inflamed. He said that he went to a physician assistant who told him it was the worst hernia he had ever seen, and that he was treated with 3 days of bedrest and antibiotics until the symptoms gradually resolved. Examination of the lower abdomen showed no evidence of an inguinal hernia, but he did have two very small cystic masses, which were consistent with paradidymal cysts.

The Veteran then attended a VA urology follow up evaluation, which analyzed his sperm count to determine if there was sterility. It found that the Veteran was hypofertile; he did have reduced sperm count, although the sperm that were present had morphology and motility within normal limits. The examiner discussed how the Veteran was treated for epididymitis in service, which was treated appropriately at that time, but that the Veteran was concerned that he had since been able to cause a pregnancy. Physical examination of the testes was normal.

In an October 1993 rating decision, service connection for small epididymal cysts was granted, but service connection was denied for any further residuals related to the in-service epididymitis. The decision found that there was no current evidence of injury or disease, and no evidence of sterility.

Since then, the medical evidence of record does not show any diagnosis or treatment for a testicular hernia. The Veteran's VA treatment records show that he has discussed his in-service testicular swelling and concerns about sterility with his providers on multiple occasions, but they do not show any diagnoses of a testicular hernia or other testicle disorder, other than findings of a small mass or nodule on the right testicle. A September 2000 physical evaluation found a 12 centimeter right epididymis nodule. A May 2005 physical examination found no inguinal hernia. In November 2005, he wrote to VA asserting that he was unable to have any more kids, and this was due to the swollen testicle he had in service. In May 2012 he had no testicular pain or swelling.

In December 2013, he reported that he had felt a testicular mass in his scrotum, and that it had been present since then, but had neither increased nor decreased in size sinc that time. In April 2017, a CT scan found a possible small hiatal hernia, with diverticula of descending colon, transverse colon and descending colon. At an October 2017 urology clinic, he reported that he had severe scrotal swelling in 1976 that resulted in left testicular atrophy and left him unable to conceive. Physical evaluation found that the Veteran's right testicle had greater volume than the left testicle, likely due to right epidid
testicular pain or swelling.

At a December 2017 endocrinology consultation, the Veteran reported that his left testicle had become swollen during service in 1976, that he was treated with antibiotics, and that it reduced in size after that, but left him with decreased sperm count, and that the left testicle was decreased in size compared to the right. He was found to have low testosterone and erectile dysfunction, but no testicular hernia or testicular masses were diagnosed. A September 2020 CT scan found a small fat-containing umbilical hernia. In October 2020, examination of the abdomen found no hernias. At a March 2021 urology evaluation, he denied any tenderness or discomfort to the testicles. A September 2021 CT scan again found a "Tiny broad-based fat-containing umbilical hernia."

After reviewing all of the evidence, the Board finds that the weight of the persuasive evidence is against finding that the Veteran had a testicular hernia, or any other testicular disability for which service connection can be granted. The Veteran's service treatment records do not show any findings or diagnoses?of a hernia.? The Veteran's VA treatment records also show no findings or diagnosis of a testicular hernia or a testicle disability.

The presence of a current disability is the cornerstone of any service connection claim.? Service connection is not?warranted?when there is no current disability. ?Brammer v.?Derwinski, 3?Vet. App.?223 (1992).? Here, there is no evidence which?demonstrates?that the Veteran had a diagnosis of?a testicular hernia at any time during the pendency of the claim, or at any time prior to the filing of the claim.??See Romanowsky v. Shinseki, 26?Vet. App.?289, 294 (2013);?McClain v. Nicholson, 21?Vet. App.?319, 321 (2007).? In the absence of such a disability, the claim cannot be granted.????

In this case, the Board finds that the weight of the evidence is against finding that the Veteran has had a testicular hernia at any time. The service treatment records show no such diagnosis, and at no time after service is there evidence of treatment or diagnosis of a testicular hernia. The Veteran did have epididymitis in service, but there is no evidence of any further residuals which occurred during the appeal period other than the small testicular nodules for which the Veteran has already been awarded service connection. There is no persuasive evidence indicating that he had any other testicular disability during the appeal period, including any disability which caused pain in the testicular or groin area.

The Veteran was not afforded a VA examination to evaluate his claim for service connection for a testicular hernia in conjunction with his reopened claim, but the duty to afford the Veteran an examination was not triggered. ?VA is obliged to provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service, or establishing that certain diseases manifested during an applicable presumptive period for which the claimant qualifies; and (3) an indication that the disability or persistent/recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability; but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim.?McLendon v. Nicholson, 20?Vet. App.?79, 81 (2006).?

In the absence of any evidence of a current disability or symptoms of a testicular hernia or other testicular disorder, there was no duty to provide a VA examination.? Because there was no evidence of a?current disability or current symptoms of a disability, the AOJ did not err by not providing the Veteran with an examination or obtaining a medical opinion. It was therefore?appropriate for?the AOJ to?pro
symptoms of a disability may be associated with the Veteran's service or with another service-connected disability; but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim.?McLendon v. Nicholson, 20?Vet. App.?79, 81 (2006).?

In the absence of any evidence of a current disability or symptoms of a testicular hernia or other testicular disorder, there was no duty to provide a VA examination.? Because there was no evidence of a?current disability or current symptoms of a disability, the AOJ did not err by not providing the Veteran with an examination or obtaining a medical opinion. It was therefore?appropriate for?the AOJ to?proceed?with adjudication?without affording the Veteran a VA examination, and the Board does not find any pre-decisional duty to?assist?error that would allow for remanding?this issue.? See?38?C.F.R. §?20.802.?

The Board acknowledges that the Veteran was found to have a possible hiatal hernia and a small fat-containing umbilical hernia, but these conditions, while also called "hernias," are not the same type of disorder that was claimed by the Veteran, and they are not encompassed in the current claim. A claim for service connection can include all diagnoses found during the claim's development that relate to the symptomatology asserted by the Veteran. Grimes v. McDonough, 34 Vet. App. 84, 89 (2021). The scope of a claim may be expanded to any disability that may reasonably be encompassed by the claimant's description of the claim, the symptoms described, and the evidence received in support of the claim. Clemons v. Shinseki, 23 Vet. App. 1 (2009).

The Board does not find that claims for a hiatal hernia or an umbilical hernia are encompassed by the Veteran's claim for service connection for a testicular hernia. According to the Mayo Clinic, an "An umbilical hernia occurs when part of your intestine bulges through the opening in your abdominal muscles near your bellybutton (navel). Umbilical hernias are common and typically harmless." See Mayo Clinic, "Umbilical Hernia," https://www.mayoclinic.org/diseases-conditions/umbilical-hernia/symptoms-causes/syc-20378685 (last visited April 20, 2026). A hiatal hernia happens when the upper part of the stomach bulges through the large muscle that separates the abdomen and the chest. Mayo Clinic, "Hiatal hernia," https://www.mayoclinic.org/diseases-conditions/hiatal-hernia/symptoms-causes/syc-20373379 (last visited April 21, 2026).

These types of hernias occur in parts of the body that are very different from the testicular region or groin. The Veteran's lay reports were very clear that he was alleging that he had a residual disorder related to his painful and swollen right testicle in service, and that the current pain affected his testicle and groin. A hiatal or umbilical hernia would not result from an infection of the testicle or result in testicular pain, and they are entirely separate conditions from the claim that is currently on appeal. At no time did the Veteran or the Appellant assert that the claim was intended to encompass claims for hiatal or umbilical hernias. The Board therefore does not find that a claim for service connection for hiatal or umbilical hernia was reasonably raised during the claim.

The Board also finds that while any residuals of the Veteran's in-service epididymitis have been reasonably raised and are encompassed in the scope of the claim, the residuals that the Veteran was found to have were already awarded service connection. The Veteran was granted service connection for small epididymal cysts found to be related to his epididymitis. The Veteran also had asserted that he was sterile due to his epididymitis. Sterility is not a disability can be awarded service connection on its own, but special monthly compensation can be awarded for loss of use of a creative organ, and the Veteran was already awarded entitlement to special monthly compensation based on loss of use of a creative organ in an August 2019 rating decision. While this grant was based on erectile dysfunction, it is not possible to award this special monthly compensation more than once, even if a veteran is unable to procreate due to two independent causes. See Westphal v. Collins, 2026 U.S. App. Vet. Claims LEXIS 72. Because service connection has already been
The Veteran also had asserted that he was sterile due to his epididymitis. Sterility is not a disability can be awarded service connection on its own, but special monthly compensation can be awarded for loss of use of a creative organ, and the Veteran was already awarded entitlement to special monthly compensation based on loss of use of a creative organ in an August 2019 rating decision. While this grant was based on erectile dysfunction, it is not possible to award this special monthly compensation more than once, even if a veteran is unable to procreate due to two independent causes. See Westphal v. Collins, 2026 U.S. App. Vet. Claims LEXIS 72. Because service connection has already been awarded for the Veteran's epididymal cysts/nodules and for the inability to procreate, these symptoms cannot be the basis for finding an additional, separate disability for which service connected can be granted. See 38 C.F.R. § 4.14; Esteban v. Brown, 6?Vet. App.?259, 261-62 (1994) (VA may not assign multiple ratings for duplicative or overlapping symptomatology.).

Lastly, the Board recognizes that the Appellant has testified that the Veteran had occasional pain in his right testicle. Even if the Veteran did have occasional testicular pain, the Board does not find any probative medical evidence indicating that this symptom was part of a disability for which service connection can be granted. Pain alone can be considered a disability where there is functional impairment, even if there is no identified underlying diagnosis. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). However, in this case, there is no evidence of any functional impairment caused by the Veteran's occasional groin pain, and the Veteran never reported having any functional impairment caused by this pain. The Board does not find that the Appellant's reports of the Veteran's occasional pain constitutes a disability for which service connection can be granted.

For the foregoing reasons, the Board finds that the weight of the probative and persuasive medical evidence is against finding that the Veteran had a right or left testicular hernia, or any other type of chronic testicular disorder which was incurred in or related to his military service.? The criteria for service connection have not been met, and the claim is denied.? The Board has again considered the applicability of the benefit-of-the-doubt doctrine; however, the evidence is not in approximate balance, and the benefit-of-the-doubt rule does not apply.??See Lynch, 21 F. 4th 776.?

PTSD

In April 2019, the Veteran submitted a request for a higher rating for his service-connected PTSD, which had been assigned a 30 percent rating since October 2009.

Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings 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 their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1.

The Veteran's PTSD was rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 30 percent rating is assigned when there is occupational and social impairment with an 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, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411.

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 (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id.

Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. ?Bankhead v. Shulkin, 29?Vet. App.?10, 22 (2017);
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; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id.

Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. ?Bankhead v. Shulkin, 29?Vet. App.?10, 22 (2017); 38 C.F.R. § 4.130.? The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages.? Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating.? Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013).??

The Veteran attended a VA examination in April 2019. The Veteran reported that he was living with his third wife since 2016, and that they often argued, but denied physical violence. He reported a close, supportive relationship with his wife, and that he had been doing better since they got together. He reported having little social contact, and that people irritated him and he tended to keep to himself. He had lost interest in activities he previously enjoyed, such as fishing and gardening. He was currently retired, and spent his days watching TV and going for walks, mostly alone. He denied any recent suicidal ideation, and he credited his wife and his therapy groups for his current emotional stability. He was taking an antidepressant and had a positive response to the medication. He reported no legal or behavioral history problems and no problematic use of drugs or alcohol. The examiner found that the Veteran had symptoms of recurrent distressing dreams, avoidance, persistent negative emotional state, markedly diminished interest in activities, feelings of detachment, irritable behavior or angry outbursts, chronic sleep impairment, depressed mood, and anxiety. The Veteran was polite and cooperative, coherent, able to express himself clearly, and well-groomed. He was oriented to person, time, and place, and was able to understand questions and respond accordingly. The examiner found that the Veteran did have a diagnosis of PTSD, and he had 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 Veteran's VA treatment records show that he regularly attended peer group therapy and took antidepressant medication to help with his psychiatric symptoms. The Board notes that although the Veteran appealed the May 2019 rating decision, and only VA treatment records up to that point would have been reviewed by the AOJ, the Appellant has, within the evidence window following the Board hearing, submitted numerous VA treatment records for the period from May 2019 until the Veteran's death in March 2023, and therefore these records will also be considered by the Board.

In January 2019, the Veteran was oriented to person, place, and time, his speech was clear and appropriate, and appearance was neat and clean. In February 2019, the Veteran reported that he was doing "good," and he denied any distressing recollections or current nightmares. His medication was helping his symptoms. He had symptoms of hyperarousal and irritability that had started the prior year, but had lessened. He was not isolating and denied hopelessness. He did not report having any anxious mood or thoughts of hurting himself. He did not currently have any acute stressors or triggers, and he was not in despair or paranoid. There was no evidence of any delusions or racing thoughts. He was easily engaged during the interview, and demonstrated motivation towards continuing to pursue mental health treatment. He denied any memory problems. He was alerted and oriented, clean and neatly dressed, and had logical and relevant speech. Insight and judgment were fair. At peer support group sessions throughout 2019, the Veteran was noted to have normal mood, goal-directed thought, and calm behavior, and he was fully oriented. He denied suicidal or homicidal ideation.

In a July 2019 mental health note, the Veteran reported that his mood was better, and he denied any thoughts of hurting himself. He was tolerating his medications well. He was not in despair and denied any acute triggers. He was alert and oriented
was easily engaged during the interview, and demonstrated motivation towards continuing to pursue mental health treatment. He denied any memory problems. He was alerted and oriented, clean and neatly dressed, and had logical and relevant speech. Insight and judgment were fair. At peer support group sessions throughout 2019, the Veteran was noted to have normal mood, goal-directed thought, and calm behavior, and he was fully oriented. He denied suicidal or homicidal ideation.

In a July 2019 mental health note, the Veteran reported that his mood was better, and he denied any thoughts of hurting himself. He was tolerating his medications well. He was not in despair and denied any acute triggers. He was alert and oriented, with logical speech, euthymic mood, organized thought process, fair insight and judgment, and logical speech. An August 2019 psychology note noted that the Veteran posed no current risk to himself or others. He expressed frustration with filling out his disability claims, but he reported being a "people person" and being motivated for treatment. He shared a need to calm down and improve his sleep pattern, and he enjoyed fishing and would continue with it, because it "clears the mind." In November 2019, he reported that he no longer had nightmares, and that he was doing better, with no new mental health issues to report. He denied racing thoughts or paranoia, and was overall doing fair. His mood was euthymic, thought process was organized insight was fair, and he was alert and oriented. At a depression and PTSD screening that month, the Veteran denied having nightmares about a traumatic event, feeling numb, being on guard, or feeling guilty. He also denied having any feelings of being depressed, hopeless, or having little interest or pleasure in doing things.

At a November 2019 care assessment, the Veteran was alert and oriented, and denied any current depression. He reported that he sometimes took sleep aids for his nightmares. He had been walking three times a week for an hour, but had moved away from that. He denied any hallucinations, mania, or delusions. He did report having some depression. In an April 2020 telehealth call, the Veteran had normal mood, logical thought, appropriate appearance, and was fully oriented.

The Veteran continued to attend group counseling sessions via telephone calls in 2020, and he always reported that his mood was good or okay, and he did not report any suicidal ideation. In May 2020, the Veteran reported that his mood was good, and his support was his group family and friends. In June 2020, the Veteran participated in a Quality of Life satisfaction study, and he reported having high levels of satisfaction with goals and values, play, love, home, and neighborhood. In August 2020, he reported supporting members of his church family and other veterans as a way that he supports himself and others.

At group therapy sessions in 2021 and 2022, the Veteran continued to report no suicidal ideas and to present as alert and oriented, with no acute complaints. At several psychiatric telehealth calls in 2021, he was found to have normal mood, goal-directed thought process, appropriate appearance, calm and cooperative behavior, and was fully oriented. In April 2021, the Veteran denied feeling sad or depressed, and in October 2021, he reported that he was in a good mood and was not suicidal or homicidal. At an April 2022 depression and PTSD screening, the Veteran reported having depression and little interest in doing things for several days in the past two weeks. He denied having any thoughts of killing himself.

At an August 2022 telehealth encounter, the Veteran was alert and oriented to person, place, and time. He was currently married, with 2 children, 6 grandchildren, and 4 stepchildren. He was retired, but still worked odd jobs plumbing part-time. In November 2022, he reported having several days in the past two weeks when he had little interest in activities, but he denied depression. In January 2023, he reported that he was still going for daily walks. He was noted to be alert and fully oriented. At a February 2023 interview with a social worker, the Veteran was alert and oriented, he was fully independent with activities of daily living, and he denied any homicidal or suicidal thoughts. In a depression screening, he denied any feelings of being depressed or hopeless in the past two weeks.

Based on a review of the evidence described above, the Board finds that the weight of the persuasive and probative evidence is against finding that a rating higher than 30 percent is warranted.

The evidence of record shows that the Veteran had mild, ongoing symptoms on PTSD, but
, but he denied depression. In January 2023, he reported that he was still going for daily walks. He was noted to be alert and fully oriented. At a February 2023 interview with a social worker, the Veteran was alert and oriented, he was fully independent with activities of daily living, and he denied any homicidal or suicidal thoughts. In a depression screening, he denied any feelings of being depressed or hopeless in the past two weeks.

Based on a review of the evidence described above, the Board finds that the weight of the persuasive and probative evidence is against finding that a rating higher than 30 percent is warranted.

The evidence of record shows that the Veteran had mild, ongoing symptoms on PTSD, but they did not produce occupational and social impairment with reduced reliability and productivity at any time. The Veteran's PTSD symptoms caused him to have some challenges with socializing, interpersonal relations, loss of interest in activities, depression, and anxiety. However, he consistently reported having a positive result from taking antidepressant medication, including a decrease in his difficulty sleeping, nightmares, and symptoms overall. He did not report having any major impairment caused by his PTSD symptoms, and continued to be able to perform odd jobs and have a positive relationship with his wife.

The April 2019 VA examiner also found that the Veteran had feelings of detachment and avoidance, but the Veteran nevertheless was able to maintain relationships with his wife and children, he participated in a peer support group and attended church, and he frequently went for walks outside. While the Veteran reported having feelings of depression, irritability, and anxiety, and he reported that he sometimes argued with his wife, he has also been able to maintain personal relationships throughout the appeal period. He had a positive relationship with his third wife for many years, and reported that helping people at church was a way that he could support others and himself. He did sometimes report having decreased interest in activities that he used to enjoy, but also reported that he did still go fishing, which he found cleared his mind, and could complete odd jobs working in plumbing.

The Board acknowledges that undertaking outside activities and maintaining positive relationships may not always have been easy for the Veteran due to psychiatric and physical symptoms, but the fact that he was able to still function so well, even with these symptoms, is commendable. He took his psychiatric care seriously and was always found to be appropriate and participatory in group counseling sessions. He took antidepressant medication that greatly lessened his symptoms, and regularly checked in with his providers regarding his mental health.

The VA examination and treatment records consistently showed that the Veteran was well-groomed, his behavior was appropriate, and his speech was normal and logical. There is no indication that his PTSD symptoms ever impacted his ability to perform all activities of daily living. He was always able to communicate normally and coherently, and his judgment and insight were always at least "fair." He was always dressed neatly and appropriately, and was always found to be alert, oriented, and cooperative, with organized, normal thought. There is no indication that he ever had speech, appearance, behavioral, or cognitive impairment from PTSD that caused occupational and social impairment with reduced reliability and productivity.

The Veteran was never found to have any problems with memory, and he did not report any problems with his memory. He had some irritability, but never reported or was found to have inappropriate behavior. He never had any incidents of violence or problems with substance abuse. While he did sometimes report having feelings of depression, these symptoms seem to have waxed and waned, and he often reported not feeling any depressive feelings. At all times, he always denied suicidal or homicidal ideation. There was no indication that the Veteran ever was a danger to himself or others, or that he had ever contemplated doing harm to himself or others.

Some of the Veteran's reported symptoms are included among those specifically listed in the General Rating Formula for Mental Disorders, pursuant to which the current 30 percent disability rating has been assigned. See 38 C.F.R. § 4.130. The Veteran demonstrated, for at least part of the appeal period, depressed mood, anxiety, irritability, nightmares, and chronic sleep impairment. The Board notes that symptoms noted in the rating schedule 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 disability rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In other words, symptoms comparable to those listed in the General Rating Formula could be considered in evaluating the Veteran's extent of occupational and social impairment. The Board finds that these symptoms are comparable indicators of the type of occupational and social impairment that could cause occasional decrease in work efficiency and intermittent
least part of the appeal period, depressed mood, anxiety, irritability, nightmares, and chronic sleep impairment. The Board notes that symptoms noted in the rating schedule 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 disability rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In other words, symptoms comparable to those listed in the General Rating Formula could be considered in evaluating the Veteran's extent of occupational and social impairment. The Board finds that these symptoms are comparable indicators of the type of occupational and social impairment that could cause occasional decrease in work efficiency and intermittent periods of having more difficulty with occupational tasks, which is consistent with a 30 percent rating. These symptoms, including when they are combined with the other symptoms discussed above, do not demonstrate symptoms of such severity and frequency that would be comparable indicators of the type of impairment contemplated in the criteria for a 50 percent rating and would constitute occupational and social impairment with reduced reliability and productivity.

The Board finds that the 30 percent rating assigned to the Veteran for his PTSD was appropriate, and that the evidence persuasively weighs against a finding that the criteria for a rating higher than 30 percent have been met. As such, the claim is denied. The Board has again considered the applicability of the benefit-of-the-doubt doctrine; however, the evidence is not in approximate balance, and the benefit-of-the-doubt rule does not apply.? See Lynch, 21 F. 4th 776.?

DELYVONNE M. WHITEHEAD

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Mary E. Rude, Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.

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