Citation Nr: 18144435 Decision Date: 10/25/18 Archive Date: 10/24/18 DOCKET NO. 13-25 264A DATE: October 25, 2018 ORDER Entitlement to a compensable initial evaluation for left knee patellofemoral syndrome with strain, degenerative arthritis, and tendonitis for the period prior to November 15, 2016, and in excess of 10 percent thereafter is denied. Entitlement to a compensable initial evaluation for right knee patellofemoral syndrome with degenerative arthritis, strain and tendonitis for the period prior to November 15, 2016 and in excess of 10 percent thereafter is denied. Entitlement to a compensable initial evaluation for right knee limitation of extension for the period beginning on November 18, 2016 is denied. Entitlement to an initial evaluation of 50 percent for posttraumatic stress disorder (PTSD) from December 4, 2010 to August 8, 2017 is granted. Entitlement to an evaluation in excess of 70 percent for PTSD from August 8, 2017 is denied. FINDINGS OF FACT 1. Prior to November 15, 2016, at its most limited, the Veteran’s left knee had forward flexion ending at 115 degrees, and extension ending at 0 degrees, with no recurrent subluxation or lateral instability. 2. After November 15, 2016, at its most limited, the Veteran’s left knee had forward flexion ending at 120 degrees, and extension ending at 0 degrees, with no recurrent subluxation or lateral instability. 3. Prior to November 15, 2016, at its most limited, the Veteran’s right knee had forward flexion ending at 140 degrees, and extension ending at 0 degrees, with no recurrent subluxation or lateral instability. 4. After November 15, 2016, at its most limited, the Veteran’s right knee had forward flexion ending at 115 degrees, with no recurrent subluxation or lateral instability. 5. For the period beginning on November 18, 2016, the Veteran’s right knee limitation of extension was at worst 5 degrees. 6. From December 4, 2010 to August 8, 2017, the Veteran’s PTSD was productive of no more than occupational and social impairment with reduced reliability and productivity. 7. From August 8, 2017, the Veteran’s PTSD was productive of no more than occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. The criteria for entitlement to a compensable initial evaluation for left knee patellofemoral syndrome for the period prior to November 15, 2016, and in excess of 10 percent thereafter have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DCs 5257, 5260, 5261. 2. The criteria for entitlement to a compensable initial evaluation for right knee patellofemoral syndrome for the period prior to November 15, 2016 and in excess of 10 percent thereafter have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, DCs 5257, 5260, 5261. 3. The criteria for entitlement to a compensable initial evaluation for right knee limitation of extension for the period beginning on November 18, 2016 have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003-5261. 4. The criteria for entitlement to an initial 50 percent evaluation for PTSD from December 4, 2010 to August 8, 2017 have been met. 38 U.S.C. §§ 5103A, 5107, 5110; 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.1-4.7, 4.21, 4.130, Diagnostic Code 9411. 5. The criteria for entitlement to an initial evaluation in excess of 70 percent for PTSD from August 8, 2017 have not been met. 38 U.S.C. §§ 5103A, 5107, 5110; 38 C.F.R. §§ 3.102, 3.321(b)(1), 4.1-4.7, 4.21, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 2000 to December 2010. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in December 2010 by the Department of Veterans Affairs (VA) Regional Office (RO). A Notice of Disagreement was received in September 2011. In July 2013, a Statement of the Case was issued, and, in September of that year, the Veteran filed his substantive appeal (via a VA Form 9). In September 2017, the Board remanded the claims on appeal for additional development and the case now returns for further appellate review. Ratings Disability evaluations are determined by comparing a veteran’s present symptomatology with criteria set forth in the VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is reviewed when making disability evaluations. See generally, 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). In deciding the Veteran’s higher rating claims, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 22 Vet. App. 505 (2007), and whether the Veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. In Fenderson, the Court held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder. In that decision, the Court also discussed the concept of the “staging” of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Id. at 126. Hart appears to extend Fenderson to all increased rating claims. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). The Board notes that the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The Court previously indicated that the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). However, the Court recently suggested that the plain language of 38 C.F.R. § 4.59 indicates that it is potentially applicable to the evaluation of musculoskeletal disabilities involving joint or periarticular pathology that are painful, whether or not evaluated under a diagnostic code predicated on range of motion measurements. See Correia v. McDonald, 28 Vet. App. 158 (2016); Southall-Norman v McDonald, 28 Vet. App. 346 (2016). In Sharp v. Shulkin, 29 Vet. App. 26, 34 (2017), the Court noted that the VA Clinician’s Guide instructs examiners when evaluating certain musculoskeletal conditions to obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from a Veteran. Disabilities of the knee are evaluated pursuant to the Schedule of ratings - musculoskeletal system, under the provisions of 38 C.F.R. § 4.71a, DCs 5256 through 5263. The Veteran’s right and left patellofemoral pain syndrome (hereinafter “knee disability”) are each rated by analogy pursuant to DC 5299-5260. Diagnostic Codes (DCs) 5260 and 5261 provide the rating criteria for limitation of knee motion. 38 C.F.R. § 4.71a. Normal range of motion of the knee is from 0 to 140 degrees. 38 C.F.R. § 4.71a, Plate II. DC 5260 provides that limitation of knee flexion to 60 degrees is rated as noncompensable; limitation of knee flexion to 45 degrees is rated as 10 percent disabling; and limitation of knee flexion to 30 degrees is rated as 20 percent disabling. Ratings above 20 percent are available for greater limitations of flexion. DC 5261 provides that limitation of knee extension to 5 degrees is rated as noncompensable; limitation of knee extension to 10 degrees is rated as 10 percent disabling; and limitation of knee extension to 15 degrees is rated as 20 percent disabling. Ratings above 20 percent are available for greater limitations of extension. In addition to ratings based on limitation of motion, a separate rating may be assigned for knee instability pursuant to DC 5257. VAOPGCPREC 23-97. A 10 percent rating will be awarded for slight instability, a 20 percent rating will be awarded for moderate instability, and a 30 percent rating will be awarded for severe instability. The words “slight,” “moderate,” and “severe” are not defined in the VA Schedule for Rating disabilities; rather than applying a mechanical formula, the Board must evaluate all of the evidence so that its decisions are equitable and just. See 38 C.F.R. § 4.6. Pursuant to DC 5258, a 20 percent rating is available for dislocation of semilunar cartilage. Under DC 5259, a 10 percent rating may be awarded for removal of semilunar cartilage. Additional ratings are available under DC 5256 for ankylosis of the knees, DC 5262 for impairment of the tibia and fibula, and DC 5263 for genu recurvatum. PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. Under the General Rating Formula For Mental Disorders, 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 assigned 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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); and inability to establish and maintain effective relationships. Id. A 100 percent rating is provided where 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); and disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran’s capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. See 38 C.F.R. § 4.126 (a). Furthermore, when evaluating the level of disability arising from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (b). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the “psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness.” Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). According to the American Psychiatric Association’s DSM-IV, GAF scores from 61 to 70 indicate some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning well and has some meaningful interpersonal relationships. GAF scores 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). Left knee prior to November 15, 2016 The Veteran has a noncompensable rating for his left knee disorder from December 4, 2010 to November 15, 2016. The Veteran underwent a VA examination in November 2010, during which the Veteran reported stiffness and pain. Physical examination findings noted that the Veteran’s gait and posture were normal. The left knee showed no signs of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malalignment, drainage, subluxation or guarding of movement. Examination of the left knee revealed crepitus. The examiner noted no genu recurvatum and locking pain and no ankylosis. The range of motion findings noted flexion to 140 degrees and extension to 0 degrees. The joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. The medial/lateral collateral ligaments stability test, the anterior/posterior cruciate ligaments stability test and the medial/lateral meniscus stability test were within normal limits. The examiner diagnosed patellofemoral syndrome. Treatment records from the Hampton VA Medical Center show continuous treatment for complaints of left knee pain, however, there is no objective evidence of painful motion prior to November 15, 2016. A VA treatment record of August 22, 2015 shows active motion of the left knee limited to 115 degrees due to stiffness, however, pain was noted as 0/10. X-rays dated April 18, 2011 show “possible” minimal degenerative changes of the lateral compartment of the left knee, however, follow-up treatment of October 5, 2016 notes that those x-ray results and more recent x-ray results of the left knee were normal with slight calcification of the left tibial tubercle. The VA treatment record of October 5, 2016 revealed full range of motion of the left knee without objective evidence of painful motion. The Board finds that the measurements from the VA examination and treatment records correspond to a noncompensable rating pursuant to diagnostic codes 5260 and 5261. Furthermore, there was no objective evidence of painful motion upon examination, and while the Veteran reported pain and stiffness, there was no objective evidence of painful motion during the examination which would warrant the assignment of a 10 percent rating pursuant to DC 5260. See 38 C.F.R. §§ 4.59, 4.71a. Although the Veteran reported some history of pain, no functional limitation due to such pain was reported. Since there was no pain or flare-ups, considerations pursuant to Correia and Sharp are inapplicable. Thus, in summary, for the period from December 4, 2010 to November 15, 2016, a noncompensable rating is warranted. Left knee from November 15, 2016 From November 15, 2016, the Veteran was rated at 10 percent for his left knee disability based upon painful motion of the knee and degenerative arthritis. The Veteran underwent a VA examination in November 2016, during which the examiner diagnosed the Veteran with knee strain, patellofemoral syndrome, tendonitis, and degenerative arthritis. The Veteran reported flare ups with 10/10 pain almost daily depending on activities and difficulty walking, jogging, standing, going up stairs, entering and exiting a vehicle, and squatting. The examiner noted that the examination was not conducted during a flare up, but that the Veteran’s reports of functional loss are consistent with the examination findings, and that flare ups may cause functional loss, but the examiner stated that he could not specify with certainty how much the Veteran’s range of motion would decrease. Flexion of the left knee was limited to 120 degrees with painful motion. There was also painful motion with extension to 0 degrees. Stability testing of the left knee was within normal limits. X-rays revealed arthritis of the left knee. A VA treatment record from November 18, 2016 revealed extension of the left knee limited to 3 degrees. The VA examination dated January 2018 noted that the Veteran reported that his knees buckle when walking or climbing stairs and that his knee pain is worsening. The Veteran reports that he has to extend his legs while sitting due to pain. The examiner noted flexion to 140 degrees and extension to 0 degrees and that there was pain on the examination which does not cause functional loss. The examiner noted pain with weight bearing with no evidence of crepitus. The examiner stated that flare ups do not impact the Veteran’s functional ability. No subluxation of ankylosis was noted. No instability, atrophy, or dislocation was shown. The examiner stated that the disability may cause disturbance of locomotion, interference with sitting, and interference with standing. The examiner noted that flexion greater than 80 degrees caused facial grimace. The Board finds that a 10 percent rating is adequate, as the Veteran does not display a loss of range of motion which would warrant a higher rating of 20 percent pursuant to diagnostic codes 5260 and 5261 even considering Court directives. A higher evaluation of 20 percent is not warranted for limitation of extension of the knee unless there is extension limited to 15-19 degrees. A higher evaluation of 20 percent is not warranted for limitation of flexion of the knee unless there is flexion limited to 16-30 degrees. Furthermore, the Veteran is now compensated for painful motion and degenerative arthritis. A higher evaluation of 20 percent is not warranted for degenerative arthritis unless there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations, and the Veteran has not shown such symptoms. There is no instability, ankylosis, or dislocation, so the Veteran does not meet the criteria for separate ratings under diagnostic codes 5257-5259. Therefore, the Board finds that a higher or separate disability evaluation is not warranted. Right knee patellofemoral syndrome prior to November 15, 2016 The Veteran has a noncompensable rating for his right knee disorder from December 4, 2010 to November 15, 2016. The Veteran underwent a VA examination in November 2010, during which the Veteran reported stiffness and pain. Physical examination findings noted that the Veteran’s gait and posture were normal. The left knee showed no signs of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malalignment, drainage, subluxation or guarding of movement. Examination revealed crepitus. The examiner noted no genu recurvatum and locking pain and no ankylosis. The range of motion findings noted flexion to 140 degrees and extension to 0 degrees. The joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. The examiner diagnosed patellofemoral syndrome. The Board finds that the measurements correspond to a noncompensable rating pursuant to diagnostic codes 5260 and 5261. Furthermore, there was no objective evidence of painful motion upon examination, and while the Veteran reported pain and stiffness, there was no objective evidence of painful motion during the examination which would warrant the assignment of a 10 percent rating pursuant to DC 5260. See 38 C.F.R. §§ 4.59, 4.71a. Although the Veteran reported some history of pain, no functional limitation due to such pain was reported. Since there was no pain or flare-ups, considerations pursuant to Correia and Sharp are inapplicable. Thus, in summary, for the period from December 4, 2010 to November 15, 2016, a noncompensable rating is warranted. A separate disability rating is not warranted because there is no instability, ankylosis, or dislocation, so the Veteran does not meet the criteria for separate ratings under diagnostic codes 5257-5259. Right knee patellofemoral syndrome from November 15, 2016 The Veteran underwent a VA examination in November 2016, during which the examiner diagnosed the Veteran with knee strain, patellofemoral syndrome, tendonitis, and degenerative arthritis. The Veteran reported flare ups with 10/10 pain almost daily depending on activities and difficulty walking, jogging, standing, going up stairs, entering and exiting a vehicle, and squatting. The examiner noted that the examination was not conducted during a flare up, but that the Veteran’s reports of functional loss are consistent with the examination findings, and that flare ups may cause functional loss, but the examiner stated that he could not specify with certainty how much the Veteran’s range of motion would decrease. Flexion of the knee was limited to 115 degrees with painful motion. There was also painful motion with extension to 0 degrees. Stability testing of the left knee was within normal limits. X-rays revealed degenerative arthritis. The VA examination dated January 2018 noted that the Veteran reported that his knees buckle when walking or climbing stairs and that his knee pain is worsening. The Veteran reports that he has to extend his legs while sitting due to pain. The examiner noted flexion to 140 degrees and extension to 0 degrees and that there was pain on the examination which does not cause functional loss. The examiner noted pain with weight bearing with no evidence of crepitus. The examiner stated that flare ups do not impact the Veteran’s functional ability. No subluxation of ankylosis was noted. No instability, atrophy, or dislocation was shown. The examiner stated that the disability may cause disturbance of locomotion, interference with sitting, and interference with standing. The examiner noted that flexion greater than 80 degrees caused facial grimace. The Board finds that a 10 percent rating is adequate, as the Veteran does not display a loss of range of motion which would warrant a higher rating of 20 percent pursuant to diagnostic codes 5260 and 5261 even considering Court directives. A higher evaluation of 20 percent is not warranted for limitation of extension of the knee unless there is extension limited to 15-19 degrees, and this was not noted until November 18 of that year, and will be discussed below in a separate rating. A higher evaluation of 20 percent is not warranted for limitation of flexion of the knee unless there is flexion limited to 16-30 degrees. Furthermore, the Veteran is now compensated for painful motion and degenerative arthritis, which is encompassed in the current 10 percent rating. A higher evaluation of 20 percent is not warranted for degenerative arthritis unless there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations, and the Veteran has not shown such symptoms. There is no instability, ankylosis, or dislocation, so the Veteran does not meet the criteria for separate ratings under diagnostic codes 5257-5259. Therefore, the Board finds that a higher or separate disability evaluation is not warranted. Right knee limitation of extension from November 18, 2016 A treatment record from the Hampton VA Medical Center dated November 18, 2016 revealed extension of the right knee limited to 5 degrees, which supports a separate 0 percent evaluation for the service connected right knee condition. A 10 percent evaluation for painful flexion of the right knee is already assigned, therefore, a 10 percent evaluation for painful extension cannot be assigned. A higher evaluation of 20 percent is not warranted for limitation of extension of the knee unless there is extension limited to 15-19 degrees. PTSD claimed as hypersomnolence from December 4, 2010 to August 8, 2017 At the October 2010 VA examination, the Veteran reported frequently falling asleep during the day and that he is treated with Provigil. The Veteran was noted to be open and forthcoming providing history with good eye contact. The Veteran was noted to be a reliable historian. Speech, thought processes, and behavior were noted to be normal and goal directed. No psychomotor abnormalities were noted. The Veteran yawned frequently. Memory function was good for three out of three objects at one and fifteen minutes. No memory deficit could be elicited. Mood and affect were euthymic. The Veteran was not acutely suicidal, homicidal, violent, psychotic, manic, hypomanic, obsessive or compulsive. Knowledge, abstraction, and mathematical calculating ability was good. Insight and judgment were good. The examiner diagnosed primary hypersomnia. The GAF score was 60. The November 2016 VA examiner diagnosed the Veteran with hypersomnolence disorder and noted it causes occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The primary symptom of your condition is chronic sleep impairment. Treatment with medication was again confirmed. The above-cited evidence reflects that the Veteran’s PTSD/ hypersomnolence was primarily manifested by chronic sleep impairment. The Board notes that the Veteran did not exhibit many of the symptoms for a 50 percent rating. The evidence of record did not demonstrate circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once per week; impairment of short-and long-term memory (e.g., retention of only highly-learned material, forgetting to complete tasks); impaired judgment; or impaired abstract thinking, flattened affect; or difficulty in understanding complex commands; disturbances of motivation and mood. The Veteran was however noted to show a mild difficulty in establishing and maintaining effective work and social relationships. Taking all factors into consideration with application of the approximating principles of 38 C.F.R. § 4.7, and the benefit-of-the-doubt doctrine, the Board finds that for the entire appeal period, the Veteran’s PTSD/hypersomnolence more nearly approximated occupational and social impairment with reduced reliability and productivity warranting a 50 percent rating. The Veteran was not; however, noted to exhibit symptoms for a 70 percent rating because the Veteran did not show 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; intermittently illogical, obscure, or irrelevant speech; 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); and inability to establish and maintain effective relationships. The Veteran did not likewise exhibit symptoms of similar severity, frequency, and duration. See Vazquez–Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (emphasis added). . Moreover, the criteria for a 100 percent rating also was not shown because the Veteran did not show 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); and disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The Board finds that the functional impairment due to the above symptomatology more nearly approximates the criteria for a 50 percent rating for the above period. PTSD from August 8, 2017 For the period beginning August 8, 2017, the Veteran’s PTSD is currently rated at 70 percent disabling. The Veteran underwent a VA psychiatric examination in August 2017. The report was rendered in September 2017. The Veteran was noted to have a diagnosis of PTSD, and was noted to have symptoms of unprovoked irritability with periods of violence, occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, suspiciousness, depressed mood, disturbances of motivation and mood, impaired impulse control, chronic sleep impairment, difficulty in adapting to stressful circumstances, difficulty in adapting to work, inability to establish and maintain effective relationships, anxiety, and difficulty in establishing and maintaining effective work and social relationships. A clarifying opinion from the VA clinical psychologist on December 1, 2017, which stated that the Veteran’s reported sleep disruption noted on the initial PTSD examination opinion written September 2017 is a symptom of PTSD and not a diagnosed separate sleep disorder of primary hypersomnia or hypersomnolence, and that the reoccurring nightmares that disrupt sleep contribute to not achieving restorative sleep at night and thereby experiencing daytime drowsiness even though the Veteran reported sleeping 8 hours per night. A Hampton VAMC January 18, 2018 sleep medicine consult noted reports of significant daytime somnolence. The Veteran stated that his sleep is not refreshing. The physician noted that it was unclear if the symptoms are related to narcolepsy. A Mental health evaluation showed no observable psychomotor agitation or retardation, auditory or visual hallucinations, ideas of reference, illusions, delusions or paranoia. Insight and judgment were good. Speech was normal. Mood was described as “okay.” Thought processes were linear, logical and goal directed. There was no evidence of suicidal or homicidal ideation, intent or plan. Memory was intact. The Board finds that a 70 percent disability rating most closely reflects the Veteran’s current symptomatology, as he has shown symptoms of 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; intermittently illogical, obscure, or irrelevant speech; 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); and inability to establish and maintain effective relationships. Id. However, a higher rating of 100 percent is not warranted, as the Veteran has not shown 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); or disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The Board is aware that the symptoms listed under the 100 percent evaluation are essentially examples of the type and degree of symptoms for that evaluation, and that the Veteran need not demonstrate those exact symptoms to warrant a 100 percent evaluation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, the Board finds that the preponderance of the evidence, including the clinical findings, shows that the Veteran’s PTSD symptoms, including those listed in the criteria and those not listed, more nearly approximate occupational and social impairment with deficiencies in most areas. J. CONNOLLY Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Hoover, Associate Counsel