Citation Nr: 1753494 Decision Date: 11/21/17 Archive Date: 12/01/17 DOCKET NO. 13-28 634A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to a higher initial rating for PTSD, rated as 30 percent disabling prior to December 29, 2016, and 70 percent thereafter. REPRESENTATION Appellant represented by: Missouri Veterans Commission ATTORNEY FOR THE BOARD E. Alexander Neff, Associate Counsel INTRODUCTION The Veteran served on active duty in the Marine Corps from May 1964 to April 1968. His awards and decorations included: a National Defense Service Medal; a Vietnam Service Medal with a device; and a Meritorious Mast. The Board sincerely thanks him for his service to his country. This matter is before the Board of Veterans' Appeals (Board) on appeal from an October 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis Missouri. In October 2015, the Board granted the Veteran's claim for an earlier effective date for PTSD, and remanded the higher rating claim (at that time 30 percent for the entire appeal period) to assess the severity of PTSD since January 2004, to also include any development necessary. Thereafter, a January 2017 rating decision granted an increased rating, to 70 percent for PTSD, effective December 29, 2016. The Board also notes that in February 2017 the Veteran perfected an appeal seeking to establish entitlement to service connection for gastric cancer. As of the time of writing this decision, the AOJ has not certified this issue to the Board as of this time. The Board shall not interfere in or complicate the AOJ's proceedings on that matter by taking jurisdiction over the issue at this time. FINDINGS OF FACT 1. Prior to September 15, 2010, the Veteran's PTSD has not been demonstrated as 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 2. From September 15, 2010, to December 28, 2016, the Veteran's PTSD has been demonstrated to cause occupational and social impairment with reduced reliability and productivity, but not as occupational and social impairment with deficiencies in most areas. 3. From December 29, 2016, the Veteran's PTSD has not been manifested by 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. CONCLUSIONS OF LAW 1. Prior to September 15, 2010, the criteria for a disability rating in excess of 30 percent for service-connected PTSD are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A and 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, and 4.130, Diagnostic Code 9413 (2017). 2. Between September 15, 2010, and December 28, 2016, the criteria for a 50 percent disability, but no higher, for service-connected PTSD are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A and 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, and 4.130, Diagnostic Code 9413. 3. From December 29, 2016, the criteria for a disability rating in excess of 70 percent for service-connected PTSD are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A and 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, and 4.130, Diagnostic Code 9413. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board notes that it has reviewed all of the evidence in the record, 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 of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim being decided. I. PTSD A. Higher Rating 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). B. Rating Criteria PTSD is rated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9411. A 30 percent evaluation is warranted where there is 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, mild memory loss (such as forgetting names, directions, recent events). Id. 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. C. Factual Background In the October 2015 remand, the Board noted that the issues before it were an entitlement to an earlier effective date for PTSD, and entitlement to a higher initial rating for same. The Board granted the claim for earlier effective date, ruling that the Veteran's service-connected PTSD was effective from January 9, 2004. As such, the Board shall consider the record from this time. The Veteran's PTSD is currently rated as 30 percent disabling prior to December 29, 2016, and 70 percent thereafter. A June 2004 psychiatry note reported that after serving in Vietnam the Veteran mentioned he had a startle reaction to some degree; nightmares, which he could not remember; short temper; and he "keeps his back covered when out in public." The clinician noted that the Veteran was affable, talked easily, with appropriate affect and mood, with no evidence of a thought disorder, and intact intellectual faculties. The impression was "symptoms consistent with dx of ptsd. Recommend: pt should continue to see[k]a comp and pension evaluation." The Board notes that the October 2015 Remand had a typographical error wherein the Board requested VA medical documents from January 2006 (instead of January 2004) to be associated with the record. However, a January 2012 VA examiner who reviewed the Veteran's VA treatment records noted that, with the exception of a June 2004 note from the St. Louis VAMC PTSD clinic, noted above, the Veteran did not receive any mental health treatment until October 2010. Notably, neither the Veteran nor his representative have indicated that there are any outstanding VA medical records. Thus, a remand for same would not provide the Veteran with any additional benefit. As such, the Board will not remand the claim in light of the aforementioned typographical error as would serve no useful purpose, and would delay the adjudication of this claim. In a September 2010 VA social work note, Veteran reported that he lived with his wife and daughter. The Veteran had been married for 40 years. He claimed that he received more emotional support from his daughter than his wife, but was not willing to go into detail. He was startled any time he heard a police/fire siren. These reminded him of the "constant airport bombing" near where he was stationed in Vietnam. The Veteran described experiencing PTSD-like symptoms, such as: hyperarousal; hypervigilance, and re-experiencing trauma. He was noted to appear alert and fully oriented. In an October 2010 VA initial psychology note, the Veteran complained of occasional initial and regular middle insomnia that occurred two to three times a night. He achieved an average of six hours of sleep per night. It was noted that he experienced marital discord. He lived with his wife, daughter, and grandchild. He described his family as protective factor, and denied past suicide attempts. He reported feeling depressed and down, and denied hopelessness. He experienced intrusive thoughts, nightmares, and emotional distress. He denied flashbacks, and did not report physical reactions. He avoided conversations about his in-service trauma; however, he did not report avoidance of things that reminded him of trauma. He did not experience impaired recall or emotional numbing. He reported having "great love" for his family, and that he had friends. He was irritable, hypervigilant, had an exaggerated startle response, and experienced a slight loss of interest. His mood was noted as "more bad days than good days lately" and his affect was tearful and guarded. He denied hallucinations and delusions. His judgment and insight were good. He did not have suicidal or homicidal ideation and/or intent. His concentration was noted as decreased. In another October 2010 VA medical note, the Veteran reported that he would wake up at 2:00 or 3:00 am. He had very restless and light sleep, and would wake up 15 or so times a night. He reported that he went to a football game and spent time with grandson. His interest was noted as very slightly improved, and he denied feelings of guilt. He reported that his energy was "lousy" and that his concentration was decreased. He denied suicidal and homicidal ideation and/or intent. His mood was "not the best ... sometimes very moody" and he initially presented with an initially guarded affect and almost appeared ashamed to be in the office [the clinician noted that the Veteran covered his face with a pamphlet to hide tears, and was self-critical of same]. As the session progressed, the Veteran's affect was noted to have brightened a bit. In a November 2010 VA medical record, the Veteran complained of terminal insomnia. His interest was noted to have very slightly improved, and he denied guilt. He rated his energy as 4/10, and reported decreased concentration. The Veteran reported significant avoidance of any conversations about Vietnam. He denied suicidal and homicidal ideation and/or intent. The Veteran's mood was below a five on a 10 scale. The clinician again noted that the Veteran presented as if he was ashamed to be in the office, noting that the Veteran held back tears as he entered the room. The Veteran was noted to have a guarded and tearful affect which appeared to warm up as session progressed. His thoughts were noted as linear and goal-directed. In a December 2010 VA medical record, the Veteran reported that his sleep had slightly improved; however, he still experienced terminal insomnia. His interest was noted to have very slightly improved, and his guilt increased. His energy was a four out of 10 and his concentration was still decreased. He denied suicidal and homicidal ideation and/or intent. His mood was less "uneasy" and he had a calm affect. In another record from this time, the Veteran was noted to have decreased prolonged concentration. He presented with significant avoidance of any emotionally distressing topics. The Veteran tried to normalize his reactions, and discussed his increased startle response. He experienced increased thoughts of incoming mortar attacks. He reported that "I get the shakes and shed a few tears." He was noted to continue to present with significant discomfort entering the clinician's office. His affect was initially noted as anxious/tearful, but he calmed down as the session progressed. The Veteran's thoughts were linear and goal-directed. In a January 2011 VA medical record, the Veteran reported that his sleep had slightly improved, but he continued to experience terminal insomnia. His interest was noted as still very slightly improved. He enjoyed watching football and was noted to have put together a train set with his grandson. His energy and concentration were noted as decreased, and his guilt was increased. He denied suicidal and homicidal intent and/or ideation. His mood was "ok but could be better" and he had a calm affect. During this session no anxiety or tears were observed. In an August 2011 private medical opinion, upon consideration of the Veteran's self reporting, the private examiner found that the Veteran experienced: alteration of sleep; poor concentration; moderate anxiety; social anxiety; isolation; delusions; compulsive behaviors; mood swings; alteration in appetite; memory difficulty; disorganization; altered judgment; flashbacks; and outburst of anger. There was no evidence of delusions or hallucinations, and the Veteran was found to be oriented. He was given a GAF score of 40. The private clinician opined the Veteran's symptoms warranted a granting of a total schedular disability rating and unemployability due to flattened affect, panic attacks, difficulty in understanding complex commands, impairment of short and long-term memory, impaired judgment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. In the January 2012 VA examination, the Veteran reported that he had been married for 41 years. He liked to stay by himself, and had a relationship with his young grandson. He would check the "perimeter" of his home, and looked for booby-traps when he entered a room. He occasionally experienced "explosive anger." The Veteran was found to experience: recurrent and distressing recollections of trauma; physiological reactivity on exposure to internal or external cues that symbolized or resembled an aspect of a traumatic event; he avoided activities, places or people that arouse recollections of the trauma. He experienced feelings of detachment or estrangement from others. He had difficulty falling or staying asleep and concentrating; He experienced irritability/outbursts of anger. He was hypervigilant and had an exaggerated startle response. He was noted to have daily distressing thoughts and mild social impairment. The VA examiner found objective symptoms of: depressed mood; suspiciousness; chronic sleep impairment; obsessional rituals which interfere with routine activities; and impaired impulse control, such as unprovoked irritability with periods of violence. The Veteran was capable of managing his financial affairs. The VA examiner opined that that the Veteran had a mental condition that was formally diagnosed, but his symptoms were not severe enough either to interfere with occupational and social functioning or to require continuous medication. He was given a GAF score of 61. This opinion was rendered with consideration of the August 2011 private medical opinion. In a January 2012 VA social work note, the Veteran reported that his mood was "absolutely wonderful" and his affect was noted as appropriate for the circumstances. He was pleasant and cooperative, and was found to be alert and fully oriented. He was independent in all activities of daily living. His supports were noted as his wife, daughter, brother, and grandson. In a March 2012 VA mental health note, the Veteran complained of ongoing terminal insomnia, and that he "still [woke] up early every single morning." His interest was noted as still improved. His guilt, was noted as still increased, and the Veteran became tearful while discussing a recent car accident that "[took] me back 40+ years." His energy and concentration were decreased, and he reported that he easily lost his train of thought. The Veteran spent time with grandson and family over the holidays. He described his mood as "good but I just blow up too easily" and his affect was noted as "again calmer today." The Veteran was reported as pleasant and engaged in content during this session. His thoughts were linear, verbose in style, and goal directed. His grooming/hygiene was noted as good. He was diagnosed with PTSD with depressive features. In a May 2012 VA mental health note, the Veteran's interest was noted as still improved. He had become more involved in military organizations, and reported some communication issues with his wife. His guilt was noted as slightly improved. His energy and concentration were decreased. His mood was reported as "things are going alright" and he had a calm affect. The Veteran was noted as remaining pleasant and engaged in content of treatment. His thoughts were linear, verbose in style, and goal directed. His grooming/hygiene was noted as good. He was diagnosed with PTSD with depressive features. In a March 2013 Statement, the Veteran's representative indicated that the Veteran believed that his PTSD warranted a "much higher evaluation" instead of 30 percent. In an October 2013 private medical opinion, the private clinician who provided the August 2011 opinion reported that the GAF was obsolete and that the World Health Organization grading of mild, moderate, and severe was currently being used. He opined that it was obvious that the Veteran suffered from severe PTSD, and he should be rated as totally disabled and unemployable due to the severity of his symptoms. He additionally noted that the GAF was intended for psychiatrists to communicate the severity of psychiatric symptoms, and not to be used to consider occupational or academic level. In an October 2013 statement, the Veteran claimed that based on the private medical opinions that he provided, including the August 2011 GAF score of 41, that he should be granted a 50 percent or higher rating for his PTSD. At the October 2014 VA examination, the Veteran voiced disagreement with his 30 percent rating, and believed that it should have been significantly higher. He reported that he wanted to "continue to help mold [his] grandson to be an asset to the community." He reported that his "biggest problem is [his] head ... I have it every daggone day." He reported that he constantly did not feel good about his head. The Veteran reported that he did not trust people due to negative reactions he experienced coming home from Vietnam. He reported nightmares that would wake him and caused a one to two hour delay in returning to sleep. He denied delay in sleep onset. He experienced flashbacks/memories due to triggers. The Veteran reported that he thought too much during the daytime, and it caused him distress. He did not identify specific worry-related thoughts, but generally worried about his family, health, and daily stressors. The Veteran reported heightened arousal/awareness. He exhibited same by requesting the door to the examination room remain locked, and he carefully looked around the room. Notably, he looked under a small side table, behind a trash can, and inside a box placed on the side table. The VA examiner opined that this behavior may have been somewhat exaggerated given the low potential for threat in the examination room. However, the VA examiner did note that the Veteran experienced some level of distress/awareness in public locations. The Veteran described his daily activities as completing errands for the household, caring for his grandson after school on Tuesdays, and spending time with other veterans. He preferred to interact with veterans on a one-to-one basis, and would speak with other veterans he noticed in public. He recently befriended another Vietnam-era veteran and discussed similarities in their experiences. He and some of his veteran friends would get together several times a month to visit with each other. He reported that he did not trust people who were not veterans. He enjoyed speaking to veterans about service, and would experience flashbacks and nightmares due to same. He did not discuss Vietnam with non-veterans. The Veteran reported that he enjoyed going out for meals. He would go alone, or with his daughter and a few friends. However, he would not sit "out in the open" and would "watch [his] back" as "no one else [would]." The Veteran reported that he separated with his wife in November 2013. Since then he resided with his daughter and grandson. He denied interest in reconciling with his wife. The Veteran was noted to have symptoms of: marked physiological reactions to internal or external cues that symbolized or resemble an aspect of a traumatic event; avoidance of or efforts to avoid external reminders that arouse distressing memories, thoughts, or feelings about or closely associated with a traumatic event(s). He had a persistent negative emotional state and feelings of detachment or estrangement from others. He was hypervigilant and had problems with concentration. The VA examiner found that the Veteran had the objective symptom of anxiety. He was capable of managing his financial affairs. The VA examiner observed that the Veteran's reported PTSD symptoms did not appear to be significantly different (e.g., neither worse nor better) than what was reported in the January 2012 examination. She opined that the Veteran experienced 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. The VA examiner noted that the Veteran endorsed some mild depressive worry that was unrelated to his PTSD. The Veteran's reported depressive ruminations resulted in sleep disturbances, and it was noted that the Veteran did not identify disturbed sleep specific to his PTSD symptoms. The Veteran's depressive symptoms appeared to be relatively mild and did not lead to a significant level of distress/impairment to current functioning. These depressive symptoms were noted related to his PTSD, and were found to not warrant a separate diagnosis. Regarding his relationship with the private clinician that provided the August 2011 and October 2013 opinions, the Veteran reported that "I just see him as needed ... very infrequent." The examiner noted that the private opinions were not "particularly relevant" to the assessment of the Veteran's current diagnosis and functioning. The VA examiner noted that the document provided by private clinician did not "reference or appear to utilize a structured clinical interview but rather endorses every symptom of PTSD without specifying frequency, intensity or duration of the symptom." Further, the private clinician also provided a GAF score that was inconsistent with the Veteran's presentation at the VA examination and other VA mental health records. It was additionally noted that at the time of examination Veteran was not followed by VA psychiatry services. In a May 2015 VA medical record, the Veteran's was noted to not have anxiety or depression. In the December 2016 VA examination, the Veteran reported an increase of PTSD symptoms, such as, daily distressing and intrusive memories. He denied experiencing anxiety. During the examination, the Veteran asked if he could lock the examination room's door so that "nobody can barge in on me ... that's what the Vietcong did [....]" He reported that he had been married for 47 years, but he had been separated for the past three years. He had a close relationships with his daughter and grandson. He reported that although he "loved" people, he did not like to be around a lot of people. He reported that his friends were ones from childhood, and that he did not make new friends. He was not involved in activities other than visiting his daughter and grandson, or babysitting his grandson. The examiner noted that the Veteran's behavior was suggestive of severe hypervigilance and/or exaggerated startle response. It was further noted that the Veteran held his head down and made no eye contact during the evaluation; The Veteran was noted to have symptoms of: recurrent, involuntary, and intrusive distressing memories of a traumatic event; recurrent distressing dreams in which the content and/or affect of the dream are related to a traumatic event; intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resembled an aspect of a traumatic event; and marked physiological reactions to internal or external cues that symbolize or resemble an aspect of a traumatic event(s). He had avoidance of, or efforts to avoid, distressing memories, thoughts, or feelings about or closely associated with a traumatic event(s). He also avoided, or tried to avoid, external reminders that aroused distressing memories, thoughts, or feelings about or closely associated with a traumatic event(s). He had persistent and exaggerated negative beliefs or expectations about oneself, others, or the world. He had markedly diminished interest or participation in significant activities, and had feelings of detachment or estrangement from others. He had irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects; reckless or self-destructive behavior. He had an exaggerated startle response, had problems with concentration, and was hypervigilant. He additionally experienced sleep disturbances. He had objective symptoms of: depressed mood; suspiciousness; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; 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; obsessional rituals which interfered with routine activities; and impaired impulse control, such as unprovoked irritability with periods of violence. He was found to have a dysphoric mood with a congruent affect. His hygiene and grooming were both adequate. The examiner opined that the Veteran had occupational and social impairment with reduced reliability and productivity. In a May 2017 statement, the Veteran stated that he wanted a 70 percent rating throughout the period on appeal. D. Analysis As an initial matter, the Board observes that during the entire period on appeal the Veteran was not shown to experience symptoms of: 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. He was not shown to have suicidal ideation, intent, or attempt, nor the same regarding homicidiality. He was not shown to have to experience symptoms of speech that was intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; or neglect of personal appearance and hygiene. He was also not shown to have impaired abstract thinking. Additionally, during the period on appeal the Veteran was diagnosed with PTSD with depressive features. In the October 2014 VA examination it was noted that the Veteran had a separate depressive disorder that was unrelated to his PTSD. The Board notes that it has considered all the Veteran's psychiatric manifestations in the aggregate as the medical evidence noted above reveals that his psychiatric manifestations cannot be separated. Mittleider v. West, 11 Vet. App. 181 (1998). As such, giving the Veteran the benefit of the doubt, his depressive symptoms shall be considered as part of his PTSD disability picture. Upon consideration of the foregoing, the Board does not find that an initial rating in excess of 30 percent is warranted for the period prior to September 15, 2010. At this time, the Veteran reported nightmares, waking up in cold sweats, and had sleep difficulties. He was hypervigilant in public, experienced startle reactions, and had a short temper. His mood was not remarkable, and his affect was appropriate to his mood. There was no evidence of thought disorder. He was not shown to have difficulties with complex commands, impaired memory, impaired judgment, disturbances of motivation and mood, or difficulty in maintaining effective work and social relationships or more severe symptoms. As noted by the January 2012 VA examiner, following a visit in June 2004, the Veteran did not present to VA for further mental health treatment until October 2010. However, the Board notes that on September 15, 2010, two weeks prior to his initial VA mental health visit, the Veteran was seen by a VA social worker wherein it was noted the Veteran underwent a psychosocial assessment. In that assessment, the Veteran first advised of worsening mental health symptoms. Notably, the record until this point does not support a claim for a higher rating as the Veteran did not receive mental treatment for PTSD from VA during this time, although he did receive other treatment, and he has not indicated that he sought any private treatment for same. See Wood v. Derwinski, 1 Vet. App. 190 (1991) (it is well established that the duty to assist is not a one-way street). As such, the Board finds that the initial period, where the Veteran was rated as 30 percent disabled, precedes this date. As such, a rating in excess of 30 percent prior to September 15, 2010 is not warranted. From September 15, 2010 to December 28, 2016, the Board finds that a rating of 50 percent, but no higher, is warranted. During this period on appeal, the Veteran was noted to have marriage difficulties, which included a separation from his wife in November 2013. He felt depressed, had intrusive thoughts, was avoidant, and experienced emotional distress. His concentration, interest, and mood were noted as decreased. While the Veteran revealed that he had friends they were generally noted as limited to other veterans, and he preferred to interact with them on a one-to-one basis. He additionally reported that preferred to be alone, and that he did not trust non-veterans. He was noted as re-experiencing trauma, and had increased guilt. He lost his train of thought easily and experienced flashbacks/memories due to triggers. At restaurants he would not sit "out in the open" and would "watch [his] back." In records from October to December 2010 the Veteran presented with significant discomfort and would become tearful, although it was noted that his affect would improve during sessions when he went for treatment. In December 2010, the Veteran tried to normalize his reactions, and discussed his increased startle response. He experienced increased thoughts of incoming mortar attacks, where he noted that he would "get the shakes and shed a few tears." In a March 2012 record, the Veteran became tearful when he had a triggered recollection of service related to a current event. The Board acknowledges the August 2011 private medical opinion; however, the preponderance of the evidence does not support a rating in excess of 50 percent during this period. The private examiner found objective symptoms of flattened affect, panic attacks, difficulty in understanding complex commands, impairment of short and long-term memory, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships. Notably, these objective symptoms fall under the criteria for 50 percent rating under Diagnostic Code 9411. While, the private examiner also noted that the Veteran both experienced and did not experience delusions, the preponderance of the evidence is against a finding that the Veteran had delusions at any point during the appeal. The private examiner's finding that the Veteran experienced delusions is less probative as the document is internally inconsistent as it also remarks the Veteran did not experience delusions. Upon review of the remaining record, the Board notes that the Veteran consistently denied delusions. As such, the Board finds that the weight of the evidence is against the finding that the Veteran experienced delusions at the time of this record, and as such this statement cannot be the basis for a higher rating. The Board further notes that the private examiner assessed the Veteran with a GAF score of 40, indicating severe symptoms, and opined that he was totally disabled. Upon review of the record the weight of the evidence is against finding that the Veteran had severe symptoms and/or was totally disabled at any time due to PTSD. Significantly, a VA examiner who assessed the Veteran only a few months later opined that that the Veteran had a mental condition that was formally diagnosed, but his symptoms were not severe enough either to interfere with occupational and social functioning or to require continuous medication. He was given a GAF score of 61. Further, the October 2014 VA examiner's opinion also assessed the Veteran with significantly less severe symptoms than the 2011 private opinion. The October 2014 examiner's opinion is highly probative as it reviewed the record, including the August 2011 private opinion. The 2014 examiner then assessed the private opinion as only minimally relevant as it did not "reference or appear to utilize a structured clinical interview but rather endorses every symptom of PTSD without specifying frequency, intensity or duration of the symptom." Further, the private clinician also provided a GAF score that was inconsistent with the Veteran's presentation at the VA examination and other VA mental health records. Notably, the October 2014 VA examiner's assessment of same was provided upon a review of the record and a contemporaneous examination of the Veteran. The Board finds that the VA opinions and treatment records are more probative than the 2011 private opinion regarding the Veteran's disability picture. As such, the Board finds that a rating in excess of 50 percent during this period is not warranted. In the January 2012 VA examination, the Veteran reported that he would check the "perimeter" of his home, and would look for booby-traps when entering a room. He occasionally experienced "explosive anger." The VA examiner found objective symptoms of: depressed mood; suspiciousness; chronic sleep impairment; obsessional rituals which interfere with routine activities; and impaired impulse control, such as unprovoked irritability with periods of violence. The VA examiner opined that the Veteran's symptoms were not severe enough either to interfere with occupational and social functioning or to require continuous medication. He was given a GAF score of 61. Upon consideration of the objective symptoms, the Board notes that depressed mood, suspiciousness, and chronic sleep impairment are criteria for a 30 percent rating under Diagnostic Code 9411. Impaired impulse control and obsessive rituals are criteria for a 70 percent rating. The assigned GAF score is one point above "moderate" severity according to that scale. Upon weighing of this evidence, the Board finds that Veteran's disability picture at this time was more severe that 30 percent, but does not reach the criteria for a 70 percent rating. Giving the Veteran the benefit of the doubt, the Board finds that the objective symptoms observed at this time suggest a 50 percent rating. The Board acknowledges the October 2013 private medical opinion, wherein the private examiner opined that the Veteran should be rated as totally disabled and unemployable due to the severity of his PTSD symptoms. The Board does not find that this record is of much probative value. This opinion did not indicate whether: the Veteran was examined; that any of his records, to include the claims file, were reviewed; if negative evidence was considered; or that any medical literature was considered. To the extent that it was intended to reassert the findings of the August 2011 private opinion, the Board reasserts its prior reasons and bases as to the diminished probative value of the August 2011 private opinion. The Board acknowledges that the October 2014 VA examiner observed that the Veteran's reported PTSD symptoms did not appear to be significantly different (e.g., neither worse nor better) than what was reported in the January 2012 VA examination. As the Board has found that the January 2012 examination is suggestive of a 50 percent rating, giving the Veteran the benefit of the doubt, the Board also finds that this examination also suggests that a 50 percent rating is appropriate. Based on the foregoing, the Board finds that a 50 percent rating, but no higher is warranted for the period between September 5, 2010, and December 28, 2016. A higher rating is not warranted on the basis that the Veteran was noted to go out to meals, interacted with other veterans, became involved in military organizations, went to sporting events, and would spend time with his family. In addition to what was noted above, he was not shown to have: near continuous panic or depression that affected his ability to near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; or had impaired impulse control. As such, a 50 percent rating, but no higher, is warranted for this period on appeal. Upon review of the record from December 29, 2016 onward, the Board finds that a rating in excess of 70 percent is not warranted. The December 2016 VA examiner, in part, noted that the Veteran did not make new friends, and that he was not involved in activities other than visiting his daughter and grandson. His behavior was suggestive of severe hypervigilance and/or exaggerated startle response. During the examination, the Veteran held his head down and did not make eye contact. He was avoidant, and had recurrent distressing dreams and involuntary intrusive memories of trauma. He experienced intense or prolonged psychological distress when exposed to internal or external cues that symbolize or resembled an aspect of the traumatic event; and had marked physiological reactions to internal or external cues that symbolize or resemble an aspect of a traumatic event(s). However, as noted above, the Veteran was not found to have symptoms such 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. As such a rating in excess of 70 percent for this period on appeal is not warranted. Additionally, in May 2017 the Veteran expressed that he wanted a 70 percent rating assessed throughout the period on appeal. In summation, a rating in excess of 30 percent rating is not warranted for the period prior to September 5, 2010; from September 5, 2010 to December 28, 2016 a 50 percent rating, but no higher, is warranted; and from December 29, 2016 a rating in excess of 70 percent is not warranted. ORDER Prior to September 15, 2010, a rating in excess of 30 percent for PTSD is denied. From September 15, 2010 to December 28, 2016, a 50 percent rating, but no higher, for PTSD is granted, subject to the laws governing the award of monetary benefits. From December 29, 2016, a rating in excess of 70 percent for PTSD is denied. ____________________________________________ M. C. GRAHAM Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs