Citation Nr: 1802530 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 09-42 158A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to an increased disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD), prior to May 10, 2017. 2. Entitlement to an increased disability rating in excess of 70 percent for PTSD from May 10, 2017. REPRESENTATION The Veteran represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD P. Franke, Associate Counsel INTRODUCTION The Veteran had active service in the United States Army from July 1963 to August 1984. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. Jurisdiction has most recently resided with the RO in Houston, Texas. On his November 2009 VA Appeals Form 9, the Veteran indicated that he desired a Board hearing and also submitted a May 2010 hearing request to that effect. However, he subsequently withdrew that request in June 2010 and the hearing request has been considered withdrawn. 38 C.F.R. § 20.704 (2017). The matter was remanded in July 2015. The Board notes that the Veteran is receiving special monthly compensation (SMC) under 38 U.S.C. 1114, subsection (k) and 38 CFR 3.350 (a) based on the loss of use of a creative organ from November 13, 2009. This appeal was processed using the Veterans Benefits Management System (VBMS) and the Legacy Content Manager Documents (LCMD) (formerly Virtual VA) electronic claims files. FINDINGS OF FACT 1. The medical evidence of record indicates that prior to May 10, 2017, the Veteran's service-connected PTSD was not manifested in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to symptoms such as those set forth under the General Rating Formula for Mental Disorders for a higher rating. 2. The medical evidence of record indicates that, from May 10, 2017, the Veteran's service-connected PTSD was not manifested in total occupational and social impairment due to symptoms. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent prior to May 10, 2017 for PTSD have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.126, 4.130 (General Rating Formula for Mental Disorders) (2017). 2. The criteria for a rating in excess of 70 percent from May 10, 2017 for PTSD have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.321, 3.159, 4.1, 4.3, 4.7, 4.126, 4.130 (General Rating Formula for Mental Disorders) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) provides that VA will notify the Veteran of the need of necessary information and evidence and assist him or her in obtaining evidence necessary to substantiate a claim, as well as obtaining a medical examination or opinion of the Veteran's disability when necessary. 38 U.S.C. § 5103 (a); 38 C.F.R. § 3.159 (b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VA has assisted the Veteran in obtaining evidence to the extent possible, in collecting service treatment records, arranging examinations and obtaining opinions. In addition, the Board is satisfied that VA has substantially complied with the directives of the Board's previous remand. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). The Veteran was afforded Compensation and Pension examinations in May 2017 and May 2008. They resulted in findings pertinent to deciding the claim for entitlement an increased evaluation of disability for PTSD. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008); see Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board finds the examinations adequate for their purposes. Moreover, neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Increased Schedular Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service connected disorder. 38 U.S.C. § 1155. The evaluation of a service-connected disorder requires a review of a veteran's entire medical history regarding that disorder. 38 U.S.C. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Evidence to be considered in an appeal from an initial disability rating is not limited to current severity, but will include the entire period of the disorder. Additionally, it is possible for a veteran to be awarded separate percentage evaluations for separate periods (staged ratings), based on the facts. See Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Lay Evidence Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Veteran's Assertions The Veteran contends that the severity of his symptoms of PTSD is reflected neither in the 50 percent disability rating for the period prior to May 10, 2017, nor in the 70 percent disability rating from May 10, 2017 onward. The Veteran further asserts in his statement accompanying his November 2009 VA Appeals Form 9 that members of his therapy group have received higher disability ratings, they and he have similar experiences and, therefore, he should receive benefits equal to theirs. Acquired psychiatric disorder, to include PTSD, depression and anxiety disorder Most psychiatric disorders, including PTSD, depression and anxiety disorder, although assigned separate diagnostic codes, are evaluated under the General Rating Formula for Mental Disorders (General Rating Formula). 38 C.F.R. § 4.130. Under the General Rating Formula, a 50 percent disability rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating is warranted for 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. A 100 percent disability rating will be assigned 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. The symptoms listed in the General Rating Formula are not intended to constitute an exhaustive list, but rather serve as 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). If the evidence demonstrates that the claimant's psychiatric disorder produces symptoms and resulting occupational and social impairment equivalent to that set forth in the criteria for a given rating, then that rating will be assigned. Mauerhan, 16 Vet. App. at 443. The record contains diagnoses which include references to Global Assessment of Functioning (GAF) scores, used as diagnostic tools in accordance with the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The fourth edition was superseded in May 2013 the fifth edition, DSM - V, which no longer subscribes to GAF scores. Nonetheless, the Veteran's record from the years preceding the change contains GAF scores and they will be considered. A GAF score is a numerical representation reflecting the psychological, social and occupational functioning on a hypothetical continuum of mental health illness. Carpenter v. Brown, 8 Vet. App. 240 (1995). An examiner's classification of the level of psychiatric impairment, by words or by a GAF score, is to be considered, but is not determinative of the percentage rating to be assigned. See VAOPGCPREC 10-95. The DSM-IV contains a GAF scale, with scores ranging from zero to 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. Higher scores correspond to better functioning of the individual. The scores relevant to this appeal include those ranging from 61 to 70, indicating some mild psychiatric symptoms (e.g., depressed mood and mild insomnia) or experiences some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household); however, the veteran is found to generally be functioning pretty well and has some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 indicate moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social or occupational functioning (e.g., few friends, conflicts with peers and co-workers). GAF scores of 41 to 50 indicate serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social or occupational functioning (e.g., no friends, unable to keep a job). While the Rating Schedule does indicate that the rating agency must be familiar with the DSM-IV, it does not assign disability percentages based solely on GAF scores. 38 C.F.R. § 4.130. Evaluation in excess of 50 percent for PTSD prior to May 10, 2017 In regard to findings made upon examinations or treatment visits which might indicate symptoms and signs for an acquired psychiatric disorder, to include PTSD, depression and anxiety disorder, at a disability rating above 50 percent, the Veteran's VA progress notes at or near August 30, 2007, the date of his PTSD claim, show that from August 2007 to May 2008, visits to Lake of the Ozarks VA and Columbia VA, his therapists, in their sessions with the Veteran noted no suicidal or homicidal ideations; no hallucinations or delusions; logical thought processes; fair to good judgment and insight; adequate to good concentration; intact memory; moderate to good eye contact; friendly and polite manner; euthymic affect; anxious and depressed mood, which improved with medication; and a report of increasing paranoid thoughts. The Veteran received diagnoses of PTSD, chronic and GAF scores of 45 to 65. In May 2008, the Veteran underwent a VA examination for PTSD. Findings upon examination included a clean general appearance; unremarkable psychomotor activity; slow speech; suspiciousness; blunted affect; and anxious, dysphoric mood; short attention span (was unable to do serial 7s, but could spell a word forward and backward); he was oriented to person, time and place; his thought process was described as evasive; thought content was low; he exhibited paranoid ideation; he did not exhibit delusions; judgment indicated and understanding of the outcome of his behavior; intelligence was average; insight indicated awareness of his problem; sleep impairment; exhibits inappropriate behavior in the form of being interpersonally guarded; can interpret proverbs; does not have obsessive/ritualistic behavior; experiences panic attacks, triggering memories of service in Vietnam; no suicidal or homicidal thoughts; fair impulse control; no episodes of violence; adequate hygiene; no problems with activities of daily living; experienced hyper arousal/hypervigilance; and mildly impaired remote, recent and immediate memory, such as failure to remember names, memory gaps and loss of interest when trying to concentrate. Additionally, the May 2008 VA examiner noted stressor events of specific combat experiences, with feelings of intense fear, terror, horror, and emotional numbness, but other instances with no feelings of hopelessness or horror. After trauma exposure testing, the May 2008 VA examiner concluded that the Veteran's overall level of traumatic stress exposure was moderate. The May 2008 VA examiner characterized the Veteran's PTSD symptoms as persistent re-experiencing the traumatic event by recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions; recurrent distressing dreams of the event; acting or feeling as if the traumatic event were recurring; intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; and physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. He further identified persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness, such as efforts to avoid thoughts, feelings, or conversations associated with the trauma; efforts to avoid activities, places or people that arouse recollections of the trauma; inability to recall an important aspect of the trauma; markedly diminished interest or participation in significant activities; feeling of detachment or estrangement from others; and restricted range of affect (e.g., unable to have loving feelings). The May 2008 VA examiner noted persistent symptoms of increased arousal, to include difficulty falling or staying asleep; irritability or outbursts of anger; difficulty concentrating; hypervigilance; and exaggerated startle response. He concluded that the Veteran's PTSD causes clinically significant distress or impairment in social, occupational or other important areas of functioning; the symptoms are chronic; and PTSD symptoms, avoidance symptoms and hyperarousal have been a daily problem. He added that re-experiencing symptoms has been increasing, while avoidance and hyperarousal symptoms have been present steadily since service. The May 2008 VA examiner further noted that behavioral, cognitive, social, affective, or somatic changes include being extremely guarded and suspicious and somewhat paranoid towards others; impaired concentration; decision making difficulty; and visual distortions due to hypervigilance. The May 2008 VA examiner diagnosed the Veteran with PTSD, based on DSM - IV criteria and assigning a GAF score of 50. He added that the Veteran remained mentally competent to understand benefits, know the amounts of monthly bills, prudently handle payments, personally handle money and pay bills, and mange financial affairs. The May 2008 VA examiner further concluded that the Veteran's PTSD symptoms did not totally impair his occupational and social functioning; the symptoms did result in deficiencies of judgment, thinking, family relations, work, and mood, such as by avoiding social contact when it would be advantageous; being indecisive and excessively cautious; being divorced twice; working in isolation; and having a depressed mood, due to service memories and guilt. From August 2008 to April 2009, the Veteran's VA individual therapy and examinations continued, as well as beginning group therapy sessions during which the Veteran's mental status examination revealed that he was well-groomed; had good eye contact; no distraction to internal stimuli; regular rate and rhythm in the amount, tone and volume of speech; his thought was logical, sequential and goal-directed; no suicidal or homicidal ideations; no hallucinations or delusions; good to fair insight and judgment; mildly depressed mood, also anxious and frustrated; and euthymic, appropriate affect. His diagnosis remained PTSD, with GAF scores ranging from 40 to 45. During this period, the Veteran reported his memories of combat service. In May 2009, the Veteran underwent a Patient Health Questionnaire (PHQ) depression screen was conducted in which the Veteran reported daily lack of pleasure in doing things; feeling depressed; sleep difficulty; little energy; and sometime a poor appetite. The Veteran was noted as alert and oriented to person, place and time and the examiner concluded the depression screen indicated he was already receiving the necessary treatment. The Veteran's therapy and treatment from June 2009 to July 2011 produced similar mental status examination results as above, with additional mention of no abnormal motor movements, no indications of psychotic process and some increasing anxiousness and irritability. In July 2011, the examiner further noted good appetite; improved energy and feeling good with loss of weight and exercise; no memory, concentration or attention problems; no evidence of psychotic process; improved motivation; and a mood about which the Veteran reported no mood swings and a good outlook. May 2010 depression screens conducted by the examiner indicated moderate depression. Anxiety disorder was added as a diagnosis in the Veteran's November 2009 individual therapy with and appears again in her diagnosis in July 2011. Between February 2012 and October 2012 psychiatry notes from the Texas North Central Federal Clinic noted the following mental status examination results: The Veteran is well groomed, casually and appropriately dressed. He is calm, cooperative, polite and appreciative of care. His gait is steady. He is mildly restless on and off shaking his knee. He is not tremulous or agitated. He makes good eye contact and he engages well in discussion. His speech is clear, regular in rate and in tone, not loud, rapid or pressured. His affect is pleasant, and he maintains a sense of humor, even though he seems tense and frustrated. His mood has been moderately tense and irritable. His thought process is well-organized. He denies having any thoughts of harming himself or anyone else. He describes being apprehensive, defensive and hypervigilant, but he is not overtly paranoid or delusional. He denies having any auditory or visual hallucinations. There is no evidence of psychosis or of dissociation on examination. He is fully alert and he does not appear to be at all sleepy or sedated. He is well-oriented, concentrates well throughout the visit and his sensorium is clear clinically. January to February 2012 individual psychotherapy notes at the Tejeda VA clinic added to the above poor insight; alert and oriented to person, place, time, and situation; no evidence of cognitive impairment; intact memory; euthymic mood; with full range, appropriate, non-labile affect; and mental status within normal limits. The examiner stated his impression as PTSD, stable, mild to moderately irritable; reporting improved energy level since switching medications; and GAF score: 55 (moderate symptoms and impairment are noted). Additionally, the doctor noted that the Veteran has never been violent or destructive and variously reported at the examinations that, due to medications, he has "good days," as many as 20 per month and has had no depression or no additional symptoms to those reported. In August 2013, the Veteran had as positive PTSD screening test at Temple VA and underwent a PTSD clinical initial assessment in which the examiner recorded mental status examination results to include an appearance within normal limits; guarded behavior; orientation to all three spheres; normal speech; a depressed, anxious and irritable mood in the past 30 days, as reported by the Veteran; cognition within normal limits; and fair judgment. She noted a prior suicide attempt, as reported by the Veteran. Additionally, she noted the Veteran's narrative of combat events, which induced fear, excitement, confusion, and guilt, but no horror or helplessness. Her assessment was the Veteran appears to be experiencing symptoms of PTSD according to DSM-IV criteria. The doctor diagnosed the Veteran with PTSD, chronic, with a GAF score of 64. An August 2013 diagnostic study note at Temple VA included moderate depression and three of the DSM - IV criteria sets were met, "suggesting" a diagnosis of PTSD. Between September 2013 and May 2015, Temple VA and Teague VA personnel made note of a report of the Veteran's wife of the Veteran's intention to commit suicide in June or July 2014. Nonetheless, the examiner's mental status examination findings were generally calm and cooperative; unshaven and disheveled hair; sense of humor; normal rate, volume and prosody of speech; linear, logical and goal-oriented thought process; poor judgment, insight and motivation; no suicidal or homicidal ideation currently; no audiovisual hallucinations; no paranoid delusions elicited; mood variously reported as edgy, poor and "neither good nor bad;" and a stable affect. He assessed the Veteran with PTSD by history. In November 2015, the Veteran presented at Poplar Bluff VA (Missouri) to establish mental health treatment for PTSD, depression and anxiety. The doctor recorded mental status examination results of calm, cooperative; alert; fully oriented; speech and eye contact within normal limits; grooming/hygiene/dress all appropriate; euthymic mood; congruent affect; organized thought processes; no overt signs and symptoms of psychosis; adequate insight and judgment; and the Veteran denied current suicide and homicide ideations. She stated her diagnostic impression as PTSD per self-report. February to May 2017 visits to Farmington VA and Poplar Bluff VA indicate that the Veteran was alert and oriented to person, place and time; he was experiencing no suicidal or homicidal ideations; and he did not have feelings of helplessness related to his physical pain, for which he was presenting. As stated earlier in this decision, it is the Veteran's contention that the above findings made in treatment visits, therapy sessions and upon examination for the period from the date of his claim, August 30, 2007, to the date of the May 2017 VA examination, in which the VA examiner found significant increase in PTSD symptoms, reflect a disability rating higher than 50 percent. As set forth above, under the General Rating Formula the next higher disability rating is at 70, which is warranted for 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. At the outset, the Board notes in the above review of clinical findings for 2008 through 2017 that, although the Veteran's wife told the doctor of the Veteran's intention to commit suicide sometime after June or July 2014, at no time did the Veteran report or exhibit, nor did a treatment provider detect, a suicide ideation. The May 2008 VA examiner concluded that the Veteran's symptoms did result in a thinking deficiency and offered the example of avoiding social contact when it would be advantageous. However, the Veteran's thought processes were also variously described by the above treatment providers as evasive; logical; logical, sequential and goal-directed; organized; well-organized; and linear, logical and goal-oriented, indicating no deficiency. Additionally, between February and October 2012, the examiner stated that the Veteran has a clinically clear sensorium. Although the May 2008 VA examiner stated that the Veteran's symptoms interfered with his judgment, presumably once again in the example of avoiding social contact when it would otherwise be advantageous or perhaps being too cautious and therefore, indecisive. Yet, the May 2008 VA examiner also assessed the Veteran's judgment as indicating an understanding of the outcome of his behavior and his insight as indicating awareness of his problem. Moreover, as stated above, in examinations and therapy between 2008 and 2017, the Veterans judgment and insight is otherwise described as adequate; fair; fair to good; and good to fair. In the same period, the Veteran's speech was characterized as slow; having regular rate and rhythm in the amount, tone and volume; clear, regular in rate and in tone, not loud, rapid or pressured; having a normal rate, volume and prosody; within normal limits; and normal. As stated above, during this period, depression is reflected in findings; for example, in one examiner's August 2013 diagnostic study and in a May 2010 depression screen by another examiner. As also stated above, anxiety disorder appears in November 2009 and July 2011 diagnoses, but this does not amount to "near-continuous panic or depression affecting the ability to function independently." Significantly, in his sessions with another doctor between February and October 2012, the Veteran himself denied having depression and asserted he had as many as 20 "good days" per month. The Veteran's family relations are most prominently on display in his relationship with his wife. Throughout the record the Veteran reports some distance between them, yet they also pray together after an altercation or raised voices; he does not challenge her criticisms or dispute her assertions; and although his impulse control may yield to his sudden irritability, there is nothing in the treatment records to indicate that his impulse control is impaired to the extent stated in the General Rating Formula by way of example as "irritability with periods of violence." For example, the May 2008 VA examiner noted fair impulse control and no episodes of violence and the doctor between February and October 2012 noted that the Veteran has never been violent or destructive. Elsewhere in the record, there are reports of no relationship with his eldest son, a good relationship with his daughter, a guarded but good relationship with his younger son; and the Veteran reported in his May 2017 VA examination that his eldest granddaughter resides with his wife and him. Most of the above may not appear to be ideal family relations, but the record does not indicate that whatever is deficient in those relations is due to any of the symptoms in the General Rating Formula for a 70 percent disability rating for the reasons already stated. In particular, the necessarily heightened effect of sudden irritability through periods of violence appears nowhere in the record. For the rest, the record does not provide instances of spatial disorientation. Moreover, the Veteran being unshaven with disheveled hair in a few instances, when his appearance and hygiene is otherwise noted between 2008 and 2017 as being within normal limits; well-groomed; well-groomed, casually and appropriately dressed; and grooming/hygiene/dress all appropriate, does not rise to the level of "neglect of personal appearance and hygiene," as it is not borne out in the observations of all the Veteran's treatment providers. The record does not reveal much of the circumstances of the Veteran's employment. He has variously reported that he stopped working because he ceased to enjoy it; he had a dispute with a supervisor; and he insisted on working alone. Yet, the May 2017 VA examiner recorded the Veteran's reports of his occupational history as including 21 years in the United States Army; eight years in the Missouri Department of Correction; and nine years as a machinist. The Veteran is over 70 years old and this work history indicates he was employed for almost 40 years. As for the period of August 2007 to May 2017, the May 2017 VA examiner noted that the Veteran had been in retirement of the last nine years. There is nothing in the record to indicate that in the period at issue the Veteran lacked the ability to adapt to stressful circumstances in a work or work-like setting, as well as establish and maintain effective relationships, as he appears to have done in the preceding 40 years when he successfully maintained gainful employment. Moreover, a total rating for individual unemployability has been assigned from March 2015, and there has been no disagreement with that determination. Under the General Rating Formula, a 100 percent disability rating will be assigned 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. The record does not reflect for total occupational and social impairment, due to the symptoms set forth above or symptoms similar in impact. As discussed above, the findings made during treatment or upon examination do not indicate symptoms which rise to the level of producing deficiencies in most areas of occupational and social functioning and, therefore, those symptoms would not result in totally precluding occupational and social functioning. For example, as already discussed, the record reveals nothing in the nature of persistent delusions or hallucinations; no indication of violence; and no hindrance of thought processes, behavior or memory which would totally inhibit functioning. Evaluation in excess of 70 percent for PTSD from May 10, 2017 In regard to findings made upon examinations or treatment visits which might indicate symptoms and signs for an acquired psychiatric disorder, to include PTSD, depression and anxiety disorder, at a disability rating above 70 percent, the Veteran's VA progress notes at or near the date of the May 2017 VA examination show that in a May 2017 visits to Poplar Bluff VA, the Veteran was alert and oriented to person, place and time; he was experiencing no suicidal or homicidal ideations; and he did not have feelings of helplessness related to his physical pain, for which he was presenting. In May 2017, the VA examiner completed a Disability Benefits Questionnaire (DBQ) for PTSD, in which he stated the Veteran's current diagnosis as PTSD. In reviewing the Veteran's record. The May 2017 VA examiner noted symptoms of depressed mood; anxiety; suspiciousness; near continuous depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances; and suicidal ideation and obsessional rituals, which interfere with routine activities. The May 2017 VA examiner rendered several opinions, in the first of which he opined that it is at least as likely as not that Veteran continues to meet the full diagnosis for PTSD, as defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM - V) as a result of his military experiences in Vietnam. The May 2017 VA examiner's clinical findings established this diagnosis, as the Veteran met the criteria in the eight criteria sets of the DSM - V. The May 2017 VA examiner next opined that it is at least as likely as not that Veteran is experiencing a significant increase in the nature and severity of his PTSD symptomatology since the date of the previous C&P examination. He explained that, since the Veteran retired from work near the same time of the last examination, he reported a significant increase in his disturbances in mood (to include greater depression, greater anxiety); significant increases in social impairment due to a drive to isolate or seclude himself away from others; and not being as successful in distracting himself from disturbing combat memories which has resulted in a flooding of disturbing memories from his service in Vietnam. The May 2017 VA examiner further opined that although Veteran is not currently working and has not for about nine years, he would likely experience moderately severe, and at times severe, occupational functional impairment if he was to work at the present time. He explained that the Veteran experiences chronic intrusive recollections of his war experiences in Vietnam would cause him problems with concentration and remaining focused on task-relevant work duties. Additionally, he exhibits significant problems with anger and difficulties interacting with others, which would likely cause significant problems effectively working with supervisors and coworkers, as well as impair his ability to remain emotionally stable in work settings that may be demanding or stressful. A 100 percent disability rating under the General Rating Formula will be assigned 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. As indicated in the May 2017 VA examination, the Veteran's increase in symptoms of PTSD indicate the 70 percent disability rating, which in fact are identified and described by the May 2017 VA examiner in the very language of the General Rating Formula, and, accordingly, the Veteran was granted the higher disability rating. However, the May 2017 VA examiner only identified symptoms "affecting the ability to function independently;" "significant increases in social impairment due to a drive to isolate or seclude himself away from others;" "difficulty in establishing and maintaining effective work and social relationships;" "difficulties interacting with others;" and "difficulty in adapting to stressful circumstances" (emphasis added). As indicated in the sparse treatment records since May 2017 set forth above, nothing in the May 2017 progress notes at Poplar Bluff VA or in the May 2017 VA examination rises to the level of the symptoms of gross impairment of thought, hallucinations, disorientation, memory loss, and others set forth in the General Rating Formula which might indicate "total occupational and social impairment." "Affecting" abilities, "increases" and "difficulties" do not bespeak the "total" impairment which under the General Rating Formula would prevent social and occupational functioning. Conclusion The Board has carefully reviewed and considered the Veteran's statements, including his statement accompanying his October 2008 notice of disagreement, the statement accompanying his November 2009 VA Appeals Form 9, his September and November 2009 correspondences, and his April 2014 Statement in Support of Claim, as well as his reports during examinations, as they appear throughout the record, all of which have assisted the Board in better understanding the nature and development of the Veteran's disability. As stated earlier in this decision, lay people are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran is competent to provide statements of symptoms which are observable to his senses and there is no reason to doubt his credibility. However, the Board must emphasize that the Veteran is not competent to diagnose or interpret accurately the past or current severity of the Veteran's acquired psychiatric disorder, as this requires highly specialized knowledge and training. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Moreover, the Board cannot render its own independent medical judgments; it does not have the expertise. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). The Board must look to the clinical evidence when there are contradictory findings or statements inconsistent with the record. In the absence of explicit indications of worsening signs and symptoms, it must rely on medical findings and opinions to establish the level of the Veteran's current disability. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). The extensive record of treatment provides detailed progress notes containing findings and conclusions, as well as the findings and opinions of the May 2017 VA examiner, which are based on accurate characterizations of the evidence of record. The Board finds the above are entitled to substantial probative weight. For the reasons stated, the Board further finds the record does not contain supporting medical findings, an adequate opinion or related factors to indicate the criteria for a disability rating under the General Rating Formula, with related diagnostic codes for rating purposes, beyond 50 percent for the period prior to May 10, 2017 or beyond 70 percent from May 10, 2017 or which indicate that the assigned rating schedules are inadequate and do not reasonably contemplate the level of severity and symptomatology of the Veteran's service-connected disability. The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. The preponderance of the evidence is against the claim, the doctrine is not applicable and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. ORDER Entitlement to an increased disability rating in excess of 50 percent for PTSD, prior to May 10, 2017 is denied. Entitlement to an increased disability rating in excess of 70 percent for PTSD from May 10, 2017 is denied. ____________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs