Citation Nr: 1822503 Decision Date: 04/12/18 Archive Date: 04/25/18 DOCKET NO. 15-06 548 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUE Entitlement to an increased evaluation in excess of 50 percent from August 4, 2010 to March 6, 2014, and in excess of 70 percent from March 7, 2014 for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: California Department of Veterans Affairs ATTORNEY FOR THE BOARD K. Laffitte, Associate Counsel INTRODUCTION The Veteran had active duty service in the U.S. Navy from May 1964 to June 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California which granted service connection for PTSD and assigned a 50 percent disability rating. The Veteran was subsequently granted a 70 percent rating effective March 7, 2014 in a January 2015 rating decision. As the maximum benefit was not granted, the issues remain in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993). In a December 2015 decision, the Board denied an increased rating for PTSD. Subsequently, in an August 2016 Joint Motion for Partial Remand, the Board's December 2015 decision was vacated and returned to comply with the Court's order. In December 2016, the Board remanded the matter per the Veteran's request for the RO to consider new evidence. The case is presently before the Board for further appellate review. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2). FINDINGS OF FACT 1. For the period prior to March 7, 2014, the Veteran's PTSD manifested with symptoms of anxiety, depression, irritability, sleep impairment, and avoidance causing occupational and social impairment with reduced reliability and productivity, but not occupational and social impairment with deficiencies in most areas, nor total occupational and social impairment. 2. For the period beginning March 7, 2014, the Veteran's PTSD manifested with symptoms of anxiety, depression, irritability, sleep impairment, avoidance, and suicidal ideation causing occupational and social impairment with deficiencies in most areas, but not total occupational and social impairment. CONCLUSIONS OF LAW 1. For the period prior to March 7, 2014, the criteria for a disability rating greater than 50 percent for service-connected PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.130, Diagnostic Code 9411 (2017). 2. For the period beginning March 7, 2014, the criteria for a disability rating greater than 70 percent for service-connected PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to provide the Veteran notification of the information and evidence necessary to substantiate the claim submitted, the division of responsibilities in obtaining evidence, and assistance in developing evidence, pursuant to the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C. § 5103 (a) (2012); 38 C.F.R. § 3.159 (b) (2017). These notice requirements were accomplished in a September 2010 letter sent prior to the adjudication of the Veteran's claims. VA has fulfilled its duty to assist the Veteran. Service treatment records, private treatment records identified by the Veteran, and VA medical treatment records, have been obtained. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. VA examinations were conducted in March 2011, March 2014, and May 2016. The examiners made all required clinical findings and provided sufficient information. 38 C.F.R. § 3.159 (c)(4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Therefore, the VA examinations are fully adequate for adjudication purposes. There is no indication in the record that any additional evidence, relevant to the issues decided, is available and is not a part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). Increased Ratings for PTSD Disability ratings are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2017). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical, as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10 (2017). Where there is a question as to which of two evaluations shall be applied, 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. See 38 C.F.R. § 4.7 (2017). Reasonable doubt regarding the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3 (2017). Separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged" ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102 (2017). The Veteran's PTSD has been evaluated as 50 percent disabling prior to March 7, 2014, and 70 percent thereafter for the period on appeal under Diagnostic Code 9411. Diagnostic Code 9411 uses the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). Under the General Rating Formula, a 50 percent rating is assigned when a veteran's PTSD causes 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-term 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; or difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). A 70 percent evaluation is warranted when 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); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). The maximum schedular rating of 100 percent is warranted when 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; and memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). In addition, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the lengths 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 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) (2017). Use of the term "such symptoms as" in § 4.130 indicates that the list of symptoms that follows is "non-exhaustive," meaning that VA is not required to find the presence of all, most, or even some of the enumerated symptoms to assign a particular evaluation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115 (Fed. Cir. 2013); see Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir.2004); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). However, because "[a]ll nonzero disability levels [in § 4.130] are also associated with objectively observable symptomatology," and because the plain language of the regulation makes clear that "the veteran's impairment must be 'due to' those symptoms," a veteran "may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio, 713 F.3d at 116-17. Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on 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), p. 32. Scores ranging from 41 to 50 are assigned when there are 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). 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). See 38 C.F.R. § 4.130 (incorporating by reference the VA's adoption of the DSM-IV for rating purposes). Lower numbers on the GAF scale reflect more severe symptoms; higher numbers reflect less severe symptoms. The Board notes that although the DSM has been updated with a 5th Edition ("DSM-V"), to include GAF scores being dropped due to their "conceptual lack of clarity," since some of the Veteran's examinations took place prior to the adoption of the DSM-V, the DMS-IV criteria will be utilized in conjunction with all other pertinent evidence of record. The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a 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 claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Factual Background In August 2010, the Veteran presented to the Livermore VAMC for a treatment plan consult. The Veteran reported having "difficulty with sleep and PTSD," anxiety 3 to 4 times a month, and anger/agitation noting that he "comes unglued real quick." The Veteran denied any suicide attempts or injury to others, but noted that he put his fist through the wall about 15-20 years ago. Occupationally, the Veteran reported obtaining his GED while in the Navy, and subsequently, obtaining a Master's Degree with a 4.0 while in college. He worked for a cable company, had six jobs in his career, and held his longest job for twenty years. The examiner noted the Veteran was dressed appropriately with no signs of neglect, his affect was neutral and euthymic, thought process and content was intact with no evidence of delusional thought, and cognitive functioning was within normal limits. The Veteran denied suicidal/homicidal ideation. The examiner diagnosed the Veteran with generalized anxiety disorder, r/o PTSD. An addendum note showed that the Veteran's PTSD screen was positive. Subsequently, in August 2010, during a mental health follow-up, the Veteran reported being worried about things that happened while in service which included being hit in the arm by a bullet and an incident when he was stuck in the harbor with bugs crawling all over. He reported having trouble sleeping, being short with people, and irritable with his wife. He further reported being depressed sometimes, and always having anxiety. The Veteran reported anhedonia, in not having an interest in sports anymore, and denied suicidal/homicidal ideation. The examiner noted the Veteran was casually dressed, with appropriate hygiene and grooming. The Veteran was cooperative, with linear thought process, and exhibited no evidence of delusions/paranoid ideation, although the Veteran stated in the past he felt paranoid while driving. He further reported hearing voices off and on with talk about "getting him." The examiner diagnosed the Veteran with anxiety NOS, r/o PTSD, and assigned a GAF score of 55. In a September 2010 medication management note, the Veteran reported sadness when remembering his experience in Vietnam, and that he was still not sleeping well. He denied nightmares, night sweats, and suicidal/homicidal thoughts. The Veteran's medications were increased and the Veteran was to follow up with care in 1 to 2 months. In March 2011, the Veteran received a VA examination for PTSD. The Veteran reported that as a radio operator while in service, he saw many dead and wounded. He further reported having to communicate messages about service members' deaths. After discharge, the Veteran reported being bothered by the disrespect he received after his return from service, and reported that he moved to southern California where no one knew him. He reported he began working for a company that manufactured cable equipment the third day he moved there. The Veteran reported that over the years, he has had some trouble in his work functioning, mostly trouble concentrating, and that he snaps at people which has caused him to lose jobs. The longest time he was with one company was for 20 years. The Veteran reported his last employment was three years ago as a consultant for high tech companies, and that he was with the last company for approximately six months. Socially, the Veteran reported that he does not do social gatherings, and that he stays away from groups of people. He reported that he goes to Costco in the morning and shops online. The Veteran reported having a good relationship with his wife, and that he has "selective friendships," and has been able to have friends come over for dinner. The Veteran further reported being involved with the Wheelchair Foundation over the years. With regard to other PTSD symptoms, the Veteran reported that he had some minor problems with intrusive thoughts and memories about Vietnam, and that after moving to California, he never spoke of Vietnam again. He reported his symptoms started to bother him after Iraq and Afghanistan as the death of the soldiers reminded him of Vietnam. The Veteran reported bad dreams vary from 1 to 5 times a week with accompanying night sweats, sleep impairment, intrusive thoughts, hypervigilance, and guarded mostly in public. He denied hallucinations, but later in the exam, the Veteran noted that he hears things in the background. The Veteran denied suicidal/homicidal ideation, and reported avoidance of thoughts, feelings, and conversations regarding Vietnam, and avoidance of crowds and gatherings. He further reported experiencing irritability and anger, but mostly after his discharge, and minor difficulty with memory and concentration. The Veteran reported recent stressors of financial problems since 2008, and his mother and sister's passing in 2007. The Veteran reported being sued in 2009 and that he received a $40,000 judgment against him. The examiner noted the Veteran was pleasant and cooperative, his mood was within normal limits, affect appropriate, and thought processes was goal-directed with no loosening of association or flight of ideation. The Veteran was not delusional and judgment was good. Short-term memory was mildly impaired, while long term memory appeared intact. The Veteran's attention and concentration were normal as he was able to spell "world" forwards and backwards, and he completed serial 7s correctly five times before being stopped. The examiner diagnosed the Veteran with PTSD and assigned a GAF score of 55 noting that the Veteran has been experiencing PTSD symptoms since his return from Vietnam with no periods of remission. The examiner found that the Veteran's PTSD symptoms impair his social and occupational functioning moderately with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. In an April 2013 Statement in Support of Claim, the Veteran reported that he had not worked since 2008 and that he began working in February 2012 as an automobile salesperson due to necessity. He reported being moody with fellow associates and that he does not believe he will last. However, he reported that he would like to continue working part-time due to his need for income. The Veteran reported that his PTSD symptoms are affected by the war in Iraq and that he is constantly looking over his shoulders. He further reported that he does not like crowds and he stays away from most people, nor does he celebrate holidays because they depress him. On March 7, 2014, the Veteran received a DBQ for PTSD. The Veteran reported that his anger, irritability, and impaired judgment caused him to be placed in contempt of court after calling the judge in the case "stupid." The examiner noted symptoms of depressed mood, anxiety, suspiciousness, panic attacks twice per week, chronic sleep impairment, and mild memory loss. The examiner further noted symptoms of impaired judgment, disturbances of motivation and mood, inability to establish and maintain effective relationships, and suicidal ideation. The examiner found that the Veteran exhibited occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. In March 2015, the Veteran met with his treating psychiatrist for medication management. The Veteran reported that he has not taken any meds since six months or more and that he "blows up pretty quickly now." He reported feeling depressed, angry, and irritable especially toward his co-workers. He further reported having problems with sleep and that he wakes up screaming with cold sweats and nightmares from Vietnam almost regularly. The Veteran further reported that he is still working three days a week and that he has suicidal thoughts off and on, more frequent in the last month. The examiner noted that she had not seen the Veteran since 2013, and that the Veteran appeared alert, oriented, and his mood was dysphoric. He denied suicidal/homicidal ideation, and insight and judgment was fair. The examiner prescribed the Veteran new medications and referred the Veteran for individual therapy. In an April 2015 follow-up visit with the Veteran's psychiatrist, the Veteran reported that he started all of his meds one week ago and that he is doing better, except he was still not sleeping well. He reported no suicidal thoughts since his last visit and that he is meeting with his Veteran friends and talks, which helps. The examiner noted the Veteran was alert, oriented, and mood was euthymic. Insight and judgment was fair, and the Veteran denied suicidal/homicidal ideations. The Veteran was to return in one month. In an October 2015 medication management note, the Veteran reported having sleep difficulties and nightmares. He further reported being married for 42 years and that he maintains a distant relationship with his wife. The examiner noted that the Veteran appeared calm, cooperative, with good eye contact, and adequate hygiene and grooming. Thought process was goal-directed, insight and judgment was fair. The Veteran denied hallucinations, and suicidal/homicidal ideations. The Veteran was diagnosed with PTSD and told to return in three months. I In December 2015, the Veteran requested to be seen by the social worker. The Veteran reported being stressed about his finances and noted "I just want to give up." The examiner noted that the Veteran had increased depressive symptoms but the Veteran denied suicidal/homicidal ideations, although he reported passive suicidal ideation in the past. The examiner further noted that the Veteran was appropriately dressed with no signs of neglect. The Veteran's mood was dysphoric, thought process was intact, and there was no evidence of delusional thought. The examiner noted the Veteran appeared angry and was upset about not being able to discuss his DBQ forms. The examiner discussed the conflict of interest with discussing the forms and advised the Veteran of treatment options. The examiner diagnosed the Veteran with generalized anxiety disorder, r/o PTSD. In January 2016, during a medication management visit, the Veteran reported being frustrated and depressed due to being denied TDIU. He reported having financial strain and that he had been fired from his job due to anger issues. The Veteran endorsed passive suicidal ideations of ending it all and that his Veteran friends took three guns from the Veteran. The Veteran reported continued problems with sleep difficulties and nightmares. Socially, the Veteran reported that he socializes with his Veteran friends quite frequently. The examiner noted that the Veteran appeared calm, cooperative, and made good eye contact. The Veteran was adequately groomed, mood was 'frustrated' with goal-directed thought process. The Veteran denied suicidal/homicidal ideation or intent or plan. The examiner noted the Veteran had increased symptoms secondary to financial strain and medical issues, and recommended "Mind over Mood" groups. The Veteran was to follow-up in 3 to 4 months. Legal Analysis After a thorough review of the evidence, the Board finds that the Veteran is not entitled to an increased rating for either period on appeal. The evidence shows that the Veteran's reported symptoms of depression, sleep impairment, anxiety, irritability, hallucinations, nightmares, and fear of people in costumes, masks, or uniforms, and the inability to be around crowds are not of the frequency, severity, and duration that would warrant a higher rating. Rather, the Veteran's symptoms occurred intermittently and increased merely during sporadic periods of stress. Additionally, the evidence shows that for the period prior to March 7, 2014, the Veteran's symptoms moderately impaired his ability to function socially and occupationally and more nearly approximate the criteria for a 50 percent rating; and, for the period thereafter, the Veteran did not exhibit total social and occupational impairment. Moreover, the evidence shows that some of the Veteran's reported symptoms are inconsistent with other evidence of record which questions the actual severity of the Veteran's condition throughout the appeal period. With regard to the period prior to March 7, 2014, the record reveals that the Veteran's symptoms occurred intermittently. The Board notes that the Veteran began group mental health treatment with a social worker at the Livermore VAMC in August 2010. During his initial evaluation for treatment, the Veteran reported difficulty with sleep and PTSD noting symptoms of anger, agitation, anxiety, and irritability. He reported having symptoms of anxiety 3 to 4 times a month. In a subsequent August 2010 visit, the Veteran reported the same symptoms in addition to symptoms of depression, anhedonia with the loss of interest in sports, and that he hears voices off and on. Alternatively, in September 2010, the Veteran denied nightmares and night sweats, and in his March 2011 VA examination, he reported that his bad dreams vary from 1 to 5 times a week, with occasional night sweats. Although he reported symptoms of sleep impairment, hypervigilance, and being guarded mostly in public, he reported having minor problems with intrusive thoughts and memories about Vietnam. He further noted that his symptoms only began to bother him again after the war in Iraq and Afghanistan. Additionally, the Veteran reported that his irritability and anger occurred mostly after discharge and that he only has minor difficulty with memory and concentration which was supported by the Veteran's ability to spell "world" forwards and backwards, and complete serial 7s correctly five times before being stopped. Further, the Veteran denied suicidal/homicidal ideation and despite his report of hearing things, he noted that this occurred a few years ago. In addition to exhibiting symptoms intermittently, the evidence shows that the Veteran's symptoms became more prominent during certain holiday periods and during times when the Veteran experienced a stressful event. For example, in October 2010 during a mental health follow-up visit, the Veteran reported sleep impairment and being anxious about Halloween coming. He reported being scared of clowns as it reminds him of past experiences in war. The examiner noted that the Veteran was mildly depressed but had no psychotic symptoms. Similarly, in November 2010 during a medication management visit, the Veteran reported being depressed on Veterans Day, and that he thought about all the people that were killed and him giving messages of death to the families of war victims. In July 2011 during another medication management visit, the Veteran reported sleep impairment and being depressed due to his dog dying, and in June 2012, the Veteran reported being sad and having a difficult couple of days during Memorial Day. Moreover, in October 2013 during his mental health group visit, the Veteran reported sleep impairment due to Halloween approaching again, and in February 2014 during group session, the Veteran reported two situations at work triggered issues of distrust and increased problems with sleep. The Board notes the Veteran's July 2013 Statement in Support of Claim, in which the Veteran reported that he currently has suicidal thoughts, obsessional rituals which interfere with his routine daily activities, and that his speech at times is illogical, obscure and irrelevant as told by his wife and friends. He further reported that his hygiene is very bad as he gets complaints from his wife, and that he will go sometimes four days without a shower wearing the same clothes. Notably, the Veteran's psychiatrist or treating social worker did not report any of these symptoms in their treatment notes. The evidence shows that the Veteran received group and individual treatment with a social worker for most of the period on appeal. The social worker's treatment notes indicated that the Veteran was an active participant during group sessions with no reports of illogical, obscured speech, or obsessional rituals evidenced. There was no indication of neglect of hygiene during any of the Veteran's noted visits, and the social worker consistently reported that the Veteran had a "stable mood" during group, and the Veteran consistently denied suicidal/homicidal ideation. These findings are further supported by the social worker's February 2016 medical opinion written in support of the Veteran's TDIU claim. In the opinion, the social worker noted in pertinent part that she has treated the Veteran since August 2010 for individual and group therapy. She reported that with increased stress, the Veteran becomes more talkative and uses humor to deal with his anxiety. She explained that his humor can be quite dry and others might interpret it as being harsh or uncaring which would not work well within a work environment. She noted that the Veteran has difficulty with sleep, lack of trust in others, memory challenges, and that he responds inappropriately or does not communicate with his work team and clients. She further noted that the Veteran "shuts down" for weeks on end when things become too tense for him. While the social worker's opinion clearly shows that the Veteran's symptoms impair him to some degree, the impairment is not to the extent that a higher rating would be warranted. Having treated the Veteran since 2010, the Board finds it plausible that if the Veteran exhibited symptoms that would have severely impaired his occupational and social functioning, the social worker presumably would have noted these symptoms in her treating notes and her 2016 medical opinion, which she did not. Further, the social worker assigned the Veteran a GAF score of 55 in August 2010, and 53 in October 2011, while the Veteran's treating psychiatrist assigned a GAF score of 58 in July 2011, all indicative of moderate symptoms. Other evidence of record that show moderate impairment includes the Veteran's social interaction. Socially, the Veteran reported that he does not like to be around crowds as the Veteran has consistently reported that he and his wife stay home during Thanksgiving, Christmas, and other celebratory functions. He further reported that he cannot attend places with large crowds such as Costco, Walmart, and Home Depot; however, the evidence does not show that the Veteran's social impairment is to the extent that a higher rating would be warranted. For example, in contrast to the Veteran's report that he avoids crowds and gatherings and that he has anhedonia with a loss of interest in sports, the Veteran reported in his March 2011 VA examination that his hobbies include season tickets to the "Sharks," and that he is not bothered by the crowds or people there. He further reported that he watches hockey, football, and golf on television. The Board also notes that the Veteran was employed as a car salesman which presumably would require the Veteran to interact with people on a daily basis. In fact, in a June 2012 Mental Health Note, the Veteran reported that he loved selling cars. Additionally, in an October 2010 treatment note, the Veteran's social worker noted that the Veteran's strengths included that the Veteran gets together with two other couples, and that he meets with other Veterans from his PTSD group for lunch on Fridays. Further, the Veteran reported that he has worked with the wheelchair foundation for several years, and in his January 2012 group counseling session, the Veteran reported that he was attending a wheelchair event outside of the states. Moreover, although the Veteran reported his relationship with his wife was in doubt, the Veteran has maintained a marriage of over 38 years as reported in his March 2011 VA examination. Occupationally, the evidence also shows that the Veteran did not exhibit serious impairment. Although the Veteran reported that he has not worked since 2008, an October 2010 treatment note revealed that the Veteran was running for office. In his March 2011 VA examination, the Veteran reported that over the years, he has had some trouble in his work functioning, mostly trouble concentrating; however, he also reported minor difficulty with memory and concentration. Additionally, the evidence shows that he obtained a Master's Degree with a 4.0 while in college, had six jobs in his career, and held his longest job for twenty years. In response to the Veteran's application for TDIU, the RO received responses from the Veteran's employers. The Veteran's former employer, Berkeley Honda, noted that the Veteran was employed from February 2012 until June 2012, working 40 hours per week until the Veteran quit. In the Veteran's February 2014 correspondence, the Veteran reported working on a part-time basis; however, his employer, Livermore Honda's response reported that the Veteran began working in June 2012 with no ending date of employment, indicating that the Veteran was still employed as of the date of the correspondence which was March 2014. Considering the evidence above, the Board finds that while the Veteran experienced an increase in symptoms at times, his increase was not of the frequency, severity, or duration that would warrant a higher rating at any time for the period prior to March 7, 2014. The evidence shows that the Veteran's symptoms of anxiety, depression, sleep impairment, irritability, and avoidance of crowds and people in costumes were of moderate impairment and occurred intermittently, while his reported symptoms of suicidal thoughts, obsessional rituals, illogical speech, and neglect of hygiene were not supported by the evidence of record. Moreover, the Veteran's reports of "hearing voices" were sporadic at best, and the Veteran reported that it occurred years prior. Further, there is no evidence of suicidal/homicidal ideations, delusions, neglect of hygiene, or any other symptoms considered "severe" that is supported by medical evidence. Moreover, the Veteran's GAF scores suggest moderate impairment. The Board acknowledges that the Veteran exhibits impairment to a degree; however, his impairment was appropriately rated at 50 percent disabling. As a result of the above, the Board finds the preponderance of the evidence weighs against the claim, and the Veteran is not entitled to a rating greater than 50 percent for the period prior to March 7, 2014. The benefit of the doubt doctrine is not applicable and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. For the period beginning March 7, 2014, the Board also finds that an increased rating is not warranted. The Board notes that the Veteran's rating was increased to 70 percent disabling based upon the results of his March 7, 2014 DBQ. In the DBQ, the Veteran reported that his anger, irritability, and impaired judgment caused him to be placed in contempt of court. The examiner noted symptoms of depressed mood, anxiety, suspiciousness, panic attacks twice per week, chronic sleep impairment, and mild memory loss. The examiner further noted symptoms of impaired judgment, disturbances of motivation and mood, inability to establish and maintain effective relationships, and suicidal ideation. As a result, the Veteran's rating was increased to 70 percent disabling. The next highest rating would be 100 percent disabling requiring a showing of total social and occupational impairment. As there is no evidence of record that shows that the Veteran exhibited total social and occupational impairment at any time during the period beginning on March 7, 2014, a higher rating is not warranted. The Board notes that while the Veteran's March 7, 2014 DBQ showed an increase in symptoms, the examiner found that the Veteran exhibited occupational and social impairment with an occasional decrease in work efficiency, which is indicative of mild impairment. Additionally, the Veteran continued to attend group therapy until May 2014, and the social worker's treatment notes continued to report a stable mood for the Veteran with no evidence of suicidal/homicidal ideation. In March 2015 the Veteran reported an increase in symptoms of feeling depressed, anger, irritability, sleep impairment, nightmares, and cold sweats; however, the Veteran reported that he had not taken his medications in about six months. While the Veteran also reported having suicidal thoughts off and on, this is in contrast to the examiner's finding that the Veteran denied suicidal/homicidal ideation. The Board notes that although the Veteran experienced an increase in symptoms, even with suicidal ideation, the increase did not rise to a level of total occupational or social impairment as the Veteran continued to work part-time. Moreover, two weeks later in a follow-up visit, the Veteran reported that he was doing better, and that he has not had any suicidal thoughts since his last visit. Shortly thereafter in May 2015, the Veteran denied nightmares and suicidal thoughts altogether. Notably, during the Veteran's May 2016 DBQ, the examiner found that the Veteran exhibited occupational and social impairment with reduced reliability and productivity, and explained that the Veteran may experience moderate difficulties functioning in occupational roles during increased times of stress, but is otherwise capable of performing vocational responsibilities in a reliable manner with no functional limitations. This finding is supported by treatment notes where the Veteran reported an increase in symptoms due to financial stress, upcoming holidays, and current events that were happening in the world. For example, in a December 2015 mental health note, the examiner noted an increase in depressive symptoms after the Veteran reported being stressed about his finances. In a January 2016 medication management visit, the Veteran reported being stressed due to his TDIU claim being denied. While the Veteran continued to report sleep difficulties, nightmares, and suicidal ideations, the Veteran noted that he still socializes with his Veteran friends quite frequently. In February 2017 during his mental health group, the Veteran reported an increase in symptoms due to the Berkley riots on campus, and in a May 2017 group counseling note, the Veteran reported the UK incident triggered anger and flashbacks. He further expressed concern over the upcoming holiday. Likewise, in a November 2017 medication management note, the Veteran reported being stressed with the current events in the country. Outside of these sporadic periods and when the Veteran was off his medication, the Veteran's symptoms were stable as evidenced by July 2016 and March 2017 medication management notes, when the Veteran reported that he gets solid sleep without frequent nightmares. He further reported that his relationship with his wife was good, denied anger outbursts, and suicidal ideation, and reported that he continues to socialize with his Veteran friends frequently. Moreover, the evidence shows that the Veteran began another PTSD group session in which the social worker consistently reported a stable mood for the Veteran with no evidence of suicidal/homicidal ideation, hallucinations, or delusions, and that the Veteran was adequately groomed with linear thought process and appropriate thought content. Considering the above and remaining evidence of record, the Board finds that an increased rating is not warranted as the evidence does not support total social or occupational impairment. The Board recognizes the statements submitted by the Veteran's friends in July 2014 which note that the Veteran is delusional, demonstrates inappropriate behavior, suicidal ideation, and neglects personal hygiene; however, these statements do not coincide with the medical evidence. As mentioned, the Veteran attended two different group treatments in which none of the clinician's treating notes, nor the social worker's letter referenced previously, written in support of the Veteran's TDIU claim, noted any symptoms that would indicate that the Veteran was totally social and occupationally impaired as suggested by the Veteran's friends' statements. To the contrary, treatment notes from the Veteran's social worker consistently noted that the Veteran was an active participant in group, had a stable mood, with no evidence of hallucinations, delusions, or suicidal ideation, even during periods when the Veteran reported an increase in symptoms. Moreover, despite an increase in symptoms and reports of suicidal ideation in his March 7, 2014 VA examination, the Veteran was found to have occupational and social impairment with an occasional decrease in work efficiency. Similarly, the May 2016 examiner found that the Veteran exhibited occupational and social impairment with reduced reliability and productivity. While the opinions differ slightly, both opinions indicate that the Veteran was experiencing less than serious or severe impairment. As explained above, the Veteran's symptoms increased merely during sporadic times of stress, and did not reach a level of total social an occupational impairment. Therefore, as the evidence does not show that the Veteran was totally occupational and socially impaired, nor that his symptoms were of the severity frequency or duration that would warrant a higher rating, an increased rating for the period beginning March 7, 2014 is denied. The Veteran has also contended an earlier effective date is warranted for his 70 percent rating. The effective date of a staged rating is the earliest date that it is factually ascertainable that the criteria for that disability rating were met. See 38 C.F.R. § 3.400 (o)(2); Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In this case, the earliest date in which an increase was factually ascertainable was March 7, 2014, the date of the Veteran's examination when the Veteran had an increase in symptoms. With regard to the Veteran's contentions that the March 7, 2014 examiner relied on the Veteran's increased difficulty in dealing with people as the basis for finding an increase in symptoms. Specifically, the Veteran's report that his angry outbursts caused employees to leave his employ, and his angry outburst which caused the Veteran to be found in contempt of court all occurred prior to the March 7, 2014 date. The Board finds that even if these events did occur prior to March 7, 2014, the events do not support a 70 percent rating prior to this date. First, the Board notes that the March 7, 2014 examiner relied on various symptoms to support his finding that the Veteran's symptoms increased in severity. In particular, the examiner noted symptoms of depressed mood, anxiety, suspiciousness, panic attacks twice per week, chronic sleep impairment, and mild memory loss. The examiner further noted symptoms of impaired judgment, disturbances of motivation and mood, inability to establish and maintain effective relationships, and suicidal ideation. The Board notes that these same symptoms were reported prior to this date in the earlier period on appeal; but occurred intermittently as explained previously. In addition, the Veteran's reports of suicidal ideation are not consistent with the evidence. In fact, the Veteran denied suicidal ideation months and weeks prior to his March 7, 2014 examination. Specifically, in his group sessions dated January 2014, February 6, 2014 and February 13, 2014, the Veteran's social worker again noted that the Veteran was an active participant in group with a "stable mood," with no evidence of suicidal/homicidal ideation. Interestingly, one week after the Veteran's March 7, 2014 examination, the social worker noted the same in March 13, 2014, and subsequently in March 20, 2014. Moreover, while the March 7, 2014 examiner found an increase in symptoms, he also found that the Veteran exhibited occupational and social impairment with an occasional decrease in work efficiency, which is indicative of mild symptoms and a corresponding 30 percent rating, as opposed to the 70 percent rating assigned to the Veteran. The benefit of the doubt was given to the Veteran based on symptoms reported, even though the Veteran's reports of suicidal ideation immediately before and after the March 7, 2014 examination are inconsistent with the evidence. As explained previously, while the Veteran reported symptoms of anxiety, depression, irritability, avoidance, sleep impairment, and fear of clowns and costume characters prior to this date, these symptoms appeared intermittently, and merely during stressful periods in the Veteran's life. The evidence has shown that the Veteran received group treatment prior to March 7, 2014 with no reports of symptoms that were serious in nature. Further, the Veteran's reports of hallucinations were found to have occurred earlier than 2010, and his reports of suicidal ideation and neglect of hygiene contradicted the other evidence of record. Moreover, the Veteran maintained full-time employment until June 2015, continued to socialize frequently, and his GAF scores and VA examinations all showed mild to moderate impairment. Therefore, as the earliest time a substantiated increase was shown to have occurred was March 7, 2014, and no earlier, the Veteran is not entitled to a 70 percent rating prior to this date and a rating greater than 70 percent is not warranted. ORDER Entitlement to an increased evaluation in excess of 50 percent prior to March 7, 2014 for post-traumatic stress disorder (PTSD) is denied. Entitlement to an increased evaluation in excess of 70 percent from March 7, 2014 for post-traumatic stress disorder (PTSD) is denied. ____________________________________________ GAYLE E. STROMMEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs