Citation Nr: 20046491 Decision Date: 07/13/20 Archive Date: 07/13/20 DOCKET NO. 15-13 511 DATE: July 13, 2020 ORDER Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is denied. FINDING OF FACT The Veteran’s PTSD is not shown to have resulted in impairment greater than occupational and social impairment with reduced reliability and productivity; occupational and social impairment with deficiencies in most areas due to psychiatric symptoms is not shown. CONCLUSION OF LAW A rating in excess of 50 percent for PTSD is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.3, 4.130, Diagnostic Code (Code) 9411. REASONS AND BASES FOR FINDING AND CONCLUSION The appellant is a Veteran who served on active duty from June 1969 to September 1971. This matter is before the Board on appeal from a September 2011 rating decision (that granted service connection for PTSD, rated 30 percent. effective August 19, 2020. In June 2018, the matter was remanded for additional development. Entitlement to a rating in excess of 50 percent for PTSD is denied. On September 2010 VA treatment, the Veteran reported having frequent anxiety, anxiety and frustration in traffic, and difficulty at night due to feeling unsafe and having to get up and check his house. He reported he sleeps about 5 hours a night and naps after coming home from work as a supervisor at transit. He reported being married, to his second wife, for 15 years. He reported having problems relating to his children, and that he had nightmares when under stress. A suicide screening was negative. He reported a quick temper, but no history of violence. On mental status exam, he was cooperative and reasonable with appropriate grooming, his mood was euthymic, affect was congruent with mood, and thought process and content were normal. His insight and judgment were good, and he was alert and fully oriented. His attention, concentration and memory were intact. On November 2010 VA examination, the Veteran reported that he had never received a prescription for psychiatric medication. He reported that he had been employed as a transit worker for 31 years and was scheduled to retire the following week; and that he enjoyed work and had good relationships with coworkers. He reported significant difficulty relating to his wife and children, often distant to them and difficulty feeling close to them; the degree and quality of his social relationships was described as fair. He reported that he had friends with whom he felt close, but these were coworkers. He reported he enjoyed working on cars and maintaining his house properly. He reported verbal outbursts at times but denied any history of physical assaultiveness and having history of suicidal ideation. On mental status examination, there was no impairment of thought process or communication, and no evidence of delusion or hallucination. The Veteran was cooperative and forthcoming. There was no evidence of suicidal or homicidal ideation. His personal hygiene was intact, and he was fully oriented. He had no significant memory problems. He did have obsessive or ritualistic behavior, specifically hypervigilant checking of his environment for safety, especially at night. His speech was normal and coherent. He reported panic attacks with varied frequency. His mood was “saddened”. He had some impaired impulse control at times. He reported interrupted sleep. The examiner opined that the Veteran experienced moderate symptoms of PTSD which had a negative impact on his family role functioning and leisure recreation activities; he did not enjoy participating in social activities involving others. On June 2012 VA treatment, the Veteran reported being anxious and dysphoric much of the time. He reported sleep disruption with nightmares which began to relate to an intense concern over the security and safety of his home and his family. He denied any suicidal or homicidal ideation. On August 2012 private vocational evaluation, the Veteran was friendly, cooperative, and responsive. His speech and eye contact were adequate. He reported that he could no longer do things such as heavy yard work, home repairs, or his own auto repairs due to shortness of breath and chest pains that worsened with exertion due to his cardiac condition. He reported stress from his physical condition, fear of going to sleep and poor sleep due to nightmares, poor memory and being forgetful. The counselor opined that the Veteran had limitations in understanding and following complex directions, inability to maintain attention and concentration for extended periods, inability to respond appropriately to supervision, and impaired judgment, resulting in reduced reliability and productivity for competitive work. On January 2014 VA treatment, the Veteran reported that he was doing relatively well, and having his son home from college made him feel safe. He reported he slept 4 to 5 hours a night with medication. He experienced feelings of sadness, irritability, and a need to isolate periodically. He reported that his relationship with his wife fluctuated. His mood was euthymic, and affect was congruent. On May 2014 VA treatment, the Veteran reported symptoms of social isolation, bouts of depression, and sleep disruption manifested by difficulty staying asleep, restlessness, and nightmares. He reported high anxiety due to his daughter now driving. He reported being a worrier and overprotective. He denied any suicidal or homicidal ideation. On May 2015 VA treatment, the Veteran reported having night fears and worries all the time. He reported trying to get out of ruts when he alienates himself, but without success. He reported conflict with his wife. He reported “okay” sleep without medication. On mental status exam, he was neatly dressed and groomed. His mood was anxious and depressed with congruent affect. His speech was clear and coherent. His thought process was linear. On October 2015 VA treatment, the Veteran reported that when he feels anxiety increasing, he goes off somewhere and talks himself down. He reported that worrying about his children is not good for him, and does not change things. He reported that his relationship with his wife had improved. He reported that he went to a reunion of coworkers and had a good time. He denied suicidal or homicidal ideation. His mood was euthymic, and affect was congruent with mood. On April 2016 VA treatment, the Veteran reported feeling anxious, annoyed, and angry because his son had relapsed in alcoholism. He reported that when he gets upset it causes him to become very paranoid and depressed. He reported that his two younger children are very supportive, that his wife was organizing a vacation for later in the year, and that there had been improvement in their relationship. He denied suicidal or homicidal ideation. On February 2017 VA treatment, the Veteran reported symptoms of sleep disruption, intrusive memories, bouts of depression, hypervigilance, a high level of anxiety, and avoidance of places and people. He reported a supportive relationship with his two younger children, both college students, and that he stayed in touch with his older daughter as well; his relationship with his older son remained difficult. He reported improvement in his relationship with his wife. On October 2017 VA treatment, the Veteran reported that he was not doing well. He reported that his marriage was strained and distant, with no affection from his wife. He reported that he was socially isolated over the past years, and was grieving the recent death of his mother, who was the one person with whom he shared his feelings. He reported that he had attempted to join a service organization, but he did not like the environment; he planned to try another organization. His mood was dysthymic, and affect was congruent with his mood. On May 2018 VA treatment, the Veteran reported that he was worked on his garden and kept busy with plans to take his boat out. He reported that his wife told him he was fighting in his sleep while dreaming. He reported stress due to issues with his older two children. He reported that he went to New Orleans with his church, and he went to Cozumel on a ship with his wife. He reported that he was trying to let go of self-blame for issues with his wife and children. On mental status exam, he was neatly dressed and groomed. His mood was anxious/depressed, and his affect was congruent. His speech was clear, coherent, and soft-spoken. His thinking was linear and logical. On November 2018 VA treatment, the Veteran reported that his night fears were worse; his wife tried to help by turning lights on in the house, but he turned them off due to bills. He reported that he was worried about his older son with whom he could not get in touch. He reported dreams related to service that caused chest pains. In an April 2019 statement, the Veteran’s treating nurse practitioner stated that he sleeps poorly and has frequent nightmares, and he gets up to check the house nightly. She stated that he is constantly troubled by intrusive memories, and experiences severe anxiety which in turn affects his cardiac condition. She stated that he isolates himself much of the time and has difficulty in relationships with his family. She stated that the Veteran’s relationship with his wife is strained at best, and he is hypervigilant about his younger two children, worrying all the time about their safety. On May 2019 VA examination, the Veteran reported living with his wife of 25 years and two young adult children. He reported that his primary social support comes from his wife, children, two younger sisters, and a friend. He reported maintaining at least weekly contact with his sisters. He reported alienating himself from others, and that he does not often socialize. He reported spending most of his time at home running errands, watching television, and sometimes cooking. He reported being able to drive and perform regular activities of daily living independently. He reported that he retired from his career at MTA in 2020 due to heart problems; he reported no impairment in his work performance over the years. He reported moderate depression occurring most days, characterized by isolation, decreased motivation, lack of interest, and anhedonia. He reported anger and tendency to ruminate over his military experiences. He reported he has distanced himself from his wife for a number of years. He reported sometimes visiting a mechanic friend. He denied feelings of worthlessness, hopelessness, or helplessness, and denied suicidal or homicidal ideation. He denied delusions and hallucinations. He reported intermittent situational anxiety characterized by nervousness and fear, and especially anxiety and hyperarousal at night. He reported sleep problems due to fear and anxiety, with difficulty falling asleep and nightmares occurring between bimonthly and twice weekly. His reported symptoms included depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. On mental status exam, the Veteran was described as casually dressed, with fair hygiene. He was fully oriented, and his attitude and behavior were cooperative and engaged. He was alert, though his attention and concentration were mildly impaired. His mood was “okay”, and his affect was mood congruent and dysthymic. His range of emotion was restricted. His psychomotor activity was unremarkable. His speech and response time were normal. His judgment was intact, and insight was fair; his tendencies of perseveration and rumination appeared to maintain his current mental health symptoms. His thought content was coherent and linear although he was circumstantial at times. His thought processes were logical and goal-oriented with ruminative tendencies. His memory was intact. No signs of perceptual disturbances were observed. He denied suicidal and homicidal ideation. The examiner opined that the Veteran’s PTSD results in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Veteran reported his symptoms had worsened, mostly due to his retirement and having more time/not being as busy with work. The examiner opined that the symptoms appeared to worsen during seasons of increased life stressors and nightmares, and opined that during these times the Veteran evidences reduced reliability and productivity in his social environment. Based on this evidence, an April 2020 rating decision granted the Veteran an increased initial rating of 50 percent for PTSD, effective August 19, 2010. Treatment records reflect symptoms largely similar to those described on the VA examinations. Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 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. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the veteran’s favor. 38 C.F.R. § 4.3. PTSD is rated under 38 C.F.R. § 4.130, Code 9411 and the General Rating Formula for Mental Disorders. A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent rating 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; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Code 9411. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remissions. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b). The evidence of record does not show that manifestations of, or impairment due to, the Veteran’s PTSD have met (or approximated) the level of impairment associated with a 70 percent or higher rating. It is not shown that at any time under consideration the PTSD was productive of occupational and social impairment with deficiencies in most areas. The treatment records and examination reports show that he has tended adequately to activities of daily living, maintain relations with close family (his wife, his sisters, and his children, and his mother until her passing in 2017) and a friend, and has consistently denied suicidal ideation. The Board notes that he has reported isolating himself from his wife at times, however, he has always described her and his younger children as supportive, and the record shows, that during the evaluation period, his wife planned, and they went on a vacation trip. There is no evidence of a cognitive/thought disorder or impaired insight or judgment. This disability picture presented does not reflect due to PTSD symptoms he has occupational and social impairment with deficiencies in most areas; instead, it reflects a reasonably well-functioning upon transitioning to retirement, with no deficiency in daily-activity functioning, ability to maintain both social and familial relationships, all albeit with the fairly normal anxiety that appears with concerns about family members who are struggling. Indeed, the November 2010 VA examiner opined that the Veteran experienced moderate symptoms, and the May 2019 VA examiner opined that the Veteran’s mental disorder resulted in occupational and social impairment with only occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation; or reduced reliability and productivity in his social environment [only] during seasons of increased life stressors and nightmares. Such findings are consistent with the criteria for the now-assigned, throughout, 50 percent rating, and the criteria for the next higher (70 percent) rating are not shown to have been met at any time. The Board notes the lay statements submitted by the Veteran in support of this claim. They describe the types of problems that are associated with his PTSD. The disability picture shown by his descriptions is encompassed by the criteria for the 50 percent rating assigned; thus, even his own lay statements do not support that an increased rating has been warranted at any time. Considering the foregoing, the Board finds that the preponderance of the evidence is against this claim. Therefore, the appeal in this matter must be denied. GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Schechner, 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.