Citation Nr: 18159821 Decision Date: 12/20/18 Archive Date: 12/20/18 DOCKET NO. 15-41 446 DATE: December 20, 2018 ORDER Entitlement to a 70 percent rating for posttraumatic stress disorder (PTSD) with anxiety disorder not otherwise specified (hereinafter “acquired psychiatric disorder”) is granted for the entire appeal period. FINDING OF FACT Throughout the appeal period, manifestations of the Veteran’s acquired physiatric disorder have most closely approximated those contemplated by a 70 percent rating. CONCLUSION OF LAW For the entire appeal period, the criteria for entitlement to a 70 percent rating, but no higher, for a service-connected acquired psychiatric disorder have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.7, 4.14, 4.25, 4.130, DC 9411, General Rating Formula for Mental Disorders (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from May 1969 to November 1970. Analysis In determining the severity of a disability, the Board applies the criteria set forth in the Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. 38 U.S.C. 1155; 38 C.F.R. 4.1. If the disability more closely approximates the criteria for the higher of two ratings, the higher rating is assigned. 38 C.F.R. 4.7. Since the effective date of service connection (March 30, 2012), the Veteran has been rated at 50 percent, which contemplates occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and/or difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9413, General Rating Formula for Mental Disorders; October 2017 Codesheet. A 70 percent rating contemplates 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 worklike setting); and/or inability to establish and maintain effective relationships. Id. A 100 percent rating contemplates 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; and/or memory loss for names of close relatives, own occupation, or own name. Id. In June 2012, the Veteran underwent a VA PTSD examination. At that time, the examiner noted symptoms including: chronic sleep impairment (difficulty falling or staying asleep, hypervigilance, exaggerated startle response); impaired judgment; suicidal ideation; impaired impulse control, such as unprovoked irritability with periods of violence; intense psychological distress and physiological reactivity during exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; efforts to avoid thoughts, feelings, conversations, activities, places, and people associated with the trauma (avoids war-related news and movies); and clinically significant distress or impairment in social, occupational, or other important areas of functioning. The examiner ultimately estimated that the Veteran had 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. In February 2013, the Veteran again underwent a VA PTSD examination. The examiner at that time noted symptoms related to the Veteran’s acquired psychiatric disability, to include: depression; anxiety; suspiciousness; chronic sleep impairment (insomnia); difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work-like setting; suicidal ideation; occasional crying spells; struggles with feelings of hopelessness and helplessness at times; sometimes low energy and low motivation; occasional auditory and visual hallucinations; paranoia; recurrent and intrusive distressing recollections to in-service experiences; hyperarousal (insomnia, irritability, anger, impaired concentration, exaggerated startle response, hypervigilance); avoidance (preference for being alone, not discussing experiences, avoids reminders); feeling detached from others; restricted affect; depression; recurrent and distressing recollections and dreams of the trauma, including images, thoughts, or perceptions; acting or feeling as if the traumatic event were recurring; intense psychological distress and physiological reactivity during exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; efforts to avoid thoughts, feelings, conversations, activities, places, and people associated with the trauma; inability to recall an important aspect of the trauma; markedly diminished interest or participation in significant activities; feeling detached or estranged from others; restricted range of affect; and clinically significant distress or impairment in social, occupational, or other important areas of functioning. The examiner ultimately estimated that the Veteran had 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. In April 2014, the Veteran underwent another VA PTSD examination. That examiner noted symptoms including: depression; suspiciousness; chronic sleep impairment; flattened affect; difficulty in adapting to stressful circumstances, including work or a work-like setting; inability to establish and maintain effective relationships; flat affect; recurrent and intrusive distressing recollections to in-service experiences; intense or prolonged psychological distress during exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; efforts to avoid thoughts, feelings, conversations, activities, places, and people associated with the trauma; persistent and exaggerated negative beliefs or expectations about self, others, or the world; persistent negative emotional state; irritable behavior and angry outbursts with little or no provocation typically expressed as verbal or physical aggression toward people or objects; hypervigilance; sleep disturbance; and clinically significant distress or impairment in social, occupational, or other important areas of functioning. The examiner ultimately estimated that the Veteran had 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. In a July 2017 Notice of Disagreement, the Veteran reported symptoms including: depression; two to three panic attacks per week; thoughts of suicide; feelings of hopelessness and helplessness; problems with spouse (things get blown out of proportion); spouse reminds him about keeping up appearance and hygiene; problems making and maintaining relationships; problems with impaired impulse control; problems with crowds and loud noises; lost jobs because of impaired impulse control and has had to leave stores because of people arguing in line. In August 2017, the Veteran was given another VA PTSD examination. At that time, the examiner noted symptoms including: depressed mood; suspiciousness; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; 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 a work-like setting; inability to establish and maintain effective relationships; impaired impulse control, such as unprovoked irritability with periods of violence; intermittent neglect of personal appearance and hygiene. Additional symptoms included recurrent, involuntary, and intrusive distressing memories of the traumatic events; recurrent distressing dreams; intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic events; marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic events; efforts to avoid thoughts, feelings, conversations, activities, places, people, objects, and situations associated with the trauma. The Veteran was also found to experience persistent and exaggerated negative beliefs or expectations about self, others, or the world; persistent negative emotional state; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; persistent inability to experience positive emotions; irritable behavior and angry outbursts (with little provocation) typically expressed as verbal or physical aggression toward people or objects; hypervigilance; exaggerated startle response; problems with concentration; sleep disturbance; and clinically significant distress or impairment in social, occupational, or other important areas of functioning. Based on these symptoms, the examiner determined that the Veteran had occupational and social impairment with reduced reliability and productivity. Based on the evidence above, and when considering other VA treatment records showing comparable symptomatology (see Memphis VAMC, Memphis Vet Center, and Nonconnah Boulevard VA Clinic records), the Board resolves all reasonable doubt in favor of the Veteran and finds that, throughout the period on appeal, the manifestations of his acquired physiatric disorder have most closely approximated those contemplated by a 70 percent rating. Specifically, the evidence above documents several of the 70 percent criteria, including: suicidal ideation; near-continuous depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; and inability to establish and maintain effective relationships. However, the Board finds that a higher rating of 100 percent is not warranted. The evidence simply does not suggest that the Veteran’s symptoms occurred at the severity or frequency contemplated by a 100 percent rating, which is characterized by gross impairment of thought processes; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; an 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. For the time period on appeal, the Veteran consistently denied delusions or hallucinations and was not found to be disoriented. Although he acknowledged some suicidal ideation, at no point was he considered to be a persistent danger to himself. Additionally, the Veteran’s long-term marriage, his social activities volunteering and his ability to interact with treatment providers and examiners is affirmative evidence against a finding that any intermittent inability to perform activities of daily living were so severe or frequent so as to result in total social impairment. Given the frequency, nature, and duration of the Veteran’s symptoms throughout the appeal period, the Board finds that the Veteran’s acquired psychiatric disorder was productive of no more than occupational and social impairment with deficiencies in most areas. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Thus, the Board finds that a 70 percent rating is warranted for the entire period on appeal. JEREMY J. OLSEN Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD H. Daus, Associate Counsel