Citation Nr: 20029226 Decision Date: 04/27/20 Archive Date: 04/27/20 DOCKET NO. 15-25 707 DATE: April 27, 2020 ORDER For the period prior to June 1, 2016, a rating in excess of 10 percent for hepatitis C is denied. For the period from June 1, 2016 to October 18, 2019, a 20 percent rating, but no higher, for hepatitis C is granted, subject to the laws and regulations governing the payment of VA monetary benefits. For the period beginning October 18, 2019, a rating in excess of 20 percent for hepatitis C is denied. For the period prior to October 21, 2019, a 70 percent rating, but no higher, for PTSD is granted, subject to the laws and regulations governing the payment of VA monetary benefits. For the period beginning October 21, 2019, a rating in excess of 70 percent for PTSD is denied. FINDINGS OF FACT 1. For the period prior to June 1, 2016, the Veteran’s hepatitis C was manifested by daily right upper quadrant pain and intermittent nausea and anorexia (lack or loss of appetite); it was not manifested by daily fatigue or malaise, the need for dietary restriction or continuous medication, cirrhosis or liver malignancy, or incapacitating episodes with a total duration of at least two weeks in in the past 12-months. 2. For the period from June 1, 2016 to October 18, 2019, the Veteran’s hepatitis C was manifested by daily right upper quadrant pain and nausea, intermittent anorexia and fatigue, and the need for continuous medication, it was not manifested by sustained minor weight loss, hepatomegaly, cirrhosis, liver malignancy, or incapacitating episodes with a total duration of at least four weeks in in the past 12-months. 3. For the period beginning October 18, 2019, the Veteran’s hepatitis C was manifested by daily fatigue, malaise, and right upper quadrant pain and intermittent nausea and anorexia; it was not manifested by sustained minor weight loss, hepatomegaly, cirrhosis, liver malignancy, or incapacitating episodes with a total duration of at least four weeks in in the past 12-months. 4. For the period prior to October 21, 2019, the severity, frequency, and duration of the Veteran’s symptoms more closely approximated occupational and social impairment with deficiencies in most areas. 5. For the period beginning October 21, 2019, the severity, frequency, and duration of the Veteran’s symptoms did not more closely approximate total occupational and social impairment. CONCLUSIONS OF LAW 1. For the period prior to June 1, 2016, the criteria for a rating in excess of 10 percent for hepatitis C have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.112, 4.114, Diagnostic Code 7354. 2. For the period from June 1, 2016 to October 18, 2019, the criteria for a 20 percent rating, but no higher, for hepatitis C have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.112, 4.114, Diagnostic Code 7354. 3. For the period beginning October 18, 2019, the criteria for a rating in excess of 20 percent have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.112, 4.114, Diagnostic Code 7354. 4. For the period prior to October 21, 2019, the criteria for a 70 percent rating, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 5. For the period beginning October 21, 2019, the criteria for a rating in excess of 70 percent have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from April 1977 to February 1983 and from January 1984 to September 1995. These matters are before the Board of Veterans’ Appeals (Board) on appeal from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). These matters were last before the Board in August 2018, when they were remanded for additional development. Regarding the Veteran’s hepatitis C claim, as noted in the prior remand, the Veteran’s notice of disagreement specifically limited his appeal to the period beginning October 8, 2013. See AB v. Brown, 6 Vet. App. 35, 39 (1993) (stating a claimant may limit his appeal to less than the maximum benefit if he expresses a clear intent to do so); Hamilton v. Brown, 4 Vet. App. 528 (1993) (stating “where...the claimant expressly indicates an intent that adjudication of certain specific claims not proceed at a certain point in time, neither the RO nor BVA has authority to adjudicate those specific claims.”). 1. Entitlement to a rating in excess of 10 percent for hepatitis C the period prior to October 18, 2019. 2. Entitlement to a rating excess of 20 percent for hepatitis C the period beginning October 18, 2019. The Veteran asserts that an increased rating is warranted for his hepatitis C. His hepatitis C is rated under 38 C.F.R. § 4.114, Diagnostic Code 7354. Under Diagnostic Code 7354, a 10 percent rating is assigned for hepatitis C manifested by intermittent fatigue, malaise, and anorexia, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least one week, but less than two weeks, during the past 12- month period. Id. A 20 percent rating is warranted for hepatitis C manifested by daily fatigue, malaise, and anorexia (without weight loss or hepatomegaly), requiring dietary restriction or continuous medication, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least two weeks, but less than four weeks, during the past 12-month period. Id. A 40 percent rating is warranted for hepatitis C manifested by daily fatigue, malaise, and anorexia, with minor weight loss and hepatomegaly, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and upper right quadrant pain) having a total duration of at least four weeks, but less than six weeks, during the past 12-month period. Id. A 60 percent rating is warranted for hepatitis C manifested by daily fatigue, malaise, and anorexia, with substantial weight loss (or other indication of malnutrition), and hepatomegaly, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and upper right quadrant pain) having a total duration of at least six weeks, but not occurring constantly, during the past 12-month period. A 100 percent rating is warranted for hepatitis C manifested by near-constant debilitating symptoms (such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain). Id. Note (1) to Diagnostic Code 7354 provides for evaluation of sequelae, such as cirrhosis or malignancy of the liver, under an appropriate diagnostic code, but prohibits use the same signs and symptoms as the basis for evaluation under Diagnostic Code 7354 and under a diagnostic code for sequelae. Note (2) provides that ‘‘incapacitating episode’’ means a period of acute signs and symptoms severe enough to require bed rest and treatment by a physician. For purposes of evaluating conditions in 38 C.F.R. § 4.114, the term “substantial weight loss” means a loss of greater than 20 percent of the individual’s baseline weight, sustained for three months or longer; and the term “minor weight loss” means a weight loss of 10 to 20 percent of the individual's baseline weight, sustained for three months or longer. 38 C.F.R. § 4.112. “Baseline weight” means the average weight for the two-year-period preceding onset of the disease. Id. As noted above, the current appeal period begins October 8, 2013. For the purposes of determining the Veteran’s baseline weight, the Board notes that VA treatment records from July 2011, January 2012, February 2012, March 2012, 2012, August 2012 indicate that the Veteran weighed 166 pounds, 166 pounds, 168 pounds, 168 pounds, 166 pounds, 167 pounds, and 163 pounds. A VA examination report from October 2012 indicates that the Veteran weighed 167 pounds. VA treatment records from December 2012, January 2013, February 2013, March 2013 respectively indicate that the Veteran weighed 160 pounds, 165 pounds, 162 pounds, 168 pounds, and 168 pounds. Thus, the Veteran’s baseline weight is approximately 166 pounds. A VA examination report from October 2013 indicates that the Veteran had daily right upper quadrant pain. The examiner indicated that the Veteran’s did not have any incapacitating episodes due to his liver condition in the last 12 months, did not require continuous medication, and did not have signs or symptoms attributable to cirrhosis of the liver. The Veteran’s weight was not documented. VA treatment records from October 2013 and November 2013 indicate that the Veteran reported ongoing “liver pain,” which he rated as a 5/10. He also reported nausea and weight loss of approximately three to five pounds despite his appetite remaining stable. He was noted to weigh between 163 and 160 pounds. He was assessed with chronic hepatitis C with ongoing right upper quadrant pain, but without evidence of cirrhosis. VA treatment records from April 2014 indicate that the Veteran had chronic hepatitis C without fibrosis but with persistent daily abdominal pain and nausea. However, he denied manifestations of decompensated liver disease, such as bleeding, confusion, edema, fatigue, decreased appetite, or weight loss. He was noted to weigh 169 pounds. In his June 2014 notice of disagreement, the Veteran reported that his hepatitis C caused pain and functional loss. An April 2015 VA record indicates that the Veteran continued to experience chronic right upper quadrant pain. He described it as a sharp knife-like stabbing pain. He denied nausea, vomiting, or weight loss. He was noted to weigh 166 pounds. In his June 2015 VA Form 9, the Veteran asserted that his hepatitis C symptoms included daily nausea, weight loss, daily liver pain, daily fatigue, and the need for liver surgery and scans. He stated that these symptoms had been ongoing since service. VA records from August 2015 indicate that the Veteran continued to have chronic hepatitis C with right upper quadrant pain without fibrosis. The Veteran denied weight loss or change in appetite. The clinician noted that the Veteran did not have extraintestinal manifestation of hepatitis such as increased abdominal girth, edema, jaundice, confusion, bleeding, fatigue, nausea, or vomiting. He was assessed as not requiring any urgent treat as he was unlikely to progress to cirrhosis, even in the absence of therapy. VA records from April 2016 indicate that the Veteran continued to endorse chronic abdominal pain that was debilitating “most every morning.” He also endorsed nausea, vomiting, and a poor appetite. He was noted to weigh 173 pounds. VA records from May 2016 indicate that the Veteran reported recent weight loss, increasing nausea, and a poor appetite. The Veteran also reported losing 10 pounds in the last month. He was noted to weigh 166 pounds. A June 1, 2016 VA record indicates that the Veteran endorsed constant right upper quadrant pain and worsening daily nausea. He denied vomiting. Upon examination, he was noted to have “possible hepatomegaly.” However, the clinician stated that accurate assessment was limited due to abdominal scar tissue. He was noted to weigh 172 pounds. Lab work revealed that the Veteran’s platelet count was low, and that further assessment was required as such could be evidence of cirrhosis. Regarding the Veteran’s nausea, while the clinician opined that that Veteran’s nausea was not related to his hepatitis C, he was instructed to take promethazine daily for nausea control. A July 2016 VA treatment record noted that the Veteran continued to have right upper quadrant pain and nausea. However, his appetite and weight were noted to be stable and he denied vomiting in recent months. He stated that he continued to treat his recurrent nausea with promethazine. VA treatment records from September 2016 indicate that the Veteran’s hepatitis C met the criteria for Elbasvir/Grazoprevir treatment, and he was started on medication therapy. VA treatment records from October 2016 and November 2016 indicate that the Veteran continued his hepatitis C medication therapy. He denied having abdominal pain, but endorsed intermittent nausea, worsening fatigue, decreased appetite, and a three-pound weight loss in the last week. He was noted to weigh 163 pounds. VA treatment records from January 2017 indicate that the Veteran’s medication therapy had been successful and that his hepatitis C viral load was no longer detectable. A February 2017 VA record indicates that the Veteran reported that his liver pains were less frequent and less intense since completing his hepatitis medication therapy. While the Veteran continued to endorse nausea, the clinician opined that symptom was unrelated to the Veteran’s hepatitis. VA treatment records from May 2017 note that the Veteran’s weight was stable, and that his appetite was okay. While the Veteran endorsed nausea with occasional vomiting, those symptoms were attributed to his gastroesophageal reflux disease. VA records from August 2017, September 2017, October 2017, and November 2017 note that the Veteran continued to have occasional right upper quadrant pain and an intermittently decreased appetite. He denied any weight change or fatigue. The clinician stated there were no symptoms to suggest decompensation of cirrhosis or liver disease. VA treatment records from February 2018 indicate that the Veteran’s weight was stable, and his energy and appetite were good. He continued to endorse chronic abdominal pain and nausea. There was no evidence of hepatosplenomegaly and the Veteran was noted to weigh 174 pounds. VA treatment records from June 2018 note that the Veteran endorsed recent weight loss, reduced appetite, and decreased energy. It was noted that his weight had decreased to 160 pounds. The Veteran denied nausea, vomiting, and abdominal pain. The clinician opined that the Veteran’s weight loss was “likely due to reduced mood related to grief over recent loss of family members,” including the Veteran’s uncle and mother. Physical examination did not reveal any evidence of hepatosplenomegaly. VA treatment records from April 2019, May 2019, and August 2019 indicate that the Veteran endorsed ongoing fatigue, and chronic abdominal pain. Specifically, he stated that he was fatigue “about half the time.” However, it was noted that his weight stable and there was no evidence of hepatosplenomegaly. An October 2019 VA examination report indicates that the Veteran completed medication therapy for his hepatitis C and his viral load was now undetectable. It was noted that his hepatitis C symptoms include daily fatigue, daily malaise, daily right upper quadrant pain, and intermittent nausea. It was noted that the Veteran’s hepatitis C did not require continuous medication, result in incapacitating episodes, or cause cirrhosis of the liver. After reviewing the evidence of record, the Board finds that the criteria for a rating in excess of 10 percent is not met for the period prior to June 1, 2016. While the Veteran reported daily right upper quadrant pain and intermittent nausea and anorexia, the preponderance of the evidence is against finding that he had daily fatigue, malaise, and anorexia, that he required dietary restriction or continuous medication, or had incapacitating episodes with a total duration of at least two weeks. The Board has not overlooked the VA treatment records indicating that the Veteran was prescribed dicyclomine (Bentyl) and amitriptyline and advised to follow a “low FODMAP diet.” Nevertheless, there is no indication that the medications or special diet were required for his service-connected hepatitis C. To the contrary, VA records from August 27, 2015, May 15, 2017, and July 25, 2017, expressly indicate that those medications and dietary restrictions were for the Veteran’s irritable bowel syndrome rather than his hepatitis C. As such, neither can satisfy the criteria for an increased rating. Beginning June 1, 2016, the Board finds that the criteria for a 20 percent rating has been met. A VA treatment record from June 1, 2016 indicates that the Veteran was prescribed promethazine daily for nausea. Additionally, a September 16, 2016 VA treatment record indicates that the Veteran met the criteria for hepatitis C medication therapy and was started on Elbasvir/Grazoprevir. The Board acknowledges that the June 1, 2016 treatment record suggests that the Veteran’s nausea was unrelated to his hepatitis C. However, as there is the conflicting evidence regarding whether the nausea was attributable to his hepatitis C, the Board will resolve reasonable doubt in his favor and find that the Veteran’s hepatitis C required continuous medication on June 1, 2016. Nevertheless, at no time since October 8, 2013 has the criteria for a rating in excess of 20 percent been met. The Board finds that the preponderance of the evidence demonstrates that the Veteran's hepatitis C was not manifested by sustained minor weight loss as defined by 38 C.F.R. § 4.112, hepatomegaly, cirrhosis, liver malignancy, or incapacitating episodes having a total duration of at least four weeks in the past 12 months. The Bord acknowledges the assertions from the Veteran and his representative that the Veteran’s hepatitis C was manifested by daily fatigue and weight loss throughout the pendency of the appeal. The Veteran and his representative are competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, their reports of ongoing daily fatigue prior to October 18, 2019 lack credibility as they are contradicted by the VA treatment records, wherein the Veteran regularly denied fatigue and stated that his energy was good. See e.g., October 8, 2013 VA examination report and VA treatment records from October 10, 2013, April 24, 2014, August 27, 2015 (noting that the Veteran denied and/or did not endorse fatigue); VA treatment records from November 19, 2018 and February 21, 2018 (noting that the Veteran reported that his “energy level was good”); April 1, 2019 VA treatment record (noting that the Veteran reported fatigued about half the time). The Board does not find that the Veteran's lay statements lack credibility merely because they are unaccompanied by contemporaneous medical evidence. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Rather, the lay statements regarding ongoing daily fatigue are found to lack credibility because they are inconsistent with and directly contradicted by the other evidence of record, including the Veteran's own statements wherein he stated his energy level was good and he denied fatigue. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (finding Board entitled to discount the credibility of evidence considering its own inherent characteristics and its relationship to other items of evidence). Regarding weight loss, the Board acknowledges that the Veteran’s weight fluctuated throughout the pendency of the appeal. Nevertheless, those fluctuations do not rise to the level of sustained minor weight loss as contemplated by 38 C.F.R. § 4.112 (2019) (requiring “weight loss of 10 to 20 percent” of baseline weight “sustained for three months or longer”). The Board also acknowledges the representative’s assertion that a higher rating is warranted because the most recent VA examination showed fatigue and malaise “with incapacitating episodes.” Contrary to the representative’s assertion, the October 2013 and October 2019 VA examination reports indicate that the Veteran did not have any incapacitating episodes during the past 12 months. Accordingly, a higher rating is not warranted for incapacitating episodes. The Board also considered the applicability of other diagnostic codes for evaluation of sequelae, such as cirrhosis or malignancy of the liver. However, in the absence of evidence of cirrhosis or malignancy, these Diagnostic Codes are not applicable. See 38 C.F.R. § 4.114, Diagnostic Code 7354, Note 1 (2019). In reaching the above conclusions, the Board considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable. See 38 U.S.C. § 5107 (b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). 3. Entitlement to a rating to a rating in excess of 50 percent for PTSD for the period prior to October 21, 2019. 4. Entitlement to a rating to a rating in excess of 70 percent for PTSD for the period beginning October 21, 2019. The Veteran asserts that an increased rating is warranted for his PTSD. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). A 50 percent rating is assigned when 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 judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when 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 worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such 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; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. Treatment records from Dr. Jabbour from July 2013 indicate that anger, anxiety, and depression were an ongoing issue for the Veteran and that he was requesting medication management. He reported that his current relationship was failing because of his anger and that his girlfriend told him he was too aggressive. Upon examination, the Veteran appeared hyper, high-strung, anxious, and restless. His speech was noted to be within normal limits but evidence some thought blocking and thought searching. There was no evidence of psychosis, hallucinations, or delusions. The Veteran denied any suicidal or homicidal ideation. His affect was constricted, and he was noted to have difficulty with focus, concentration, and recall. An August 2013 treatment record from Dr. Jabbour indicates that the Veteran reported that he felt like he could not handle his job anymore. He noted that he had ongoing problems with his boss and a co-worker and had been less patient and more irritable recently. A November 2013 treatment record from Dr. Jabbour notes that the Veteran reported that he continued to work but was “not doing much well” and his girlfriend told him he was “snappy.” Upon mental status examination, there was no evidence of psychosis, delusions, hallucinations, suicidal or homicidal ideation. A November 2013 VA record indicates that the Veteran reported anxiety attacks from loud noises and other events that scare him. The clinician opined that the Veteran’s attacks appeared to be acute anxiety spells rather than “panic attacks.” The Veteran reported that he slept approximately four hours per night and had occasional nightmares and flashbacks. Upon mental status examination, he was oriented to time, place, and person, his mood was noted as good, and he denied depression, mania, hallucinations, and suicidal or homicidal ideation. A February 2014 record from Dr. Jabbour indicates that the Veteran reported improvement with his current medications. However, he continued to endorse issues with being in crowds and maintaining relationships. He stated that he had general discomfort in crowds and obsessive thoughts about danger. Upon mental status examination, the Veteran appeared anxious and somewhat disheveled. His mood was anxious and depressed. His affect was congruent to mood, but somewhat blunted with evidence of psychomotor retardation. His thought process displayed some thought blocking, word searching, and delayed thought, but no flight of ideas, looseness of association, or circumstantial thought. He denied any hallucinations, suicidal and homicidal thoughts, or self-injurious behavior. A VA examination from April 2014 indicates that the Veteran reported frequent panic attacks, general anxiety, and irritability. He reported that he had been with his girlfriend for three years and described the relationship as “somewhat stable.” However, he stated that his mood interfered with their ability to truly enjoy the relationship and noted that his girlfriend often commented on his irritability and “overly aggressive tone.” He reported having an unstable work history and stated he had difficulty keeping a job due either to his skills or his attitude. He noted that he currently worked at an airport, but felt his termination was pending due to his attitude. The Veteran reported taking trazodone, clonazepam, and sertraline, but did not feel his symptoms were improving. He reported poor sleep and reported averaging three hours of sleep per night. He denied nightmares or flashbacks. He endorsed elevated anxiety levels and panic attacks. He denied paranoia, exaggerated startle response, feeling uncomfortable in public places, or being hypervigilant. However, he noted that he did check doors at home and search for exits in public. The Veteran reported issues with short-term memory and concentration but denied any long-term memory problems. He endorsed episodes of depression but denied ever feeling so depressed that he was unable to function. He noted that sometimes he considered driving himself off the road, but denied any intent to ever take his life, but stated he found the thoughts bothersome. Upon mental status examination, the Veteran was casually dressed, his mood was mildly dysphoric with congruent affect. He was oriented to person, place, time, and situation. His thought process was within normal limits with no evidence of psychosis, compulsions, or obsessive tendencies. Speech was goal directed and within normal limits. The examiner indicated that the Veteran’s PTSD symptoms included depressed mood, anxiety, weekly or less often panic attacks, chronic sleep impairment, mild memory loss, impaired judgement, disturbances of motivation and mood, difficulty establishing and maintaining effective relationships, and difficulty adapting to stressful circumstances. A June 2014 record from Dr. Jabbour notes that the Veteran endorsed ongoing problems with socialization and reported that he stayed home most of the time. He noted that he continued to have some issues at his job. He also reported symptoms including flashbacks, nightmares, and hyperarousal. Upon mental status examination, he appeared anxious and somewhat disheveled. His affect was blunted. His speech was within normal limits. His thought process did not evidence any flight of ideas, looseness of association, or circumstantial thought, but there was evidence of thought blocking, word searching, and delayed thought. A September 2014 record from Dr. Jabbour notes that the Veteran reported that his condition was about the same, except he had been more claustrophobic recently. He noted that he was taking his medication as prescribed with some improvement in his sleep. He continued to endorse anxiety, moodiness, reclusiveness, and irritability. He stated that he continued to work at the airport, but otherwise spent most of his time at home and did not have much social interaction. He denied any having suicidal or homicidal ideation, self-injurious behavior, hallucinations, or delusions. Mental status examination remained largely unchanged. A January 2015 record from Dr. Jabbour notes that the Veteran continued to experience anxiety, hypervigilance, and claustrophobia, which affected his daily life and secondary job as an “HVAC” (presumably heating, ventilation, and air conditioning). He reported that his sleep had improved, and his mood was about the same. He endorsed flashbacks and nightmares when exposed to triggers or stressful situations. He denied experiencing hallucinations or suicidal or homicidal ideation. Mental status examination remained largely unchanged. A November 2015 record from Dr. Jabbour indicates that the Veteran continued to work at the airport but had problems at work because he forgot procedures and had interpersonal problems with his co-workers and supervisor. He reported that he felt overwhelmed with fear and anxiety to the point that he cannot function. Mental status examination remained largely unchanged. A January 2017 record from Dr. Jabbour indicates that the Veteran continued to work at the airport as a skycap where he was doing okay. The Veteran reported that his short-term memory was not good and that he had to force himself to concentrate. He also endorsed an increase in his claustrophobia. He noted increased problems in his relationship with his girlfriend and stated that she complained that was very loud and needed to control his temper. The Veteran reported conceded that he was moody, snappy, and easily angered. Upon mental status examination, his speech was within normal limits, his mood was described as “up and down,” and his affect was constricted. His thought process and content revealed no evidence of flight of ideas, looseness of associations, hallucinations, suicidal ideation, or homicidal ideation. A July 2017 record from Dr. Jabbour notes that the Veteran reported stress at work and that he had broken up with his girlfriends after he had not responded to her request to get married. He stated he had fluctuating levels of anxiety and that his mood continued to be “up and down.” Mental status examination was otherwise unchanged. An October 2017 record from Dr. Jabbour indicates that the Veteran reported that his uncle had a terminal medical condition, which the Veteran found saddening. He reported that he had been crying a lot and not going out. He described his anxiety level as “not good” and he was observed to appear more depressed than usual. Upon mental status examination, the Veteran’s affect was constricted, there was no evidence of flight of ideas, looseness of association, hallucinations, delusions, or suicidal or homicidal thought. A January 2018 record from Dr. Jabbour notes that the Veteran’s uncle had passed away and that the Veteran was very emotional. He reported that otherwise not much had changed, and he was still working at the airport. An April 2018 record from Dr. Jabbour notes that the Veteran reported increased nightmares and intrusive thoughts. The Veteran also endorsed depression, irritability, and restlessness. Mental status examination was largely unchanged. A February 2019 record from Dr. Jabbour indicates that the Veteran continued to have difficulties with social and work relationships. He endorsed symptoms including depressed, mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty adapting to stressful circumstances, suicidal ideation, and an inability to establish and maintaining effective relationships. An October 2019 VA examination report notes that the Veteran had broken up with his girlfriend due to his PTSD symptoms. He reported ongoing symptoms including moodiness, mood swings, anger, irritability, suspiciousness, nightmares, extreme claustrophobia, sleep deprivation, short-term memory loss, emotional detachment, fear of intimacy, emotional distance, passive thoughts of death without any plan, fear of impending problems, and reclusiveness. The Veteran reported that since breaking up with his girlfriend, he had been unable to start or sustain a relationship, so he mainly stayed to himself. Upon mental status examination, the Veteran was well groomed and oriented to time, place, and person. His mood was anxious and edgy. His speech was productive, and his thought process was logical without evidence of delusional thinking, hallucinations, inappropriate behavior, obsessive or ritualistic behavior, or psychosis. It was noted that he had no apparent attention or memory difficulties. His insight and judgment were assessed as adequate. The Veteran denied any current suicidal or homicidal ideation. The examiner indicated that the Veteran’s symptoms included depressed mood, anxiety, suspiciousness, more than weekly mild panic attacks, chronic sleep impairment, mild memory loss, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective relationships, and difficulty adapting to stressful circumstances. After reviewing the evidence of record, the Board finds that the criteria for a 70 percent rating is met for the period prior to October 21, 2019. Specifically, the record indicates that the Veteran's symptoms included impaired judgment, verbal aggression, intermittent passive suicidal ideation, intermittent neglect of personal appearance, difficulty adapting to stressful circumstances, and an inability to establish and maintain effective relationships. Nevertheless, at no time during the pendency of the appeal have the Veteran’s PTSD symptoms more nearly approximated total occupational and social impairment. Mental status examinations from VA and private treatment records and the April 2014 and October 2019 VA examinations indicate that there was no evidence of disorientation to time or place, gross thought impairment, gross communication impairment, persistent hallucinations or delusions, grossly inappropriate behavior, persistent danger of hurting himself or others, an inability to perform activities of daily living, including maintenance of minimal personal hygiene, or memory loss for names of close relatives, his own occupation, or own name. Additionally, the evidence of record has not indicated that presence of any unlisted symptoms that are similar to the nature, severity, or frequency of the symptoms detailed in the criteria for a 100 percent disability rating or that would otherwise be productive of total occupational and social impairment. The Board acknowledges that that his April 2014 VA examination the Veteran reported that “sometimes he considered driving himself off the road.” However, the Board finds that the nature, severity, and frequency of this symptoms is distinguishable from a persistent danger of self-harm, which is contemplated by the 100 percent criteria. Bankhead, 29 Vet. App. at 19. Specifically, the Veteran regularly denied thoughts, intent, or a plan involving self-harm at his mental health appointments, and during the April 2014 and October 2019 VA examinations. Additionally, while the Veteran’s appearance was at times noted to be “somewhat disheveled,” which suggests some difficulty maintaining personal hygiene, that manifestation is less severe than the inability to perform minimal personal hygiene, which is contemplated by the 100 percent rating. As such, the Veteran’s passive suicidal ideation and intermittently disheveled appearance do not demonstrate the level of impairment associated with a 100 percent rating. In short, the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran’s symptoms resulted in the level of impairment required for a 100 percent rating at any time during the pendency of the appeal. As such, the criteria for a 100 percent or higher rating are not met and the appeal must be denied. In reaching the above conclusions, the Board considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Michael L. Marcum Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Anderson 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.