Citation Nr: 1807151 Decision Date: 02/02/18 Archive Date: 02/14/18 DOCKET NO. 07-34 767A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for residuals of a fracture of the left lateral wall of the maxillary atrium, inferior orbital ridge, and zygomatic arch. 2. Entitlement to an initial rating greater than 30 percent prior to September 8, 2007, greater than 50 percent from September 8, 2007, to August 27, 2008, from November 1, 2008, to January 29, 2010, and from April 1, 2010, to March 13, 2013, and greater than 70 percent from March 13, 2013, to November 27, 2015, for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Michael J. Hofrichter, Attorney WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The Veteran had active service from May 1966 to May 1968, including in combat in the Republic of Vietnam. This case has a long procedural history. It comes before the Board of Veterans' Appeals (Board) on appeal from a November 2005 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia, which granted, in pertinent part, the Veteran's claim of service connection for PTSD, assigning a 10 percent rating effective August 31, 2004, and denied the Veteran's claim of service connection for residuals of a fracture of the left lateral wall of the maxillary atrium, inferior orbital ridge, and zygomatic arch ("residuals of left eye trauma"). The Veteran disagreed with this decision in January 2006 with respect to the denial of his service connection claim for residuals of left eye trauma and in March 2006 with respect to the initial rating assigned for his service-connected PTSD. He perfected a timely appeal on both of these claims in November 2007. A Travel Board hearing was held at the RO in July 2010 before the undersigned Veterans Law Judge and a copy of the hearing transcript has been added to the record. In an October 2007 rating decision, the RO assigned a higher initial 30 percent rating for PTSD effective August 31, 2004. Because the initial rating assigned to the Veteran's service-connected PTSD is not the maximum rating available for this disability, this claim remains in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993). In a March 2009 rating decision, the RO assigned a temporary total (100 percent) rating effective August 27, 2008, because of hospitalization over 21 days and a 30 percent rating effective November 1, 2008, for the Veteran's service-connected PTSD. In a February 2010 rating decision, the RO assigned, in pertinent part, a higher initial 50 percent rating effective February 24, 2009, for the Veteran's service-connected PTSD. In a September 2010 rating decision, the RO assigned a temporary total (100 percent) rating effective January 29, 2010, because of hospitalization over 21 days and a 50 percent rating effective April 1, 2010, for the Veteran's service-connected PTSD. In August 2011 and in March 2017, the Board remanded this matter to the Agency of Original Jurisdiction (AOJ) for additional development. A review of the claims file shows that there has been substantial compliance with the Board's remand directives. In August 2011, the Board directed the AOJ to schedule the Veteran for appropriate examinations to determine the nature and etiology of his residuals of left eye trauma and to determine the current nature and severity of his service-connected PTSD. The requested PTSD examinations occurred in May 2012, March 2013, and in November 2015. And the requested eye examinations occurred in March 2013 and in January 2015 along with an opinion concerning the nature and etiology of the Veteran's residuals of left eye trauma obtained in October 2015. In March 2017, the Board directed that the AOJ obtain the Veteran's Social Security Administration (SSA) records and schedule him for appropriate examination to determine the nature and etiology of his residuals of left eye trauma. The Veteran's SSA records subsequently were associated with his claims file. And the requested examination occurred in May 2017. See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In a February 2016 rating decision, the AOJ assigned a higher initial 50 percent rating effective September 8, 2007, an initial 70 percent rating effective March 23, 2013, and an initial 100 percent rating effective November 27, 2015, for the Veteran's service-connected PTSD. The Board notes that the AOJ granted a claim for a total disability rating based on individual unemployability (TDIU) effective July 22, 2009, during the pendency of this appeal. This AOJ action does not moot the higher initial rating claim for PTSD for any period of time when this disability is evaluated as less than 100 percent disabling. Having reviewed the record evidence, the Board finds that the Veteran's higher initial rating claim for PTSD should be characterized as stated on the title page. FINDINGS OF FACT 1. The record evidence shows that no current residuals of left eye trauma are related to active service. 2. The record evidence shows that, prior to September 8, 2007, the Veteran's service-connected PTSD is manifested by, at worst, complaints of trouble falling and staying asleep, nightmares several times a week, and anger outbursts. 3. The record evidence shows that, from September 8, 2007, to August 27, 2008, from November 1, 2008, to January 29, 2010, and from April 1, 2010, to March 13, 2013, the Veteran's service-connected PTSD is manifested by, at worst, worsening social withdrawal and isolation, daily anger outbursts, and panic attacks more than once a week. 4. The record evidence shows that, from March 13, 2013, to November 27, 2015, the Veteran's service-connected PTSD is manifested by, at worst, ongoing irritability, social isolation, anxiety, and depression. CONCLUSIONS OF LAW 1. Residuals of a fracture of the left lateral wall of the maxillary atrium, inferior orbital ridge, and zygomatic arch were not incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1154, 5103, 5103A, 5107 (West 2012); 38 C.F.R. §§ 3.303, 3.304 (2017). 2. The criteria for an initial rating greater than 30 percent prior to September 8, 2007, greater than 50 percent from September 8, 2007, to August 27, 2008, from November 1, 2008, to January 29, 2010, and from April 1, 2010, to March 13, 2013, and greater than 70 percent from March 13, 2013, to November 27, 2015, for PTSD have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.130, Diagnostic Code (DC) 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran contends that he incurred residuals of a fracture of the left lateral wall of the maxillary atrium, inferior orbital ridge, and zygomatic arch after getting punched in the left eye during active service. He also contends that his service-connected PTSD is more disabling than currently (and initially) evaluated throughout the appeal period. Factual Background and Analysis The Board finds that the preponderance of the evidence is against granting the Veteran's claim of service connection for residuals of a fracture of the left lateral wall of the maxillary atrium, inferior orbital ridge, and zygomatic arch. Despite the Veteran's assertions to the contrary, the record evidence does not show that any current residuals of a fracture of the left lateral wall of the maxillary atrium, inferior orbital ridge, and zygomatic arch ("residuals of left eye trauma") are related to active service or any incident of service. For example, the Veteran's available service treatment records show that, on outpatient treatment on August 1, 1966, the Veteran complained of being hit in the left eye with a fist. X-rays revealed a fracture of the left wall of the maxillary atrium, inferior orbital ridge, and zygomatic arch. Physical examination showed a contusion injury to the eyelids and a temporal hemorrhage, full extraocular movements, and no limitation of motion. Slit lamp examination was normal. The impressions included an orbital rim fracture, a fracture of the lateral wall of the left maxillary sinus, and a fracture of the left zygomatic arch. On August 2, 1966, the Veteran had slightly less edema and was "very comfortable." His fractures of the facial bones were "in very good position" with no facial asymmetry. The in-service clinician stated, "If no sinus problems become apparent, surgical intervention should not be necessary at the present time. No prolapse or diplopia of [the] left eye today." On outpatient treatment dental treatment on August 3, 1966, the Veteran was "progressing well." He had less edema and no complaints of pain. His fractures of the left zygomatic arch and infraorbital rim "are in very good position and do not need surgical repair." There was no prolapse or diplopia of the left eye. The Veteran was medically cleared to take leave. The Board notes that the absence of contemporaneous records does not preclude granting service connection for a claimed disability. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). The post-service evidence also does not support granting the Veteran's claim of service connection for residuals of a fracture of the left lateral wall of the maxillary atrium, inferior orbital ridge, and zygomatic arch ("residuals of left eye trauma"). Despite the Veteran's assertions to the contrary, this evidence shows that any residuals of left eye trauma currently experienced by him are not related to active service or any incident of service. For example, private eye examination in February 2004 showed visual acuity of 25/20 in the right eye and 20/20 in the left eye. Physical examination of the eyes showed pupils equal, round, and reactive to light and accommodation, no abnormalities of the orbits, white and quiet conjunctivae, deep and clear anterior chambers, clear lenses, normal optic discs, and normal retinas. The diagnoses were myopia, regular astigmatism, presbyopia, and exphoria. On VA cranial nerves examination in July 2005, the Veteran complained of a 5-year history of diplopia. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran reported being struck in the face with a fist while trying to break up a fight between 2 other service members while on active service. "He states he was told there was no time to do surgery as he was getting ready to deploy to Vietnam." He denied being treated for his eye condition or experiencing any residuals until diplopia began 5 years earlier. He described his diplopia as "increasing intermittent horizontal and oblique diplopia, especially when driving." He denied any facial pain, pain or discharge from the eyes, recurrent or chronic sinus infections, or loss of feeling or loss of motor function in any part of his face. Physical examination in July 2005 showed "a slight asymmetry of facial features with a mild drooping of the facial features on the left as when compared to the right," a palpable notching inferonasally in the left orbital ridge which was not tender to palpation, intact and equal extraocular movements in both eyes, intact cranial nerves, " no loss of sensation in any aspect of the face," symmetric movement of all facial muscles on both sides of the face, and no facial muscle paralysis. The impression was old facial fractures of the left lateral wall of the maxillary atrium, inferior orbital ridge, and zygomatic arch with residual diplopia by history and mild asymmetry of facial features. On VA outpatient optometry consult in November 2005, the Veteran's complaints included "some difficulty with distance and near vision." A history of left eye trauma in 1966 "resulting in fractures of the nasal and orbital floor" was noted. "He was left with occasional intermittent diplopia lasting for seconds at a time." The Veteran's visual acuity was 20/25 in the right eye and 20/20 in the left eye. Physical examination showed intermittent exotropia in the left eye, minimal restriction in the left eye "in extreme right gaze," full confrontation fields in both eyes, pupils equal, round, and reactive to light without afferent pupillary defect, normal slit lamp examination, and normal fundi. The diagnoses included orbital trauma with resultant orbital fractures and resultant intermittent left exotropia with intermittent diplopia when the Veteran "breaks fusion." The VA optometrist concluded, "As the diplopia only lasts a few seconds at a time no additional treatment is indicated at this time." On VA eye conditions Disability Benefits Questionnaire (DBQ) in November 2013, the Veteran's complaints included feeling "like the left eye doesn't move completely left when looking left - chronic but getting worse." The VA examiner reviewed the Veteran's electronic claims file, including his service treatment records and post-service VA treatment records. The Veteran's in-service left eye trauma was noted. Visual acuity testing showed 20/40 vision in both eyes (corrected and uncorrected). Physical examination showed pupils equal, round, and reactive to light and accommodation, no afferent pupillary defect, no diplopia, normal conjunctiva, corneas, anterior chambers, irises, lenses, fundi, and no visual field defects. There was a questionable slight adduction weakness in the left eye. There also was grossly apparent exotropic deviation of the left eye. The VA ophthalmologist stated that the Veteran's current exotropia was not present at the time of his in-service left eye injury in August 1966 because no diplopia or exotropia was noted at that time. The diagnoses included diplopia, exotropia, and a history of a zygomatic complex fracture of the left eye. On VA eye diseases DBQ in January 2015, the Veteran complained that his left eye had not "aligned properly" since he was hit in the left eye during boot camp. The VA examiner reviewed the Veteran's electronic claims file, including his service treatment records and post-service VA treatment records. Visual acuity was 20/70 uncorrected distance vision in both eyes, 20/100 uncorrected near vision in both eyes, and 20/40 corrected distance and near vision in both eyes. Physical examination showed pupils equal, round, and reactive to light and accommodation, no afferent pupillary defect, intermittent left exotropia with diplopia "when looking left and down" which was greater than 40 degrees laterally, normal conjunctiva, corneas, anterior chambers, irises, lenses, fundi, and no visual field defects. The diagnosis was a normal left eye. The Board notes here that, because it previously found an October 2015 VA clinician's opinion to be less than probative, this opinion will not be discussed and was not relied upon in adjudicating the Veteran's claim. On VA eye conditions DBQ in April 2017, the Veteran's complaints included that his left eye "crosses a lot and I get involuntary double vision" including when bending over. The VA examiner reviewed the Veteran's electronic claims file, including his service treatment records and post-service VA treatment records. The Veteran's in-service left eye trauma was noted. Visual acuity was 20/50 corrected to 20/40 or better in distance and near vision in the right eye, 20/40 or better uncorrected distance vision corrected to 20/40 or better in the left eye, and 20/70 corrected to 20/40 or better in near vision in the left eye. Physical examination showed pupils equal, round, and reactive to light and accommodation, no afferent pupillary defect, no diplopia, 3 mm ptosis in the left eyelid without decreased visual acuity or other visual impairment, bilateral pre-operative bilateral cataracts without decreased visual acuity or other visual impairment, normal conjunctiva, corneas, anterior chambers, irises, fundi, and no visual field defects. The VA examiner stated that the Veteran's fractures of the inferior orbital ridge and zygomatic arch had resolved. This examiner also stated that the Veteran's slight decrease in visual acuity was "related to aging and is correctable with glasses." This examiner stated further that the Veteran had monocular exotropia in the left eye but no diplopia in either of his eyes. The diagnoses were monocular exotropia in the left eye, ptosis in the left eye, and bilateral cataracts. On VA sinusitis/rhinitis DBQ in April 2017, the Veteran's complaints included "double vision when looking to [the] left side." The VA examiner reviewed the Veteran's electronic claims file, including his service treatment records and post-service VA treatment records. Physical examination showed a traumatic deviated nasal septum with less than 50 percent obstruction on both sides. X-rays showed a mild deviated nasal septum. The diagnoses were deviated nasal septum and old fracture of the left maxillary bone. In a May 2017 addendum to the April 2017 VA eye conditions DBQ, the VA ophthalmologist who conducted this DBQ stated that he had reviewed the Veteran's electronic claims file, including his service treatment records and post-service VA treatment records, again. This VA examiner opined that the Veteran's currently diagnosed eye disabilities (exotropia, cataracts, and ptosis) were not related to active service or any incident of service, to include the fractures of the left orbital wall, maxillary atrium, inferior orbital ridge, and zygomatic arch. The rationale for this opinion was that exotropia was "a centrally controlled fusion center in the brain, not from any pathology in the orbit, or related to previous fracture." The rationale also was that exotropia was not found on exams conducted immediately after the in-service fractures. The rationale further was that there was no pathological link between the Veteran's in-service injuries "and the development of cataracts because they are not traumatic." The rationale finally was that ptosis was not found on exams conducted immediately after the in-service fractures and was not seen on the March 2013 examination. The VA examiner stated instead that the Veteran's currently diagnosed eye disabilities were most likely due to another etiology. In a May 2017 addendum to the April 2017 VA sinusitis/rhinitis DBQ, a VA clinician stated that he had reviewed the Veteran's electronic claims file, including his service treatment records and post-service VA treatment records. This clinician opined that it was less likely than not that the Veteran's deviated nasal septum was related to active service or any incident of service, to include the fractures of the left orbital wall, maxillary atrium, inferior orbital ridge, and zygomatic arch. The rationale for this opinion was that the April 2017 examination had shown only a deviated nasal septum and, although the Veteran clearly fractured his left orbital rim, left maxillary sinus, and left zygomatic arch in service, he did not require surgery and no deviated nasal septum was noted at that time. The rationale also was that a 2009 examination showed that the Veteran's nasal septum was normal at that time. The Veteran contends that he currently experiences residuals of left eye trauma which are related to active service. The record evidence does not support his assertions regarding an etiological link between any current eye or nasal disabilities (variously diagnosed as monocular exotropia in the left eye, ptosis in the left eye, bilateral cataracts, and deviated nasal septum) and active service or any incident of service. The Board acknowledges here that the Veteran fractured his left lateral wall, maxillary atrium, inferior orbital ridge, and zygomatic arch in August 1966 while on active service. The Board also acknowledges that the Veteran currently is diagnosed as having and treated for monocular exotropia in the left eye, ptosis in the left eye, bilateral cataracts, and deviated nasal septum. The medical evidence clearly shows that none of the Veteran's current eye or nasal disabilities are related to active service or any incident of service. The April 2017 VA eye conditions DBQ examiner specifically found that the Veteran's fractures of the inferior orbital ridge and zygomatic arch had resolved. This examiner also stated that the Veteran's slight decrease in visual acuity seen at that examination was "related to aging and is correctable with glasses." This examiner subsequently opined in May 2017 that the Veteran's currently diagnosed eye disabilities (exotropia, cataracts, and ptosis) were not related to active service or any incident of service. A different VA examiner opined in May 2017 that the Veteran's currently diagnosed deviated nasal septum was not related to active service or any incident of service. All of these opinions were fully supported. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (finding that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The Veteran also has not identified or submitted any evidence demonstrating his entitlement to service connection for residuals of a fracture of the left lateral wall of the maxillary atrium, inferior orbital ridge, and zygomatic arch. In summary, the Board finds that service connection for residuals of a fracture of the left lateral wall of the maxillary atrium, inferior orbital ridge, and zygomatic arch is not warranted. The Board next finds that the preponderance of the evidence is against granting the Veteran's claim for an initial rating greater than 30 percent prior to September 8, 2007, greater than 50 percent from September 8, 2007, to August 27, 2008, from November 1, 2008, to January 29, 2010, and from April 1, 2010, to March 13, 2013, and greater than 70 percent from March 13, 2013, to November 27, 2015, for PTSD. The Veteran essentially contends that his service-connected PTSD is more disabling than currently (and initially) evaluated during each of the time periods at issue in this appeal. The record evidence does not support the Veteran's assertions. It shows instead that, prior to September 8, 2007, his service-connected PTSD is manifested by, at worst, complaints of trouble falling and staying asleep, nightmares several times a week, and anger outbursts. For example, on VA outpatient treatment on November 17, 2004, the Veteran complained that he was unable to manage "his bad dreams or painful memories" of serving in combat in Vietnam. He also complained of easy irritation, a short fuse, mood swings, and anger outbursts. He had a good relationship with his current wife and had been married to her for 7 years. Mental status examination of the Veteran showed full orientation, appropriate dress and grooming, unremarkable speech, logical and goal directed thoughts, no delusions or hallucinations, no suicidal or homicidal ideation, and "somewhat limited insight of his conditions." The Veteran's Global Assessment of Functioning (GAF) score was 50, indicating serious symptoms or any serious impairment in social, occupational, or school functioning. The Axis I diagnoses included chronic combat-related PTSD. On VA PTSD examination on November 27, 2004, the Veteran's complaints included being depressed, decreased sleep, "bad dreams when he would wake up sweaty and cannot recall anything about the dream but he thinks it is related to combat." The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran reported working for 27 years for Pepsi Cola Company but had been unemployed for 2 years. He had been married 3 times and had been married to his current wife since 1996. "He states that he gets along well and has been having a fantastic relationship with his family." The Veteran stated that he did not have a lot of friends "because he needs to know the person before he makes him a friend." He denied having any intrusive thoughts or flashbacks. He participated "in significant activities" and "reports having some problem with his concentration. He does not keep his guard up all the time and does not have any increased startle response." He had decreased energy, interests, concentration, "and occasionally feeling hopeless and worthless." Mental status examination of the Veteran on November 27, 2004, showed he was calm, cooperative, pleasant, good personal hygiene, no abnormal movements, normal speech, logical thought process, no looseness of associations, no flight of ideas, no suicidal or homicidal ideation, no hallucinations, delusions, or paranoia, full orientation, and fair insight and judgment. The Veteran's GAF score was 70, indicating some mild symptoms or some difficulty in social, occupational, or school functioning but generally functioning pretty well and with some meaningful interpersonal relationships. The VA examiner concluded that the Veteran did not meet the DSM-IV criteria for PTSD. The Axis I diagnosis was depressive disorder, not otherwise specified. On VA PTSD examination in May 2005, the Veteran's complaints included continued nightmares several times a week where he "wakes up from these nightmares in sweats and has a hard time going back to sleep. In the daytime, he claims he has anxiety attacks on exposure to events that remind him of Vietnam. He claims he has tightness of his chest and starts smelling an odor at that time." The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran reported increased irritability and anger outbursts "which is his main concern at this time." The Veteran's 3 marriages, including his current marriage, were noted. "He is mostly verbally abusive and denies any physically abusive behaviors." He was very active in his church and went there 3-4 times a week. He also spent time working around his house and "enjoys playing golf with his friends from time to time." Mental status examination of the Veteran in May 2005 showed good eye contact, "somewhat loud but coherent and logical" speech, logical and goal-directed thought processes, no auditory or visual hallucinations, no paranoia, no suicidal or homicidal ideation, full orientation, intact recent and remote memory, and fair concentration, insight, and judgment. The Veteran's GAF score was 65, indicating some mild symptoms. The Axis I diagnosis was mild PTSD. On VA outpatient treatment in June 2005, the Veteran's complaints included "nightmares and some panic symptoms including a recent anxiety attack at church." Objective examination showed an irritable and dysphoric mood, no suicidal ideation, normal speech and thoughts, logical and coherent thought process, no hallucinations or delusions, and full orientation. The assessment was chronic PTSD. The Veteran was advised to start taking clonazepam. In November 2005, the Veteran complained of "brief panic spells during the day" which lasted for seconds at a time. He reported improved sleep after taking clonazepam. Objective examination showed a less irritable and dysphoric mood, no suicidal or homicidal ideation, less hyperactive motor activity, no psychotic signs, and full orientation. The assessment included chronic PTSD. In June 2006, the Veteran's complaints included "some memory and concentration problems" and "a lot of irritability." Objective examination showed he was neatly dressed, good eye contact, a tense and irritable mood "but calmer in recent weeks," fluent and productive speech, no hallucinations, and a clear sensorium. The assessment included chronic PTSD. In October 2006, the Veteran's complaints included 2 panic attacks in the previous week since starting a new job, continued "temper outbursts which affect him at work and at home," social isolation, sleep disrupted by nightmares "which are violent and wake up memories of his" service in Vietnam. Objective examination showed he was casually dressed, cooperative, good eye contact, a very irritable mood, reported recent panic attack episodes, no suicidal thinking, productive speech, logical and coherent thought process, no perceptual disturbances or delusions, and full orientation. The assessment included chronic PTSD. In February 2007, the Veteran's wife accompanied him to his outpatient treatment visit and reported that "he lost another job because of his anger." The Veteran "agrees that he is still very irritable and cannot control his short fuse." The Veteran's wife also reported that he was having tearful episodes but would not talk to her about them. Objective examination showed he was casually and neatly attired, a tense and constricted affect, a very irritable and somewhat depressed mood, no suicidal ideation, productive and goal-directed speech, logical and coherent and thought processes, no hallucinations or delusions, and full orientation. The assessment was unchanged. In May 2007, the Veteran reported that he had a new job but "still having anger outbursts at home" which he and his wife are able to talk about "without escalation." He reported 2 panic episodes in the previous month "which is better than before. He feels the current medication plan is helping" him. Objective examination showed he was casually dressed, cooperative, goal directed and normal speech, a reported irritable and dysphoric mood, no suicidal ideation, logical and coherent thought process, "no motor changes except for his limp on the left side," no hallucinations or delusions, and full orientation. The assessment was unchanged. The Veteran contends that his service-connected PTSD is more disabling than currently (and initially) evaluated prior to September 8, 2007. The record evidence does not support his assertions. It shows instead that, prior to September 8, 2007, this service-connected disability is manifested by, at worst, complaints of trouble falling and staying asleep, nightmares several times a week, and anger outbursts. The Veteran himself reported at his November 2004 VA examination that he had a "fantastic relationship with family." His GAF score of 70 at that examination reflected only mild symptoms of reported increased depression and decreased sleep. Subsequent VA examination in May 2005 documented complaints of nightmares several times a week, daytime anxiety attacks, difficulty falling and staying asleep, and anger outbursts; however, the Veteran also reported that he was very active at church and was diagnosed as having only mild PTSD with a GAF score of 65 also reflecting mild symptoms. The Veteran's VA outpatient treatment records dated prior to September 8, 2007, show that his sleep improved after he started taking clonazepam although he also reported ongoing anger or temper outbursts at home and work and very brief episodes of panic or panic attacks which occurred less than twice a month. The Veteran stated in May 2007 that his current PTSD medications were helping his symptoms. There is no indication that, prior to September 8, 2007, the Veteran experienced occupational and social impairment with reduced reliability and productivity, deficiencies in most areas, or total occupational and social impairment (i.e., a 50, 70, or 100 percent rating under DC 9411) due to his service-connected PTSD such that an initial rating greater than 30 percent is warranted for this time period. See 38 C.F.R. § 4.130, DC 9411 (2017). There also is no indication that, prior to September 8, 2007, the Veteran experienced symptoms of similar frequency, severity, and duration as are required for an initial rating greater than 30 percent for PTSD during this time period. See also Vazquez-Claudio v. Shinseki, 713 F. 3d 112 (Fed. Cir. 2013). The Veteran further has not identified or submitted any evidence demonstrating his entitlement to an initial rating greater than 30 percent prior to September 8, 2007, for his service-connected PTSD. Thus, the Board finds that the criteria for an initial rating greater than 30 percent prior to September 8, 2007, for PTSD have not been met. The Veteran also is not entitled to an initial rating greater than 50 percent effective from September 8, 2007, to August 27, 2008, from November 1, 2008, to January 29, 2010, and from April 1, 2010, to March 13, 2013, for his service-connected PTSD. The Board notes initially that, because the Veteran is in receipt of a temporary total (100 percent) disability rating for his service-connected PTSD between August 27, 2008, and October 31, 2008, and from January 30, 2010, to March 30, 2010, there is no higher initial rating for consideration during these time periods. The Board next notes that, despite the Veteran's assertions to the contrary, the record evidence does not show that his service-connected PTSD warrants a higher initial rating than 50 percent from September 8, 2007, to August 27, 2008, from November 1, 2008, to January 29, 2010, or from April 1, 2010, to March 13, 2013. It shows instead that this disability is manifested by, at worst, worsening social withdrawal and isolation, daily anger outbursts, and panic attacks more than once a week during each of these time periods. For example, on VA PTSD examination on September 8, 2007, the Veteran reported increased social withdrawal and isolation, increased anger leading to verbal altercations, memory impairment, and difficulty staying asleep. "His most significant subjective complaint is that there are periods where he would get very angry for little or no provocation and he would become irate and get into verbal altercations to the point of sometimes making a fist." These episodes lasted no more than 2 minutes "and after that he feels remorseful." The Veteran reported working 50-55 hours a week in his current job for the previous 5 months although he had been fired from another job "for becoming angry and using profanity." He got along well with his wife and talked to 3 grown children who lived out of state. He reported becoming "more and more withdrawn and isolative. He stated that this is a change for him and that he used to be quite outgoing in the past. He has no leisure time activities and he stated that he simply sits doing nothing." Mental status examination of the Veteran on September 8, 2007, showed he was casually dressed, adequately groomed, no impairments of thought process or communication, no delusions although he reported seeing shadows occasionally up to 5 times a week but not at all in the previous few weeks, good eye contact, no inappropriate behavior, no suicidal or homicidal ideation, a grossly intact ability to maintain adequate personal hygiene and other activities of daily living, full orientation, memory impairment, normal speech, logical, coherent, and goal-directed thought processes, reported "panic attacks which occur at variable intervals usually associated with his visual phenomenon of seeing shadows," readily anxious, and difficulty staying asleep. He was a regular churchgoer "but does not get involved in any activities there." The Veteran's GAF score was 60, indicating moderate symptoms or moderate difficulty in social, occupational, or school functioning. The Axis I diagnosis was PTSD. The Veteran was an inpatient at a VA domiciliary treatment program for PTSD between August 27, 2008, and October 17, 2008. At discharge, the Veteran's Axis I diagnosis was chronic PTSD and his GAF score was 50-55, indicating serious to moderate symptoms. On VA PTSD examination in July 2009, the Veteran's complaints included ongoing anger/irritability, severe social withdrawal and isolation, and memory difficulties. He reported daily anger outbursts which caused his relationships with others to suffer, including an estrangement from his sister due to his verbal outbursts, conflict with 2 other Vietnam Veterans whom he considered his friends, and daily arguments with his wife. He also reported flashbacks, sporadic nightmares, and concentration difficulties. He retired early from his most recent job in March 2008 "due to feeling 'fed up' with it." He had "superficial and short conversations with his [adult] children on the phone a few times per week." Mental status examination of the Veteran showed appropriate dress and grooming, full orientation, no reported problems with activities of daily living, appropriate eye contact, normal rate of speech "somewhat harsh in tone," no inappropriate behavior, no psychosis, obsessive or ritualistic behavior, or panic attacks, "basically logical" thoughts with "a tendency to ramble and become unfocused during conversation," no suicidal or homicidal ideation, fair impulse control, somewhat impaired sleep with multiple reported awakenings at night, and an "essentially intact" memory. The Veteran's GAF score was 50, indicating serious symptoms. The VA examiner concluded that the Veteran's impairment due to his PTSD had worsened since his most recent examination in September 2007 due to more pronounced social isolation and worsening interpersonal relationships. The Axis I diagnoses included PTSD. Subsequent VA outpatient treatment records dated in 2009-2010 show ongoing complaints of and treatment for chronic PTSD. The Veteran himself reported continuing problems with irritability which led to frequent arguments with his wife. The Veteran was hospitalized at a VA Medical Center from January 29, 2010, to March 10, 2010, for treatment of his service-connected PTSD. On VA outpatient treatment on April 9, 2010, the Veteran reported feeling better about dealing with his anger following the completion of a 6-week inpatient PTSD program at a VA Medical Center from January to March 2010. He also reported adjustment problems at home with his wife "and he is still reluctant to 'socialize'" since his discharge. He was "sleeping much better and less irritable." Objective examination showed he was well-dressed, cooperative, a less irritable and dysphoric mood, no suicidal or homicidal ideation, goal-directed and relevant speech, logical and coherent thought process, and full orientation. The assessment was chronic PTSD. The Veteran testified at his July 2010 Board hearing that he experienced multiple daily anxiety attacks due to his his service-connected PTSD. See Board hearing transcript dated July 19, 2010, at pp. 4. He also testified that his service-connected PTSD limited his social activities. Id., at pp. 6. The Veteran's wife testified that her husband got angry very quickly and very often. Id., at pp. 9-10. On VA outpatient treatment in December 2010, the Veteran reported experiencing less intense anxiety attacks due to a new medication. "He is more engaged and more of a participant in getting better." Objective examination and the assessment were unchanged. In April 2011, the Veteran reported ongoing problems with anxiety and "socialization." Objective examination and the assessment were unchanged. On VA PTSD DBQ in May 2012, the Veteran's complaints included panic attacks and nightmares. The VA examiner reviewed the Veteran's electronic claims file, including his service treatment records and post-service VA treatment records. This examiner stated that the Veteran's PTSD symptoms were panic attacks more than once a week and an inability to establish and maintain effective relationships. The Veteran lost his most recent job due to his vocational frustrations and becoming easily annoyed. He reported that "he was verbally abusive" at his last job. The VA examiner concluded that the Veteran experienced, at worst, occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks. The Veteran's GAF score was 60. The Axis I diagnosis was PTSD. Subsequent VA outpatient treatment records dated in 2012-2013 show the Veteran's ongoing complaints of anxiety and difficulty sleeping. For example, in December 2012, he reported waking up hourly overnight. The VA clinician increased the Veteran's buspirone to 40 mg daily and started him on trazodone to help his insomnia. Following subsequent VA outpatient treatment in January 2013, the Veteran's buspirone was increased to 60 mg daily and his trazodone was increased to 150 mg at bedtime. Mental status examinations of the Veteran conducted during this timeframe repeatedly showed he was alert, appropriately groomed, good eye contact, normal motor activity, clear speech, no memory problems, logical/coherent thoughts, age appropriate judgment and insight, impulse control within normal limits, and no suicidal or homicidal ideation. The Board acknowledges that VA PTSD examination on September 8, 2007, documented worsening symptoms attributable to the Veteran's service-connected PTSD, warranting an initial 50 percent rating under DC 9411 effective on that date. See 38 C.F.R. § 4.130, DC 9411 (2017). Despite the Veteran's assertions to the contrary, however, the record evidence does not support the assignment of an initial rating greater than 50 percent effective from September 8, 2007, to August 27, 2008, from November 1, 2008, to January 29, 2010, and from April 1, 2010, to March 13, 2013, for his service-connected PTSD. It shows instead that this disability is manifested by, at worst, worsening social withdrawal and isolation, daily anger outbursts, and panic attacks more than once a week during each of these time periods. The Veteran's GAF scores obtained during this time period reflect that his symptoms were moderately to seriously disabling. His ongoing problems with anger outbursts towards his family also are well documented during this time period. The July 2009 VA examiner specifically concluded that the Veteran's impairment due to his PTSD had worsened since his most recent examination in September 2007 due to more pronounced social isolation and worsening interpersonal relationships. Although the Veteran reported in April 2010 that his symptoms had improved following completion of a 6-week inpatient treatment program (for which he is in receipt of a temporary total (100 percent) disability rating), he also reported adjustment problems at home with his wife and a reluctance to participate in social activities following his discharge from this program. The May 2012 VA examiner concluded that the Veteran experienced, at worst, occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks (i.e., a 30 percent rating under DC 9411). See 38 C.F.R. § 4.130, DC 9411 (2017). The Veteran continued reporting ongoing problems with anxiety and difficulty sleeping on subsequent VA outpatient treatment visits conducted after this examination, however, which suggests persuasively that his service-connected PTSD symptomatology was more disabling than what the VA examiner noted in May 2012. These complaints also prompted the Veteran's VA treating clinicians to increase his medication dosages during this time period. Taken together, the record evidence dated from September 8, 2007, to August 27, 2008, from November 1, 2008, to January 29, 2010, and from April 1, 2010, to March 13, 2013, shows that the Veteran's service-connected PTSD merited an initial 50 percent rating during these time periods under DC 9411. Id. It does not show that the Veteran experienced either occupational and social impairment with deficiencies in most areas or total occupational and social impairment (i.e., a 70 or 100 percent rating under DC 9411) such that an initial rating greater than 50 percent is warranted from September 8, 2007, to August 27, 2008, from November 1, 2008, to January 29, 2010, or from April 1, 2010, to March 13, 2013, for PTSD. Id. There also is no indication that, from September 8, 2007, to August 27, 2008, from November 1, 2008, to January 29, 2010, or from April 1, 2010, to March 13, 2013, the Veteran experienced symptoms of similar frequency, severity, and duration as are required for an initial rating greater than 50 percent for PTSD. See also Vazquez-Claudio, 713 F. 3d at 112. The Veteran further has not identified or submitted any evidence demonstrating his entitlement to an initial rating greater than 50 percent from September 8, 2007, to August 27, 2008, from November 1, 2008, to January 29, 2010, or from April 1, 2010, to March 13, 2013, for PTSD. Accordingly, the Board finds that the criteria for an initial rating greater than 50 percent from September 8, 2007, to August 27, 2008, from November 1, 2008, to January 29, 2010, or from April 1, 2010, to March 13, 2013, for PTSD have not been met. The Veteran finally is not entitled to an initial rating greater than 70 percent from March 13, 2013, to November 27, 2015, for PTSD. Despite the Veteran's assertions to the contrary, the record evidence does not indicate that his service-connected PTSD was totally disabling as is required for a 100 percent rating under DC 9411. See 38 C.F.R. § 4.130, DC 9411 (2017). It shows instead that this disability is manifested by, at worst, ongoing irritability, social isolation, anxiety, and depression (as seen on VA PTSD DBQ on March 13, 2013). At this examination, the VA examiner stated that the Veteran "gets angry easily and curses and yells. He stays home mostly and is socially isolated." The Veteran experienced nightmares, flashbacks, diminished interest in activities, and difficulty sleeping. The VA examiner stated that the Veteran's PTSD symptoms were depressed mood, anxiety, suspiciousness, panic attacks weekly or less often, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Mental status examination of the Veteran showed he was alert, casually dressed, neatly groomed, full orientation, no suicidal or homicidal ideation, no thought disorder, no auditory or visual hallucinations, intact cognition, and fair insight and judgment. The VA examiner concluded that the Veteran's level of occupational and social impairment due to his service-connected PTSD was occupational and social impairment with deficiencies in most areas. The Veteran's GAF score was 55, indicating moderate symptoms. The Axis I diagnosis was PTSD. On VA outpatient treatment in April 2013, the Veteran requested that his buspirone be discontinued because it was not helping him. Mental status examination of the Veteran showed he was alert, appropriately groomed, good eye contact, normal motor activity, clear speech, no memory problems, age appropriate judgment, impulse control within normal limits, logical/coherent thoughts, and no suicidal or homicidal ideation. The diagnoses included PTSD. In October 2014, the VA clinician stated, "The Veteran is in a very good mood." The Veteran reported that he had "taken a leadership/service position with the men of his church and next month will be giving a lecture for them." Mental status examination of the Veteran showed appropriate/good hygiene, episodic anxiety, a content mood, full orientation, no perceptual distortions, logical thought processes, thought content within normal limits, and good judgment and insight. The diagnosis was PTSD with panic attacks. The Veteran essentially contends that his service-connected PTSD has been totally disabling since March 13, 2013, entitling him to an initial rating greater than 70 percent between March 13, 2013, and November 27, 2015 (when a 100 percent scheduler rating was assigned for this disability) under DC 9411. See 38 C.F.R. § 4.130, DC 9411 (2017). The record evidence does not support his assertions. It shows instead that, throughout this time period, the Veteran's service-connected disability is manifested by, at worst, ongoing irritability, social isolation, anxiety, and depression. Although the Veteran reported on VA examination on March 13, 2013, that he was increasingly socially isolated and preferred to stay at home, he subsequently reported in October 2014 that he had taken a leadership position at his church and would be giving a lecture to other church members in the near future. This suggests that the Veteran's social isolation had lessened. The March 2013 VA examiner specifically found that the Veteran's occupational and social impairment due to his service-connected PTSD equated to a 70 percent rating under DC 9411. Id. The Veteran's GAF score of 55 at his March 2013 VA examination also suggested, at worst, the presence of moderately disabling symptoms attributable to his service-connected PTSD. More importantly, there also is no indication that, between March 13, 2013, and November 27, 2015, the Veteran experienced symptoms of similar frequency, severity, and duration as are required for an initial rating greater than 70 percent for PTSD. See also Vazquez-Claudio, 713 F. 3d at 112. The Veteran further has not identified or submitted any evidence demonstrating his entitlement to an initial rating greater than 70 percent from March 13, 2013, to November 27, 2015, for PTSD. Accordingly, the Board finds that the criteria for an initial rating greater than 70 percent from March 13, 2013, to November 27, 2015, for PTSD have not been met. ORDER Entitlement to service connection for residuals of a fracture of the left lateral wall of the maxillary atrium, inferior orbital ridge, and zygomatic arch is denied. Entitlement to an initial rating greater than 30 percent prior to September 8, 2007, greater than 50 percent from September 8, 2007, to August 27, 2008, from November 1, 2008, to January 29, 2010, and from April 1, 2010, to March 13, 2013, and greater than 70 percent from March 13, 2013, to November 27, 2015, for PTSD is denied. ____________________________________________ R. FEINBERG Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs