Citation Nr: 20005092 Decision Date: 01/23/20 Archive Date: 01/22/20 DOCKET NO. 19-34 096 DATE: January 23, 2020 ORDER An initial rating in excess of 30 percent for unspecified trauma and stressor related disorder is denied. FINDINGS OF FACT 1. The Veteran had active service from May 1968 to August 1970. 2. The Veteran’s psychiatric disorder has been productive of subjective symptoms of sleep disturbances, nightmares, flashbacks, anxiety, and occasional intrusive thoughts resulting in no more than occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. CONCLUSION OF LAW Throughout the entire rating period on appeal, the criteria for a rating in excess of 30 percent for an unspecified trauma and stressor related disorder have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.130, Diagnostic Code (DC) 9435 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSION Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. All psychiatric disabilities are evaluated under a General Rating Formula for Mental Disorders (“General Rating Formula”). Under the General Rating Formula, a 50 percent rating is warranted under the General Rating Formula for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect, circumstantial, circumlocutory, or stereotyped speech, panic attacks occurring more than once a week, difficulty in understanding complex commands, impairment of short-term memory (i.e. retention of only highly learned material or forgetting to complete tasks), impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing effective work and social relationships. The symptoms listed under the rating criteria are meant to be examples of symptoms that would warrant the rating, but they are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Initially, the record does not contain any VA or private clinical treatment records for a psychiatric disorder. The Veteran specifically stated at his October 2018 VA examination that he has never sought private or VA treatment for psychiatric disorder or for any related mental health disorder. He also reported that he was never hospitalized, nor did he seek medication. Turning to the evidence of record, in an October 2018 VA examination, the Veteran reported that he averaged only about three to four hours of sleep per night, and that he experiences nightmares and flashbacks about being in a helicopter during service. He reported that helicopter sounds were huge triggers for him, and induced flashbacks. He further noted that as he grew older, he was experiencing more intrusive thoughts about the wounds he acquired during service. Finally, he stated that he often got “worked up” for no reason, was very restless, and that he preferred to be by himself and often avoided social interaction. The Veteran additionally reported that he had two surviving siblings with whom he maintained close relationships. He also reported further family ties to include his adult son, two grandchildren, and his wife of 53 years. He stated that his marriage was doing okay. Additionally, he reported that he held the same job at a warehouse for more than 23 years, until he retired for 2008. Upon evaluation, the examiner noted symptoms of anxiety, chronic sleep impairment, and difficulty in establishing and maintaining effective work and social relationships. The examiner reported that the Veteran was appropriately dressed and well-groomed, with good eye contact, cooperative and conversational throughout the session. His mood was euthymic, and his affect was consistent. He denied any suicidal or homicidal ideations. His thought processes were linear, logical, and not loose or tangential. His cognition, attention and judgment were normal and intact, and he was oriented to person, time and place. The examiner opined that based on his clinical interview and assessment, the Veteran did not meet the full criteria for a diagnosis of posttraumatic stress disorder (PTSD), as his symptoms were not sufficient to support such a diagnosis. However, the examiner found that the Veteran had symptoms due to trauma related stress disorder. The examiner opined that the Veteran’s symptoms were mild and impacted his social and interpersonal functioning. Considering all symptoms, the examiner found that the Veteran had occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. As there are no other clinical records for further evaluation, the Board assigns great probative weight to the October 2018 examination report. Especially as the examiner interviewed the Veteran, reviewed his medical history, and noted all of the reported symptoms. Furthermore, there is no evidence that any opinion or conclusion was based upon an erroneous or miscommunicated fact. The Veteran asserts that the examiner was distracted and ridiculed him, and that the examiner did not understand PTSD because of his age. The Board has carefully reviewed the findings of the examination in light of the Veteran’s concerns but finds no indication that the examination was otherwise inadequate. The examiner clearly identified the Veteran’s symptoms, provided a diagnosis, and submitted a rationale for the thought process behind any diagnosis. The examiner also reliably reported the Veteran’s in-service stressors which aligned with the Veteran’s reports and military personnel records (MPRs). As such, the examination report was sufficient, and great probative weight is assigned to the clinical findings, especially as there is no other evidence to contradict these findings. In considering the frequency, severity, and duration of the Veteran’s symptoms, a rating in excess of 30 percent is not warranted. During the pendency of this appeal, his psychiatric disability primarily manifested by ongoing sleep impairment and intrusive thoughts. Although the Veteran experienced some difficulty in establishing social relationships, such that his network of friends was limited, he also reported positive relationships with his child, grandchildren, wife and extended family. Further, he presented as capable of appropriate appearance, insight, judgment, and interpersonal communication upon examination. At no time has the Veteran reported the presence of more severe symptoms such as suicidal or homicidal ideations or obsessional rituals. Instead, he presents as largely capable of functioning independently and appropriately. Accordingly, the disability picture during the rating period on appeal is most properly like or similar to the criteria for a 30 percent rating. The Board has also considered the Veteran’s lay statements that his disability is worse than contemplated by the current rating. While he is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran’s trauma disorder has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and other clinical evidence) directly address the criteria under which this disability is evaluated. Moreover, as the examiner has the requisite medical expertise to render a medical opinion regarding the degree of impairment caused by the disability and had sufficient facts and data on which to base the conclusion, the Board affords the medical opinion great probative value. As such, these records are more probative than the Veteran’s subjective complaints of increased symptomatology. In sum, after a careful review of the evidence of record, the benefit of the doubt rule is not applicable and the appeal is denied. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board’s consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (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). L. HOWELL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Yacoub, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.