Citation Nr: 1822528 Decision Date: 04/12/18 Archive Date: 04/25/18 DOCKET NO. 07-21 086 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to an increased disability rating for post-traumatic stress disorder (PTSD), currently rated 30 percent disabling. 2. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION The Veteran represented by: John S. Kamarados, Esq. ATTORNEY FOR THE BOARD Grace J. Suh, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1966 to August 1968, during the Vietnam Era. For his service, he received the Purple Heart with one start, National Defense Service Medal, Vietnam Service Medal with one star, Vietnam Campaign Medal with device, Navy Achievement Medal with combat "V." This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburg, Pennsylvania. In March 2011, the Board remanded this matter for further development; namely, to obtain the Veteran's VA treatment records and to afford him a VA examination, each of which were accomplished. See Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that a Court or Board remand confers upon a veteran the right to substantial, but not strict, compliance with that order). The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Prior to September 18, 2006, the Veteran's PTSD was manifested, in pertinent part by depressed mood; anxiety; occasional panic attacks; and chronic sleep impairment. 2. From September 18, 2006 to May 5, 2011, the Veteran's PTSD was manifested, in pertinent part, by passive suicidal ideation; difficulty adapting to stressful circumstances in a work setting; and an inability to establish and maintain effective relationships. 3. From May 6, 2011, the Veteran's PTSD was manifested, in pertinent part, by disturbances of mood or motivation; anxiety and depression, but with the ability to function independently, appropriately, and effective; difficulty in establishing and maintaining relationships. CONCLUSIONS OF LAW 1. The criteria for an increased disability rating in excess of 30 percent for PTSD prior to September 18, 2006 have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.6, 4.7, 4.27, 4.126, 4.130, Diagnostic Code (DC) 9411 (2017). 2. The criteria for an increased disability rating of 70 percent, but no higher, for PTSD from September 18, 2006 to May 5, 2011 have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.6, 4.7, 4.27, 4.126, 4.130, DC 9411. 3. The criteria for an increased disability rating of 50 percent, but no higher, for PTSD from May 6, 2011 have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.6, 4.7, 4.27, 4.126, 4.130, DC 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran contends that he is entitled to an increased disability rating in excess of 30 percent for PTSD. See June 2005 Letter from the Veteran's Representative. Preliminarily, the Board notes the applicable DC is 9411, which is evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. §§ 4.27, 4.130. Under the General Rating Formula for Mental Disorders, a 30 percent disability rating is warranted for 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; and, mild memory loss (such as forgetting names, directions, and recent events). A 50 percent disability rating is warranted for occupational and social impairment with reduced reliability and productivity due to 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 (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgement; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgement, thinking, or mood, due to symptoms such as: suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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. A 100 percent disability rating is warranted for 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. The Board acknowledges the psychiatric symptoms listed in the rating criteria are not exhaustive, but are examples of typical symptoms for the listed disability rating. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (2013); see also Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). As another matter, the Board is cognizant the Veteran was on psychiatric medication throughout most of the relevant time period. A higher disability rating may not be denied on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). However, a review of the claims file reveals he was not always compliant with his medication regimen and discontinued it on a few occasions. Despite his occasional non-compliance or stoppage, they did not necessarily correlate with an increase in the severity of his symptomatology. When he was compliant with his medications, the evidence of record indicates varying levels of efficacy according to his lay reports. Therefore, the Board must consider and weigh the entirety of the evidence available. Generally, in assessing the evidence of record, the Board acknowledges the Veteran is competent to provide evidence regarding the lay observable symptoms of his PTSD. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007) (holding that while a lay person is not competent to opine as to medical etiology or render medical opinions, they are competent to establish the presence of observable symptomatology), abrogated on other grounds by Walker v. Shinseki, 708 F.3d 1331 (2013). However, as his statements relate to a clinical assessment of occupational or social impairment stemming from his PTSD, the Board is unable to accord them any probative weight because he is not competent to render a medical diagnosis or opinion on such a complex medical question. See Barr, supra; see also Jones v. West, 12 Vet. App. 460, 465 (1999) (holding that only those with specialized medical knowledge, training, or experience are competent to render a medical diagnosis). As such, the Board finds the medical evidence of record most probative. As in this instance, where an increase in the disability rating assigned is at issue, the primary concern is the Veteran's present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994); cf. Fenderson v. West, 12 Vet. App. 119 (1999). In such cases, if factually ascertainable, the effective date assigned may be up to one year prior to the date the application for increase was received. 38 U.S.C. § 5110 (2012). Therefore, the relevant timeframe for consideration is October 25, 2003 to the present. See October 2004 Letter from the Representative (initiating the claim for an increased disability rating for PTSD, which was received by the VA on October 25, 2004). The first relevant medical evidence of record is the December 2004 PTSD VA Examination Report. During December 2004 examination, the Veteran claimed that his PTSD symptoms have worsened since he stopped working. He worked for the United States Postal Service as a letter carrier for 23 years until he retired one and a half years ago due to a back injury. He denied that his PTSD symptoms led to his retirement. Since retiring, he has suffered from increased nightmares and intrusive thoughts about his service in Vietnam. Whereas he used to have nightmares approximately twice per year before his retirement, he now averaged twice per week. He also experienced physiological reactivity to exposure cues, diminished interest, emotional detachment, sleep disturbances, irritability and anger, as well as difficulty concentrating. While he denied feeling depressed, he admitted to having thoughts that it would be better and easier if he was no longer around. Even so, he adamantly denied suicidal ideation. The Veteran relayed that his primary care physician has prescribed him medication for his anger issues. According to him, the medication helped him by curbing his aggression. His primary care physician referred him to a psychiatrist who prescribed him another medication altogether, which was less effective. Even still, while there were days that he just needed to get away from people, he denied any history of assaultive behavior. He denied any current psychiatric treatment. He last received treatment through the VA about 20 years prior. The Veteran reported being married to his wife for the past 34 years and they have two adult daughters. He described his relationship with them was good. While he had some friends, he equivocated that they were more like acquaintances. He generally preferred to do things by himself or with close family members. He enjoyed gardening, working on cars and motorcycles, and landscaping. The VA examiner observed the Veteran was pleasant, polite, and cooperative during the examination. His speech was within normal limits; mood was euthymic with a full affect range; there was no evidence of suicidal or homicidal ideation, auditory or visual hallucinations, psychosis, or mania; thought process was goal-directed with appropriate content. In the end, the VA examiner determined his PTSD symptoms were moderate and would not render him unemployable. Following this VA examination, the Veteran began receiving psychiatric treatment through the VA. From December 2004 to June 2005, VA Mental Health Notes disclose at each appointment he presented with good grooming and hygiene; was alert and oriented; exhibited normal speech; normal thought processes; and showed no evidence of psychosis or agitation. For the most part, his mood was depressed or dysphoric. Cf. June 2005 VA Mental Health Note (noted the Veteran reported his mood was "ok," variable). The Veteran continued to endorse intrusive thoughts and nightmares. He experienced frequent nightmares; between two to three times per week. Following the his retirement from the USPS, he reported becoming more ruminative because he had more down time, which he believed was exacerbating his symptoms. January 2005 VA Social Work Note. While he described his sleep was fair, he stated his energy level was low. Of note, in March 2005, he claimed he could not get excited about anything and had little zest for life. March 2005 VA Mental Health Note; see also May 2005 VA Mental Health Note (noted the Veteran's report that he cannot accomplish the tasks that he used to be able to). However, at no time did his VA treatment providers find any evidence of suicidal ideation. Until May 2005, the Veteran's VA treatment providers observed he exhibited moderate irritability and moderate anxiety with occasional panic attacks. Although he did not mention this during the December 2004 VA examination, with regard to his irritability, he averred that his USPS co-workers had been afraid of him. February 2005 VA Mental Health Note. By May 2005, his panic attack episodes had subsided. May 2005 VA Mental Health Notes. Throughout this period, he also admitted smoking cannabis to keep calm and relaxed. The Veteran discontinued his psychiatric treatment through the VA after June 2005, but resumed it briefly in September and October 2006. In September 2006, he reported that he was returning for treatment because his wife has been asking him to for the past six months. September 18, 2006 VA Mental Health Note. Notably, he relayed not getting along with his wife. They no longer had a relationship. He stated he continued to take psychiatric medications, but did not believe they were helping with his anxiety because he was having difficulty managing it. He had poor sleep and low energy. Upon examination, the VA treatment provider noted he presented as alert and oriented; with good grooming and hygiene; normal speech; normal thought processes; and without evidence of suicidal or homicidal ideation, or psychosis. However, his mood was depressed, with a restricted affect range. The VA examiner assessed his anxiety ranged from moderate to severe, without any recent panic attack episodes; and his irritability was high. Just one month later, the VA treatment provider noted the Veteran again presented with high irritability and anger. October 2006 VA Mental Health Note. In fact, he left the room while they were discussing a treatment plan. He was also upset about the VA's denied of an increased disability rating for his PTSD. He confirmed that he was still taking psychiatric medication, but stated that since they were changed they did not seem to be helping. The VA examiner documented he presented as alert and oriented; with normal speech; normal thought processes; and without evidence of suicidal or homicidal ideation, or psychosis. However, his mood was depressed and angry. Once more, the VA treatment provider assessed his anxiety was moderate and his irritability was high. After October 2006, there are no relevant medical records of evidence until January 2011. Beginning in January 2011, the Veteran returned to the VA for psychiatric treatment. From January 2011 to April 2011, VA Mental Health Notes reveal he presented as alert and oriented; with fair grooming and hygiene; normal speech; normal thought processes; without evidence of psychosis; and with fair impulse control, insight, and judgement. During this time, he was complaint with his psychiatric medications. As the session progressed his mood improved from irritable with a congruent affect to "okay" with an appropriate affect. Of particular note, an early January 2011 VA Mental Health Note indicated the Veteran's relationship with his wife was not improving. January 6, 2011 VA Mental Health Note. He stated that they just co-existed. He was detached from others and had no friends. He described himself as an "unhappy, angry man." He spent time gardening, landscaping, working on cars and motorcycles, but felt less interest in such activities. He suffered from increasing anxiety, with episodes where it felt as though his heart would explode. Although he admitted to suicidal ideation in the past, he denied experiencing any current suicidal or homicidal ideation; audio or visual hallucinations; or delusions. He continued to experience intrusive thoughts and sleep disturbances due to nightmares and night sweats between two to three times per night. He remained hypervigilant; easily startled; and depressed. Significantly, he relayed that he was working once more, this time as a school bus driver. However, he was having issues at work. He reported that he has gotten called into the office between 30 to 40 times for being too mean and stern with the kids. The VA treatment provider observed he demonstrated moments of irritability when speaking about his symptoms and past treatment. Notably, by late January 2011, while he continued to feel detached from others, the Veteran reported his relationship with his wife was improving. January 26, 2011 VA Mental Health Note. By February 2011, he relayed he was communicating with friends who also served in Vietnam. February 2011 VA Mental Health Note. While the severity of his social impairment improved, speaking with these friends also triggered an anxiety attack when they began talking about a friend who died in Vietnam. Id. The Veteran continued to describe feeling stressed due to work, until April 2011 when he reported quitting his job as a school bus driver. April 2011 VA Mental Health Note. The Veteran was afforded another VA examination in April 2011. April 2011 PTSD VA Examination Report. During this examination, he relayed resigning from his job as a school bus driver recently. He quit because the stress was too much for him. Between August and December, he had been called into his supervisor's office 30 times for complaints by parents because he did not put up with "bullshit" on the bus and enforced the rules. He also had three of four meetings with the school principal and a meeting with the school superintendent. On one occasion, the parents called the police because they claimed he was out of control screaming and yelling. In terms of his other psychiatric symptoms, the Veteran stated he continued to have trouble sleeping, which gave him a lot of time to think. This has led to flashbacks. He continued to suffer from nightmares and night sweats, and wakes up screaming and thrashing about twice per week. Of importance, he reported thinking about killing himself. However, he denied having any plan or intent to act on it. Socially, the Veteran admitted having two close friends, but he denied socializing with them. He stated he did not even go out to do things with his own family. He remained married. He reported his wife broke her hip in 2006, and since then he has done much of the household chores. The VA examiner confirmed the Veteran was seen for treatment until 2006, and he did not resume treatment again until January 2011. With respect to his psychiatric medications, the VA examiner noted he was non-complaint, and taking his wife's Xanax instead. The VA examiner observed the Veteran presented appropriated dressed with good grooming and hygiene. He was alert and oriented. While his speech was loud in volume and tone, it was normal in rhythm and rate. However, the content was tangential and somewhat perseverative. Even so, it was direct and coherent. His mood was superficially pleasant, but he reported he was irritable and had a lot of anger. He had a broad affect range. His thought process was generally logical and sequential. While he averred he experienced a visual hallucination, the VA examiner noted he was relaying an incident in service. In the end, the VA examiner opined the Veteran demonstrated mild to moderate PTSD symptoms. While his scores on some of the tests showed moderate PTSD symptoms and extremely severe depression, the VA examiner explained that these scores were not consistent with his verbal reports, which suggested over reporting on the tests. With respect to his anxiety, the VA examiner noted he could be experiencing marijuana induced anxiety. Overall, his symptoms were stable, and there was not significant different from those in 2004. Between May and July 2011, the Veteran's symptoms appeared to have improved. During this time, he reported he was doing okay. He continued to take his psychiatric medications, which he reported were helping. Each VA Mental Health Note documented he presented as alert and oriented; cooperative; with good grooming. His speech was within normal limits. His mood ranged from was "okay" to good with an appropriate affect. His thought process was linear, without any suicidal or homicidal ideation; perceptual disturbances; delusions, or paranoia. His impulse control, insight, and judgment were fair. Of note, in June 2011, the Veteran relayed that he recently returned from visiting his daughter in Florida. He enjoyed the visit, and during it he experienced no nightmares, flashbacks, or anxiety. June 2011 VA Mental Health Note. However, between August and December 2011, the Veteran's psychiatric condition appears to have declined somewhat. His mood ranged from "okay" with an appropriate affect to anxious and down with a congruent affect. Starting in August 2011, he reported experiencing increased anxiety. August 2011 VA Mental Health Note. Once more, he relayed suffering from nightmares. He also stated he experienced a flashback after speaking to a friend, who was also a veteran. In October 2011, he relayed he was isolating himself more and did not want to be around other people. October 2011 VA Mental Health Note. He stated September was a bad month for him because it was an anniversary of his Vietnam service. This led to increased nightmares and thoughts about his Vietnam experiences. Nevertheless, his VA treatment provider's findings were, for the most part, consistent with the May and July 2011 findings. Throughout 2012, the Veteran's VA treatment provider's general findings remained consistent with those in May and July 2011, with the exception of mood and affect. In 2012, each of his VA Mental Health Notes indicated his mood was down with a constricted affect. He continued to report suffering from nightmares and thoughts about his experiences in Vietnam. He also continued to smoke marijuana off and on because he claimed it helped him to relax. Of note, in February 2012, he stated he stopped taking his psychiatric medication while visiting a friend. February 2012 VA Mental Health Note. Even so, he did not report an appreciable increase in the severity of his symptomatology. A July 2012 VA Nurse Practitioner Note documented the Veteran's admission that he was close with his wife, two adult children, and adult grandchildren. Again, he claimed he was not taking any psychiatric medications because they were not helping. July 2012 VA Nurse Practitioner Note. However, he did not report any increase in the severity of his symptomatology aside from feeling hopeless about the future. By September 2012, the Veteran was back on psychiatric medications, but there was no noticeable improvement in the severity of his symptomatology. September 2012 VA Nurse Practitioner Note (noted the Veteran exhibited significant depression). The Veteran's psychiatric symptomatology remained the same in 2013. March 2013 VA Nurse Practitioner Note; August 2013 VA Nurse Practitioner Note. In June 2013, the Veteran was examined again by the VA again. June 2013 PTSD VA Examination Report. At that time, he reported spending most of his time caring for his wife and household. Although he stated he has been a loner for the most of his life, he described that his relationship with his wife and children remained good. He also relayed having difficulty remembering to take his medications, which has been a recurring problem for the past three to four years. Upon examination, the VA examiner observed the Veteran presented appropriately dressed with good grooming and hygiene. He was alert and oriented. His mood was dysphoric with a restricted affect. While his thought processes were relevant and goal-directed. His insight and judgment were fair. There was no evidence of memory impairment. The VA examiner found the relevant symptoms for rating purposes were anxiety, chronic sleep impairment, disturbances of motivation and mood. However, the Board notes the VA examiner expressed some concerns about the inconsistencies between his reports in the VA treatment records, and questioned how forthcoming he has been with his treatment providers. The VA examiner confirmed the Veteran's diagnosis of PTSD, but also diagnosed him with alcohol dependence and cannabis abuse. Even though the VA examiner indicated it was possible to differentiate the symptoms between the different diagnoses, a closer review of the VA examiner's explanation suggests that is not the case. According to the VA examiner, cannabis abuse increased sleep disruption, mood instability, and irritability; and overall would increase the severity of his PTSD symptoms. The VA examiner did not provide any guideposts for distinguishing the increase in severity of his PTSD symptoms solely due to his marijuana abuse. As such, the Board considers the overall severity of his sleep disruption, mood instability, and irritability due to both his service-connected PTSD and nonservice-connected cannabis abuse. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). In the end, the VA examiner assessed the severity of the Veteran's PTSD symptoms were mild to moderate, resulting in occupational and social impairment due to mild or transient symptoms, which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress or his symptoms were controlled by medication. There is only one medical record in the claims file for 2014. According to an April 2014 VA Nurse Practitioner Note, the Veteran continued to relay feeling hopeless about the future. Nonetheless, he also continued to report maintaining a close relationship with his wife, two adult children, and adult grandchildren. April 2014 VA Nurse Practitioner Note. At that time, he admitted that he was not taking all his psychiatric medications because he was unable to refill one. Even still, there was no noteworthy increase severity of his symptomatology. The VA treatment provider's findings were consistent with those in 2012. The next relevant medical evidence of record is the June 2015 VA Psychiatry Note. At the time, the VA treatment provider noted the Veteran has not been seen by the VA in a year. June 2015 VA Psychiatry Note. During this appointment, he reported experiencing an increase in nightmares over the past few weeks. Although he denied any suicidal ideation, he stated that at times he preferred not to wake up. Subsequent VA treatment records suggest an improvement in the Veteran's symptoms. In particular, he reported satisfactory sleep and denied any anxiety. August 2015 VA Psychiatry Nurse Practitioner; November 2015 VA Psychiatry Nurse Practitioner. The VA treatment providers found his mood was euthymic with a broad affect. His insight and judgement were good. In all other respects, the VA treatment provider's findings were consistent with those in 2012. The singular relevant VA treatment record for 2016 documented the same findings as above. March 2016 VA Psychiatry Nurse Practitioner Note. There are only two pertinent VA treatment records for 2017. By early March 2017, the Veteran reported that he was taking care of his wife after she had a stroke. March 6, 2017 VA Psychiatry Note. He was feeling sad and depressed. His energy level was low. He was easily angered. He had discontinued taking his psychiatric medications. Still, he denied experiencing any anxiety. The VA treatment provider observed he presented with good grooming and was alert and oriented. While his mood was dysphoric, but he had a broad affect. His thought process was linear and goal-directed. There was no evidence of suicidal or homicidal ideation, or perceptual abnormalities. His insight and judgement were fair. At the end of March 2017, the Veteran contradicted his claim above by asserting that he experienced depression and anxiety while he was off psychiatric medications for the past six months. March 24, 2017 VA Psychiatry Note. At that appointment, he confirmed that he continued to take care of his wife. He relayed an improvement in his depression after restarting his psychiatry medications and energy level, describing that it was "not bad." He also admitted that his motivation was improving. The VA treatment provider observed he presented with good hygiene. His speech was within normal limits. His affect was reactive and within normal range. His thought process was linear and goal-directed. There was no evidence of suicidal or homicidal ideation, hallucinations, or delusions. His concentration and memory were intact. His insight and judgement were good. In contemplating the evidence above, the Board finds the preponderance of the evidence does not support an increased disability rating in excess of 30 percent prior to September 18, 2006 for his PTSD. See 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017); see also Fagan v. Shinseki, 573 F.3d 1282, 1287 (2009); Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). Throughout the entire appeal period, the Veteran presented appropriately dressed and groomed with good hygiene. There was no indication that he was unable to perform his daily living activities at any time. He remained alert and oriented. His speech was within normal limits at all times. Even though he exhibited a restricted or constricted affect at times, he never displayed a flattened affect. In fact, more often than not, he demonstrated a full affect range during the appeal period. At no time, did he demonstrate impaired judgment. His judgement consistently ranged from fair to good throughout. He never demonstrated impaired thought process during the appeal period. At all times, his thought process was relevant, linear, and goal-directed. Further, his memory remained intact throughout the appeal period. While the Veteran's VA treatment record disclosed the Veteran suffered from panic attacks from December 2004 to February 2005, beginning in May 2005 they indicate his panic attacks ceased. Thereafter, there is no reference to any episodes of panic attacks whatsoever until January 2011. Notably, his VA treatment records from December 2004 to February 2005, simply documented that his panic attacks occurred occasionally. Thus, there is insufficient evidence to warrant a 50 percent disability rating, which requires panic attacks more than once a week. Despite the Veteran's claims that he isolated and detached himself from others, prior to September 18, 2006, the evidence of record reveals that he has been able to maintain effective social relationships. Although he described his friends were more like acquaintances, he maintained good relationships with his wife and adult children. Therefore, the evidence does not rise to the level of difficulty in establishing and maintaining effective work and social relationships to support a 50 percent disability rating. During the December 2004 VA examination the Veteran relayed having thoughts that it would be better and easier if he was no longer around, he adamantly denied any suicidal ideation. In fact, upon examination, the December 2004 VA examiner concluded there was no evidence of suicidal ideation. At all other times during the relevant timeframe, his lay statements did not suggest any suicidal ideation and the VA treatment providers expressly found no evidence of suicidal ideation. At no time during the relevant time period did the Veteran manifest any other symptoms of a similar severity, frequency, or duration of those typically associated with a 50 percent disability rating or higher for PTSD. See Vazquez-Claudio, supra; see also Mauerhan, supra. From September 18, 2006 to May 5, 2011, the Board finds the preponderance of the evidence justifies an increased disability rating of 70 percent, but no higher, for his PTSD. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; May 6, 2011 VA Mental Health Note; see also Fagan, supra; Hart, supra. Notably, during this timeframe, the Veteran's relationship with his wife began deteriorating. In September 2006, he relayed that they were no getting along and they no longer had a relationship with each other. In early January 2011, he stated their relationship was not improving; they just co-existed. However, by the end of January 2011, began demonstrating an ability to establish and maintain effective social relationships. His relationship with his wife began improving and he reported interacting with friends. Thus, during a portion of this period the evidence of record suggests an inability to establish and maintain effective relationships. Most significantly, the Veteran demonstrated increased anxiety and irritability throughout this time period. In September 2006, the VA treatment provider assessed his anxiety ranged from moderate to severe, but without any recent panic attack episodes; and his irritability was high. Of note, in early January 2011, he exhibited moments of irritability during his treatment sessions while speaking about his symptoms and past treatment. Further, he relayed having issues at work due to his irritability. He stated that he has gotten called into the office between 30 to 40 times for being too mean and stern with the kids. During the April 2011 VA examination, he relayed resigning from his job because the stress was getting to be too much. At that time, in addition to the 30-40 office visits, he admitted he also had three of four meetings with the school principal as well as a meeting with the school superintendent. Of note, on one occasion, the parents called the police because they claimed he was out of control screaming and yelling. Although this does not establish impaired impulse control rising to the level of unprovoked irritability with periods of violence, it demonstrates difficulty in adapting to stressful circumstances in a work setting. In early January 2011, the Veteran claimed having had suicidal ideation in the past. While he did not indicate when this occurred or the frequency with which it occurred at that time, during the April 2011 VA examination he explicitly stated he had thoughts of killing himself. However, he denied any plan or intent to act on it. These references to suicidal ideation are the only ones of record throughout the entire appeal period. Consequently, there is insufficient evidence of suicidal ideation during this period, much less persistent danger of hurting self or others to justify a 100 percent disability rating. During the pertinent timeframe, the Veteran did not manifest any other symptoms of a similar severity, frequency, or duration of those typically associated with a 100 percent disability rating or higher for PTSD. See Vazquez-Claudio, supra; see also Mauerhan, supra. From May 6, 2011 to the present, the Board finds the preponderance of the evidence does substantiate an increased disability rating of 50 percent, but no higher, for his PTSD. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Fagan, supra; Hart, supra. As noted above, even before May 6, 2011, the Veteran's social impairment due to his PTSD symptoms improved. His relationship with his wife continued to improve. By 2012, he reported having a close relationship with his wife, adult children, and adult grandchildren. During the April 2011 VA examination, he admitted to having two close friends outside his family as well. In fact, in February 2012, he reported traveling to visit a friend. Thus, there is insufficient evidence of record showing an inability to establish and maintain effective relationships to support a 50 percent disability rating. Despite the Veteran's statement in March 2017 that he was easily angered, after resigning from his position as a school bus driver, the evidence of record is devoid of any other references to impaired impulse control. In fact, throughout the pertinent time period, his VA treatment providers found his impulse control remained fair. Consequently, there is insufficient evidence demonstrating difficulty in adapting to stressful circumstances during this time period to warrant a 70 percent disability rating. To the contrary, from at least June 2013, in spite of his PTSD symptoms, he is not only able to take care of himself but his wife and household as well due to her various health issues. Although the Veteran continued to experience anxiety and depression during this period, the evidence of record fails to show that it either was near-continuous and affected his ability to function independently, appropriately, and effectively for the reason noted above. At no time during the relevant period did the Veteran manifest any other symptoms of a similar severity, frequency, or duration of those typically associated with a 70 percent disability rating or higher for PTSD. See Vazquez-Claudio, supra; see also Mauerhan, supra. ORDER An increased disability rating in excess of 30 percent prior to September 18, 2006 for PTSD is denied. An increased disability rating of 70 percent, but no higher, from September 18, 2006 to May 5, 2011 for PTSD is granted, subject to the laws and regulations governing the payment of monetary awards. An increased disability rating of 50 percent, but no higher, from May 6, 2011 for PTSD is granted, subject to the laws and regulations governing the payment of monetary awards. REMAND The Veteran contends that he is unable to secure or follow a substantially gainful occupation due to his service-connected disabilities. See June 2016 Veteran's Application for Increased Compensation Based on Unemployability. The Veteran reported receiving disability income from the Social Security Administration (SSA) during the April 2011 VA examination. April 2011 PTSD VA Examination Report. However, the Board notes there are no records from SSA associated with the claims file and no requests have been made for the same. As such, a remand is necessary to obtain these records. Accordingly, the case is REMANDED for the following action: Obtain a copy of the Veteran's relevant SSA records. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims remanded by the Board or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ R. FEINBERG Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs