Citation Nr: 1752650 Decision Date: 11/16/17 Archive Date: 11/22/17 DOCKET NO. 16-31 441 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement for an increased rating for posttraumatic stress disorder (PTSD), currently rated at 50 percent. (The issues of entitlement for service connection for a right knee disability, a left knee disability, and a low back disability are the subject of a separate Board decision). REPRESENTATION Appellant represented by: Colin E. Kemmerly, Attorney at Law ATTORNEY FOR THE BOARD E. Alexander Neff, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1967 to September 1969, with subsequent service in the Alabama Army National Guard. His awards and decorations included a National Defense Service Medal and a Parachute Badge. The Board sincerely thanks him for his service to his country. This matter is before the Board of Veterans' Appeals (Board) on appeal from a May 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). Regarding this claim, in the June 2016 VA Form 9 the Veteran indicated that he did not want a hearing for this claim. As such, one was not provided. FINDING OF FACT The evidence is in equipoise that during the period on appeal the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas, but not total occupational and social impairment. CONCLUSION OF LAW The criteria for a 70 percent rating, but no higher, for PTSD during the period on appeal are met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.14, 4.20, 4.123, 4.124, 4.124a, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION I. Legal Criteria A. The Duties to Notify and Assist As an initial matter, the Board finds that, with respect to the claim discussed herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 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; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Board has reviewed all of the evidence in the Veteran's virtual file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that each item of evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board will summarize the evidence as deemed appropriate, and the analysis below will focus specifically on what the evidence shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). B. Higher Ratings Disability ratings are assigned in accordance with VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from a disability. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. When a question arises as to which of two ratings shall be applied under a particular diagnostic code, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. A disability rating may require re-evaluation in accordance with changes in a Veteran's condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. Id at § 4.1. Nevertheless, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board notes that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). C. Rating Criteria PTSD is rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent evaluation is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted for total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The list of symptoms in the General Rating Formula for Mental Disorders is not intended to constitute an exhaustive list, but rather provides examples of the type and degree of symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, "a [V]eteran 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 (Fed. Cir. 2013). Furthermore, 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 solely on the basis of social impairment. 38 C.F.R. § 4.126. The Global Assessment of Functioning (GAF) Scale is used to report the clinician's judgment of the individual's overall level of functioning. The GAF Scale is to be rated with respect only to psychological, social and occupational functioning. See American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders 44 (4th ed. 1994). The Board notes that the GAF scale was removed from the more recent DSM-5 for several reasons, including its conceptual lack of clarity, and questionable psychometrics in routine practice. See DSM-5, Introduction, The Multiaxial System (2013). GAF scores range from 1-100 with the higher numbers representing higher levels of functioning. A GAF score of 41 to 50 is defined as denoting serious symptoms or any serious impairment in social, occupational, or school functioning. GAF scores from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupation, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupation, or school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well with some meaningful relationships. II. Factual Background In June 2007, the Veteran filed to reopen his claim for entitlement to service-connection for PTSD. In May 2015, the RO reopened and granted his claim, and awarded a 50 percent rating, effective June 27, 2007. The Veteran appealed the initial rating, requesting "70% at minimum." In August 2009 private medical records, it was noted that the Veteran enjoyed time with his wife. He had friend with a "little general store" and he would go there and sit down. He enjoyed metal detecting at school yards, beaches, battlefields, and other such places. He had "good days and bad days," and was noted as fully oriented. In another record, the Veteran reported that he had not been in an aircraft since the military. The clinician noted that the Veteran seemed to feel that he had intrusive thoughts, panic attacks, and avoidance. The Veteran planned on running errands with his wife. In another record, the Veteran complained of poor sleeping patterns. He tried to stay busy within his community. He would watch over the little general store so his friend could run errands. He looked forward to a paratrooper reunion. In a September 2009 private medical record, the Veteran noted that he would have conversations with his veteran friends, and that he tried to stay busy in the neighborhood. He reported that some conversations lead to recurrence of symptoms. In an October 2009 private medical record, the Veteran reported that he went on an enjoyable trip with his wife. In a November 2009 private medical record, the Veteran reported that he had a small "meltdown" at a department store related to feelings that the store's employees were not doing their job properly. He managed to control himself. He reported that this occurred from time to time. In a February 2009 private medical record, the Veteran complained of difficulty sleeping and occasional nightmares. In an April 2009 private medical record, the Veteran reported sleeping trouble that occurred in waves. He was contacting "old army buddies" and trying to organize a reunion. In a May 2010 statement, Dr. A, a clinician at VA who specializes in PTSD treatment who served with the Veteran in a paratrooper unit, reported that the Veteran experienced symptoms of: panic attacks related to stimuli that triggered recollection of a traumatic in-service event; avoidance of these stimuli; major depression; sleep disorder; hypervigilance; explosive episodes of anger; and daily intrusive thoughts. The Veteran additionally developed a phobia of flying since separation, and has not flown in an airplane since. His depression led to the development of an eating disorder, which was surgically treated. He further reported that the Veteran's family has also "felt the burden of a family dynamic wrought" by this disability. In a May 2010 statement, the Veteran's wife reported that the Veteran had been treated with medication for depression for many years. He had a sleep disorder and had to wear a CPAP machine. He had explosive episodes of anger, an eating disorder, and was afraid to fly. He had nightmares about his experiences, and would kick her in his sleep. In a June 2010 private medical record, the Veteran reported that he would sit and talk with his friend who owned a convenience store, and the people who would come to the store. The next month, it was noted that the Veteran had generally isolated himself to some extent, and that he did not do well in crowds. It was noted that he appeared to be doing well around his house. In an August 2010 VA mental health note, the Veteran was noted to participate in group therapy. He was noted as an active participant and appeared to listen closely to all material presented. In private medical records from September 2010 and October 2010, the Veteran reported that he did not like crowds, was afraid of any public gathering (especially if fireworks were involved), and did not fly on airplanes. He was noted to be doing well in his limited space. He was diagnosed with depression not otherwise specified. In an April 2011 VA mental health note, the Veteran complained of nightmares related to service. He was noted as fully oriented. His mood was good, and had an affect that was constricted in the sad range. His thought process was goal directed. He denied suicidal and homicidal ideation and/or intent. He had no delusions, ideas of reference, preoccupations, or obsessions/compulsions. He denied hallucinations. His concentration, recent and remote memory, judgment, and insight were good. He was given a GAF score of 40. In a May 2011 VA mental health note, the Veteran's mood was "OK" and his affect was constricted in the sad range. His thoughts were goal directed, and his insight and judgment was good. He was assessed with PTSD and depression not otherwise specified. In a July 2011 VA mental health note, the Veteran complained of frequent disturbing dreams. His mood was "up and down" and his affect was constricted in the sad range. His thoughts were structured, and he denied suicidal and homicidal thoughts. He reported that he occasionally experienced visual hallucinations of "shadows," but denied any auditory hallucinations. His insight and judgment were good. In an August 2011 VA mental health note, the Veteran's mood was "OK" and his affect was slightly constricted. His thoughts were goal directed and free of suicidal or homicidal ideation and/or intent. He denied hallucinations. His insight and judgment were good. He was assessed with PTSD and depression not otherwise specified. In a September 2011 VA mental health note, the Veteran's mood was "alright," and he had an affect that was constricted in the sad range. His thoughts were structured and goal directed. He denied any suicidal or homicidal ideation, as well as hallucinations. His insight and judgement were good. He was assessed with PTSD and depression not otherwise specified. In an August 2012 VA mental health note, the Veteran's mood was "okay," and he had an affect that was constricted in the sad range. His thoughts were structured and goal directed. He denied any suicidal or homicidal ideation, as well as hallucinations. His insight and judgement were good. In an October 2012 VA mental health note, the Veteran complained of chronic nightmares related to service that worsened due to running out of medication. He avoided situations that triggered memories of service, was often irritable, and had "significant discomfort" in crowds. He denied homicidal and suicidal ideation. He was fully oriented. His mood was noted as "antsy," and he had an anxious affect. His thought process was goal directed. In a January 2013 VA mental health note, the Veteran complained of depression and difficulty sleeping secondary to the death of his father in November. He experienced service-related nightmares, which were partially suppressed by medication, and his sleep was sometimes restless. According to his wife he had been somewhat more irritable. He denied suicidal or homicidal ideation. He was assessed with chronic symptoms of PTSD and experiencing bereavement. He was fully oriented. His mood was noted as "so-so," and he had a sad affect. His thought process was goal directed. In an April 2013 VA mental health note, the Veteran reported chronic irritability and occasional nightmares. His mood and anxiety level fluctuated, and he was "especially troubled" by general lack of energy. He denied suicidal or homicidal ideation. He was fully oriented. His mood was noted as "doing okay," and he had a somewhat anxious affect. His thought process was goal directed. In an August 2013 VA mental health note, the Veteran reported that he was easily irritated ,but did not express any homicidal thoughts. His nightmares were less frequent. His medication was noted to have been of some benefit in reducing the intensity of PTSD symptoms. He denied suicidal ideation. He was fully oriented. His mood was noted as "alright," and he had a constricted affect. His thought process was goal directed. In a December 2013 VA mental health note, he reported that his mood varied somewhat from day to day and that he was easily irritated. He had a poor quality of sleep and nightmares. He did not express any suicidal or homicidal ideation. He was fully oriented. His mood was noted as "alright," and he had a constricted affect. His thought process was goal directed. In a March 2014 VA mental health note, the Veteran reported less frequent and intense nightmares since his medication was increased. He was occasionally irritable, but felt that it was largely controlled with his current medications. He was concerned about an upcoming flight, and requested medication to control anxiety. He denied suicidal or homicidal ideation. He was fully oriented. His mood was noted as "not too good," and he had a constricted range of affect. His thought process was goal directed. In a July 2014 VA mental health note, the Veteran reported that his mood varied considerably from day to day. He denied suicidal or homicidal ideation. He was occasionally irritable, and had frequent nightmares related to service. He denied recent intrusive memories of his experiences, but they were triggered when he saw an Army C-130 aircraft. He was assessed with experiencing some persistent symptoms of PTSD. He was fully oriented, and his thought process was goal directed. His mood was "alright" and he had a bright affect. In a November 2014 VA mental health note, the Veteran reported that he felt more depressed since his last visit. His sleep had deteriorated, but his medication provided some relief from nightmares. He denied experiencing suicidal or homicidal ideation. He was fully oriented and had adequate concentration. His mood was "a little depressed," and he had an anxious affect. His thought process was goal directed, and he had appropriate thought content. His insight and judgment were grossly intact. In a February 2015 VA mental health note, the Veteran's mood improved due to medication. His medication was effective in reducing the intensity of his nightmares, but he continued to have difficulty remaining asleep. Notably, he was unable to return to sleep after a sleep disturbance. He denied suicidal or homicidal thoughts. He was fully oriented and had adequate concentration. His mood was "okay, and his affect was noted as initially somewhat anxious, but it became brighter during appointment. His thought process was goal directed with appropriate thought content. His insight and judgment were grossly intact. In the May 2015 VA examination, the Veteran reported current symptoms of: nightmares that occurred once a week, daily intrusive thoughts, anxiety, and irritability. He reported that his marriage was very good, as were his relationships with his children and grandchildren. The examiner noted that the Veteran appeared to be dependent on his wife, and that he showed no eye contact at first and struggled to answer the most simple questions. He noted that the Veteran's cooperation and social skills were very poor. The examiner found that the Veteran experienced recurrent involuntary and intrusive distressing memories and dreams related to an in-service. He had intense or prolonged psychological distress at exposure to internal or external cues that symbolized or resemble an aspect of a traumatic event. He had avoidance of, or efforts to avoid, distressing memories, thoughts, or feelings about or closely associated with a traumatic event. He had markedly diminished interest or participation in significant activities. He experienced feelings of detachment/estrangement from others. He had irritable behavior and angry outbursts (with little or no provocation) that were typically expressed as verbal or physical aggression toward people or objects. He was hypervigilant, and experienced sleep disturbances. He had objective symptoms of: depressed mood; anxiety; chronic sleep impairment; disturbances of motivation and mood; and impaired impulse control, such as unprovoked irritability with periods of violence. The examiner's behavioral observations were that the Veteran had "odd, reserved, [and] poor social skills." The Veteran was capable of managing his financial affairs. He was diagnosed with mild PTSD. The examiner opined that that the Veteran's psychiatric disability caused occupational and social impairment due to mild or transient symptoms which decreased work efficiency and the ability to perform occupational tasks only during periods of significant stress; or, symptoms controlled by medication. He was given a GAF score of 45 to 50. In a June 2015 VA mental health note, the Veteran reported increased irritability in the past week, but was unable to specify why. He denied any physical aggression and did not express any homicidal or suicidal thought. He experienced poor quality of sleep, and had frequent nightmares. It was noted that the Veteran was to fly in an airplane, and he request anxiety medication. The clinician noted that the Veteran experienced significant symptoms of PTSD which may be exacerbated by inadequately controlled sleep apnea. He was fully oriented, and his concentration was poor. His mood was noted as "a little depressed," and he had a relatively constricted range of affect. His thought process was goal directed, and thought content was appropriate. His insight and judgment were grossly intact. In an October 2015 VA mental health note, the Veteran reported that over the past several months he had become increasingly more irritable and argumentative, but was not physically aggressive. He experienced more frequent intrusive memories. His sleep varied in duration and quality, and he had occasional nightmares. The clinician noted that the cause of the Veteran's increased irritability was not entirely clear; however, his chronic pain was a significant stressor. He was fully oriented and had poor concentration. His mood was "okay" and he had a somewhat anxious affect. His thought process was goal directed, and his thought content was appropriate. His insight and judgment were grossly intact. He denied homicidal and suicidal ideation/thoughts, as well as hallucinations and delusions. In October 2015 the Veteran's VA mental health clinician completed a form provided by the Veteran's representative. Therein, the clinician noted that the Veteran experienced: a moderate restriction of activities of daily living; a marked degree of difficulty in maintaining social functioning; and constant deficiencies of concentration, persistence, or pace resulting in a failure to complete tasks in a timely and appropriate manner. He noted that the Veteran could experience four or more expected episodes of decompensation in work or a work-like setting which would cause him to withdraw, or to experience an exacerbation of signs and symptoms for a period lasting at least two weeks. He had a moderate limitation to understand, carry out, and remember instructions, and a marked limitation to respond appropriately to supervision, co-workers, customary work pressures. He had a moderate limitation to perform simple tasks, and marked limitation to perform repetitive tasks and to complete work related activities in a normal workday or workweek. These limitations were opined to last for 12 months or longer. No formal psychological evaluation was obtained, but it was noted that the answers were obtained as an evaluation of routine treatment. The clinician noted that the Veteran had difficulty concentrating, was irritable, and easily frustrated. This would impair his ability to work. It was noted that the Veteran was diagnosed with PTSD and depressive disorder. The clinician opined that the Veteran's PTSD should be rated at 70 percent disabled. In a November 2015 VA examination, the Veteran reported that he argued with others too much and fought. He had nightmares, and their occurrence improved with medication. He noted that he could be triggered by stimuli that reminded him of service, and that he was irritable. Regarding his marriage, he described relationship as "good sometimes, bad sometimes." He did not often speak with his adult children. He described his hobbies as "going off by myself in the woods." In response to whether he could work, he noted that he had back problems and stated "I don't know if I can stand to be around anybody." The Veteran was found to have recurrent involuntary and intrusive distressing memories and dreams related to an in-service event. He had intense or prolonged psychological distress at exposure to internal or external cues that symbolized or resembled an aspect of a traumatic event. He had avoidance of, or efforts to avoid, distressing memories, thoughts, or feelings about or closely associated with a traumatic event. He experienced feelings of detachment or estrangement from others, as well as sleep disturbances. The examiner found objective symptoms of: depressed mood; anxiety; and chronic sleep impairment. Other symptoms attributable to the Veteran's psychiatric/mood disabilities included anger/aggression, irritability, impulsivity, and poor interpersonal relationships- due to antisocial personality characteristics. The examiner noted that the Veteran was diagnosed with more than one mental disorder, and that their symptoms were distinguishable. These conditions were depression and other specified trauma and stressor-related disorder (the examiner noted that the Veteran did not meet full criteria for PTSD during this encounter). The Veteran's depression caused decreased enjoyment and interest in people in activities, decreased energy, sad mood, self criticalness, and pessimism. His trauma disorder caused: anxiety; recurrent and intrusive recollections of trauma; recurring dreams about same; discomfort when exposed to things that remind him of trauma; avoidance of thoughts, conversations, and things that reminded him of the trauma; hypervigilance; and discomfort in large crowds. The examiner found that the Veteran's depression and maladaptive personality characteristics appeared to cause the majority of his irritability, anger, apathy, and lack of motivation. His trauma disorder resulted in minimal functional limitation, other than avoidance of aircraft. The examiner found that the Veteran would likely have difficulty working in an avionics field, but otherwise his trauma disorder would only cause minimal, transient problems due to anxiety when in stressful situations. During the examination, the Veteran interacted in an irritable, but cooperative manner. His mood was noted as depressed, and he had an irritable and somewhat flat affect. The Veteran did not appear unusually anxious. His thought processes were centered around negative comments and complaints. There were no signs of psychosis or unusual behavior. The Veteran was capable of managing his financial affairs. Combined, his depression and trauma disorder caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. However, the examiner noted that it was possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder. The trauma disorder caused transient symptoms which decreased work efficiency and his ability to perform occupational tasks only during periods of significant stress. His depression caused an occasional decrease in work efficiency. In a March 2016 VA mental health note, the Veteran reported that he was often somewhat depressed, but denied experiencing suicidal ideation. He denied being unduly irritable, and did not express any homicidal thoughts. He lately did not often experience nightmares, and his sleep was generally adequate. He was fully oriented and had poor concentration. He did not precisely describe his mood, and he was noted to have a constricted range of affect. His thought process was goal directed, and his thought content was appropriate. His insight and judgment were grossly intact. In a July 2016 VA mental health note, the Veteran was more depressed than usual and was to mourning the death of his dog, who died earlier this year. His sleep was often disrupted by nightmares, and he had not been unduly irritable. He did not express any homicidal or suicidal thoughts. It was noted that the Veteran had modest PTSD symptoms, and had mild depression as a result of death of his dog. He was fully oriented, and his concentration was fair. His mood was "alright," and he had a sad affect. His thought process was goal directed, and his thought content was appropriate. His insight and judgment were grossly intact. In a November 2016 VA mental health note, the Veteran reported that he sometimes experienced a moderately depressed mood, but denied any recent periods of profoundly depressed mood, or loss of motivation. He denied recent periods of being unduly irritable or anxious recently. His sleep was fairly good, and he experienced fewer nightmares than in the past. He did not express any suicidal or homicidal thoughts. The clinician noted that the Veteran presently exhibited limited symptoms of PTSD and depression due to medication. He was fully oriented and his concentration was adequate. His mood was noted as "doing alright" and he had a bright affect. His thought process was goal directed, and thought content was appropriate. His insight and judgment were grossly intact. In a March 2017 VA mental health note, the Veteran reported that his mood varied considerably from day to day, but he was presently in a reasonably good mood. He was sometimes irritable, and sometimes his sleep was disrupted by nightmares. He denied suicidal or homicidal ideation. The clinician assessed the Veteran with moderate and persistent symptoms of PTSD. He was fully oriented, and his concentration was adequate. His mood was noted as "okay" and he had a bright affect. His thought process was goal directed, and his thought content was appropriate. His insight and judgment were grossly intact. III. Analysis Upon consideration of the foregoing, the Board finds that evidence is in at least equipoise that during the period on appeal, the Veteran's service-connected PTSD warrants a 70 percent rating, but no higher. In October 2015, the Veteran's VA clinician provided an opinion, upon review of the mental illness rating criteria and consideration of the medical record, that the Veteran should be rated as 70 percent disabled. The Board notes that the October 2015 opinion provided by the Veteran's VA clinician was soon after followed by the November 2015 VA examination. The Board notes that the November 2015 examiner found that the Veteran had distinguishable depression and trauma-related disabilities that cumulatively did not meet the threshold for a 70 percent rating. The Board finds that both opinions are equally competent, credible, and probative. They were made upon review of the medical record, and were based upon an examination, or reviews thereof, of the Veteran. As both opinions are of equal probative weight, the evidence is in equipoise and the benefit of the doubt goes in favor of the Veteran. The Board further notes that the VA clinician that provided the October 2015 opinion indicated that the earliest date that the Veteran's symptoms/limitations applied to was "2011 or before." The Board observes that record indicates that this VA clinician first began to provide medical treatment to the Veteran around October 2012. However, review of the record demonstrates that the Veteran experienced symptoms of impaired impulse control (anger/irritability), depression, and avoidance (including airplanes) of stimuli prior to this time. The Board finds that the persistence and severity of these symptoms more closely approximates a 70 percent rating than a 50 percent rating. This is also supported by April 2011 and May 2015 GAF scores that suggest serious symptoms or a serious impairment in social, occupational, or school functioning. As such, a 70 percent rating, but no higher, is warranted during the period on appeal. The Board acknowledges that the November 2015 examiner noted that he was able to separately identify the effects of the Veteran's psychiatric disabilities. However, the Board notes that 38 C.F.R. § 4.130's rating criteria considers symptoms such as depression as a symptom to consider for rating mental illnesses. See Mauerhan v. Principi, 16 Vet. App. 436 (2002) (the General Rating Formula for Mental Disorders is not intended to constitute an exhaustive list, but rather provides examples of the type and degree of symptoms, or their effects, that would justify a particular rating). Further, in the May 2015 grant of PTSD by the RO considered depressed mood as part of its initial evaluation. As such, giving the Veteran the benefit of the doubt, the Board has considered the effects of the Veteran's separately diagnosed depression and PTSD together in determining his total disability picture. The Board finds that a total schedular rating for PTSD is not warranted during any portion of the period on appeal. Notably, the Veteran has not been shown to have a gross impairment of thought processes or communication. He did not have persistent delusions or auditory hallucinations. He did not exhibit grossly inappropriate behavior and was not a persistent danger to hurt himself or others. It was not demonstrated that he experienced intermittent inability to perform activities of daily living. He was not shown to be disoriented to time or place, and did not have memory loss relating to close relative, his prior occupation, or his name. As such, a total schedular rating is not warranted during the period on appeal. The Board notes that the Veteran indicated that he sometimes experienced visual hallucinations in July 2011. However, the Board does not find that a total schedular rating is warranted on the basis of this record alone. Notably, the Veteran has otherwise, on a consistent basis, denied hallucinations and delusions throughout the period on appeal. While the Veteran is competent to claim that he has experienced hallucinations, the weight of the evidence is against a finding that they are "persistent" for rating purposes. As such, the Board finds that this record alone is not illustrative of the Veteran's total disability picture, and that a total schedular rating is not warranted on the basis of this record at any time during the appeal period. In summation, a 70 percent rating, but no higher, for PTSD is warranted during the period on appeal. IV. Total Disability Based on Individual Unemployability (TDIU) In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for TDIU is part of an increased rating claim when such claim is raised by the record. The Veteran indicated in a July 2015 application for increased compensation based on unemployability indicated that he became too disabled to work in 1991. He noted that his service-connected PTSD prevented him from securing or following any substantial gainful occupation. During the period on appeal, the Veteran's PTSD is rated at 70 percent, which meets the threshold minimum schedular rating requirement for a TDIU rating under 38 C.F.R. § 4.16(a). However, the Board finds the record during the period on appeal does not demonstrate that the Veteran was unable to sustain gainful employment due to his PTSD. The Veteran completed three years of high school and worked as a welder until 1991. He reported that he had not tried to obtain employment since that time. The May 2015 examiner found that the Veteran's psychiatric disability caused mild or transient symptoms which decreased work efficiency and his ability to perform occupational asks only during periods of significant stress, or; symptoms controlled by medication. The Veteran's VA clinician noted in October 2015 found that the Veteran had "constant" deficiencies of concertation, persistence, or pace resulting in the failure to complete tasks in a timely and appropriate manner. He further found that the Veteran was expected to have four or more episodes of decomposition in work/work-like setting that would cause the Veteran to withdraw from that situation or experience an exacerbation of signs and symptoms for a period lasting at least two weeks. The Board notes that the record is silent for episodes of decomposition. Further, despite these findings, the Veteran's clinician opined that the Veteran's psychiatric disability caused moderate (defined by the form as affecting but not precluding the ability to function independently, appropriately, or effectively on a sustained basis) to marked (defined by the form as a step above moderate, i.e. serious impairment, but below "extreme" which is a "severe" impairment) difficulties/restrictions to social and work-like activities. He finally opined that the Veteran's had occupational and social impairment with deficiencies in most areas. The November 2015 examiner noted that the totality of the Veteran's psychiatric disabilities caused a 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. Considering the above, at the record demonstrates that during the period on appeal the Veteran was not shown to be unemployed or unemployable due to his PTSD. Notably, the competent and credible medical evidence found that the Veteran's psychiatric disability was not to such a degree that it would preclude him from securing or following any substantial gainful occupation. As such, the Board finds that the Veteran's 70 percent rating during the period on appeal accurately reflects the degree of his disability. ORDER An evaluation of 70 percent, but no higher, for PTSD during the period on appeal is granted, subject to the laws and regulations governing monetary awards. ______________________________________________ M. C. GRAHAM Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs