Citation Nr: 1807527 Decision Date: 02/06/18 Archive Date: 02/14/18 DOCKET NO. 14-15 268A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a rating in excess of 30 percent prior to August 18, 2017 and in excess of 50 percent thereafter for service-connected posttraumatic migraine headaches. 2. Entitlement to a rating in excess of 30 percent prior to August 18, 2017 and in excess of 50 percent thereafter for service-connected posttraumatic stress disorder (PTSD) with alcohol abuse with alcohol induced anxiety disorder (previously rated as generalized anxiety disorder and PTSD) (hereinafter, PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. Connor, Counsel INTRODUCTION The Veteran served on active duty from September 1983 to January 1984. This appeal to the Board of Veterans' Appeals (Board) is from a May 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. During the course of the appeal, in a November 2017 rating decision, the RO increased the Veteran's service-connected posttraumatic migraine headaches disability rating to 50 percent, effective August 18, 2017, and increased the Veteran's service-connected PTSD disability rating to 50 percent, effective from August 18, 2017. The Veteran continues his appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Veteran was also assigned a total disability rating based on individual unemployability. He has not expressed disagreement with the assigned effective date (February 11, 2006). FINDINGS OF FACT 1. For the entire period on appeal, the Veteran was shown to suffer from very frequent prostrating attacks of headaches productive of severe economic inadaptability. 2. For the period prior to September 25, 2016, the Veteran's PTSD was productive of no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; higher levels of occupational and social impairment are not demonstrated. 3. For the period from September 25, 2016, the Veteran's PTSD is manifested by an occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as near-continuous panic or 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 an inability to establish and maintain effective relationships. CONCLUSIONS OF LAW 1. For the entire period on appeal, the criteria for a rating of 50 percent for posttraumatic migraine headaches have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.124a, Diagnostic Code 8100 (2017). 2. Prior to September 25, 2016, the criteria for a disability rating in excess of 30 percent for service-connected PTSD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.130, Diagnostic Code 9400, 9411 (2017). 3. From September 25, 2016, the criteria for a disability rating of 70 percent, but no higher, for service-connected PTSD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.130, Diagnostic Code 9400, 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that all the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Increased Ratings Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). The Veteran's entire history is reviewed when making a disability determination. 38 C.F.R. § 4.1 (2017). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in such cases when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability at issue and such symptoms warrant different evaluations, staged evaluations may also be assigned. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Headaches Under Diagnostic Code 8100, a maximum disability rating of 50 percent is warranted for very frequent completely prostrating attacks productive of severe economic inadaptability. A 30 percent disability rating is warranted when there is evidence of characteristic prostrating attacks occurring on average once a month over the last several months. 38 C.F.R. §4.124a, DC 8100. (The rating criteria do not define "prostrating;" however, Dorland's Illustrated Medical Dictionary defines "prostration" as "extreme exhaustion or powerlessness." See Dorland's Illustrated Medical Dictionary 1531 (32nd ed. 2012)). During an October 2010 VA examination, the Veteran reported headaches about 3 to 4 times a month that last 30 minutes to several hours. He noted nausea with the headaches and sometimes vomiting. The Veteran denied visual symptoms and extremity weakness or loss of consciousness. Although he was previously prescribed daily medication, it was discontinued and he was, at that time, treated on an "as needed" basis with Imitrex. The examiner found no significant increase or worsening in the Veteran's neurological status. During a VA neurology consultation in November 2010, the Veteran reported that he was getting one weekly headache for the previous 2 months with some relief from Imitrex. In the previous 10 days, he reported 2 headaches with no help from the medication. In March 2011, the Veteran reported getting two bad headaches per week. In October 2011, he reported continued headaches but less severe with the addition of Topamax. He indicated he still had about one severe headache per week lasting about 7 hours with nausea and occasional vomiting. In January 2012, the Veteran reported at least 2 or 3 severe headaches a week. He stated that he was trying acupuncture for relief. In October 2013, the Veteran noted that his headaches seemed to have been worsened by a recent change in medication. Additionally, there was increased nausea since the medication change. In January 2014, a neurology procedure note documents his "monthly" nerve block to assist with headache pain. The Veteran reported only 2 weeks of relief before the headaches returned. In July 2015, the Veteran indicated that he had four headaches per week that require medication. The Veteran said the headaches affect both sides of the head and the pain lasts for more than 4 hours with associated photophobia, sonophobia, and nausea. During a VA examination in June 2016, the examiner noted the Veteran's use of prescribed medication for his migraine headaches. The Veteran reported pulsating or throbbing pain on both sides of the head that has associated sensitivity to light, sensitivity to sound, changes in vision, and sensory changes. The duration of the pain was typically less than 1 day. The examiner found that the Veteran has prostrating attacks of non-migraine attacks more frequently than once per month, but did not consider them very frequent and prolonged attacks. The Veteran stated that he had an inability to focus when having headaches which interfered with his ability to work. In August 2016, the Veteran reported migraines occurring more than 15 days per month. He was on a botulinum toxin injection regimen every 3 months. During a VA examination in July 2017, the Veteran indicated he had headaches on the left side that were pulsating about 4 or 5 times weekly. They can last all day and have associated sound, light, and vision changes. He reported that the headaches were more frequent over the years. The examiner noted that the Veteran had headache pain on both sides of the head that last less than one day; however, the examiner found that the migraines were not manifested by characteristic prostrating attacks. The examiner also indicated that the Veteran's headaches do not impact his ability to work. During the most recent VA examination in October 2017, the Veteran described pulsating or throbbing head pain on both sides of the head that worsens with physical activity. The headaches had associated nausea, sensitivity to light, sensitivity to sound, and changes in vision. The examiner characterized the Veteran's headaches as very prostrating and prolonged attacks of migraine pain productive of severe economic inadaptability. Based on the above, in affording the Veteran the benefit of the doubt, the Board finds that a rating of 50 percent is warranted for the Veteran's service-connected chronic headaches for the entire appeal period. The Veteran has consistently reported at least weekly migraines with associated sensitivity to light and sound and cause vision changes. He is competent to report on symptoms which are capable of lay observation including symptoms of severe, recurrent head pain. Layno v. Brown, 6 Vet. App. 465 (1994). The Board finds such reports credible and probative of his level of severity of headache pain. The Board recognizes that the examiners did not find the Veteran's headaches to be include very prostrating and prolonged attacks productive of severe economic inadaptability prior to October 2017. However, while there was some discussion in the record of the Veteran being prescribed several medications for her headaches, the ameliorative effects of the medication were not considered by the examiners. See Jones v. Shinseki, 26 Vet. App. 56 (2012). Tthe Veteran's treatment records show continuous, regular treatment for weekly migraines, including prescribed medication, nerve blocks, acupuncture, and botulinum toxin injections. The Veteran repeatedly notes that all efforts are temporary and that he maintains very frequent headaches that interfere with his ability to focus. He further noted only partial relief from pain medications. Accordingly, and resolving all doubt in his favor, the Board finds that a 50 percent disability rating is warranted for the entire appeal period. This is the maximum schedular rating for migraines. Anxiety Disorder The Veteran's PTSD with alcohol abuse with alcohol induced anxiety disorder was rated as 30 percent disabling under Diagnostic Code 9400 for generalized anxiety disorder prior to August 18, 2017. Thereafter, the rating was increased to 50 percent under Diagnostic Code 9411 for PTSD. Both generalized anxiety disorder and PTSD are rated under the General Rating formula for Mental Disorders. See 38 C.F.R. § 4.130, Diagnostic Codes 9400, 9411. Under these criteria, a 30 percent disability rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to particular symptoms such as: flattened affect; circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating for anxiety disorder is warranted where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent rating for anxiety disorder is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. In addition, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a) (2017). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b). The Board notes that with regard to the use of the phrase "such as" in 38 C.F.R. § 4.130 (General Rating Formula for Mental Disorders), ratings are assigned according to the manifestations of particular symptoms. However, the use of the phrase "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve only as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The United States Court of Appeals for the Federal Circuit emphasized that the list of symptoms under a given rating is a non exhaustive list, as indicated by the words "such as" that precede each list of symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). It held 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. Other language in the decision indicates that the phrase "others of similar severity, frequency, and duration," can be thought of as symptoms of like kind to those listed in the regulation for a given disability rating. Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the Diagnostic and Statistical Manual of Mental Disorders. VA has implemented DSM-5. The Secretary of VA, however, has determined that DSM-5 does not apply to claims certified to the Board prior to August 4, 2014, such as in the instant appeal. See 79 Fed. Reg. 45, 093, 45,094 (Aug. 4, 2014). Hence, this appeal is governed by DSM-IV. Under the DSM-IV, one factor for consideration is the GAF score, which is based on a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), page 32). GAF scores ranging from 61 to 70, reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). GAF scores ranging from 31 to 40 reflects some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant), or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). A VA psychiatry note from November 2010 indicates that the Veteran reported depression, anxiety, insomnia, nightmares, flashbacks, and intrusive thoughts. He noted temper problems, crying spells, and intrusive thoughts. He also indicated he was back to work. A GAF score of 55 was assigned. VA treatment in May 2011 indicates that the Veteran brought his youngest child to the appointment. He was relaxed with no stresses since he retired. The examiner described the Veteran as cooperative, responsive, coherent, and goal-directed with good eye contact. There were no mood or anxiety manifestations and he had a full range of affect. There were no psychotic features identified and the Veteran denied suicidal and homicidal ideation. He was alert and oriented with good memory, insight, and judgment. A GAF score of 60 was assigned. Treatment in January 2012 indicated that the Veteran had a good attitude and good eye contact. He was coherent, goal-directed, and alert and oriented (times 3). There were no mood or anxiety manifestations and he had a stable affect with no psychotic features. He had good memory, insight, and judgment. A GAF score of 68 was assigned. During a VA examination in April 2012, the examiner noted that the Veteran was diagnosed with generalized anxiety disorder and assigned a GAF score of 60. The examiner found that the Veteran's anxiety was productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care, and conversation. The Veteran reported having 4 children; he was estranged from the oldest, had some contact with another, and had regular contact with the youngest 2. The Veteran stated that he was not currently in a relationship but that he had friends that he socialized with. The Veteran was unemployed at the time of the examination. He was in bimonthly therapy and prescribed medication. He reported feeling anxious, restless and on edge, fatigued, having difficulty concentrating, irritability, and sleep difficulty. The Veteran had mild memory loss but was capable of managing his financial affairs. During VA treatment in September 2013, the Veteran reported that he traveled to New York to visit a friend that was ill but that the friend passed away before he arrived. The Veteran reported he was coping adequately to this event. The examiner indicated that the Veteran was dressed appropriately with appropriate grooming. His motor activity was described as "anxious" and he was cooperative. His speech was of normal rate and volume and his mood was okay with a broad affect. He was oriented (times 4) with normal attention and concentration. Both recent and remote memory were intact and his thought process was normal with no evidence of auditory or visual hallucinations or delusional thoughts. Judgment, insight, and impulse control were fair. He denied suicidal and homicidal ideation. A GAF score of 58 was assigned. In February 2014, the Veteran reported nightmares and hearing voices of those who were in the in-service accident with him. He denied suicidal and homicidal ideation. He was described as oriented (times 3) and appeared his stated age. He was neatly groomed, cooperative, had normal eye contact, and was focused and calm. His remote and recent memory were grossly intact. His speech was a normal rate and volume, his cognition logical, and his thought content realistic and coherent. There was no evidence of psychosis and his judgment and insight were intact. His mood was depressed with a consistent affect. In July 2015, the Veteran reported having flashbacks 2 or 3 times a day. He stated that he likes to cook but had no interest "in anything" lately. He denied suicidal and homicidal ideation. He was described as oriented (times 4) and appeared his stated age. He was neatly groomed, dressed appropriately, cooperative, and was focused and fidgeting. His remote and recent memory were grossly intact. His speech was spontaneous with a normal rate, his cognition logical, and his thought content realistic. He reported hallucinations in terms of hearing his sergeant calling him. His actions were contrary to his desired outcomes but he recognized the relationship between his behavior and his emotional state. His mood was anxious with a consistent affect. In February 2016, the Veteran reported that he and his ex-girlfriend moved back in together in December 2015. He said it was a challenge because he had a strong desire to isolate. The Veteran denied suicidal ideation but said he had fleeting thoughts about once a week. When that happened, he would call a friend in New York who he talked to at least twice a week. The Veteran denied current suicidal and homicidal ideation. He was described as oriented (times 4) and appeared his stated age. He was neatly groomed, dressed appropriately, cooperative, and was focused and fidgeting. His remote and recent memory were grossly intact. His speech was clear, slow, and soft, his cognition logical, and his thought content realistic and coherent. There was no evidence of psychosis but he reported auditory or visual hallucinations 2 to 3 times per week. He understood the likely outcomes of his behavior and was self-aware. His mood was guarded and anxious with a consistent affect. During a VA examination in September 2016, the examiner found that the Veteran's depression and PTSD caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. The Veteran reported being married for a couple of months. He was living with his wife and youngest 2 children. He indicated he and his wife were starting to have problems and he had a poor relationship with his children who he said "stay away" from him. He stated he had only one friend who he talked to "every now and then." He stated he enjoys few activities, but he does not do much other than watch television during the day. He reported that his family still maintains contact and calls to check on him. The Veteran stated that he noticed an increase in hypervigilance when he retired and he had thoughts about taking his life. That caused him to turn in his gun permit and sell his gun. He continued with mental health treatment and was prescribed medication. He was irritable and had angry outbursts. The Veteran reported sleep disturbances and nightmares about 2 to 3 times a month. He reported hypervigilance, suspiciousness, poor concentration, and poor memory. He said his daughter has to set up his medication because he kept forgetting to take it. The Veteran reported he was in an altercation in a grocery store because he thought someone was following him and he had a domestic violence charge related to grabbing his current wife by the neck prior to the marriage. The Veteran was described as casually dressed and groomed with poor eye contact. He appeared anxious and reported a depressed, irritable, and anxious mood. He had a flattened affect. His thought processes were logical but he reported difficulties with concentration and maintaining attention. He denied any current suicidal and homicidal ideation. There were no unusual speech patterns and he spoke in a clear and goal-directed manner. There were no delusions or hallucinations evident or reported. Memory functions were impaired and he had difficulty recalling time periods and the ages of his children. Judgment and insight were also impaired due to his mental health issues. During an August 2017 VA examination, the Veteran indicated that he had not worked since leaving the MTA where he was suspended for repeated verbal altercations. He denied domestic violence and physical fights in the previous 3 to 4 years. He reported ongoing intrusive symptoms, avoidance behaviors, alterations in mood, and hyperarousal symptoms. He voiced intermittent hallucinations 2 or 3 times a month of either mumbled voices or screams/sounds related to the in-service accident. He evidenced severe depression, anhedonia, loss of pleasure in nearly all activities, despondency, marked psychomotor agitation, and other symptoms. He denied active thoughts of self-harm or intent but acknowledged ongoing passive thoughts of death as a relief and belief that he and others would be better without him. The Veteran reported being married for about 2 years and stated that he and his wife have their problems and argue a lot. He has 2 children from a previous marriage, one of which he talks to occasionally and the other he has no relationship with after a physical altercation over a decade prior. He had 2 children and a step-daughter with his current wife. He reported a strained relationship with his step-daughter. His youngest biological children were "somewhat frustrated" with him because he does not want to do activities with them. The Veteran was described as adequately dressed and groomed with poor eye contact. He appeared alert and reported an anxious mood. He had an appropriate affect that was congruent with demeanor and conversational content. His thought processes were goal-directed, coherent, and logical and his attention was adequate. He denied active thoughts of self-harm or intent. Judgment and insight were fair. The examiner found the severity of the Veteran's symptoms consistent with occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. During the most recent VA examination in October 2017, the examiner found the Veteran's symptoms consistent with 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. He reported getting married in 2015 and was still married "barely". He reported ongoing mental health treatment. The Veteran was casually dressed and the examiner indicated that the Veteran "appears to be making an effort to appear restless, shaky, tremulous." His attitude was cooperative and his speech of normal pitch and tone. His mood was mild to moderately anxious and depressed and his affect was constricted. His thought processes were goal-directed with no formal thought disorder. There was no evidence of delusions or hallucinations, no evidence of obsessions or compulsions, and he denied suicidal and homicidal ideation. He was cognitively alert and oriented (times 3). Based on the foregoing, the Board finds that prior to September 15, 2016, the Veteran's PTSD was manifested by no more than an occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The record shows that the Veteran maintained contact with friends and family and even got married during this period. Despite strained relationships with 2 of his children, he was close with his youngest children. He was notably described as casually and appropriately dressed, being cooperative, and alert and oriented. The GAF scores assigned during this time, ranging from 55 to 68, are also consistent with mild to moderate symptomatology. The Board fully recognizes that the presence or absence of certain symptoms is not necessarily determinative. However, occupational and social impairment with reduced reliability and productivity is not demonstrated. The available VA medical reports are adequate and persuasive, and the evidence demonstrates that the assigned 30 percent rating is appropriate. Entitlement to a rating in excess of 30 percent prior to September 25, 2016 is not warranted. Looking at the period from September 25, 2016, the Board finds that the evidence demonstrates that the Veteran's PTSD was manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The examiner noted the Veteran had lost interest in activities other than watching television. He reported getting into an altercation at a grocery store based on suspicions he was being followed. He endorsed difficulty in relationships, having only one friend and a strained relationship with his new spouse and even his youngest children. He reported thoughts of suicide to the point he found it necessary to sell his firearm. See Bankhead v. Shulkin, 29 Vet. App. 10 (2017) (Held that the presence of suicidal ideation alone may cause occupational and social impairment with deficiencies in most areas). Additionally, the Veteran's memory and judgment were impaired and he reported occasional hallucinations, despite no evidence of psychosis. However, there is no probative evidence that his PTSD causes a total occupational and social impairment. There is no evidence of gross impairment in thought processes or communication, grossly inappropriate behavior, danger of hurting self or others, intermittent inability to perform activities of living, disorientation to time or place, or memory loss for names of close relatives, occupation, or own name. The fact that he maintains a marriage, albeit considerably strained, and has some social relationships belies the notion of there being total social impairment. Therefore, entitlement to an increased 70 percent rating, but no higher, effective from September 25, 2016, is warranted. In reaching this decision, the Board has considered the lay evidence. The Board is fully aware that the Veteran is competent to report his symptoms. The medical findings discussed directly address the Veteran's contentions and the criteria under which the Veteran's psychiatric disability is evaluated. The medical evidence indicates the Veteran has had no more than mild to moderate symptoms prior to September 25, 2016 and moderate to severe difficulty in social and occupational functioning thereafter. Such is consistent with the 30 percent and 70 percent disability ratings assigned. ORDER Entitlement to an increased 50 percent rating for service-connected posttraumatic migraine headaches is granted for the entire appeal period, subject to the regulations governing the payment of monetary awards. Entitlement to a rating in excess of 30 percent for service-connected PTSD prior to September 25, 2016 is denied. Entitlement to an increased 70 percent rating for PTSD from September 25, 2016 is granted, subject to the regulations governing the payment of monetary awards. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs