Citation Nr: 18142475 Decision Date: 10/15/18 Archive Date: 10/15/18 DOCKET NO. 14-31 690 DATE: October 15, 2018 ORDER Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder is denied. REMANDED Entitlement to a total disability rating based on individual unemployability prior to July 25, 2018 is remanded. FINDING OF FACT For the entire appeal period, the Veteran’s PTSD more nearly approximated occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. CONCLUSION OF LAW The criteria for an initial rating in excess of 30 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.16, 4.125-4.129, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Army from May 1958 to April 1961, from October 1961 to August 1962, and from September 1963 to August 1966. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2013 rating decision issued by the Department of Veterans Affairs (VA). In September 2016 and September 2017 decisions, the Board remanded the appeal for further development. In an August 2018 rating decision, the Regional Office (RO) awarded entitlement to a total disability rating based on individual unemployability (TDIU) effective July 25, 2018. As this is less than the maximum benefit allowed under VA law and regulation, a claim of entitlement to a TDIU prior to July 25, 2018 remains on appeal. AB v. Brown, 6 Vet. App. 35 (1993). The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Increased Rating Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder The Veteran seeks an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). The appeal period before the Board begins on February 8, 2012, the effective date of service connection. For the reasons that follow, the Board finds that an increased evaluation is not warranted. The Veteran’s PTSD has been evaluated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. Under the General Rating Formula, a 30 percent rating is warranted when 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; and mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more often 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. Id. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation, obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The rating of psychiatric disorders is ultimately based upon their resultant level of occupational and social impairment. 38 C.F.R. § 4.130; Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117-18 (2013). The evaluation, however, is symptom-driven, meaning that the symptomatology should be the fact-finder’s primary focus in determining the level of occupational and social impairment. Vazquez-Claudio, 713 F.3d at 116-17. This includes consideration of the frequency, severity, and duration of those symptoms. 38 C.F.R. § 4.126(a); Vazquez-Claudio, 713 F.3d at 117. Significantly, however, the symptoms enumerated in the rating criteria are merely examples of those that would produce such level of impairment; they are not exhaustive, and VA is not required to find the presence of all, most, or even some of the enumerated symptoms to assign a particular evaluation. Vazquez-Claudio, 713 F.3d at 115; Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). If the Board finds that the Veteran suffers from symptoms of similar severity, frequency, and duration that cause occupational and social impairment equivalent to that which would be produced by the specific symptoms enumerated in the rating criteria, then the appropriate equivalent rating will be assigned. 38 C.F.R. 4.21; Mauerhan, 16 Vet. App. at 443; see also Vazquez-Claudio, 713 F.3d at 117. VA intends the General Rating Formula to provide a regulatory framework for placing veterans on a disability spectrum based on their objectively observable symptoms. Vazquez-Claudio, 713 F.3d at 117 (emphasis added). Accordingly, in evaluating the Veteran’s disability the Board will place great probative value on the Veteran’s observable symptoms as demonstrated in clinical treatment notes and mental status evaluation. As the claim on appeal was pending before the Agency of Original Jurisdiction (AOJ) on or after August 4, 2014, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013) (DSM-5) is for application. 79 Fed. Reg. 45093, 45094 (Aug. 4, 2014). Consequently, Global Assessment of Functioning (GAF) scores may not be considered. Golden v. Shulkin, 29 Vet. App. 221 (2018). A. Factual Background In March 2012, the Veteran began private treatment with Dr. H.J. He reported he was currently widowed and held a 10th grade education. After discharge from service, he held jobs in factories or construction. His most recent job was as a trucker; however, he quit in 1985 due to back pain and applied and was awarded Social Security Disability Income (SSDI). He reported that he has not worked since then. Regarding social functioning, he reported he does not having many friends, only associations. He reported that he has lost interest in activities that he used to enjoy and feels distant and cut off from other people. Regarding symptomology, the Veteran reported having repeated disturbing memory and thoughts about his service in Vietnam; he reported he gets those quite a bit. He also reported frequently experiencing dreams about the same thoughts. He reported he tries to avoid thinking about Vietnam and tries to avoid activities that remind him of it. He reported he feels emotionally numb and that his future will be shortened. He reported trouble staying asleep and experiencing insomnia. He reported irritable and angry outbursts, difficulty concentrating, feeling guarded, and being startled easily. He reported he is sad sometimes, does not expect things to work out, feels like a failure, feels guilty over things he has done, feels that he has been punished, and has lost interest in pleasure. He reported that he is very restless and cries more than he used to because he lost interest in people more relative to his past. He reported feeling indecisive and worthless. He reported feeling less energy. He reported feeling tired and fatigued easily. On mental status examination, the examiner noted the Veteran was dressed casually. He was able to relate well. He seemed to be a reliable historian. He denied hallucinations, and homicidal and suicidal ideation. He had a constricted affect and was anxious. His thought process included some word searching but was otherwise within normal limits. He also demonstrated some concentration and focusing issues. The examiner diagnosed PTSD and depressive disorder, NOS. A GAF score of 45 was assigned. Medication was prescribed. The Veteran saw Dr. H.J. again in May 2012. He reported the medication was causing him stomach problems and not aiding with sleep much. He reported that he does not feel relaxed so he cannot go to sleep. He reported continuing nightmares and flashbacks. He reported feeling very anxious and restless, especially at night. He denied hallucinations and homicidal or suicidal ideation. The Veteran saw Dr. H.J. in August 2012. He reported that he was worried about his (non-psychiatric) health as had been having a number of issues lately. He reported that he continues to avoid anything that reminds him of traumatic events in his past, like watching war movies or the evening news. He reported that he stays at home, he does not like to go out and mix with crowds. He felt that his prescribed medications had provided some benefit. The Veteran saw Dr. H.J. in November 2012. He reported feeling very guarded and watching his surroundings all the time; he noted he had felt this way since Vietnam. He continued to have a constricted affect, flashbacks, and nightmares. He reported avoiding situations which remind him of traumatic events or service, like war movies or talking about wars. He reported that he does not socialize much. He stays home most of the time. He reported getting annoyed easily by other people, situations, or crowds and that he felt much more peaceful at home. The Veteran underwent a VA examination in December 2012. The examiner diagnosed PTSD and opined that it manifested in occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care, and conversation. Regarding social history, the Veteran reported he was living alone and widowed. His wife passed away a few years ago, though he noted they had been separated since 1976. He reported he had two daughters. He also had a third, but she was killed by a drunk driver in 1989. Regarding occupational history, he reported being popular in high school but leaving in the 10th grade. After military service, he worked as a truck driver until 1985 when he hurt his back loading his truck. Since then he had received SSDI and has not worked. Regarding symptomology, the examiner noted anxiety, suspiciousness, chronic sleep impairment, and disturbances in motivation and mood. The section of the examination report concerning PTSD criterion also provided additional symptoms: recurrent and distressing recollections, recurrent distressing dreams, acting or feeling as if the event were recurring, intense psychological distress and reactivity at exposure to cues that symbolize or resemble an aspect of the event, efforts to avoid thoughts, feelings, or conversations associated with the trauma; efforts to avoid activities, places, or people that arouse recollections of the trauma; markedly diminished interest or participation in significant activities, feeling of detachment or estrangement from others, restricted range of affect, difficulty falling or staying asleep, irritability or outbursts of anger, hypervigilance, and exaggerated startle response. The examiner also noted that on examination he evidenced irritable and guarded presentation, gave poor reports to his history, and was able to give concrete examples of his symptoms. The Veteran began psychiatric treatment with VA in April 2013. He reported that he had seen a non-VA psychologist, and his prescribed medications helped him calm down and fall asleep. Her reported that he felt well and there was nothing in particular bothering him. When asked how he looked on a bad day, he reported he was said about his parents passing, his friend’s passing in Germany, two friends dying in Vietnam, and his youngest daughter being killed by a drunk driver. He began crying and reported that he cries and gets mad every time he thinks about it. He reported the visions of Vietnam have stayed in his head. He reported they do not keep him from doing anything. He reported he gets one flashback per month. He has nightmares that occur intermittently, ranging from once every other week to not for three or four months. He reported he lives in senior housing. He still socializes, and has close contact with his living daughters. He reported he is lucky to get a good four to five hours of sleep a night, and may take a nap while watching TV during the daytime. On mental status examination, he appearance was clean and dress appropriate. He made fair eye contact. He was not in apparent pain and had no problem sitting. He had non-antalgic gait. Psychomotor activity was normal. Speech was at a normal rate, rhythm, volume, and prosody. He related that his mood was fine. His affect was reactive; he cried when speaking of his daughter dying. Thought process was linear and goal directed, and thought content was without delusions, obsessions, or overvalued ideas. There were no hallucinations or homicidal or suicidal ideation. Cognition was grossly intact, though not formally tested. Judgement and insight were good. The examiner provided a diagnosis of depression, NOS, and prolonged bereavement. The Veteran was adjudged to be stable on current medications. It was noted his symptoms relating to PTSD were not as prominent as the deaths of his mother, father, and daughter. A GAF score of 65 was assigned. The Veteran saw Dr. H.J. in June 2013. He reported that he has been about the same. He has been getting easily frustrated. He reported having flashbacks and nightmares every time he was exposed to a trigger. He reported being worried about a lot of things lately, especially finances. He reported that he has not been going many places, staying in his house, and that he did not have much energy or desire to go and engage with people or activities. The examiner noted a constricted affect and that he appeared slightly disheveled but the Veteran denied hallucinations of homicidal or suicidal ideation. A July 2013 VA treatment record showed the Veteran reported an occasional flashback and added that it is just something he deals with. He reported his medications keep him smooth and he wants to continue with them. He reported getting three to four-and-a-half hours of sleep per night and sometimes sleeping during the daytime for approximately one hour. He reported that he loves to bowl and has 29 “300” games to his credit. He reported that one of his goals is to join the senior tour. On mental status examination, appearance was clear and eye contact was good. Psychomotor activity was normal. Speech was of normal rate, rhythm, and prosody. Mood was sometimes mellow, sometimes, not. Affect was reactive. Thought process was linear and goal directed, and thought content was with no delusions, obsession, or overvalued ideas. There were no hallucinations or homicidal or suicidal ideation. Cognition was grossly intact. He was oriented in all four spheres. And insight and judgment were good. The examiner remarked that the Veteran’s PTSD remains minimal, and he has lived with these issues which have minimal interference. A May 2014 VA treatment record shows the Veteran reported he was doing well. He reported another “300” bowling game in March and stated that is what keeps him going. He reported a stable appetite and good and bad nights sleeping. He noted that on bad nights he has thoughts of war and flashbacks; he was unable to quantify their frequency. He reported he has support from his daughter who lives nearby and his bowling friends from multiple leagues. On mental status examination, it was noted he dressed in jeans, a t-shirt, and a baseball cap. He had fair eye contact and normal psychomotor activity. His speech was of normal rate, rhythm, and prosody. His mood was that he has good and bad days. His affect was reactive. Thought process was linear and goal directed and thought content was without delusions, obsession, or overvalued ideas. He reported no hallucinations or homicidal or suicidal ideation. Cognition was grossly intact. Insight was good. Judgment was intact. A November 2014 VA treatment record shows the Veteran reported bowling in three different leagues, but this was a reduction in activity due to back and knee pain. He reported his mood had been stable. He said he works on not letting things get to him. He reported he has good and bad nights of sleep and nightmares are less frequent, occurring only four to five times per month. He said he made a connection between consuming alcohol and increased frequency of nightmares. He reported he drinks alcohol about once every three to four months. He reported he remains physically active and social. On mental status examination, he appeared dressed in casual clothes, made good eye contact, and was friendly. He showed normal psychomotor activity. His speech was of normal rate, rhythm, and prosody. Mood was euthymic. Affect was reactive. Thought process was linear and goal directed. Thought content was without delusions, obsessions, or overvalued ideas. There were no hallucinations of any kind or homicidal or suicidal ideation. Cognition was grossly intact. He was oriented in all four spheres. Judgment was intact. A November 2015 VA treatment record shows the Veteran reported feeling so-so. He reported sleeping up to four hours per night, and that he will doze off during the daytime. He reported nightmares once every two months and flashbacks two to three times per week. He reported feeling depressed at times. He reported he is hypervigilant, constantly looking around in public. He reported being startled by loud noise. He reported mood swings, and being irritable and angry. He reported that he feels someone is in his place when there is no one, and that he hears voices at times. He denied suicidal or homicidal ideation. He reported that he goes bowling and visits his daughter, and he thinks about his daughter and grandchildren. On mental status examination, he appeared casually dressed. He was cooperative and had normal psychomotor activity. He was alert and oriented in all spheres. His mood was withdrawn. His affect was congruent with mood, non-labile, appropriate. His speech was normal. Memory was grossly intact. Concentration, insight, and judgment were good. Thought process was coherent, linear, and goal directed. Thought content was without obsession, psychotic symptoms, hallucinations, or suicidal or homicidal ideation. A February 2016 VA treatment record showed the Veteran reported he feels so-so. He reported sleep is erratic, with three to five hours per night. He reported nightmares now and then; he had two nightmares in the last month. He reported flashbacks five to six times per month. He reported feeling depressed, and that he thinks about his friends he lost in Vietnam. He reported he is startled by noise. He reported he stays to himself. He denied suicidal and homicidal ideation. On mental status examination, he appeared casually dressed. He was cooperative. He had normal psychomotor activity. He was alert and oriented in all spheres. Mood was withdrawn. Affect was congruent with mood, non-labile, appropriate. His speech was normal and memory was grossly intact. Concentration, insight, and judgment were good. Thought process was coherent, linear, and goal directed. Thought content was without obsession, psychotic symptoms, hallucinations, or suicidal or homicidal ideation. A March 2016 VA treatment record showed the Veteran reported feeling pretty good. He reported getting four to five hours of sleep per night, with combat-related nightmares every now and then. He reported flashbacks every now and then, and that he feels down sometimes. He denied mood swings. He reported he tries to keep himself calm and not let things both him. He denied hallucinations or suicidal or homicidal ideation. He reported he is not anxious, and his medication are working ok. He reported he goes fishing and keeps himself busy around his house. On mental status examination, he appeared casually dressed. He was cooperative. He had normal psychomotor activity. He was alert and oriented in all spheres. His mood was euthymic. Affect was congruent with mood, non-labile, appropriate. Speech was normal and memory was grossly intact. Concentration, insight, and judgment were good. Thought process was coherent, linear, and goal directed. Thought content had no obsession, psychotic symptoms, hallucinations, or suicidal or homicidal ideation. A June 2016 VA treatment record showed the Veteran reported he is doing so-so. He reported sleeping up to five hours per night, and that he has had two nightmares in the last month and three to four flashbacks in the last couple months. He reported feeling depressed now and then, and that he tries to keep himself in good spirits. He reported he gets angry at times and talks himself to calm down. He reported that he feels like he hears things at times, no visual hallucinations, no homicidal or suicidal ideation. He reported that he felt his medications were helping him. He reported that he goes fishing and bowling. A September 2106 VA treatment record showed that he reported doing pretty good. He reported sleeping four and a half hours per night. He reported nightmares every now and then, and flashbacks every two to three weeks triggered by any conversation about Vietnam. He reported that he walks away from those conversations because it brings back too many bad memories. He reported that he feels depressed every now and then and tries to pull himself out of it. He reported he tries to be positive all the time but gets angry at times. He denied hallucinations or homicidal or suicidal ideation. A December 2016 VA treatment record showed the Veteran reported doing pretty well. He reported sleeping up to 6 hours per night. He reported no nightmares and flashbacks only now and then. He reported feeling depressed. He reported he does not want to be bothered and wants to be by himself. He reported hearing noises and gunshots, no visual hallucinations. He denied suicidal and homicidal ideation. He reported mood swings. He reported he gets angry quicker and is irritable. He reported that his medications are helping. He reported that he lives by himself and his daughter checks in on him. On mental status examination, he appeared casually dressed. He was cooperative. He displayed normal psychomotor activity. He was alert and oriented in all spheres. His mood was withdrawn. His affect was congruent with mood, non-labile, and appropriate. He speech was normal and memory was grossly intact. Concentration, insight, and judgment were good. Thought process was coherent, linear, and goal directed. Thought content had no obsession, psychotic symptoms, hallucinations, or suicidal or homicidal ideation. The Veteran underwent a VA examination in February 2017. The examiner noted a prior diagnosis PTSD and opined it manifests in occupational and social impairment due to mild or transient symptoms that decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The examiner wrote the Veteran’s mental health symptoms result in mild impairment of daily functioning; although, it appears he generally functions quite well and has some meaningful interpersonal relationships. For example, the Veteran described strong relationships with his children and siblings, ongoing daily social contact with a group of close friends, and engagement in enjoyed activities (e.g., bowling, fishing, and socializing). That said, his symptoms do impact his daily life in that he has ongoing hypervigilance when out in public and significant re-experiencing symptoms triggered by reminders of his time in Vietnam. Regarding work, it was noted the Veteran was able to effectively work until a back injury in the mid-1980s. The Veteran opined that he would still be able to work presently were it not for that injury. Nonetheless, the examiner noted that the Veteran would likely experience some difficulty if required to engage in work in a highly stressful environment, one that include cues related to his military service, or one which involved managing interpersonal conflict. The Veteran denied any difficulty engaging in his daily activities, which included self-care, significant physical therapy for his knee, substantial leisure activities in public locations (e.g., bowling alley), and prolonged interpersonal interactions with friends and acquaintances. The examiner noted the Veteran’s recent medical records are consistent with this description, and he is largely functional with the aid of medication, though he does have some notable ongoing symptoms. The Veteran specifically described his social functioning. He reported he sees one sister living in Raleigh, North Carolina, twice a month but they talk over the phone more frequently. He speaks with another sister living in New York on a monthly basis. He speaks with a brother living in California once every two months. He described all those relationships as very good and real close. He also reported good relationships with his two living daughters. He reported one lives nearby and he sees her twice a week and speaks on the phone with her two to three times per week. He reported another daughter in Houston, Texas. He noted that he had not seen her in several years but they talk on the phone three to four times per month. He also reported that he has several bowling buddies that he sees daily to socialize and go bowling together. Regarding his interpersonal relationships, he reported that everybody knows him and he gets along with everybody. The Veteran described his typical day. He reported waking up around 5:30 or 6:00am. Taking a shower, making breakfast, and doing chores and watching TV until around noon. Then he will leave and go to a friends’ house to talk, although sometimes they will go to a sweepstakes place. He will socialize until 3:30 or 4:00pm and then return home or dinner. After dinner he will go to the bowling alley to bowl and socialize with friends. He will get home between 9:30 and 10:00pm and watch TV, falling asleep between 11:30pm and 12:00am. He reported that sometimes he will fall asleep immediately and sometimes it will take fifteen to twenty minutes. He reported that he typically only wakes to use the restroom, which occurs one to five times per night. Regarding symptomology, the examination report noted anxiety and suspiciousness. Additional symptoms noted in the PTSD criterion section were recurrent and distressing recollections, recurrent distressing dreams, intense psychological distress and reactivity at exposure to cues that symbolize or resemble an aspect of the event, efforts to avoid thoughts, feelings, or conversations associated with the trauma; efforts to avoid activities, places, or people that arouse recollections of the trauma; persistent and exaggerated negative beliefs or expectations about oneself, others, or the world; persistent negative emotional state, hypervigilance, and exaggerated startle response. On mental status examination, the Veteran was noted to be open, cooperative, and a reliable informant. He presented with good hygiene and grooming. He was dressed casually in jeans and light jacket. He walked unassisted with a slight limp and gross motor function within normal limits. His speech was normal. He was alert, attentive, and oriented in all four spheres. His memory was intact. Abstract reasoning was present. Thought process was logical and organized. There was no evidence of delusional thought content or perceptual disturbances. He characterized his current mood as alright, and he presented with a normal range of affect. When asked about his general mood over the past month, he reported that he tries to stay up-spirited and noted that he is generally successful. He denied recent suicidal ideation. He reported that his most significant mental health problem is nightmares. He reported that on a day-to-day basis, his mental health symptoms do not really affect him in a bad way but they do make his nerves on edge. A March 2017 VA treatment record shows the Veteran reported getting four to six hours of sleep per night. He denied nightmares and depression but reported some flashbacks. He reported that he tries to keep himself uplifted but he has mood swings every now and then. He denied hallucinations and homicidal or suicidal ideation. On mental status examination, he appeared casually dressed and was cooperative. He displayed normal psychomotor activity. He was alert and oriented in all spheres. His mood was withdrawn. His affect was congruent with mood, non-labile, appropriate. Speech was normal and memory was grossly intact. Concentration, insight, and judgment were good. Thought process was coherent, linear, and goal directed. Thought content had no obsession, psychotic symptoms, hallucinations, or suicidal or homicidal ideation. A May 2017 VA treatment record shows the Veteran reported getting two hours of sleep per night and nightmares four times per week. He reported flashbacks four to five times per week. He denied depression or mood swings. He reported getting irritable at times. He reported hearing gun fires and having vision of being in Vietnam. On mental status examination, he appeared casually dressed. He was cooperative and with normal psychomotor activity. He was alert and oriented in all spheres. Mood was withdrawn. Affect was congruent with mood, non-labile, appropriate. Speech was normal and memory was grossly intact. Concentration, insight, and judgment were good. Thought content had no obsession, psychotic symptoms, or suicidal or homicidal ideation. Audio and visual hallucinations were noted. A July 2017 VA treatment record showed the Veteran reported sleeping four to five hours per night. He reported nightmares and flashbacks every now and then. He reported he tries to keep his mind off it and tries to keep himself in good spirits. He denied mood swings. He denied anger or irritability. He reported that he hears noises now and then and looks around and there is nothing. On mental status examination, he appeared casually dressed and was cooperative. There was normal psychomotor activity. He was alert and oriented in all spheres. His mood was withdrawn. His affect was congruent with mood, non-labile, appropriate. Speech was normal and memory was grossly intact. Concentration, insight, and judgment were good. Thought process was coherent, linear, and goal directed. Thought content showed no obsession, psychotic symptoms, hallucinations, or suicidal or homicidal ideation. The Veteran underwent a VA examination in October 2017. The examiner diagnosed PTSD and unspecified adjustment disorder secondary to knee surgery. He opined the disorders, considered together, cause occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress and his symptoms are controlled by medication. The examiner indicated that the symptoms of the disorders could be separated. PTSD manifested in nightmares, flashbacks, guilt, hypervigilance, startle response, avoidance behaviors, anxiety, and suspiciousness. Unspecified adjustment disorder manifested in irritability, somatic complaints (e.g., fatigue), and isolation. The examiner also indicated the occupational and social impairment caused by each disorder could be separated but then simply reiterated how the symptoms are different. It was again clarified that, regardless of the additional diagnosis, the Veteran’s overall occupational and social functioning was at the mild or transient level. Regarding social impairment, the examiner wrote the Veteran enjoys good relationships with his daughters, grandchildren, and living siblings. He has friends with whom he bowls; however, his activities have been limited as of last due to poor recovery from knee surgery. The Veteran’s irritability and complaint of somatic symptoms increased since the knee surgery. Regarding occupational impairment, the examiner wrote that the veteran was retired since 1985 after suffering a back injury. He denied sleep or concentration problems that would interfere with his ability to complete tasks in an efficient manner. Regarding social impairment, the Veteran reported that there were no recent changes in his social life, which is quiet. Occasionally he goes to his friends’ homes for dinner or a small party. His hobby is bowling but his participation has been limited due to recovery from knee surgery. He stated that he is easy to get along with. The Veteran described his symptoms. He reported nightmares, which generally occur whenever he talks to people about Vietnam. He noted he typically walks away from those conversations, and it has been a while since he did so. He reported flashbacks every now and then, with the last one occurring one and a half months ago. He noted it was triggered after he turned on the TV and there was a war show on. He reported occasional intrusive thoughts, particularly when he encounters people who want to talk about Vietnam. He reported an associated physiological response, described as being shaky on the inside. He reported feeling connected and close to family and friends but not feeling like dealing with others since his knee surgery. He reported hypervigilance and startle response. He denied sleep problems, noting that he gets four to seven hours of sleep per night. He also noted that he did not have fatigue prior to the knee surgery. He reported depressed mood occurring once or twice per years. He denied anhedonia. He reported heeling more anxious than nervous, depending on the situation. He denied panic attacks. Regarding self-esteem, he reported that he did not want to sound conceited but he felt really good about himself. Symptoms identified by the examiner were anxiety and suspiciousness, in addition to those found in the PTSD criterion section, which were similar to those noted on the February 2017 VA examination report. The examiner’s behavioral observations showed the Veteran was open and cooperative. He put forth good effort and was deemed a reliable informant. He presented with good hygiene and grooming, and was casually dressed. He walked unassisted and gross motor function was within normal limits. His speech was normal and memory intact. He was alert, attentive, and oriented in all four spheres. His thought processes were logical and organized. There was no evidence of delusions or hallucinations. He described his current mood as good. Affect was euthymic. He described his mood over the prior month as jovial and happy-go-lucky. An October 2017 VA treatment record showed the Veteran reported his sleep as so-so. He reported sleeping about four to seven hours per night, and that he has weird dreams. He reported flashbacks every now and then. He denied depression. He reported that he tries to control his temper. He gets irritable and angry. He denied hallucinations and homicidal or suicidal ideation. He reported he continues to live by himself and his daughter checks on him. He reported he goes bowling and visits family. On mental status examination, he appeared casually dressed. He was cooperative and displayed normal psychomotor activity. He was alert and oriented in all spheres. Mood was withdrawn. Affect was congruent with mood, non-labile, and appropriate. Speech was normal and memory was grossly intact. Concentration, insight, and judgment were good. Thought process was coherent, linear, and goal directed. Thought content showed no obsession, psychotic symptoms, hallucinations, or suicidal or homicidal ideation. The Veteran sought VA treatment for an unrelated disability in November 2017. He reported that he lives alone and is a widower. He reported that he has a daughter that lives in Wake Forest, North Carolina, and a sister, nephew, and niece that live in Raleigh, North Carolina. He reported that he generally goes bowling twice a week and has bowled a “300” game 37 times. He reported no other form of structured exercise. B. Analysis Based on consideration of all evidence of record, the Board finds that an initial rating in excess of 30 percent for PTSD is not warranted. With regard to the enumerated symptomology under DC 9411, the preponderance of the evidence does not support the criteria for a 50 percent rating. The evidence is not consistent with flattened affect. Generally, mental status examinations from the 2012-2013 period showed constricted or restricted range of affect. As the appeal period continued, the range of affect displayed during mental status examinations increased to reactive or congruent with mood. Thus, the range of affect tended to increase from constricted to normal throughout the appeal period. At no time was affect indicated to be flat. There is no doubt to be resolved in this regard. The evidence does not show the Veteran’s PTSD was productive of circumstantial, circumlocutory, or stereotyped speech. Every mental status examination conducted during the appeal period found that speech was normal. There is no indication from either the Veteran’s statements or his medical records that this symptom was present at any time during the appeal period. The evidence does not show panic attacks more than once a week. There is no evidence of record indicating the Veteran has a history of panic attacks. Panic is not defined in the rating schedule but is generally defined as “acute, extreme anxiety with disorganization of personality and function.” Dorland’s Illustrated Medical Dictionary 1220 (28th ed. 1994). The evidence does not show impaired judgment. Every mental status examination conducted during the appeal period found that the Veteran’s judgment intact or good. There is no indication from either the Veteran’s statements or his medical records that it was otherwise impaired at any time during the appeal period. The evidence does not show difficulty in understanding complex commands. It is noted that every mental status examination conducted during the appeal period found that the Veteran’s cognition was grossly intact. There was one March 2012 private treatment record that indicated difficulty concentrating and focusing, but, otherwise, concentration and insight were both characterized as good, as well. There is no indication from either the Veteran’s statements or his medical records that the ability to understand complex commands was impaired at any time during the appeal period. The evidence was not consistent with impairment of both short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks). Every mental status examination conducted during the appeal period found the Veteran’s memory grossly intact. There is no indication from either the Veteran’s statements or his medical records that it was otherwise impaired at any time during the appeal period. The evidence is not consistent with impaired judgment or impaired abstract thinking. On every mental status examination conducted during the appeal period, judgment was characterized as good or intact. Abstract reasoning was noted to be present in the February and October 2017 VA examination reports; there is no indication from either the Veteran’s statements or his medical records that it was otherwise impaired at any time during the appeal period. The evidence shows there was occasional disturbance of motivation and mood during the appeal period. The Board notes that the General Rating Formula includes depressed mood as a symptom consistent with a 30 percent rating; thus, disturbance of motivation and mood is deemed to be of greater severity. The symptom of disturbance of motivation and mood was identified on the December 2012 VA examination report but absent from the February 2017 and October 2017 VA examination reports. Secondary evidence of this symptom was found in the 2012-2013 private treatment records from Dr. H.J. where the Veteran reported having low energy and a disinterest in engaging in activities that he normally enjoyed. See, e.g., private treatment record (06/04/2013). Secondary evidence was also intermittently found in VA treatment records. E.g., VA treatment records (02/02/2016) (reported he stays to himself) and (12/13/2016) (reported he felt depressed and wanted to be by himself). The evidence from the 2012-2013 period shows he may have had difficulty establishing and maintaining effective work and social relationships. Private treatment records from this period show he reported to not having many friends, not wanting to leave his house, and not socialize with others. Mitigating this secondary evidence, however, is that he maintained effective relationships with his siblings and children, to include socializing in-person with those who lived nearby. The Board notes the Veteran made similar statements regarding isolation during VA treatment in February and December 2016; however, not only did he maintain familial relations during those periods, he also continued to participate in his bowling league(s). The Board notes that no VA examination identified the Veteran as having difficulty establishing and maintaining effective work and social relationships. Given the forgoing, the Board finds the symptom was present intermittently, with greater frequency during the beginning of the appeal period, and its impact was mild given the apparent familial and, later on, social bowling relationships he maintained and/or cultivated. Regarding the enumerated symptomology corresponding to a higher 70 percent rating, the evidence was not consistent with 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; spatial disorientation, difficulty adapting to stressful circumstances (including work or a work-like environment), or inability to establish and maintain effective relationships. There is evidence of impaired impulse control. No VA examination identified the presence of this symptom. There was secondary evidence of it in that the Veteran occasionally reported irritability or outbursts of anger. This was intermittent, and he noted that he tried to keep it in check. There was no associated violence. Accordingly, the Board finds it to be of limited frequency and severity. Regarding neglect of personal appearance or hygiene, a June 2013 private treatment record described the Veteran as disheveled. Otherwise, all other evidence of record indicated his appearance and hygiene to be normal, and the symptom was not noted on any VA examinations. Accordingly, the Board finds that PTSD did not result in neglect of personal appearance or hygiene. Regarding the enumerated symptomology corresponding to a higher 100 percent rating, the evidence was not consistent with gross impairment in thought processes or communication, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. There was no evidence of delusions. There were three notations indicative of possible hallucinations. A November 2015 VA treatment record showed the Veteran reported hearing voices but, when read as a whole, this was attributed to his flashbacks and hallucinations were not found. A May 2017 VA treatment record showed the Veteran described hearing gun fire and having visions of being in Vietnam. The mental status examination for that record marked positive for audio and visual hallucinations. A July 2017 VA treatment record showed the Veteran reported hearing noises now and then and looking around and seeing nothing. That record indicated the Veteran does not experience hallucinations. When the assessment provided by the examiner is read as a whole with the remainder of the treatment record, the Veteran’s subjective reports were attributed to his known flashbacks. The Board notes that during the October 2017 VA examination the Veteran described his flashbacks as he had in the prior two VA treatment records; his statements were not interpreted as hallucinations. Every other mental status examination of record showed no hallucinations. Given the forgoing, the Board finds the Veteran did not have hallucinations at any point during the appeal period. The notations of such in the May 2017 VA treatment record are inconsistent with the remaining evidence of record, the severity of his condition, and simply align with his own characterization of flashbacks, which were a regular occurrence. The Board acknowledges the evidence shows the Veteran’s PTSD manifested in additional symptomology, such as nightmares, flashbacks, depressed mood, anxiety, suspiciousness, chronic sleep impairment, hypervigilance, exaggerated startle response, etc. These symptoms align with the enumerated symptomology corresponding to a 30 percent rating under DC 9411. They do not support the claim for a higher rating. In sum, the Veteran’s PTSD manifests in symptomology that is generally consistent with a 30 percent rating. There is evidence of disturbance of motivation and mood, difficulty establishing and maintaining effective work and social relationships, and impaired impulse control, symptoms that correspond to ratings in excess of 30 percent; however, the intermittent nature and relatively mild severity of these symptoms leads the Board to conclude that they do not result in the Veteran’s PTSD more nearly approximating the criteria corresponding to a rating in excess of 30 percent. The Board has also considered the occupational and social impairment produced by the Veteran’s symptomology. The February 2012 VA examiner described it as 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 normal conversation. The February and October 2017 VA examiners described the level of occupational and social impairment as mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. It was also noted that, for the most part, his symptoms are controlled by medication. The February 2017 VA examiner opined that, as it relates directly to work, the Veteran would likely experience some difficulty if required to engage in work in a highly stressful environment, one that included cues related to his military service, or which involved managing interpersonal conflict. During the October 2017 VA examination, the veteran denied that sleep or concentration problems would interfere with his ability to complete tasks in an efficient manner. The Veteran’s medical records have also described his functional status. In April 2013, he reported to a VA clinician that his visions of Vietnam do not keep him from doing anything and that he still socializes. In a July 2013 VA treatment record, the examiner described the Veteran’s PTSD as being minimal and the Veteran dealing with these issues that have minimal interference. On more than one occasion, the Veteran related to an examining physician that he believed he would still be working today were it not for the prior back injury. Given the forgoing, the Board cannot conclude that the Veteran’s occupational and social impairment more nearly approximated that corresponding to a higher 50 percent rating under DC 9411 at any point during the appeal period. The Board recognizes the Veteran’s assertion in the May 2013 notice of disagreement that a higher rating should be warranted based on a GAF score of 45 assigned during initial treatment by Dr. H.J. The Board declines to do so merely on this basis as the DSM-5 no longer includes consideration of GAF scores because of their lack of clarity and questionable psychometrics in routine practice. Nonetheless, the symptomology and related occupational and social impairment described in those private treatment records was considered in this evaluation. In sum, neither the Veteran’s symptomology nor occupational and social impairment have more nearly approximated the criteria corresponding to a higher 50 percent rating under DC 9411 at any point during the appeal period. Incidentally, the assignment of a staged rating is not warranted. There is no doubt to be resolved; an initial rating in excess of 30 percent for PTSD is not warranted. The associated issue of entitlement to a TDIU will be discussed in the REASONS FOR REMAND section below. There are no additional issues expressly or reasonably raised on the record related to this claim. REASONS FOR REMAND 1. Entitlement to a total disability rating based on individual unemployability prior to July 25, 2018 is remanded. The Veteran seeks entitlement to a TDIU prior to July 25, 2018. For the reasons that follow, the Board finds that remand is required for referral to the Director Compensation Service for extraschedular consideration of a TDIU. Total disability ratings for compensation may be assigned when a veteran is unable to secure and follow a substantially gainful occupation. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is “whether the veteran’s service connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993); see Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (the ultimate question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment). Consideration may be given to the veteran’s level of education, special training, and previous work experience when arriving at this conclusion; factors such as age or impairment caused by non-service connected disabilities are not to be considered. 38 C.F.R. §§ 3.341, 4.16, 4.19. The Board may grant a TDIU to a veteran who meets certain disability percentage thresholds set forth in § 4.16(a) and is unable to secure and maintain substantially gainful employment. If a veteran fails to meet the disability percentage standards, then the Board cannot grant a TDIU in the first instance. If warranted, the Board may instead refer the claim to the Director, Compensation Service, for extraschedular consideration. 38 C.F.R. § 4.16(b). Upon review of the Veteran’s compensation history, he does not meet the rating threshold set forth in § 4.16(a) prior to July 25, 2018. Thus, the entire appeal period under consideration must be addressed on an extraschedular basis. Prior to August 18, 2015, the Veteran was only service-connected for PTSD (rated 30 percent disabling). From August 18, 2015 onward, he was also service-connected for a lumbar spine disability (rated 10 percent disabling from August 18, 2005; and 20 percent from July 25, 2018), right wrist disability (rated 10 percent disabling), right knee disability (rated 10 percent disabling), tinnitus (rated 10 percent disabling), right lower extremity radiculopathy (rated 10 percent disabling), left lower extremity radiculopathy (rated 10 percent disabling), and bilateral hearing loss (rated 10 percent disabling). The Veteran’s combined rating is 30 percent from February 28, 2012; 60 percent from August 18, 2015; and 70 percent from July 25, 2018. Effective July 25, 2018, the Veteran was awarded a TDIU. Given the effective dates of service connection for the above disabilities, the Board will proceed to evaluate the Veteran’s functional status as separated into two distinct periods: prior to August 18, 2015, and from that date to July 25, 2018. The Veteran did not complete high school. He stopped attending in the 10th grade and did not complete a General Education Development (GED) degree. He has no other specialized training or experience. His work history consisted of working in factories, construction, and as a truck driver. He last worked in 1985 after injuring his back. He applied and was awarded SSDI as a result of that injury; however, VA requested those records from the Social Security Administration and no medical records were available. Prior to August 18, 2015, the Veteran was only service-connected for PTSD. The February 2012 VA examiner opined the disorder would cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. There were no problems with understanding complex commands, judgment, or thinking, and relatively mild problems with motivation and mood and establishing and maintaining effective work and social relationships. The disease did manifest in daytime fatigue, but there was no indication it would preclude employment. Later in this portion of the appeal period, a VA examiner described the Veteran’s PTSD as minimal and causing minimal interference. Moreover, the Veteran’s occupational history consisted of physical employment, and there appeared to be no limitations in being able to handle work of a similar type. Based on the evidence of record during this portion of the appeal period, the Board cannot conclude that the Veteran’s service-connected PTSD would have caused an inability to secure or maintain substantially gainful employment consistent with the Veteran’s prior education and work history. From August 18, 2015 onward, the Veteran was service-connected for a number of musculoskeletal and neurological disabilities, to include those affecting the knees, lumbar spine, wrist, and bilateral sciatic nerves in the lower extremities. VA examination reports from July 2016 and October 2017 described the functional impairment caused by these disabilities. The Veteran would have difficulty performing occupational tasks with his right hand due to problems with lifting, pinching, gripping, weakness, and limitation of motion in the wrist. His knees caused gait and imbalance problems, pain, and difficulty with prolonged standing and walking. His back and associated radiculopathy caused difficulty with bending, climbing stairs, rising from a sitting or lying position, and sitting, standing, or walking for prolonged periods of time. Weighing against these functional deficits is the fact that the Veteran participated in multiple bowling leagues and went fishing. However, the Board finds these recreational activities distinguishable from that to be expected in a factory, construction, or trucking workplace based on the duration an employee would be expected to sit or stand or walk. In particular, the recreational activities allow the Veteran to function at a leisurely pace; he may stand or sit as he pleases. The type of work consistent with occupational history, however, required sitting, standing, walking, or other forms of physical activity for prolonged periods of time. This was particularly true of his most recent occupation – truck driver. Entitlement to a TDIU is based on an individual’s particular circumstances. Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). It is an acknowledgement that even though a rating less than 100 percent under the rating schedule may be correct, there are subjective factors that may permit 100 percent rating to a particular veteran under his or her own circumstances. See Parker v. Brown, 7 Vet. App. 116, 118 (1994). The Board finds that this is such a case. While the Veteran’s musculoskeletal and neurological disabilities are not individually rated in excess of 10 percent, when considered together, the Board finds that the evidence reasonably shows the Veteran would likely be unable to secure and maintain substantially gainful employment consistent with his limited educational attainment and occupational history consisting solely of physical or “blue collar” labor. This is because his service-connected disabilities would interfere with the prolonged physical actions required of such occupations. However, the Board is precluded from assigning TDIU on an extraschedular basis in the first instance. Accordingly, remand is required for referral to the Director, Compensation Service, for extraschedular consideration of a TDIU. 38 C.F.R. § 4.16(b). The matter is REMANDED for the following actions: Refer to the Director, Compensation Service, the issue of entitlement to a TDIU prior to July 25, 2018, on an extraschedular basis. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Mike A. Sobiecki, Associate Counsel