Citation Nr: 1808364 Decision Date: 02/09/18 Archive Date: 02/20/18 DOCKET NO. 11-18 818 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to a rating in excess of 40 percent for lumbar spine degenerative disc and joint disease with spinal stenosis. 2. Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder prior to September 14, 2012, and in excess of 50 percent thereafter. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Veteran and Spouse ATTORNEY FOR THE BOARD Gregory T. Shannon, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from February 1968 to February 1970 and from October 1970 to March 1990, and was awarded the Bronze Star Medal. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. A December 2017 hearing before the undersigned was held at the Waco, Texas RO and a transcript of the hearing is of record. FINDINGS OF FACT 1. For the entire appeal period, the evidence shows no ankylosis of the thoracolumbar spine, favorable or unfavorable and less than one week of incapacitating episodes over the prior twelve months. 2. Throughout the period at issue, the Veteran's posttraumatic stress disorder is best assessed as manifested by occupational and social impairment with reduced reliability and productivity due to symptoms such as anxiety, continuous depression that did not affect the ability to function independently, chronic sleep impairment, mild memory impairment, intrusive thoughts, irritability, panic attacks, suspiciousness, occasional suicidal ideation, auditory hallucinations and difficulty in establishing and maintaining effective work and social relationships. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 40 percent for lumbar spine degenerative disc and joint disease with spinal stenosis are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.71a, Diagnostic Codes (DC) 5237 and 5243 (2017). 2. Prior to September 14, 2012, and thereafter, throughout the period of the appeal, posttraumatic stress disorder was 50 percent disabling, but not higher. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 3.102, 4.7, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017). 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 duty to assist argument). II. Increased Rating Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1 (2013); Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The effective date of an increased rating is the date of ascertainable increase or date of receipt of claim, whichever is later, under 38 U.S.C. § 5110(a) and 38 C.F.R. § 3.400(o)(1); unless the ascertainable increase precedes receipt of the claim, in which case the effective date is the date of ascertainable increase if the claim is received within one year thereof under 38 U.S.C. § 5110(b)(2) and 38 C.F.R. § 3.400(o)(2). Harper v. Brown, 10 Vet. App. 125, 126 (1997); see also Deliso v. Shinseki, 25 Vet. App. 45, 58 (2011). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, the Veteran has already been assigned staged ratings for PTSD. In evaluating a claim, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a); Layno v. Brown, 6 Vet. App. 465, 470 (1994). Lay evidence can also be competent and sufficient evidence of a diagnosis if (1) the medical issue is within the competence of a layperson, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). If the evidence is competent, the Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995). If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § 4.3 (2017). A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. i. Lumbar Spine Evaluation of a service connected disability involving the musculoskeletal system rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 (2017) and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45 (2016). See DeLuca v. Brown, 8 Vet. App. 202 (1995). The Veteran's lumbar disability is evaluated under Diagnostic Code group 5235-5243, 38 C.F.R. § 4.71a (2017). Accordingly, the regulations provide for evaluation of the Veteran's lumbar spine disability under the General Rating Formula for Diseases and Injuries of the Spine. See 38 C.F.R. § 4.71a. Under the General Rating Formula, a 40 percent evaluation is assigned for forward flexion of the thoracolumbar spine limited to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent evaluation is assigned for unfavorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243 (2017). Note 1 to the General Rating Formula provides for a separate evaluation for any associated, objective neurologic abnormalities. 38 C.F.R. § 4.71a (2017). With consideration of provisions of Note 1 of the General Rating Formula, the Veteran was granted service connection for radiculopathy, right lower extremity and left lower extremity associated with his lumbar spine degenerative disc and joint disease with spinal stenosis. Both are currently rated at 40 percent disabling. As the Veteran is separately evaluated for his neurological deficits and these are not on appeal, Note 1 is not applicable here. Intervertebral disc syndrome (IVDS) is evaluated (preoperatively or postoperatively) either on the basis of incapacitating episodes over the past 12 months, or under the General Rating Formula (which provides the criteria for rating orthopedic disability, and authorizes separate evaluations of its chronic orthopedic and neurologic manifestations), whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. Under Diagnostic Code 5243, a 40 percent rating is warranted for incapacitating episodes having a total duration of at least four weeks, but less than six weeks, during the past 12 months. A maximum, 60 percent rating is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. The notes following Diagnostic Code 5243 define an incapacitating episode as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Analysis Upon review of the evidence of record, the Board finds a rating in excess of 40 percent for lumbar spine degenerative disc and joint disease with spinal stenosis is not warranted throughout the period on appeal. The Veteran was awarded an increase in rating for his lumbar spine disability to 40 percent, in a September 2000 rating decision. In March 2009 the Veteran sought service connection for arthritis of his lumbar spine. The RO interpreted this as a request for an increased rating of his lumbar spine disability and denied an increase in rating. The Veteran disagreed with the denial, but not the characterization of the issue as that of an increased rating request. As noted above, for a rating in excess of 40 percent the evidence of record must establish unfavorable ankylosis of the entire thoracolumbar spine, unfavorable ankylosis of the entire spine, or incapacitating episodes having a total duration of at least six weeks during a 12 month period. A review of the evidence or record fails to demonstrate the existence of such ankylosis or incapacitating episodes. The Veteran does not contend, and the evidence does not show, any ankylosis of the spine. Indeed, at the most recent VA examination of the Veteran's lumbar spine, the examiner checked a box stating there is no ankylosis of the spine. See March 2017 VA examination. Based on the above, the Board finds that the Veteran's lumbar spine disability is not manifested by ankylosis and therefore a rating in excess of 40 percent is not warranted, pursuant to Diagnostic Code 5237. The Board has considered other appropriate diagnostic codes, particularly Diagnostic Code 5243, Intervertebral Disc Syndrome (IVDS). See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Review of a May 2013 VA thoracolumbar spine examination report reveals the Veteran was found to have IVDS with less than one week of incapacitating episodes over the prior twelve months. The Veteran does not contend, and the evidence does not show, any other incapacitating episodes or evidence of prescribed bedrest as contemplated by Diagnostic Code 5243, Note 1. Therefore, a rating in excess of 40 percent is not warranted, pursuant to Diagnostic Code 5243. The Board notes that during a March 2017 examination of his lumbar spine, the Veteran reported functional impairment from urinating more often and also constipation. The Veteran was scheduled for examinations in September 2017 for urinary tract conditions, gallbladder and pancreas conditions and intestinal conditions. With regard to urinary tract conditions, the examiner found the Veteran to be normal and that the findings did not warrant a diagnosis. The examiner noted an increase in frequency only if the Veteran has increased his intake. Furthermore, the examiner attributed voiding dysfunction to his service connected prostate cancer. Similarly, the examiner did not find a gallbladder or pancreas condition and the Veteran denied the existence of one. The intestinal examination also revealed the Veteran to not have an intestinal condition. The Veteran also denied an intestinal condition. The examiner did note some constipation after a prostate biopsy. Furthermore, a September 2011 VA examiner noted "[t]here is no bowel or bladder changes related to the lumbar spine." In light of the above, the Board finds the Veteran's reported urinary and bowel issues are not related to the Veteran's lumbar spine disability. During the December 2017 Board hearing, the Veteran and his spouse testified on the nature, frequency, and severity of the low back disability. The Veteran testified that he experienced severe back and lower extremity pain that made it difficult to rise from bed, limited his standing and walking endurance, required the use of a back brace. He testified that he was able to operate an automobile but with pain. He reported regular use of pain medication but no on-going therapy or recommendations for surgery. The Veteran reported during an August 2017 VA PTSD examination that he retired in 2013 when his back gave out. The Board notes the Veteran was awarded a total disability rating for individual unemployability (TDIU) effective October 30, 2013, the day after he retired. During a May 2013 VA examination, the Veteran reported that he was being accommodated by his employer/supervisor at the time, and if not for the accommodation he would be unable to be employed at the job. However, a review of the record does not indicate the Veteran was precluded from sedentary work and his psychiatric issues discussed below did not prevent him from working during this time. On the contrary, the May 2013 report specifies the Veteran stated he was limited to about 15 minutes of standing and walking, before needing to sit down and rest. There is no indication the Veteran would be unable to retain a job which predominately involved sitting (sedentary). In light of this, a TDIU prior to October 30, 2013 is not warranted. Except for the urinary, bowel and TDIU issues, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ii. PTSD PTSD is rated pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. This Diagnostic Code provides that PTSD should be rated under the general rating formula for evaluating psychiatric disabilities other than eating disorders. Under the general formula, a 30 percent rating is warranted for occupational and social impairment with an 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 a depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, and recent events). A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013) the Federal Circuit stated 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." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). Effective August 4, 2014, VA amended the regulations regarding the evaluation of mental disorders by removing outdated references to DSM-IV. The amendments replace those references with references to the recently updated "DSM-5." According to the DSM-5, clinicians do not typically assess GAF scores. The DSM-5 introduction states that it was recommended that the GAF be dropped from DSM-5 for several reasons, including its conceptual lack of clarity (i.e., including symptoms, suicide risk, and disabilities in its descriptors) and questionable psychometrics in routine practice. In reviewing the evidence of record, the Board will consider the assigned GAF scores; however, the Board is cognizant that GAF scores are not, in and of themselves, the dispositive element in rating a disability. Analysis Upon review of the evidence of record, the Board finds that a 50 percent rating, but not higher, for PTSD is warranted effective the date of receipt of claim. A review of the record reveals the Veteran's overall level of occupational and social impairment has been relatively consistent throughout the period on appeal, although reporting of certain manifestations was inconsistent. The Veteran testified at his Dec 2017 Board hearing that he has had his most severe symptoms of memory loss, suicidal thoughts and social withdrawal for several years, including to 2009. During a December 2007 VA PTSD examination, the Veteran denied hallucinatory experiences, rated his depression as 9 on a 10 point scale, admitted to suicidal rumination, but denied any intent or plan. The Veteran also denied losing time from work due to PTSD symptoms, but reported that he did have frequent interpersonal conflicts and did not tolerate other people with "an attitude". The examiner noted the Veteran's thought processes were generally logical and goal directed, speech was normal in rate and tone, that the Veteran was able to maintain minimal personal hygiene and other basic actives of daily living. The examiner also noted the Veteran's memory in all spheres was intact and overall intellectual functioning was estimated to be in the average range. Insight and judgement were considered intact, with no report or evidence of obsessive or ritualistic behavior. There was no report of panic attacks, no evidence of impaired impulse control and no evidence of frankly delusional thinking. The Veteran's major complaint was insomnia, noting he is experiencing intrusive thoughts daily and nightmares 3-4 times a week. The examiner concluded the Veteran's "PTSD signs and symptoms have negatively affect his family relations, thinking and mood. Veteran has admitted to mistrust of others, social avoidance, problems with interpersonal intolerance, as well as insomnia and irritability." At an October 2008 group meeting, the Veteran denied suicidal ideation. A mental status examination from the same day was largely consistent with the December 2007 examination, except no suicidal ideation was reported. See October 27, 2008 VA treatment note. A July 2009 VA PTSD examination was also largely consistent with the December 2007 examination, except the Veteran reported panic attacks occurring two to three times per week and mild memory loss was noted (forgets where he places keys or what he was going to do when going from one room to another; states he has to constantly retrace his steps to remember). Consistent with the prior examination, the Veteran reported a depressed mood a majority of the time and anxiety all of the time. The examiner noted the Veteran had no suicidal plans or intent, but did not comment on ideation. The Veteran reported he had no prior hospitalizations due to a psychiatric condition. The Veteran was employed in housekeeping at the Waco VA Medical Center (VAMC). The examiner opined the Veteran's "PTSD signs and symptoms result in deficiencies in most of the following areas: work, school, family relations, judgment, thinking, and mood." The examiner provided examples of pertinent symptoms in support of this opinion. "Veteran's avoidant behaviors, hypervigilance, insomnia, irritability all contribute to his need to isolate, to limited activities, and to short-term relationships." The examiner further opined the Veteran's prognosis for change was fair. In September 2009, the Veteran reported no current thoughts about suicide or self-harm, and no history of past attempts. He further reported he did not feel hopeless or helpless. He was deemed a low risk of suicide. See September 11, 2009 VA treatment note. In his August 2010 notice of disagreement, the Veteran reported conflict with family and coworkers, and "thoughts of suicidal ideation are more prevalent as I feel checking out would be far better than the problems I'm experiencing." The Veteran underwent another VA PTSD compensation and pension examination in October 2010. The results were relatively consistent with the December 2007 and July 2009 examinations e.g. no memory loss or impairment; normal orientation to person, place and time; no obsessive or ritualistic behavior, and no issue with communication/speech; reported social issues (has two kids and only speaks to one, rarely). However, the Veteran reported visual and auditory hallucinations and the examiner found impairment of the Veteran's thought process due to the Veteran's belief that he is being followed, people reading his thoughts, and that others put thoughts in his head. The Board notes the Veteran's treatment records do not reflect reports of visual hallucinations. The Veteran also reported his panic attacks were daily. Another difference is that the examiner found the Veteran has impaired impulse control, noting there "is evidence of self-destructive impulse and he reported periodically desires to harm others and described this as 'spells of violence.'" There is no indication the Veteran acted on these reportedly daily desires. The Veteran also reported a recent incident in which he contemplated suicide. He was loading a weapon when his wife intervened and took possession of the magazine. This is consistent with the testimony of the Veteran's wife. The examiner stated this "[r]ecent event represent second suicide attempt". The Board is unable to locate evidence of a first attempt, and notes the Veteran previously denied prior suicide attempts. The examiner opined the Veteran's PTSD signs and symptoms result in deficiencies in most of the following areas: work, school, family relations, judgement, thinking and mood. In support of this opinion, the examiner noted the "Veteran has numerous complaints and concerns, is confused, experiences atypical thinking, suicidal ideation, depression, and anxiety. He is quite impulsive, alienated, and troubled by fears of 'dying and/or going crazy.' Veteran estimates 14 days last year in which he was too distraught to go to work. At these times, he indicated being focused on thoughts of Vietnam." In August 2011 the Veteran denied suicidal ideation and reported no current thoughts of suicide or self-harm. See August 16 and 18, 2011 VA treatment notes. On August 25, 2011, the Veteran told a treatment provider that on "bad days" he thinks of suicide, with an onset of suicidal ideation being a "few years". The Veteran also denied current suicidal thoughts/ideations, noting "it's on the back burner now that I have to care for my grandbaby". The event in which he had a gun in hand was five months prior, but admitted to suicidal ideation in the past month. Veteran was found to be low risk and no intervention was indicated "as suicide risk has not been found to be a clinically significant issue". The Veteran reported he has been caring for his grandchild since March 2011. The Veteran also reported panic attacks once a month. It was also noted the Veteran was reliving flashbacks, but not having hallucinations or dissociative events. The Veteran's coping skills were noted as alcohol, medication and attending church. See August 25, 2011 VA treatment notes. Treatment records from November 2011, April 2012 and August 2012 note the Veteran is not suicidal or psychotic, has no suicidal ideations, delusions or hallucinations, and has fair insight and judgement. He was also alert and fully oriented. Upon a PTSD VA examination in September 2012, the Veteran reported he is "doing about the same" since his last evaluation. He also reported symptoms of depression, including anhedonia, social withdrawal, hopelessness, and helpless ness. "However, the Veteran's depression is better considered as secondary to PTSD." In a list of symptoms on the report, the examiner did not check suicidal ideation or persistent delusions or hallucinations. The Veteran also stated that work was going well, although he doesn't like all of his fellow employees. The examiner opined the Veteran's level of occupation and social impairment with regard to his mental diagnoses was an 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. VA treatment records from February 2013 indicate the Veteran had no current suicidal thoughts or ideation and was considered a low risk of harm to self and others. At times he gets depressed, but his affect was full and appropriate, no formal thought disorder was found and his cognition was intact. See VA treatment notes from February 2, 2013. The Veteran was also having recurrent distressing intrusive images, thoughts and perceptions, reliving his experience and having psychological reactivity in response to reminder of his PTSD event. He was assigned a GAF score of 70 and was to be seen semi-annually. See VA treatment noted from February 14, 2013. A treatment record from July 23, 2013 indicates the Veteran was not suicidal or psychotic, and had no suicidal ideations, delusions or hallucination. A depression screen was negative. A December 30, 2013 treatment record similarly indicates no current suicidal thoughts or ideation and was a low risk of harm, but the Veteran admitted to hearing voices. At his July 2014 appointment, the Veteran had no current suicidal thoughts or ideation and was considered a low risk for suicidal behavior. The Veteran was mildly depressed, his affect full and appropriate, with no formal thought disorder, and psychomotor activity was normal. He admitted to hearing voices sometimes and feels suspicious at times. The treatment provider noted there was no evidence of any delusional thinking. The Veteran was to follow-up in six months. In January 2015, the Veteran had no current suicidal thoughts or ideation and was considered a low risk of harm to self or others. It was noted that medication was helping with PTSD symptoms and there are no side effects due to medications. He admitted to hearing several voices which are mumbling to him. The Veteran felt suspiciousness. There was no evidence of delusional thinking and cognition was intact. An August 18, 2015 treatment note was similar to the January 2015 note, except the Veteran reported hearing one voice and it was telling him that he is worthless. A January 5, 2016 record is similar except he the Veteran reported sometimes hearing several voices, but that he could not recollect the voices, "they are like blurs." On June 2, 2016 the Veteran endorsed suicidal ideation or thoughts, but this was due to his prostate cancer. His speech was spontaneous, coherent, relevant, logical and goal oriented. He admitted to hearing voices, which he could not make out, and feeling suspicious most of the time. No evidence of any delusional thinking was found. On December 6, 2016 the Veteran again denied suicidal ideation, was considered a low risk and admitted to hearing several voices telling him to get help. On July 18, 2017 the Veteran denied suicidal ideation and there was no report of voices. However, on August 15, 2017 the Veteran endorse suicidal thoughts or ideation, in that the night before he did not want to live. He again admitted to hearing voices off and on, and they tell him not to hurt himself. The Veteran underwent an additional VA PTSD examination in August 2017. The Veteran indicated he has problems with memory and concentration, and that he is socially withdrawn, experiences significant irritability and anxiety in social situations. The Veteran reported having a good relationship with his wife, but denied any social activity outside of his family. "He indicated some suicidal thoughts, and his wife had to take his gun out of his hands 3 months ago. He did not remember the incident afterward. There is no mention of hearing voices. In a list of symptoms on the report, the examiner did not check suicidal ideation or persistent delusions or hallucinations. The Veteran presented to the evaluation casually dressed and well groomed. He was oriented. His mood appeared neutral, and his affect was congruent. The Veteran was friendly and cooperative with the examiner. The examiner stated that "[b]ased upon the examination, the claimant does not need to seek any follow up treatment at this time. The claimant does not appear to pose any threat of danger or injury to self or others." The examiner also opined the Veteran's level of occupation and social impairment with regard to his mental diagnoses was 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. During the December 2017 Board hearing, the Veteran and his spouse testified on the nature, frequency, and severity of his symptoms that were substantially the same as reported during the August 2017 examination. Review of the record reveals that some VA examiners' opinions prior to September 14, 2012 contain reports by the Veteran of some manifestations consistent with the 70 percent rating criteria. However, when considering and weighing the entire record over the period of the appeal, the Board finds a 50% rating is warranted bath prior to September 14, 2012 and thereafter. The Veteran's reports to treating clinicians and non-treating examiners are somewhat inconsistent, particularly regarding suicidal ideations and auditory hallucinations. The Veteran testified at his December 2017 hearing to having continuous suicidal thoughts and severe memory loss for about the last eight or nine years. The Veteran similarly reported to the RO and some VA compensation and pension examiners to having suicidal thoughts or ideation. However, a review of the Veteran's medical records reveal brief periods of time in which he reported to treatment providers as having suicidal ideation or thoughts. As noted above, the Veteran often denied suicidal ideation or thoughts and was considered a low risk of harm to self or others. Notably, only one occasion regarding a firearm required intervention by his spouse and no use of crisis counseling or urgent medical intervention or hospitalization. Similarly, the evidence of record does not support the Veteran's report of severe memory loss. VA examiners noted mild or no memory loss. Although the Veteran is competent to report symptoms including suicidal ideation and hearing voices, the Board finds the Veteran's testimony and reports to non-treatment examiners warrant less probative weight because of repeated denials of suicidal ideation to treatment providers. Care providers also note that the auditory hallucinations did not produce delusional thinking or inappropriate actions or behavior. The Board also finds the evaluations of VA compensation and pension examiners to warrant less probative weight when they relied on all of the Veteran's reports. The Board notes its concern is not limited to suicidal ideation, and instead extends to his reports to non-treatment providers generally, particularly VA compensation and pension examiners. For example, each of the examiners discussed the Veteran's reported social withdrawal, but none were made aware of his attendance at church, which was reported to a treating provider. Furthermore, although the Veteran testified that when he attended church meetings his involvement was somewhat limited, his wife testified that they both "do a lot of things at church" and that the Veteran is on the security team and serves as an usher. There is no indication that any of the VA examiners were made of aware of this. Despite this, the Board finds credible the reports of the Veteran having difficulty in establishing and maintaining effective work and social relationships, having some memory loss and having panic attacks. Although the Veteran's occasional suicidal ideation and auditory hallucinations are contemplated under the 70 percent rating criteria, the Veteran's symptomatology more nearly approximates a 50 percent rating. For example, the Veteran does not have symptoms such as obsessional rituals, abnormal speech, near-continuous panic or depression affecting his ability to function independently, impaired impulse control (although irritable, did not have unprovoked irritability with periods of violence), spatial disorientation, neglect of personal hygiene/appearance, or an inability to establish and maintain effective relationships (although he had difficulty, he was and is able). Overall, the evidence shows the Veteran's service-connected PTSD more nearly approximates social and occupational impairment with reduced reliability and productivity due to the nature, frequency, and severity of his symptoms prior to and after September 14, 2012 as well as the limitations imposed on his daily activities. The Veteran is able to leave the home and engage in some activities such as shopping and attending church, and communicate effectively. As noted above, the Veteran's December 2007 examination is relatively consistent with subsequent examinations, particularly the Veteran's reported intrusive thoughts, irritability and difficulty in establishing and maintaining effective work and social relationships. Therefore, the evidence of record supports the Veteran had an ascertainable increase in symptomatology more than one year prior to when the claim on appeal was received. Consequently, the effective date of the increased rating shall be the date of receipt of claim. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). ORDER Entitlement to a disability rating in excess of 40 percent for lumbar spine degenerative disc and joint disease with spinal stenosis is denied Entitlement to a disability rating of 50 percent, but not higher, for posttraumatic stress disorder prior to September 14, 2012 is granted. Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder from September 14, 2012 is denied. ____________________________________________ J. W. FRANCIS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs