Citation Nr: 1722402 Decision Date: 06/15/17 Archive Date: 06/29/17 DOCKET NO. 09-46 703 A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUE Entitlement to increases in the staged (30 percent prior to January 5, 2010, and 50 percent from January 5, 2010 to September 17, 2014) ratings assigned for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Schechner, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from May 2004 to May 2008. This matter is before the Board of Veterans' Appeals (Board) on appeal from a July 2009 rating decision by the New York, New York Regional Office (RO) of the Department of Veterans Affairs (VA), which in pertinent part granted service connection for PTSD, rated 30 percent. In April 2010, a Decision Review Officer hearing was held at the RO. A May 2010 rating decision granted a 50 percent rating for PTSD, effective January 5, 2010. In February 2013 a videoconference hearing was held before an Acting Veterans Law Judge (VLJ) because a transcript of the hearing was not possible due to a recording malfunction, the Veteran was offered the opportunity for another hearing before a VLJ who would decide his appeal, and opted for such hearing. In June 2014 a videoconference hearing was held before the undersigned; a transcript is in the record. In August 2014 and March 2016, this matter was remanded for additional development. A September 2015 rating decision granted a 100 percent rating for PTSD, effective September 17, 2014. According, the period of time from that date is not before the Board. FINDINGS OF FACT 1. Prior to January 5, 2010, the Veteran's PTSD is not shown to have been manifested by symptoms productive of impairment greater than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; symptoms productive of occupational and social impairment with reduced reliability and productivity were not shown. 2. From January 5, 2010 to September 17, 2014, the Veteran's PTSD is reasonably shown to have been manifested by symptoms productive of deficiencies in most areas were not shown; PTSD symptoms productive of total occupational and social impairment were not shown. CONCLUSION OF LAW The Veteran's PTSD warrants "staged" ratings of 30 percent (but not higher) prior to January 5, 2010 and 70 percent (but no higher) from that date to September 17, 2014. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.3, 4.130, Diagnostic Code (Code) 9411 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). As the rating decision on appeal granted service connection and assigned a disability rating and effective date for the award, statutory notice had served its purpose, and its application was no longer required. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). A December 2009 statement of the case (SOC) provided notice on the "downstream" issue of entitlement to an increased initial rating, and a July 2016 supplemental SOC readjudicated the matter after the Veteran responded and further development was completed. 38 U.S.C.A. § 7105; see Mayfield v. Nicholson, 20 Vet. App. 537, 542 (2006). The Veteran has not alleged that notice was less than adequate. See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) ("where a claim has been substantiated after the enactment of the VCAA, the Veteran bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream issues"). During the June 2014 videoconference hearing, the undersigned advised the Veteran of what is needed to substantiate the claim (evidence of worsening of his PTSD during the relevant appeal period); his testimony reflects that he is aware of what is needed. A hearing notice deficiency is not alleged. Following the hearing the case was remanded to assist the Veteran in securing evidence to substantiate his claim. The Veteran's pertinent treatment records have been secured. He was afforded VA examinations in June 2008, June 2009, July 2010, March 2012, and September 2014; those examinations are reported in greater detail below, and are cumulatively adequate for rating purposes. Notably, the 2014 examination resulted in an award of a 100 percent rating. VA's duty to assist is met. Legal Criteria, Factual Background, and Analysis Disability ratings are determined by applying the criteria set forth in 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; 38 C.F.R. § 4.1. With the initial rating assigned following a grant of service connection, separate (staged) ratings may be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. PTSD is rated under Code 9411 and the General Rating Formula for Mental Disorders. A 30 percent rating is warranted when the evidence demonstrates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events. A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted 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; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002). Because "[a]ll nonzero disability levels [in § 4.130] are also associated with objectively observable symptomatology," and the plain language of this regulation makes it clear that "the veteran's impairment must be 'due to' those symptoms," "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). "[I]n the context of a 70[%] rating, § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Id. at 117. Therefore, although the veteran's symptoms are the "primary consideration" in assigning a disability evaluation under § 4.130, the determination as to whether the veteran is entitled to a 70% disability evaluation "also requires an ultimate factual conclusion as to the veteran's level of impairment in 'most areas.'" Id. at 118. The Board has considered the Global Assessment of Functioning (GAF) scores assigned documented in the record. The scores reflect the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (DSM). [Per revised changed regulations, the rating criteria are based upon the American Psychiatric Association's DSM-5, which has not incorporated use of GAF scores.] 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). Lesser scores reflect increasingly severe levels of mental impairment. See 38 C.F.R. § 4.130 (2013). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remissions. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b). The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence, as deemed appropriate, and the Board's analysis will focus specifically on what the evidence shows, or does not show, as to the claim. On June 2008 VA examination, the Veteran reported that he had friends whom he saw often and had good relationships with his parents and grandmother. He hung out with friends in his leisure time and had joined a gym to stay in shape. He was unemployed but had enrolled in community college. He enjoyed being with friends, but did not like crowds. He reported he felt happy 50 percent of the time, but felt mildly depressed twice a week, and felt lonely and bored, like his life was on hold, daily. He was nervous and impatient about starting school, but denied any anxiety or panic. He became easily angry to the point of losing control, especially when drinking. He denied suicidal or homicidal ideation and denied auditory hallucinations. He reported having memories of his first firefight as well as other images of Iraq but denied avoiding people, places, things, or certain experiences. He denied hypervigilance but reported that he questioned others' motives. He denied nightmares. On mental status examination, the Veteran was adequately groomed with appropriate eye contact. His motor functioning was unremarkable. He presented as immature, psychologically naïve and cooperative. His mood was primarily positive, with some evidence of occasional expressions of dysphoria. His speech was clear and understandable. His thought process was logical and goal directed, and his thought content was unremarkable. There was no evidence of delusions and he denied auditory hallucinations. As recently as 2 months prior he had felt someone nearby, but could not say if that was a perception or a feeling. H denied suicidal and homicidal ideation; his judgment and insight were grossly intact. The examiner opined that the Veteran met the DSM-IV criteria for alcohol abuse, and a GAF score of 55 was assigned; there was no evidence that he met the diagnostic criteria for a second diagnosis, including PTSD. He did not report persistently re-experiencing traumatic events, avoiding stimuli associated with the events, or a numbing of general responsiveness. He reported irritability and outbursts of anger, as well as difficulty staying asleep which he attributed to alcohol use. The examiner opined that the Veteran's alcohol abuse was not caused by or a result of his military experience, as he started excessive drinking when he was 16 or 17 years old. On June 2009 VA examination, the Veteran reported that he had attended community college for the last two semesters but was having trouble concentrating and feeling motivated; the examiner opined that these were likely due to PTSD. The Veteran reported that his school attendance had been reasonably consistent, and that he had not been gainfully employed for the previous 12 months because he was attending college, not because of his psychiatric symptoms (emphasis added). The Veteran reported that he went to bars or clubs with friends occasionally and had been involved in several fights "for no reason". He described his family relationships as stable but emotionally distant, and reported he was often anxious in public. He went to a gym for recreation but otherwise had no real hobbies or outside interests. The examiner opined that the Veteran's social withdrawal, physical altercations, and anxiety in public situations were at least as likely as not the result of PTSD. The Veteran reported heavy abuse of alcohol, which he attributed to a need to control his anxiety. He reported occasional distressing memories and nightmares about his service in Iraq. His sleep patterns were disrupted, leaving him fatigued during the day. He reported trouble concentrating, often feeling unmotivated, and anxiety in public unless he was drinking. He reported losing his temper quickly, getting into physical fights, and that he had occasional panic attacks. Lorazepam and sertraline were prescribed in December 2008, and reduced the frequency and intensity of his panic attacks, but he stopped such treatment because of his school schedule. On mental status examination, the Veteran was described as appropriately groomed, and oriented to all spheres; he made adequate eye contact. He displayed appropriate behavior and his hygiene was unremarkable. His mood was anxious; his affect was difficult to gauge because he smiled nervously throughout the examination. He denied suicidal or homicidal ideation. His speech and thought processes were essentially unimpaired. His speech was normal in intonation, rhythm, and volume. His thinking was linear and without signs of formal thought disorder. He denied hallucinations or delusions. His long term recall was inconsistent; his short term recall and concentration were variable but adequate. He did not report panic attacks, obsessions or phobias that interfered with normal functioning. He admitted frequent abuse of alcohol, resulting in exacerbation of PTSD symptoms. He reported adequate maintenance of dress, diet, finances, and other activities of daily living; his judgment and insight were intact. The examiner opined that the Veteran's alcohol abuse appeared to have begun prior to enlistment and was therefore less likely as not the result of an in-service event or injury; however, his drinking exacerbated his PTSD symptoms, especially his irritability, and it was therefore impossible to evaluate separately from PTSD its effects on his functioning. The examiner opined that the Veteran's panic attacks likely represented a progression of PTSD, and he did not report symptoms consistent with other psychiatric disorders. The examiner opined that the Veteran was possibly not given the diagnosis of PTSD by the first VA examiner because of cultural differences in the way he expresses or acknowledges affect. The diagnosis was chronic PTSD, and a GAF score of 55 was assigned (reflecting irritability, hypervigilance, sleep disturbance, social withdrawal, physical fights, and alcohol abuse to the point of intoxication, with fighting while intoxicated). A GAF of 45 to 60 was assigned for the previous year. The examiner opined that the Veteran displayed moderate symptoms, recurring daily, and present without remission since his return from Iraq. The examiner opined that there was occasional decrease in work efficiency or intermittent periods of inability to perform occupational tasks due to signs and symptoms of PTSD but generally satisfactory functioning (routine behavior, self-care and conversation normal). The examiner noted the Veteran's difficulties concentrating on school work, his mediocre grades, and his reports of social withdrawal and dysfunction (including fighting) because of his PTSD symptoms. On January 5, 2010 VA treatment, the Veteran reported drinking 3 to 6 beers a night to help him sleep. He stated that he had diagnoses of major depression, anxiety, and PTSD. He reported a March 2009 suicide attempt for which he was never hospitalized. He reported an emergency room visit following an anxiety attack while riding the subway and noted that was why he moved to California (as New York was too crowded and caused panic attacks). He had Clonazepam, Sertraline and Trazodone prescribed. He reported getting into physical altercations when he went out drinking but denied any arrests or legal problems. On mental status examination, the Veteran was alert, attentive, and oriented to all spheres. He was cooperative and reasonable with appropriate grooming. His speech had normal rate and rhythm and his language was intact. His mood was anxious to euthymic and his affect was congruent with his mood. He reported having auditory hallucinations. His thought process was normal and coherent and he reported no unusual thought content. He denied suicidal or violent ideation. His insight was limited and his judgment was impulsive. His memory was intact. He reported irritability, and constant nightmares, flashbacks and panic attacks. The diagnoses included PTSD and alcohol abuse. His symptoms included intense acute agitation or anxiety, medication non-adherence, acute intoxication, insomnia, anhedonia, and a moderate risk for suicide. A GAF score of 41 was assigned. At an April 2010 DRO hearing, the Veteran testified that he had panic attacks five to six times per week, and occasionally several times in a day. He testified that his PTSD impaired his ability to remember events. He testified that he moved from New York to California to escape the crowds and to live with his brother because his parents could not handle him living with them. He testified that he would drink and have violent behavior and had attempted suicide. He could not sit in a restaurant if he did not have a view of all exits. He testified that he would fight his friends and his brother for no reason. On one occasion he sought emergency room treatment after getting in a fight the previous night and on another occasion due to a panic attack. He attended therapy weekly, including individual and group therapy sessions, and took four medications for his psychiatric disability. He was not employed despite submitting employment applications. On July 2010 VA medical examination, the Veteran reported having mild traumatic brain injury diagnosed in 2007. He reported headaches described as pulsating throbbing migraines, spontaneous at times, for a few seconds to a few minutes; he was able to work during the headaches with medication. He reported mood swings, confusion, slowness of thought, problems with attention/concentration, difficulties understanding directions, and problems with reading. He reported having problems with anxiety described as not being able to breathe, and being lightheaded and nervous. He reported depression described as being down, sad and lonely. He reported having a severe memory problem described as forgetting what he was watching on television, a topic of conversation, appointments, or taking medications. He reported symptoms of fatigue and not wanting to get out of bed. He reported being irritable, having no patience, restlessness, trouble sleeping, and not being able to fall asleep. He reported difficulty finding the right words to say and pronouncing words. He reported that the symptoms causing his overall functional impairment included difficulty being in crowded or public places and trouble balancing. The diagnosis was TBI with subjective factors including headaches reportedly from the head trauma, and a normal neurologic examination. The examiner opined that this disability has no effect on the Veteran's usual occupation or daily activity. On July 2010 VA psychological evaluation, the Veteran reported he was getting along well with his family but did not see them very often. He had a few local friends in California but remained in contact with friends in New York. Testing found a moderate impairment of memory, attention, concentration and/or executive functions which also resulted in a moderate functional impairment. He had mildly impaired judgment. His social interaction was occasionally mildly inappropriate. His neurobehavioral effects included irritability, impulsive unpredictable lack of motivation, being verbally aggressive and physically aggressive, and moodiness. The examiner opined that the Veteran's demonstrated cognitive impairment is at least as likely as not due to TBI. On October 2011 VA treatment, the Veteran's medications included Klonopin, Trazodone, and Abilify. He reported that he had run out of medications but was doing "okay" without them. He reported feeling overwhelmed with his schoolwork, he had a lack of motivation and energy, and he continued to experience sleep deprivation. On mental status examination, he was alert and oriented to all spheres. His mood was somewhat depressed and anxious, and his affect was appropriate to his mood. No psychotic symptoms were acutely observed. He denied suicidal or homicidal ideation. The assessments included PTSD with significant mood and behavior symptoms by history, with possibly concurrent or underlying bipolar affective disorder. On March 2012 VA psychiatric examination, the Veteran reported that he had maintained contact with his family and had gotten married in May 2011. He attempted to participate in social activities but had difficulty due to paranoid thoughts and anxiety around others. He was not employed, but he had enrolled in school in 2011 to pursue a degree in product design. He participated in VA treatment in 2010 but had not returned to therapy since the end of 2011; he took his medications occasionally. He exhibited some impulse control difficulties when he would become angry and suspicious which had led to several fights. His reported PTSD symptoms included depressed mood, anxiety, suspiciousness, chronic sleep impairment, impairment of short and long term memory, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, suicidal ideation, and impaired impulse control such as unprovoked irritability with periods of violence. The diagnoses included PTSD and alcohol abuse, and a GAF score of 50 was assigned. TBI was also diagnosed. The examiner stated regarding the PTSD and alcohol abuse diagnoses that the symptoms associated with PTSD include re-experiencing, avoidance, and increased arousal; the symptoms associated with alcohol abuse involve a maladaptive pattern of alcohol use and adverse consequences of the use. The examiner opined that the Veteran's alcohol abuse exacerbated his self-destructive behavior and interpersonal problems. The examiner further opined that it is not possible to differentiate the symptoms of the Veteran's PTSD and TBI because the residual effects of TBI overlap his PTSD symptoms; for example, he experiences an irritable mood and impulse control difficulties when he becomes angry or suspicious, both of which are characteristic of both PTSD and TBI. The examiner opined that the Veteran's psychiatric disabilities result in occupational and social impairment with reduced reliability and productivity. The examiner explained that the Veteran's occupational and social impairment is attributable to his PTSD; his alcohol use has been a function of his PTSD-related anxiety and avoidance, and his alcohol use had decreased significantly in the previous two years though his PTSD symptoms continued to be present as well as his associated social and occupational impairment. Regarding the influence of TBI, the examiner opined that the majority of the Veteran's occupational and social impairment is caused by PTSD symptoms, yet the residual effects of TBI also contribute to his impairments; as the symptoms overlap, it is difficult to determine the portion of impairment caused by each disorder. March 2013 records from Methodist Hospital (submitted by the Veteran pursuant to the Board's March 2016 remand) show that he was very anxious and agitated upon arrival, and he seemed very fearful. The treating emergency room physician opined that he did not believe the Veteran was suicidal or psychotic but noted that he has PTSD and clearly was exercising poor judgment by drinking to the point of intoxication in public and then getting into an altercation with police. His blood alcohol level was 0.223. The physician noted that it had apparently taken a combination of six police officers and firemen to subdue him and, therefore, when he at least presented to the ER, he was at risk to others and to himself, although he denied suicidality; since his chemical sedation, he was calm and cooperative, arousable, and sleeping comfortably. The final impressions included acute alcohol intoxication, agitation, sinus tachycardia, and acute hypokalemia. VA treatment records show that in March 2013, the Veteran telephoned his treating social worker to report that he was arrested over the weekend and later sent to a hospital in Arcadia due to a panic attack. He was drinking the night of the arrest, became claustrophobic in the police car, and began banging his head. He reported concerns about hospital bills. In April 2013, the telephoned the social worker again to continue seeking assistance with ambulance and hospital bills related to the recent arrest and panic attack. At the June 2014 hearing before the Board, the Veteran testified that he experiences anxiety and nervousness two to three times a day and has feelings of fatigue and dread. He testified that he had panic attacks four to five times a week and sleep impairment nearly every night. He testified that he attended art school for product design on a full time basis (through VA's vocational rehabilitation program), but had difficulty focusing throughout the day, and difficulty interacting and socializing with peers. He was permitted to participate in classes from home when necessary due to his disability. He could not see himself actively working due to depression, hopelessness, and inability to take orders. He sometimes neglected personal hygiene, had difficulty adapting to stressful circumstances, and avoided crowds. He had persistent delusions or hallucinations. He testified that his family is very attentive to his disability and that he does not contact them or friends. He described an incident the previous year when he was yelling in the street, was arrested and placed him in a police car, and began having a panic attack and hitting his head against the car window in an attempt to kill himself; he was sedated by paramedics and woke up in an emergency room. He testified that his VA treatment consists of monthly therapy and medication management. He reported hallucinations of dark figures following him. On September 17, 2014 VA examination, the Veteran reported that his parents and friends in general treated him with caution and care, with the Veteran feeling that they either pity or fear him. His parents were very concerned with him, but had learned how to handle him so as to avoid arguments. He reported that, based on his history of explosiveness and not always being stable, people often avoid him. He reported being married since 2011 but mostly living apart from his wife, who emotionally supports him but understands that he needs to find himself. In March or April 2013 he was arrested and feared that he was being taken captive; he reported that he blacked out and tried to kill himself by banging his head against a car. He reported that he dropped out of art school in May 2013 because he had trouble keeping up with the other students despite being given accommodations. He moved to Seattle and then New York for one year, drinking heavily and not working, before moving back to California in May 2014 and returning to school. He reported that he expected to earn a diploma in September 2014, and he did nothing other than go to school, stay in his room and watch movies. He was not currently in mental health treatment because it was too far away. On mental status examination, the symptoms included depressed mood (feeling down on a daily basis for most of the day); anxiety; suspiciousness; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; impairment of short- and long-term memory; flattened affect; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work-like setting; impaired impulse control, such as unprovoked irritability with periods of violence; persistent delusions or hallucinations; persistent danger of hurting self or others; and neglect of personal appearance and hygiene. The Veteran was tearful at times and had trouble maintaining eye contact during the examination. The diagnoses included PTSD, major depressive disorder, and moderate alcohol use disorder. The examiner opined that differentiating between depression and PTSD was not possible due to both disorders showing a loss of interest in activities and sleeping problems, whereas the alcohol use disorder could be distinguished from the other disorders in terms of cravings; however, other alcohol use disorder symptoms could not be distinguished from PTSD and depression due to an overlap of failure to fulfill major activities and engaging in reckless behavior. Noting that the Veteran also has a diagnosed TBI, the examiner opined that difficulty concentrating and impulsiveness are symptoms that overlap between the TBI and other diagnoses. The examiner opined that the Veteran's mental diagnoses result in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood; the examiner opined that the Veteran's diagnoses overlap and reinforce each other, creating a global level of impairment. The examiner noted that the Veteran had frequent conflicts and physical fights, his friends and family monitored him due to concerns about his safety while others kept their distance, and he was much less active than previously; other than going to school, he remained isolated, and he was depressed and anxious every day for most of the day. Additional VA treatment records throughout the appeal period reflect symptomatology largely similar to that shown on the examinations described above. The claims file also includes an August 2015 memorandum stating that the Veteran's Vocational Rehabilitation records have been lost and are unavailable. The Veteran contends that his symptoms met the criteria for a 100 percent schedular rating prior to September 17, 2014. At the outset, the Board notes that the Veteran is separately service connected for traumatic brain injury (TBI). In the instant case, the examiners have distinguished symptoms due to the Veteran's PTSD from those due to TBI whenever possible to avoid pyramiding, or evaluating the same manifestation under different diagnoses. 38 C.F.R. § 4.14. The evidence prior to January 5, 2010, shows that the Veteran's PTSD disability picture prior to that date is best characterized as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, consistent with the 30 percent rating assigned for that period. In June 2008 it was noted that he enjoyed good family relations, had friends with whom he socialized. Kept in shape at a gym, and had enrolled in a community college. In June 2009 VA examination, while he reported some difficulty concentrating in class and feeling motivated, his attendance at the community college for the last two semesters was described as reasonably consistent. He socialized with friends occasionally, his family relationships were stable but emotionally distant and, although he was often anxious in public, he went to the gym for recreation. The examiner opined that the Veteran displayed moderate symptoms, recurring daily, and present without remission since his return from Iraq. The examiner opined that there was occasional decrease in work efficiency or intermittent periods of inability to perform occupational tasks due to signs and symptoms of PTSD but generally satisfactory functioning (routine behavior; self-care and conversation normal). In short, the Board finds that the evidence prior to January 5, 2010 reflects impairment no greater than that contemplated by the 30 percent rating assigned. From January 5, 2010 to September 17, 2014, the Board finds that the Veteran's PTSD is reasonably shown to have resulted occupational and social impairment with deficiencies most areas, consistent with a 70 percent rating (rather than the 50 percent rating assigned). In the January 5, 2010 treatment record it was noted that the Veteran had moved to California (he had had a panic attack on a subway, and felt New York was too crowded). He reported auditory hallucinations. A GAF score of 41 was assigned. In April 2010 it was noted that the Veteran was having panic attacks. In July 2010 it was noted that while the Veteran reported good family relations, he did not see them often. Testing revealed impaired attention, memory, concentration, and executive functions; his social interactions were noted to be mildly inappropriate, all consistent with deficiencies in most areas. Notably, throughout this time he was unemployed; while he was participating in vocational rehabilitation (presumably with the purpose of preparing for employment), it appears that his participation in the schooling required accommodations. In October 2011 the veteran was noted to have significant mood and behavior symptoms. In March 2012 it was noted he had married (suggesting some improved social function), however, it was also noted that he had difficulty functioning, paranoid thoughts, and anxiety. In March 2013 further social functioning deterioration is reflected by an altercation with police, when he apparently experienced some paranoid ideation; that month he was arrested and hospitalized in connection with a panic attack. In summary, the overall evidence reasonably reflects that throughout the period from January 2010 to September 17, 2014, the Veteran's service connected psychiatric disability was manifested by symptoms that resulted occupational and social impairment with deficiencies in most areas. He was unemployed; became more distanced from family and friends; had difficulty coping with authority; and while he participated in a vocational rehabilitation program, struggled and required accommodations. Notably GAF scores of 41 to 50 reported during this period are consistent with serious symptoms. Resolving remaining reasonable doubt (regarding degree of disability) in his favor, as required, the Board finds that a 70 percent rating is warranted. A rating in excess of 70 percent is not warranted for any period of time prior to September 17, 2014 as total occupational and social impairment was not shown at any time. Notably, the Veteran maintained relationships with family and friends, socialized, and attending classes to train for future employment. There is no indication that he was unable to tend to activities of daily living. At no time prior to the September 17, 2014 VA examination was it shown that the Veteran's PTSD symptoms met the schedular criteria for 100 percent rating. The Board also notes the lay statements submitted by the Veteran. Those statements detail the types of problems that result from the Veteran's symptoms of PTSD; they are consistent with the assignment of a 70 percent rating from January 2010. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, No. 15-2818, 2017 U.S. App. Vet. Claims LEXIS 319, *8-9 (Vet. App. March 17, 2017) (the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Finally, the matter of a total disability rating based on individual unemployability due to service-connected disability (TDIU) is not asserted specifically or raised by the record. Throughout the period under consideration the Veteran appears to have been unemployed; however, he was in training for possible future employment. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). ORDER For the period prior to January 5, 2010 a rating in excess of 30 percent for PTSD is denied. From January 5, 2010 to September 17, 2014 a 70 percent rating for PTSD is granted, subject to the regulations governing payment of monetary awards. ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs