Citation Nr: 1605706 Decision Date: 02/12/16 Archive Date: 02/18/16 DOCKET NO. 10-27 113 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES Entitlement to an initial disability rating in excess of 70 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Robert V. Chisholm, Attorney ATTORNEY FOR THE BOARD Steve Ginski, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Army from December 1968 to December 1970. This appeal comes before the Department of Veterans Affairs (VA) Board of Veterans' Appeals (Board) from a December 2009 rating decision of the VA Regional Office (RO) in Roanoke, Virginia. By rating action dated in February 2011, the RO granted a temporary total rating (100 percent disability) for a period of hospitalization related to PTSD from September 27, 2010 to November 30, 2010. This period of time is not on appeal. By decision in December 2012, the Board granted a 50 percent disability rating for PTSD and remanded the claim of a total rating based on unemployability due to service-connected disability for further development. The Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). Pursuant to a June 2013 Joint Motion for Partial Remand, the Court vacated the Board's December 2012 decision to the extent that it denied a disability rating in excess of 50 percent for PTSD for the appeal period. The case was remanded for further development in April 2014. The Board again remanded this case in May 2015 for additional development. In that decision, the Board also remanded the Veteran's claim of entitlement to a total disability rating based on individual unemployability (TDIU). In an October 2015 rating decision, the RO granted TDIU for the entire appeal period. This represents a total grant of the benefit sought for that claim. Accordingly, the issue of TDIU is no longer in appellate status. The RO also granted a higher disability rating of 70 percent for the Veteran's PTSD in the October 2015 rating decision. Because this increase is less than the maximum available benefit, the increase granted does not abrogate the pending appeal. AB v. Brown, 6 Vet. App. 35 (1993). The issue of entitlement to an inial disability rating in excess of 70 percent for PTSD is properly before the Board, having been returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). FINDING OF FACT The Veteran's PTSD results in occupational and social impairment with deficiencies in in most areas, but not total social and occupational impairment. CONCLUSION OF LAW The criteria for an initial rating in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1-4 .14, 4.130, Diagnostic Code 9411 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating claims for VA benefits. See e.g. 38 U.S.C.A. §§ 5103, 5103A (West 2014) and 38 C.F.R. § 3.159 (2015). VA provided adequate notice in a letter sent to the Veteran in March 2009. Next, VA has a duty to assist the claimant in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. With regard to the issues decided in the instant document, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained service and VA treatment records, as well as private treatment records and records from the Social Security Administration (SSA). Also, VA afforded the Veteran relevant examinations in September 2009, August 2011, and January 2015. The resulting reports describe the Veteran's psychiatric disability, reflect consideration of the relevant history, and provide an adequate rationale for any conclusions reached. The Board finds them collectively adequate for adjudication purposes. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). The Board also finds compliance with the Board's May 2015 Remand directives. In that remand, the RO was directed to obtain any additional private treatment records, specifically, all private treatment records from the Princeton Veteran's Center since 2009. These records have been obtained. The Board also finds compliance with the directives found in the April 2014 Board remand, which requested record development and a VA examination for the Veteran's PTSD. The examination was conducted in January 2015. The record development was completed pursuant to the May 2015 remand. Thus, there has been compliance with the Board's Remand directives, and the Board may continue with appellate consideration. Stegall v. West, 11 Vet. App. 268 (1998). II. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2015). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 (2015). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2 (2015); Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7 (2015). It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2015). PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. This diagnostic code uses the general rating formula for mental disorders, which provides that a 70 percent disability rating is warranted for a mental disorder when 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 work-like setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. The maximum schedular rating of 100 percent is warranted for a mental disorder when there is total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. The criteria set forth in the rating formula for mental disorders do not constitute an exhaustive list of symptoms, but rather are examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Nevertheless, the Veteran must demonstrate the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013) (also explaining that VA intended the General Rating Formula to provide a regulatory framework for placing veterans on the disability spectrum based upon their objectively observable symptoms). The Board recognizes that the Veterans Benefits Administration is now required to apply concepts and principles set forth in the American Psychiatric Association 's Fifth Edition of the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM-5); however, the Secretary of VA has specifically indicated that DSM-IV is still to be applied to claims pending before the Board. 79 Fed. Reg. 45094 (Aug. 4, 2014). The DSM-IV utilizes Global Assessment of Functioning (GAF) Scores. GAF scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. GAF scores ranging between 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). See 38 C.F.R. § 4.130 (2012) [incorporating by reference the VA's adoption of the DSM-IV for rating purposes]. The Veteran filed a claim for service connection for PTSD on February 27, 2009. He currently is in receipt of a 70 percent disability rating as of that date. As noted above, the RO granted a temporary total rating for a period of hospitalization related to PTSD from September 27, 2010 to November 30, 2010. This period is not on appeal. Shortly after he filed his claim of service connection for PTSD, the Veteran submitted a December 2008 Princeton Veteran's Center mental health evaluation. The report shows that the Veteran was noted to be anxious, with memory functioning impaired, tense motor activity and fair judgment. Presenting symptoms included difficulty falling and staying asleep, restlessness, fatigue, irritability, anger outbursts, anxiety, tension, suicidal thoughts with no plans, and vivid memories of prior unpleasant experiences and avoidance of activities that reminded him of them, memory impairment, concentration problems, trouble trusting others, loss of interest in usual activities, depression, emotional numbing, and panic attacks. The evaluating social worker noted that the Veteran's medical retirement had exacerbated these problems. The social worker assigned diagnoses of PTSD, chronic and severe, major depression, recurrent, and panic disorder. It was noted that the Veteran had social and occupational impairment and a GAF score of 45/50 was assigned. In a March 2009 statement, the Veteran reported that he was fatigued the majority of the time. He would tire very quickly during any activity. He was able to fall asleep quickly sometimes, but other times he would wake up not long afterwards, unable to sleep thereafter. He did not like to be in large crowds of people as it made him feel as if everyone was watching every move he made. A March 2009 VA mental health progress note shows the Veteran reporting that he had started to have a problem with anxiety about three to four months prior. He was worried about his wife's health, and he was not able sleep soundly, a problem that had been worsening. He was sleeping at least five hours a night and reported that he was restless. Before he had been sleeping soundly but lately his sleep was being interrupted and was not restful. He reported that his wife and son were supportive of him and that he was an active Baptist. A contemporaneous mental status examination showed that he was alert and attentive, oriented to time, person, and place, cooperative, and reasonable. His grooming was appropriate. During the interview, he was pleasant and responsive, and he made good eye contact. His speech had a normal rate and rhythm, language was intact, and affect was congruent with mood (i.e. anxious). He denied auditory or visual hallucinations or suicidal or homicidal ideations. His thought process was normal and coherent. His insight and judgment were fair and his memory was generally intact. He did report impairment in short term memory in that he could not remember names. The diagnosis was anxiety disorder, not otherwise specified. The treating physician assigned a GAF score of 60. A subsequent April 2009 VA progress note shows that the Veteran continued to have nightmares about his Vietnam experiences at least once a week. He would wake up in a cold sweat. He also had a flashback of being shot. A mental status examination showed blunted to appropriate affect and neutral mood, which was at times sullen. A July 2009 VA mental health progress note shows that the Veteran had noticed a decline in the frequency and intensity of his nightmares. He continued to prefer solitude and would isolate himself. He denied flashbacks but did have frequent, severe intrusive thoughts about Vietnam. He related that heavy rains were a strong trigger. He was avoidant and hypervigilant with an exaggerated startle response. A mental status examination showed euthymic mood with congruent affect. Cognition and memory appeared intact and judgment and insight were good. A GAF score of 50 was assigned. VA afforded the Veteran an examination for his PTSD in September 2009. At that time, the Veteran reported that the combination of psychiatric medications and group counseling he was receiving was effective. At his most recent mental health check-up in July 2009, it had been noted that the medications were helping and sleep was averaging 5 to 6 hours per night with fewer, less intense nightmares. He reported good appetite, good family relations and no substance abuse. The examiner noted the July 2009 VA appointment at which the Veteran did report persistent symptoms of intrusive thoughts of Vietnam, some continued hypervigilance and social discomfort, strong startle response and occasional fleeting and passive suicidal thoughts with no intent for self-harm. He did not have any history of suicide attempts. The only symptom of clinical depression the Veteran could describe was decreased sleep. He reported having what may have been a full panic disorder episode secondary to his emergency hospitalization in 2007 for migraine headache pain but he was unable to describe other full panic episodes and the records did not document him having an extended history of panic episodes. The Veteran described his relationship with his spouse as pretty good. Their 32 year-old son was married and lived in Ohio with one son of his own. The Veteran and his wife visited the son and his family every few months. He indicated that he got along well with all of these family members. He also socialized with his younger brother who lived next door to him as well as members of his wife's large family. He attended church weekly and had many friends among his congregation. He enjoyed attending church and social events and had recently attended a moderately sized family reunion. He did chores around the house and spent a lot of time watching TV. He also read the bible and enjoyed sitting on the front porch. He attended church every Sunday with his wife and they would occasionally visit family or friends afterwards. He and two brother-in-law's would drive twice a month to attend a Vietnam Veterans support group. He spent most of his time at home but was capable of functioning in the community. He drove his wife to the stores and did the shopping with her. He went out to eat with his spouse and attended church regularly. He was socially active with various family and local friends. Mental status examination showed that the Veteran was mildly anxious with a constricted affect. He was partially correct when doing serial 7s with the difficulty seemingly due to anxiety. He was able to spell a word forward and partially backwards. He understood the outcome of his behavior and he understood that he had a problem. He had been experiencing a diminished sleep pattern for many years. The initial insomnia was due to anxiety as well as physical pain. Most of his awakening during the night was due to physical pain. He recognized that proverbs were to be interpreted as an abstract concept with a message but his interpretations lacked the full meaning of the proverbial sayings. He experienced acute anxiety at times but it was unclear if his symptoms were actual panic episodes. He did not experience any homicidal thoughts. He had occasional passive suicidal thoughts about once every two to three months. His last suicidal thoughts had probably been a couple of months prior and he did not currently have any suicidal ideation or intention. His impulse control was found to be good. He was able to maintain minimum personal hygiene and did not have any problem with activities of daily living. His remote memory was normal and his recent memory was mildly impaired. He was somewhat forgetful regarding medications and with people's names. He had tried to write some things down in order to remember them. On examination, the Veteran's short term memory appeared adequate. The evaluating psychologist found that the Veteran exhibited recurrent and intrusive distressing recollections of the traumatic event, including images, thoughts or perceptions, along with recurrent, distressing dreams of the event. He also made efforts to avoid thoughts, feelings or conversations associated with the trauma, and activities, places or people that aroused recollections of the trauma. He experienced difficulty falling or staying asleep, hypervigilance and an exaggerated startle response. The psychologist found that the Veteran's symptoms were chronic but did not cause significant distress or impairment in social, occupational or other important areas of functioning. The psychologist noted that the Veteran had had some post-traumatic symptoms since Vietnam and that his current PTSD symptoms were mild in degree. During the years he worked (between 1970 to 1993), the Veteran reported having very little difficulty with PTSD symptoms because staying busy distracted him and he did not have time to think about the war. His symptoms increased after he could no longer be employed. He indicated that he was uncomfortable and guarded in social settings due to PTSD. Otherwise, he described few changes in somatic, affective and behavioral functioning. Affectively, he had always been more anxious than average in his functioning since returning from Vietnam. The psychologist diagnosed the Veteran with PTSD, chronic and mild, and depressive disorder N.O.S. The psychologist commented that the Veteran's anxiety in social settings, sleep difficulty, hypervigilance and guardedness were due to his PTSD. His depressive symptoms of occasional sad mood, limited interest in activities and occasional passive, fleeting suicidal thoughts were attributable to clinical depression, which developed after (and as a reaction to) his loss of employment status, the onset of physical pain and limitations on his activity. A GAF score of 61 was assigned. The psychologist commented that the Veteran had some mild residual symptoms from his PTSD as well as depression, but was generally functioning fairly well and had meaningful activities and interpersonal relationships. Both the Veteran and his VA treatment provider agreed that he had had some level of favorable response to treatment. An October 2009 VA mental health medication management progress note shows that the Veteran was seen for 20 to 30 minutes. The diagnosis was PTSD and a GAF score of 50 was assigned. He had had an increase in flashbacks and intrusive thoughts about Vietnam. He was emotionally detached/withdrawn/numb to his surroundings. He disliked crowds and timed his errands to avoid them. Mental status examination produced findings similar to July 2009. A January 2010 VA mental health medication management progress note shows that the Veteran was having nightmares approximately one or two times every couple of weeks. When going out, he would sit with his back against a wall where he could see everyone. He checked doors, windows and the perimeter of his home and he had to investigate noises that he would hear in the home. Mental status examination produced findings similar to July 2009. A GAF score of 50 was assigned. During a March 2010 private psychiatric examination, the Veteran reported that he continued to have war-related nightmares and flashbacks. He did not sleep well, stayed restless during the night with nightmares and woke up feeling panicky. His appetite was fair and he reported that he could not tolerate large crowds and loud noises and preferred to be alone. He felt tired and would lose his temper easily. He also felt depressed, hopeless, helpless and worthless but denied any suicidal thoughts. He had difficulty dealing with stress. During the daytime, he would sit around, watch television and try to help his wife with chores. He did not go out much but did go and shop for necessities. He denied having any hobbies. He did attend church services. Mental status examination showed that the Veteran was cooperative but distant. His affect was anxious and his mood was depressed. He was oriented to place, person, time and situation. He presented with a poverty of thoughts and had difficulty relating to the examiner. His speech revealed frustration and his concentration was fair. His recent and remote memory was intact and he did not have any difficulty repeating or recalling during the interview. His impersonal judgment was intact. He appeared to have a fair amount of insight into his difficulties but a low amount of self-esteem. The diagnostic impressions were PTSD, profound, neurotic depression, severe and generalized anxiety disorder, chronic and moderately severe. A GAF score of 45 was assigned. The examiner commented that the Veteran continued to have emotional difficulties originating from his experiences while stationed in Vietnam that were affecting his daily life significantly. He did not appear to tolerate much stress or handle any gainful employment. He was not a good candidate for vocational rehabilitation. In an April 2010 clinical summary update, a Veteran's Center social worker indicated that the Veteran continued to present with chronic and severe PTSD symptoms. He exhibited occupational and social impairment with deficiencies in most area such as work, family relations, judgment, memory, concentration and mood due to such symptoms as circumstantial and stereotyped speech, dissociation, panic attacks and major depression, affecting his ability to function independently, appropriately and effectively. He continued to have great difficulty adapting to stressful circumstances, which resulted in behaviors of avoidance, isolation and irritability manifesting as rage toward those around him. He had few friends and relied very heavily for his wife for support. The Veteran's level of functioning was guarded with a current GAF score of 48 assigned. Due to the severity of his symptoms, there was minimal improvement expected. His diagnosis remained essentially unchanged since the last critical summary. The social worker concurred with the March 2010 private psychiatrist's assessment that the Veteran was unable to handle any gainful employment. A May 2010 VA mental health medication management progress note shows that the Veteran indicated that he was continuing to have problems initiating as well as sustaining sleep. He continued to have nightmares that were mainly about the military. He was going to receive a three day evaluation the following week for a six week VA PTSD inpatient treatment program. Mental status examination produced findings similar to July 2009. A GAF score of 50 was assigned. A May 2010 VA psychiatric inpatient discharge summary shows that the Veteran received the 3 day evaluation for a 6 week PTSD program. The discharge diagnoses were PTSD and depression. GAF score was 40 on admission and 40 on discharge. A December 2010 VA discharge summary shows that the Veteran underwent a 6 week inpatient PTSD program. He was noted to have symptoms of intrusive recollections, re-experiencing, avoiding thoughts/feelings, detachment/estrangement, irritability/anger, hypervigilance, depressive symptoms, affective dysregulation, distressing dreams, physiological distress, avoiding activities/places/people, diminished interest in activities, restricted range of affect, sleep disturbance, concentration problems, exaggerated startle response and impaired relationships. The treatment team noted that the Veteran's reported symptoms were consistent with PTSD. At admission, he denied any current suicidal or homicidal ideation and stated that he had had fleeting thoughts of death when in severe pain, such as "why bother (with life)." However, he reported that he did not dwell on these thoughts and typically looked for something to do. He denied suicidal and homicidal ideation throughout his time in the program and at discharge. The Veteran identified his anxiety as his most problematic symptom. It was noted that the Veteran's individual goals were to better understand PTSD and to manage PTSD and anxiety and that he successfully accomplished these objectives. Overall, he did well in the program, worked toward understanding himself and making changes, and expressed that the program was a positive experience for him. The Veteran was discharged on November 10, 2010. At the time of discharge his goals related to improving his relationship with his family members and getting out more. In a February 2011 rating decision, the RO granted a temporary 100 percent rating for the Veteran's PTSD from September 27, 2010 to December 1, 2010 based on hospitalization for more than 21 days. On August 2011 VA psychological evaluation, the Veteran was diagnosed with anxiety disorder NOS. The examiner commented that the Veteran previously met the criteria for a PTSD diagnosis. However, based on the current interview, he did not endorse the frequency and severity of symptoms required to meet DSM IV criteria for a diagnosis of PTSD. It appeared that his PTSD treatment program had improved his functioning and caused a reduction in symptoms. However, the Veteran's diagnosis of anxiety disorder NOS was related to his military trauma. The examiner assigned a GAF score of 60. He noted that the Veteran demonstrated stable and adequate psychosocial functioning. He reported good relationships with family members and friends and was able to enjoy social activities. The examiner found that the Veteran exhibited 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 examiner noted that the Veteran had been married for 40 years. The couple had one son who they visited every 2 to 3 months, along with their two grandchildren. The Veteran indicated that his relationship with his wife was "o.k." The couple had experienced an increase in disagreements. The Veteran was attending church weekly and had several friends and good social support from the church community. He noted that he also had several friends outside of church. He added that he had a brother with whom he was also close. The examiner noted that the Veteran had attended the inpatient PTSD program. The Veteran indicated that he went to the program because he was experiencing suicidal ideation and isolating himself. He was currently prescribed Elavil for depression and he attended group therapy twice a month at the Veteran's Center. He also attended medication management appointments every 3 to 4 months. He appeared compliant with treatment and denied legal or behavioral problems. The examiner found that the Veteran had symptoms of recurrent distressing dreams of the traumatic event but no persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness. He also had difficulty concentrating and exhibited hypervigilance. Additionally, he exhibited depressed mood, anxiety, mild memory loss, such as forgetting names, directions or recent events and difficulty adapting to stressful circumstances, including work or worklike setting. Mental status examination showed that eye contact was limited. His affect was full and his reported mood was nervous. He denied any self-harmful, suicidal or homicidal thoughts or intentions. His memory was intact. His insight was poor and his judgment appeared marginal. He could remember 1 out of 3 words after a 5 minute delay and could spell world correctly forwards but not backwards. The Veteran reported that he experienced intrusive thoughts that the examiner described as "triggered" thoughts. He also reported nightmares every few weeks, after which he would have to get out of bed and watch television. Certain television shows, the news and rain reminded him of trauma from Vietnam. When he encountered these triggers, he felt exhausted. He stated that he avoided people but this was because he did not want to feel awkward when he did not remember their names. He noted that since the PTSD inpatient program, he had gone to a carnival with his son and used deep breathing techniques to get through the uncomfortable aspects of the exposure. He reported that he was emotionally attached to his wife, son, and grandchildren. He also felt connected to his pastor, deacons and members of his church. His feelings could get hurt easily and he could experience a variety of emotions. He indicated that he achieved about 7 hours of sleep per night. He was easily awakened during the night. He had some problems with anger and irritability but noted that he could catch himself before he yelled. He could become easily bothered and upset by small things and reported concentration problems, which were evident during the examination. He noted some hypervigilance and reported that he was on guard at all times. He checked the doors and windows in his home and if he heard a sound, he would have to go check to see about it. He denied an exaggerated startle response. VA treatment records from February 2012 document a mental health assessment for the Veteran's PTSD. The diagnosis of PTSD was affirmed, and the Veteran received a GAF score of 50. Symptoms at that time were "pretty much the same." The Veteran preferred solitude and would isolate himself. He disliked crowd and would arrange appointments or errands for when there would be less people. The attending physician reiterated that the Veteran was emotionally "detached/withdrawn/numb" to his surroundings. He was avoidant and hypervigilant with an exaggerated startle response. The Veteran would check doors, windows, and the perimeter of the property. The attending physician noted the Veteran was a light sleeper and had to investigate any noises in the home. Next, of record is a February 2012 assessment from the Princeton Vet Center, in which the medical treatment provider assessed the Veteran's PTSD. The provider noted that the Veteran continued to present with chronic and severe PTSD symptoms, exhibiting occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, and mood due to such symptoms as anxiety, suicidal ideation, dissociation, panic attacks two times per week, poor concentration, memory problems, chronic major depression, and intermittent explosive rage that would affect his ability to function independently, appropriately, and effectively. The Veteran had continued to report great difficulty in adapting to stressful circumstances, resulting in avoidance, isolation, and irritability. These symptoms would manifest as rage directed toward those around the Veteran. The treatment provider continued by noting the Veteran had been unable to establish and maintain effective relationships. He had no friends, and he relied heavily on his wife for support. The treatment provider found that the Veteran's level of functioning was guarded, and assigned a current GAF score of 45. The Veteran subsequently presented for a March 2012 psychiatric assessment with the same private treatment provider who assessed the Veteran in March 2010. The Veteran was prompt for his appointment, cooperative for the interview, but he was noticeably withdrawn and anxious. He was neatly and casually dressed. Affect was anxious, and mood was frustrated. He was oriented to place, person, time, and situation. The assessing physician noted the Veteran "presented with poverty of thoughts, had difficulty relating with the examiner, had poor eye contact, and his speech revealed frustration." Concentration was impaired, and the Veteran was only able to recall the present and preceding presidents when asked to name the five most recent presidents of the United States. His intellect appeared to be low borderline. He was able to count by threes up to thirty on his fingers, but he was unable to do serial seven subtractions. He was also unable to do a simulated purchase or make change for one dollar. Recent memory and remote memory were fair. The Veteran did not have any difficulty repeating or recalling during the interview. There were no symptoms of organic brain syndrome. He understood the provided proverbs. The Veteran had difficulty abstracting. He appeared to have fair amount of insight into his difficulties but a low amount of self-esteem. The Veteran did not appear to have any auditory or visual hallucinations during the interview. He also did not present with any delusional thinking, ideas of reference, or loose associations. The assessing physician diagnosed the Veteran with severely profound PTSD, moderately severe neurotic depression, chronic and severe generalized anxiety disorder, and assigned a GAF score of 45. Of record is an undated correspondence from the Veteran's wife. She described how the Veteran always seemed to distance himself from her and their son. Things would have to be done the Veteran's way. He was a "character of habit" with the same routine every day. The Veteran's wife described the Veteran often becoming agitated easily. Lately, when the Veteran had become aggravated, he would shake, jerk, and pull on his pant legs. His arms would stiffen, and he would put his hands into his fists. The Veteran's wife also described him grinding his teeth with a strange look on his face. The Veteran had an out building and sometimes stay in there for "hours on end." The Veteran's wife recalled how he was having recurring dreams of Vietnam since he began his group therapy. Next, the Veteran underwent an employment evaluation for his then-pending TDIU claim in July 2013. At that time, the Veteran was diagnosed with PTSD, major depressive disorder, and panic disorder. The examiner assigned a GAF of 45/50. The Veteran continued treatment at the VA medical center after the Court's June 2013 JPMR. In November 2013, the Veteran was evaluated for his PTSD. The treatment provider noted the Veteran continued to experience severe daily PTSD symptoms. The Veteran preferred solitude and isolated himself. He avoided crowds, experienced flashbacks as well as intrusive thoughts, and he was emotionally detached, withdrawn, and numb to his surroundings. In addition to be avoidant, the Veteran was hypervigilant with an exaggerated startle response. He showed signs of paranoia by checking his doors, windows, and the perimeter of his property. He was a light sleeper, and he had to investigate noises in the home. A mental status examination was normal. The Veteran was assigned a GAF score of 50. These findings were largely corroborated in a July 2014 VA treatment note. Pursuant to the Board's April 2014 remand, VA afforded the Veteran an examination to assess the severity of his PTSD in January 2015. The examiner affirmed the diagnosis of PTSD, and opined that it resulted in occupational and social impairment with reduced reliability and productivity. During the clinical interview, the Veteran described having recurrent, involuntary, and intrusive distressing memory. He also reported recurrent distressing dreams regarding his traumatic events experienced while in Vietnam. He would suffer intense, prolonged psychological distress at exposure to internal or external cues that symbolized or resembled an aspect of his traumatic experiences in Vietnam. The Veteran indicated he would feel depressed and guilty in response to any experienced reminders of his combat traumas. He described avoidance symptoms, especially in relation to thoughts, feelings, or conversations about military trauma. The Veteran showed persistent distorted cognitions about the cause or consequences of the traumatic event. He also showed a persistent negative emotional state. The examiner noted hypervigilance, problems with concentration, and sleep disturbances. The examiner found the Veteran's PTSD resulted in depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, such as forgetting names, directions, or recent events, and disturbances of motivation and mood. Pursuant to the Board's May 2015 remand, the RO obtained updated records from the Princeton Veteran's Center. The records show that the Veteran has been participating in individual and group therapy since 2009 for his PTSD. The records document the topics discussed on a group or individual basis throughout the visits, and do indicate the Veteran exhibits symptoms already discussed. The Board need not discuss these records in depth, as they are redundant of reports already detailed in the decision above. The therapy notes indicate the Veteran was showing minimal improvement over the course of treatment. Last, of record is a September 2015 psychological consultation conducted by Dr. G.A.B. Dr. G.A.B. indicated he reviewed the Veteran's case file and performed a clinical interview with the Veteran in order to fully assess the Veteran. Since his VA examination in January 2015, the Veteran had been grieving multiple deaths in his immediate family, including two brothers and one sister. At the time of the September 2015 evaluation, the Veteran reported a good relationship with his wife, though sometimes they quarreled The Veteran and his wife would visit with their son and his children about once every two months. Regarding the relevant mental health history, the examiner noted the Veteran had consistently shown symptoms of avoidance of crowds, social isolation, flashbacks, intrusive recollections, emotional detachment, withdrawal, and numbing, hypervigilance, exaggerated startle response, and being a light sleeper. During the clinical interview, the Veteran provided an account of his experiences in the Army that led to his diagnosis of PTSD. The Veteran stated his depression had worsened and his health was failing him. The Veteran also described experiencing suicidal ideation, but also indicated he tried not to act on it. He reported difficulties sleeping at night, noting that he was miserable a lot of times. He described nightmares that would startle him awake. The Veteran stated that although he went to church and occasionally visited his grandchildren, he did not like large crowds and was wary of people. He acknowledged being paranoid and not trusting of people and that he preferred isolation instead. Last, the Veteran described occasionally suffering from panic attacks. He reported that he still attended his PTSD groups at the Veteran's center and that he found the therapy helpful. Dr. G.A.B. opined that the Veteran had PTSD, major depressive disorder, and anxious distress, moderate. Dr. G.A.B. noted it was impossible to separate the social and occupational impact of the symptoms of the Veteran's psychiatric diagnoses. The doctor noted that the Veteran's behavioral presentation was significant for depression, anxiety, flashbacks, startle response, nightmares, panic attacks, paranoia, irritability, suspiciousness/hypervigilance, and social isolation. Dr. G.A.B. opined that an appropriate rating for the Veteran from 2009 to present would be 70 percent according to VA disability rating criteria. During the appeal period, opined Dr. G.A.B., the Veteran's occupational and social functioning had been adversely impacted by the previously noted symptomatology, and he had deficiencies in most areas. The doctor emphasized the Veteran's propensity toward social isolation, depression, anxiety, paranoia, and hypervigilance. He also noted the Veteran's considerable deficiency in thinking, judgment, and mood. There are other VA treatment records and group counseling notes that document the Veteran's PTSD. However, these are either redundant of evidence already detailed above, or do not document the then-present severity of the Veteran's PTSD. At the outset, the Board notes that when it is not possible to separate the effects of the service-connected condition and the non-service-connected condition or conditions, VA regulations clearly dictate that such signs and symptoms be attributed to the service-connected condition. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Although the March 2009 VA examiner did differentiate the effects of the Veteran's service-connected PTSD to some extent, other mental health professionals who have evaluated the Veteran have not made this clear distinction. Consequently, the Board shall consider all of the Veteran's various psychiatric symptoms in assigning a rating for the PTSD. See Mittleider at 182. After a thorough review of the record, the Board finds that the Veteran's psychiatric impairment cannot be described as "total," and the record does not show the type of cognitive and behavioral impairment reserved for a 100 percent evaluation. The symptoms required for such an evaluation or their equivalent are neither complained of nor observed by medical health care providers, including 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. Moreover, his documented symptoms do not equate in frequency, severity or duration to total social and occupational impairment. Particularly probative to the Board in making this determination is the September 2015 psychiatric evaluation by Dr. G.A.B., who found the Veteran's symptoms resulted in occupational and social deficiency in most areas. However, the symptoms detailed over the course of the appeal period do not approximate total occupational and social impairment. Though the Veteran expressed extreme reluctance in going into public places, he has not exhibited any evidence of being unable to perform activities of daily living. He has had symptoms such as avoidance of crowds, social isolation, flashbacks, intrusive recollections, emotional detachment, withdrawal, and numbing, hypervigilance, exaggerated startle response, and being a light sleeper. For the most part, he was alert, oriented to person, place, and time, and was neatly dressed and groomed. He did have deficiency in thinking, judgment, and mood. Additionally, he has maintained a successful marriage and consistently reported visits and a good relationship with his son, grandchildren, and his brother, not to mention a community at church. Consequently, the symptoms described do not equate to the frequency, severity or duration required for total social and occupational impairment. Last, the Veteran's GAF scores have ranged between 40 and 60 throughout the appeal period. The scores demonstrate a wide range of severity during the course of the Veteran's appeal. However, at no time did the GAF scores demonstrate that the Veteran's symptoms overall were of such frequency, severity, and duration as to equate those symptoms attributable to a 100 percent disability rating under DC 9411. Rather, they support the 70 percent disability rating which has currently been assigned for occupational and social impairment with deficiencies in most areas. In summary, while the evidence clearly demonstrates that the Veteran has significant social and occupational impairment attributable to PTSD, his overall symptomatology is not consistent with the criteria for a 100 percent disability rating because total social and occupational impairment is not shown. Therefore, the Board finds that the Veteran's PTSD does not approximate a 100 percent disability rating for the appeal period. There is no reasonable doubt to be resolved in this matter. 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. § 3.102 (2015); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (CONTINUED ON NEXT PAGE) ORDER Entitlement to an initial disability rating in excess of 70 percent is denied. ____________________________________________ GAYLE E. STROMMEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs