Citation Nr: 18150828 Decision Date: 11/15/18 Archive Date: 11/15/18 DOCKET NO. 16-00 176A DATE: November 15, 2018 ORDER Entitlement to an initial disability rating higher than 70 percent for posttraumatic stress disorder (PTSD) with major depressive disorder is denied. FINDING OF FACT Throughout the entire appeal period, the Veteran’s service-connected PTSD with major depressive disorder has been manifested by symptomatology more nearly approximating occupational and social impairment with deficiencies in most areas, but less than total occupational and social impairment. CONCLUSION OF LAW The criteria for a rating higher than 70 percent for PTSD with major depressive disorder have not been met at any time during the appeal period. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.125, 4.126(a), 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran’s psychiatric disorder is currently rated as 70 percent disabling, effective August 28, 2013. Psychiatric disabilities, such as PTSD and major depressive disorder, are evaluated under the General Rating Formula for Mental Disorders (pertinent portions listed below). See 38 C.F.R. § 4.130, Diagnostic Codes 9411, 9434. Under the General Rating Formula for Mental Disorders, a 100 percent disability rating requires 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; or memory loss for names of close relatives, own occupation, or own name. Id. A 70 percent disability rating requires 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); or inability to establish and maintain effective relationships. Id. When evaluating mental health disorders, the factors listed in the Rating Schedule are simply examples of the type and degree of symptoms, or their effects, that would justify a particular rating; the analysis should not be limited solely to whether a veteran exhibited the symptoms listed in the Rating Schedule. Rather, the determination should be based on all a veteran’s symptoms affecting his level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The lists of symptoms under the Rating Schedule are meant to be examples of symptoms that would warrant the disability evaluation, but are not meant to be exhaustive. Id. Further, the United States Court of Appeals for the Federal Circuit has acknowledged the “symptom-driven nature” of the General Rating Formula and that “a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.” Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116 (Fed. Cir. 2013). The Federal Circuit has explained that “symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating.” Id. at 117. The Veteran contends that his PTSD and depression symptomatology is more severe than contemplated by the disability rating assigned. For the Veteran to obtain a rating higher than 70 percent his symptomatology needs to result in total occupational and social impairment. For the reasons explained below, the Board finds that a disability rating of 100 percent is not warranted for any time during the timeframe on appeal. The Veteran was afforded a VA examination in October 2014. He was diagnosed with agoraphobia. The examiner concluded his symptoms were not severe enough to either interfere with occupational and social functioning or to require continuous medication. At the time of examination, the Veteran was residing with his grandfather. His work history was reported as working at a golf course in maintenance while in the reserves. After being discharged he worked at a post office for a year. At the time of the examination he was employed, working as manager of renewals for an insurance company that was owned by his grandfather. The examiner indicated that the Veteran was extremely anxious, did not want to talk about certain things, would not watch war movies, had decreased participation in activities, hypervigilance, difficulty concentrating and sleeping, he would become very anxious when having to interact with people, he would get extremely distressed in any kind of crowds, and he showed significant psychological problems. He was not considered a danger to himself or others. He was unusually anxious and agitated and did a great deal of movement with his limbs. The symptoms for VA rating purposes were depressed mood, anxiety, chronic sleep impairment, and difficulty in adapting to stressful circumstances including work or worklike setting. The Veteran was being treated for his psychiatric disorder and was taking prescribed medication. There are VA medical records dated August 2014 to March 2018 that show the Veteran has been consistently treated for his PTSD with major depressive disorder. He underwent a 60-minute VA session in August 2014. He reported difficulty sleeping, having nightmares, poor focus, feeling depressed, feeling isolated, and being on the edge. The examiner listed the following as the Veteran’s exhibited symptoms: hypervigilance, avoidance, and intrusive thoughts. His social history included being raised by his mother and never knowing his father. His mother re-married and had five additional children, giving him four half-sisters and a half-brother. He reported residing with his grandparents, being single and not having any children. He described having friends and enjoying beaching, camping, and kayaking. He is a high school graduate and at the time of the examination was in school. He has a police license. He works at his family’s insurance agency, and volunteers as a volunteer police officer once a month. The Veteran was oriented to person, place, and time, his appearance neatly groomed, casually dressed, attitude toward the examiner irritable, affect normal. His mood anxious, depressed, and irritable. His affect narrow in range and almost flat. He exhibited insight, good impulse control and judgment. The following symptoms were not indicated: auditory hallucinations, visual hallucinations, thought disorder, paranoid ideations, suicidal or homicidal ideations. He denied feelings of hopelessness, helplessness, or intent to harm himself or others. The examiner concluded that the Veteran was not at significant risk of self-harm. An August 2014 VA screening revealed the following: little interest or pleasure in things, feeling down, depressed, or hopeless, trouble sleeping, trouble concentrating, constantly on guard, and feeling numb and detached from others. The Veteran denied any feelings of wanting to hurt himself or thinking it would be better if he were dead. During a September 2014 VA 30-minute session, the Veteran reported difficulty with focus and concentration at work. He has been employed as an insurance agent at Carolina Beach since July. He denied exacerbation of any mood symptoms, suicidal ideation, homicidal ideation, auditory or visual hallucinations. He had a restricted blunted affect with very short, mostly yes/no answers, despite the examiner’s attempt to encourage and facilitate a discussion of his symptoms. A September 2014 VA 15-minute session revealed that the Veteran was oriented to time, person, and place, his mood unchanged, still with anxiety. There was no indication of auditory hallucinations, visual hallucinations, thought disorder, paranoid ideations, suicidal or homicidal ideations. He exhibited insight, good impulse control and judgment. A November 2014 VA primary care note shows that the Veteran was alert and oriented to time, person, place, and situation. The examiner indicated that the Veteran’s depression appeared better, though his affect was still somewhat constricted. During a July 2015 VA traumatic brain injury (TBI) consultation, the Veteran reported difficulty sleeping, averaging no more than 4 hours a night, having nightmares 1 to 2 times a week, and reported that neither the prescribed medications for his PTSD symptoms or inability to sleep have alleviated the severity. He denied any suicidal ideation. During a July 2015 VA speech pathology consultation, he continued to report experiencing PTSD symptoms and difficulty sleeping, having broken sleep 3 to 4 hours a night. At the time of the consultation he was living with his wife and stated that he enjoys going to the gym (going 3 times a week), fishing, and swimming with his wife. During an August 2015 VA 45-minute session, he continued to report difficulty sleeping and getting little to no relief from his prescribed medication. It was also expressed that the Veteran was oriented to time, person, and place, his mood not improved, and affect narrow in range. There was no indication of auditory hallucinations, visual hallucinations, thought disorder, paranoid ideations, suicidal or homicidal ideations. He exhibited insight, good impulse control and judgment. The examiner concluded that the Veteran requires continued mental health services to maintain stabilization, prevent further deterioration, and/or relapses. A September 2015 VA 60-minute session revealed that the Veteran was pleasant, alert, and engaged in conversation minimally. Attitude was appropriate, behavior cooperative, thoughts linear and goal oriented. He denied any current suicidal or homicidal ideation. He had another 60-minute session in September 2015 that revealed the same results. He did report anger, increased irritability and feeling de-motivated. A September 2015 VA mental health medication management note indicates continued reporting of prescribed medication failing to alleviate symptoms. Any alleviation was attributed to him working out 3 times a week. He reported hypervigilance, describing “clearing” a hotel before allowing his wife to enter. He reported being able to fall asleep, but not able to remain asleep. He stated he wakes up rested. He also stated he avoids driving, as it makes him anxious. He is employed full time as an insurance agent and attends school at night in pursuit of a general degree, with an emphasis in entrepreneurship. The Veteran was oriented to time, person, and place, his mood depressed, and affect blunted. The examiner indicated that the Veteran had almost had no facial expression, no animation, essentially flat. He stared without blinking and there was no emotion expressed. At the same time, he appeared sad. There was no indication of auditory hallucinations, visual hallucinations, thought disorder, paranoid ideations, or suicidal or homicidal ideations. He exhibited insight, good impulse control and judgment. The examiner concluded that the Veteran required continued mental health services to maintain stabilization, prevent further deterioration, and/or relapses. He was not at significant risk for self-harm. He had 2, 60-minute VA sessions in October 2015 that revealed the same results as the September 2015 sessions. An October 2015 VA mental health note shows the Veteran was separated from his wife and his anxiety had gotten worse. He described having two anxiety attacks in the past week. He also described problems sleeping, feeling tired all the time, difficulty concentrating, and lack of motivation to go to school or perform work tasks. During a November 2015 VA 25-minute session, he reported somewhat improved mood while on a prescribed medication. He completed group therapy and stated his desire to want to continue with another group. The following symptoms were not indicated: auditory hallucinations, visual hallucinations, thought disorder, paranoid ideations, suicidal or homicidal ideations. He exhibited insight, good impulse control and judgment. The examiner concluded that the Veteran required continued mental health services to maintain stabilization, prevent further deterioration, and/or relapses. A December 2015 VA urgent care note indicates he was oriented to all three spheres, alert, cooperative, and pleasant. During a December 2015 VA 25-minute session he continued to struggle with anxiety, PTSD symptoms in general, and poor sleep. The examiner stated that the Veteran had an unusual presentation in that he is flat, moves very little, made eye contact but more in a stare, and answers questions briefly with little elaboration. Monoamine oxidase inhibitors (MAOIs) were discussed as other medications had not helped much. He stated he gets some relief from his constant thinking and worrying when his is alone in isolated places. Discussion was had about how getting a dog would help. He reported that he would be moving to Iowa in a couple of weeks. A September 2016 VA mental health note summarizes how the Veteran has been doing since he left for Iowa. He returned to North Carolina a month prior. While in Iowa, he worked in a chicken processing plant and hated it. He returned to his employment as an insurance agent. He has family support in North Carolina. He is still separated from his wife and believes that their relationship is over. He has been off all psychiatric prescribed medication for several months and did not receive mental health treatment when he was in Iowa. He reported the return of all PTSD symptoms, including anxiety. The Veteran was oriented to time, person, and place, and his mood and affect were anxious. He was quiet, pleasant, answered questions briefly and had good hygiene. There was no indication of auditory hallucinations, visual hallucinations, thought disorder, paranoid ideations, suicidal or homicidal ideations. He exhibited insight, good impulse control and judgment. The examiner concluded that the Veteran needs continued mental health services to maintain stabilization, prevent further deterioration, and/or relapses. A January 2017 DBQ by a private provider is of record. The examiner concluded that the Veteran’s PTSD symptomatology resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and or mood. The Veteran attributed the separation from his wife to the constant arguing, stating “I would yell a lot at my wife.” He avoided being around people and avoided leaving the house. He reported having few close friends from the military, whom it is easier being around. He reported having multiple jobs in the past year, all ending due to his anxiety associated with talking to people. He reported experiencing attacks while driving, and panic-like symptoms while talking to strangers. He described being hypervigilant, as he always checked peoples’ hands, and he described obsessively checking his locks. He described contemplating suicide 1 to 2 years ago because he was no longer with his unit and because of the distressing nightmares. His plan was to crash his car into a tree. Upon examination, it was stated that the Veteran appeared anxious, had mainly flat affect and became visibly upset on several occasions. The symptoms for VA rating purposes were depressed mood, anxiety, suspiciousness, panic attacks more than once a week, near continuous panic or depression affecting the ability to function independently, appropriately, and effectively, chronic sleep impairment, mild memory loss, impairment of short and long term memory, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including work or worklike setting, inability to establish and maintain effective relationships, obsessive rituals which interfere with routine activities, and impaired impulse control such as unprovoked irritability with periods of violence. During a February 2017 VA DBQ the Veteran was diagnosed with PTSD and major depressive disorder. The examiner stated she was able to distinguish the symptoms for each disorder, attributing re-occurring nightmares, flashbacks, intrusive memories, avoidance behaviors, hypervigilance, depressed mood, anxiety, problems concentrating, sleep disturbance arousal and reactivity to PTSD and depressed mood, anhedonia, irritability, lack of motivation, difficulty concentrating, memory problems, isolation, suicidal ideation, crying spells, and feelings of hopelessness to major depressive disorder. The examiner concluded that the Veteran’s PTSD/major depressive disorder symptomatology resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. The Veteran attended college off and on since 2010 in pursuit of his Associate of Arts (AA) degree. At the time of the examination, he was employed as an insurance agent for the last 6 months. He was still separated from his wife of 2 years. The symptoms for VA rating purposes were depressed mood, anxiety, suspiciousness, panic attacks more than once a week, panic attacks that occur weekly or less often, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, chronic sleep impairment, impairment of short and long term memory, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including work or worklike setting, inability to establish and maintain effective relationships, neglect of personal appearance and hygiene, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. Upon mental examination, the Veteran was alert, oriented to time, person, place, and situation. Immediate memory intact and delayed was impaired. He was cooperative, answered all questions and maintained consistent eye contact. Rate and tone of speech were normal. He presented as very depressed with flattened affect. He appeared anxious and restless throughout the evaluation. He did not report or exhibit any symptoms of thought disorder. He denied suicidal ideation, intent or plan, and did not present as a risk for self-harm. During a September 2017 VA 45-minute session, the Veteran reported feeling “depressed,” having low energy, concentration/focus as “way down” and being irritable as “I get mad for no reason.” He stated that he still has problems falling asleep and staying asleep. He failed 6 or 7 classes, quit on-line classes and lost his financial aid for Cape Fear and Iowa. He is on academic probation at Cape Fear. He reported attending night school full-time. He still worked full time as an insurance account manager. He was still separated from his wife in Iowa. He has no children. He lives in an apartment with one roommate. He stated his desire to resume taking medication and to obtain an application for Paws to Pets. The Veteran was alert, oriented to time, person, and place. There was no indication of auditory hallucinations, visual hallucinations, thought disorder, paranoid ideations, or homicidal ideations. He expressed suicidal ideation at times. He described feeling hopeless and maybe driving off the road. He is able to dismiss these thoughts and he would never do it. His best friend, who was also a veteran, killed himself 2 to 3 weeks prior. The Veteran reported having guns, but stated that they were in a safe. He denied any prior suicide attempts. The examiner concluded that the Veteran’s risk for potential suicidal behavior is low to moderate, is not judged to be a significant risk for self-harm and that he is seeking help and his guns are locked. He exhibited insight, good impulse control, and judgment. The examiner concluded that the Veteran needs continued mental health services to maintain stabilization, prevent further deterioration, and/or relapses. Following this evaluation, a 20-minute evaluation was done and a safety plan was comprised and a copy given to the Veteran. This plan details warning signs, coping skills, support persons, how to make his home environment safe and that the Veteran was not considered a high risk for suicide. The plan did detail that he would be re-evaluated for high risk suicide at a minimum of every 90 days. An October 2017 VA psychosocial assessment indicated no new information regarding the Veteran’s employment, separation from his wife, or severity or changes in his PTSD symptoms. It did mention that he was living alone in an apartment or house, and that his religion/spirituality is very important to him. It also mentioned that he had his Bachelor’s degree, emergency medical technician (EMT) license, police certification, and an Associate Arts Insurance license. During an October 2017 VA psychosocial medical rehabilitation outpatient visit the Veteran mentioned the suicide of his best friend, and reported that his aunt committed suicide a year prior. He described being separated from his wife as a result of him being a jerk on a daily basis. He and his wife, though separated, talk on a daily basis. He recently started taking Prozac and increased his dosage and reported that it has helped with mood stabilization. He endorsed the following feelings: irritability, less tolerance, increased frustration with situations that did not used to set him off, and feeling uncomfortable/uneasy in public places. He denied suicidal or homicidal ideation. Upon mental examination, the Veteran’s attitude was normal, mood demeanor without abnormality, thought process showed no deficiency, rate of thought normal, attention span not decreased, and no impairment of thought content. He could answer questions, had no difficulty following conversation, and he was able to formulate complete sentences and ideas with little difficulty in expressing them. A November 2017 VA 30-minute session follow up summarized how he had been doing since starting on fluoxetine a month prior. He reported still feeling down, but not as bad as before. He stated that he still does not feel joy, but that he feels less suicidal ideation. He said school is still difficult for him at night and he still has a hard time focusing at work. His wife called him that morning to tell him that if he does not return to Iowa, she would file for divorce. He reported feeling “pissed off about it.” The Veteran was alert, oriented to time, person, and place, casually dressed, and reasonably groomed. The following symptoms were not indicated: auditory hallucinations, visual hallucinations, thought disorder, paranoid ideations, or homicidal ideations. The wife’s ultimatum about their marriage was listed as a stressor, but he denied specific suicidal ideation in relation to the divorce. As described above, suicidal ideation is decreased. He exhibited insight, good impulse control, and judgment. During a December 2017 VA 60-minute session he reported still having nightmares, difficulty sleeping, still being tired, and mood still down. He reported that his wife ceased talking to him. His employment status was unchanged. He no longer went to the gym, but would walk a half mile with his roommate. The Veteran was alert, oriented to time, person, and place. The following symptoms were not indicated: auditory hallucinations, visual hallucinations, thought disorder, paranoid ideations, or homicidal ideations. He stated there are days when he gets down, and denied having suicidal ideation, stating “not really.” He exhibited insight, good impulse control and judgment. The examiner concluded that the Veteran needs continued mental health services to maintain stabilization, prevent further deterioration, and/or relapses. A December 2017 VA TBI consultation shows that he was oriented to all spheres, had good visual interaction and relaxed conversation. He was very irritable, but very cooperative, had normal conversation and answered questions appropriately, and could formulate ideas and express them without difficulty. His attitude cooperative and he was willing to follow instructions without difficulty. His mood was irritable, thought processes were all normal attention span. During a January 2018 VA 60-minute session, he reported that he is not sleeping, that he is on alert all the time, checking his doors, locks, always on the edge and that he does not like having people behind him. He also reported that he has a lot dreams, he does not like being around people and that he does not like loud noises. He reported still taking the fluoxetine and described feeling worse and sadder when he does not take it. The examiner commented on how some of the Veteran’s reporting of worsening of PTSD symptoms appear to be a result of his chronic pain. He owns firearms that are secured in a safe. He experienced panic attacks twice a week. His employment status and marital situation remain unchanged. He had friends from high school, including his roommate. The Veteran was awake and alert, and oriented to time, person, place, and situation. Mood stated as irritable and depressed, affect assessed as dysphoric. There was adequate attention to grooming and hygiene, but rare eye contact as he hid behind the desktop. His speech was well articulated, but it lacked spontaneity. His thoughts were organized and goal directed, thought content was negative for delusional ideas. He had fair impulse control. Attention, concentration, and cognition were grossly intact. He exhibits good decision making and judgment, partial insight into problems and current situation, and has the ability to seek emergency services if at risk. He denied current suicidal or homicidal ideation, intent, or plan. He also denied hallucinations in any sensory modality. The examiner concluded that the Veteran needs continued mental health services to maintain stabilization, prevent further deterioration, and/or relapses. A suicide risk assessment was performed and the examiner concluded that the Veteran was no a significant risk for self-harm and indicated that the Veteran is seeking help, his guns are locked, crisis line number is known, and provider contact information was provided to him. In January 2018 a VA DBQ was administered. He was diagnosed with PTSD and major depressive disorder. The examiner stated he was not able to distinguish the symptoms for each disorder. The examiner concluded that the Veteran’s level of impairment resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and or mood. He reported having a tough week last week. He described feeling concerned that he would be fired from his grandfather’s insurance company since he did not show up consistently and already had been demoted. His wife said she would take him back if he moves back to Iowa. He reported feeling very concerned about leaving North Carolina and all the contacts and resources he has utilized through VA. He also expressed his concern that state services in Iowa are 4 hours away from where he would be living. The symptoms for VA rating purposes were depressed mood, anxiety, chronic sleep impairment, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including work or worklike setting, inability to establish and maintain effective relationships, and neglect of personal appearance and hygiene. Upon mental examination it was found that the Veteran had extremely depressed affect, sad, quiet, voice, tearful, poor eye contact, and speech was clear and coherent. He was disheveled with only fair hygiene, and had a shaking leg. The examiner concluded that for the VA established diagnosis of agoraphobia with PTSD and major depressive disorder, to include anxiety condition the diagnosis has changed and it is a new and separate diagnosis. The examiner made some observations. The examiner observed that the Veteran is severely depressed and its affecting his work. He is very tearful and hopeless. He is not showering regularly. He has no social life and no friends. He watches TV and plays darts once in a while, and has been regularly sedentary due to the chronic physical pain he deals with from his neck, back, leg, and hands. The examiner clearly concluded that the Veteran does not have symptoms of agoraphobia that is not better explained by PTSD. He is missing key elements of agoraphobia such as he leaves his house to go to work each day and he is not scared of being trapped or having a panic attack in public. He needs specialized therapy and does not pose a threat of danger or injury to self or others. A January 2018 VA note shows the Veteran’s inquiry about starting an inpatient PTSD program. He also indicated that he had to take a leave of absence from work. A January 2018 VA administrative note indicates that the Veteran was found not be medically stable for admission to the PTSD residential rehabilitation treatment program (RRTP) due to chronic functionality limiting pain. During a March 2018 VA DBQ the Veteran was diagnosed with panic disorder with agoraphobia and major depressive disorder. The examiner stated she could the symptoms for each disorder, attributing anxiety, heart racing, and fear of dying to panic disorder with agoraphobia and hopelessness, depressive moods, and irritability to major depressive disorder. The examiner did not evaluate for PTSD because the DBQ she was presented with was for mental disorders. She concluded that the Veteran would meet the PTSD criteria and recommended a PTSD evaluation. The Veteran reported his marriage of three years did not work out. He stated that as of the day of the examination he would be legally separating from his wife. He stated that she could not deal with “me being sad or paranoid…I just kept pushing her away.” The examiner concluded the Veteran’s impairment as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupation tasks although generally functioning satisfactorily, with routine behavior, self-care, and conversation. The symptoms for VA rating purposes were depressed mood, anxiety, suspiciousness, panic attacks more than a week, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including work or worklike setting, and inability to establish and maintain effective relationships. Upon mental examination, the Veteran was flustered, upset, and shaking. He arrived 40 minutes late as he was given the wrong address and directions. Mood and affect sad and anxious. Speech within normal limits. Thoughts linear and goal directed. Insight and judgment fair to poor. There was no suicidal or homicidal ideation or psychotic process. For the entire period on appeal, the Board finds that a rating higher than 70 percent is not warranted for the Veteran’s PTSD. As noted above, the Veteran’s PTSD with major depressive disorder was uniformly manifested by symptoms of anxiety, depression, feelings of hopelessness, avoidance, sleep impairment, irritability, difficulty concentrating, panic attacks, memory problems, isolation, difficulty in adapting to stressful circumstances including work or worklike setting, and the inability to establish and maintain effective relationships—all resulting in deficiencies in most areas, but less than total social and occupational impairment. The preponderance of the evidence demonstrates that the criteria for a disability rating higher than 70 percent for the Veteran’s PTSD with major depressive disorder have not been met at any point during the relevant appeal period. Specifically, the Veteran’s PTSD with major depressive disorder has not been manifested by symptomatology more nearly approximating total occupational and total social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. As such, the Board finds that a 100 percent disability rating is not warranted at any time during the relevant appeal period. 38 C.F.R. §4.130, Diagnostic Code 9411. In reviewing the criteria for a 100 percent disability rating and determining whether an evaluation higher than 70 percent is warranted, the Board finds that the evidence does not establish that during the appeal period, the Veteran’s PTSD with major depressive disorder manifested in total occupational and social impairment. Regarding these areas, the Board has fully considered the frequency, severity, and duration of all the Veteran’s psychiatric symptoms with respect to their effect on his overall occupational and social functioning. 38 C.F.R. §4.126(a). Throughout the appeal period, the Veteran’s impairment was significant and impacted his work and family life. He consistently exhibited symptoms of difficulty sleeping, intrusive memories, trouble concentrating, memory loss, anxiety, depression, hopelessness and isolation. The record shows that the Veteran’s hygiene, with the exception of one medical examination, was consistently stated as adequate, neatly groomed or reasonably groomed; his impulse control and judgment as good and speech as normal and well- articulated. The January 2018 VA examiner noted that the Veteran appeared disheveled with only fair hygiene and was not showering regularly. There are no medical records of evidence either prior or after this examination that reflects the Veteran’s hygiene was anything but reasonable. The January 2017 VA examiner described the Veteran’s impulse control as impaired. The March 2018 VA examiner described the impulse control as fair to poor. However, much like the hygiene, there are no other medical records in the file that describes his impulse control as anything other than good. The evidence indicates that throughout the appeal period, the Veteran’s symptomology approximated a 70 percent disability rating. Therefore, the Board finds that throughout the appeal period there were deficiencies in most areas due to psychiatric symptoms, and therefore a disability rating of 70 percent is warranted. As will be discussed below, at no time during the appeal period did the Veteran’s PTSD with major depressive disorder symptoms warrant a disability rating of 100 percent. Throughout the appeal period the Veteran’s family relationship and dynamics changed. Initially he was single, living with his grandparents. Later he married, reporting the enjoyment he gets when going for a swim with his wife. The most recent records showed that he and his wife separated, and were living apart. He then went from living by himself to living with a roommate. He attributed the downfall of his marriage to their constant arguing, stating “I would yell a lot at my wife” and him being a jerk on a daily basis. The most recent examination of record showed that the Veteran was to be legally separated from his wife, as he “kept pushing her away” and she was unable to deal with his psychiatric disorder symptoms. Despite reporting feelings of isolation and avoidance, he consistently described having some contact with family and friends. Even when during his separation with his wife, he would talk to her on a daily basis. He returned to North Carolina as he had family support there. In addition to having his support system he described how his religion/spirituality is very important to him. The Board notes there was mention by the January 2018 VA examiner that the Veteran had no social life and no friends. However, this one record alone does not negate the Veteran’s consistent reporting of interaction with family and friends and reporting of enjoying certain hobbies. For the most part, the Veteran has been employed full-time during the appeal period. His most consistent position was at an insurance agency. At one point he moved out of state and worked in a chicken processing plant. When he returned to North Carolina, he resumed his employment as an insurance agent. In the October 2017 VA psychosocial assessment report, it was stated that he had his Bachelor’s degree, EMT license, police certification, and Associate Arts Insurance license. A January 2018 note indicates the Veteran reported taking a leave of absence from work. However, the overwhelming majority of evidence shows the Veteran was employed full-time during the appeal period. The most recent VA examination of record indicates he was employed full-time. Although the Veteran did present with suicidal ideation at times during the appeal period, this symptom is contemplated by a 70 percent disability rating. Also, the record shows that he does not have gross impairment of 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, or disorientation to time or place. The Veteran did not show symptoms consistent with total occupational or social impairment at any time during the appeal period. Not one of the VA examiners, or the private examiner, opined that the Veteran’s psychiatric disorder symptoms resulted in total occupational and social impairment. In fact, the October 2014 VA examiner’s assessment was more in line with a non-compensable rating and the most recent examination illustrates an opinion consistent with a 30 percent disability rating. The majority of the VA examiners and the private examiner agreed that the Veteran’s PTSD with major depressive disorder symptomatology resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and or mood—consistent with a 70 percent disability rating. Therefore, looking at the totality of the circumstances the Veteran’s symptoms are best represented by a 70 percent rating. In arriving at this conclusion, the Board has carefully considered the lay assertions of the Veteran. The Board understands his belief that his symptoms warrant a disability rating higher than 70 percent. However, the Board has considered the Veteran’s statements in conjunction with the medical evidence in finding that a rating higher than 70 percent is not warranted. Even considering the Veteran’s reports, the most probative evidence shows significant occupational and social impairment as evidenced by his 70 percent rating, but it does not show that he has total occupational and social impairment due to his PTSD symptoms. The Board finds that the Veteran’s deficiencies must be “due to” symptoms listed for that rating level, “or others of similar severity, frequency, and duration. Vasquez-Claudio, 713 F.3d at 117. Here, the symptoms noted during the VA examinations during the appeal period are of similar severity, frequency, and duration of those noted under the criteria for a 70 percent rating. As the preponderance of the evidence is against the claim for a disability rating higher than 70 percent, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. H.M. WALKER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Talamantes, Associate Counsel