Citation Nr: 21066843 Decision Date: 11/02/21 Archive Date: 11/02/21 DOCKET NO. 17-46 841 DATE: November 2, 2021 ORDER Entitlement to an initial disability evaluation of 70 percent, but no higher, prior to November 5, 2015 for persistent depressive disorder is granted. Entitlement to an increased evaluation after November 5, 2015, in excess of 70 percent for post-traumatic stress disorder (PTSD), with persistent depressive disorder, is denied. FINDINGS OF FACT 1. The objective medical evidence shows during the period prior to November 5, 2015, the Veteran's persistent depressive disorder more closely approximated occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to associated symptoms, and did not approximate total occupational and social impairment, due to associated symptoms. 2. The objective medical evidence shows from November 5, 2015, PTSD, with persistent depressive disorder, did not more closely approximate total occupational and social impairment, due to associated symptoms. CONCLUSIONS OF LAW The criteria for an initial disability evaluation of 70 percent prior to November 5, 2015, for persistent depressive disorder, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.6, 4.130, Diagnostic Codes 9411, 9435 (2020). The criteria for an increased disability evaluation in excess of 70 percent from November 5, 2015 for PTSD, with persistent depressive disorder, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.6, 4.130, Diagnostic Codes 9411, 9435 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from October 2008 to June 2011. Schedular Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. When a reasonable doubt arises regarding the degree of disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Additionally, it is possible for a veteran to be awarded separate percentage evaluations for separate periods (staged ratings), based on the facts. See Fenderson v. West, 12 Vet. App. 119, 12627 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the relevant overall temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under several diagnostic codes, known as "pyramiding," must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14. 1. Entitlement to an initial disability evaluation in excess of 50 percent prior to November 5, 2015 for persistent depressive disorder. 2. Entitlement to an increased evaluation in excess of 70 percent from November 5, 2015 for PTSD, with persistent depressive disorder. Prior to November 5, 2015, the Veteran's service-connected persistent depressive disorder was rated under Diagnostic Code 9435 for unspecified depressive disorder. From November 5, 2015, PTSD, with persistent depressive disorder, is rated under Diagnostic Code 9411 for PTSD. However, all mental disorders under Diagnostic Codes 9201 through 9440 in turn defer to the General Rating Formula for Mental Disorders (General Rating Formula) for actual rating criteria, as set forth in 38 C.F.R. § 4.130. Therefore, the Veteran receives one rating under the General Rating Formula for all symptoms associated with all service-connected psychiatric disorders. As such, after November 2015, the issue has been characterized accordingly to include both PTSD and persistent depressive disorder, as separately rated claims would not permitted, as this would be "pyramiding" the same, similar or overlapping symptoms and diagnoses one upon the other. 38 C.F.R. § 4.14. Under the General Rating Formula, a 50 percent evaluation requires demonstrated evidence of 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 (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and/or difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A 70 percent disability rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent disability rating will be assigned for total occupational and social impairment, due to symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting one's 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, one's own occupation or own name. Id. The symptoms listed in the General Rating Formula are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of symptoms, or their effects, which would justify a rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence demonstrates that the claimant's psychiatric disorder produces symptoms and resulting occupational and social impairment equivalent to that set forth in the criteria for a given rating, then that rating will be assigned. Mauerhan, 16 Vet. App. at 443. Turning to the record, the Veteran received an initial rating of 50 percent in February 2013 for persistent depressive disorder, effective June 4, 2011, the day after the Veteran's separation from active service. The Board has considered evidence from 1 year prior to that date. As stated above, from November 5, 2015, the issue has been characterized as PTSD with persistent depressive disorder, rated from that date at 70 percent. As the Veteran is presumed to seek the maximum benefits allowed under regulation, the Board has considered evidence for this claim both prior to and after November 5, 2015. In the period prior to November 5, 2015, the Veteran attended VA group psychotherapy sessions from April through November 2012, in which, his depression remained prevalent in his reports and depression screenings, but he also reported improvement in symptoms, although related symptoms of anger and irritability remained. In this period, the Veteran consistently reported anxiousness. In November 2012, the Veteran underwent a VA examination for mental disorders, to exclude PTSD and eating disorders, in which the examiner diagnosed depression, NOS (not otherwise specified) and polysubstance dependence. The examiner found 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 level of impairment of which the examiner noted as "solely related to vet's diagnosis of Depression NOS," which in turn under the General Rating Formula would warrant a 10 percent rating. He noted the Veteran's reports of little motivation, although he still enjoyed outdoor activities such as fishing, hunting and camping, he no longer dated. He saw one friend occasionally and his sleep was disrupted due to nightmares. Mental status examination results show the veteran was punctual, clean and well-groomed, dressed casually, no abnormal behavior evident, normal posture and gait, and needed no aid to ambulation. His facial expressions were normal and responsive, voice well-modulated, speech clearly articulated, oriented to time, place and person, logical and relevant responses, no evidence of psychosis, denied audio or visual hallucinations, good to fair attention and concentration, memory appeared intact, and he denied current suicidal and homicidal ideation. The Veteran described his mood as somewhat depressed recently and the range of his affect was full and appropriate. The examiner further found symptoms associated with the Veteran's diagnosis to be depressed mood, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and impaired impulse control, such as unprovoked irritability with periods of violence. The examiner added that another symptom attributable to the Veteran's mental disorders is "[e]xtreme periods of anger at times - a couple times in the past year and always related to alcohol us[]age." The same examiner rendered a positive opinion for service connection in February 2013, which was in part the basis for the Veteran's initial 50 percent rating. In early June 2012, the Veteran reported to a VA mental health provider that he was "[p]hysically and mentally paralyzed by my depression" in the last several months, adding he had very little energy, continues to struggle with sleep, had a very poor appetite, and was unable to attend treatment, meetings, "etc." The Veteran stated, "I'm finally at a place where I know I need help, and I'm willing to ask for it. I'm not alone, I want to get better." A June 2012 mental status examination showed the Veteran oriented to time, place and person, cooperative, grooming appropriate, very jittery, normal speech rate/rhythm, anxious and depressed mood, affect congruent with mood, also blunted, no hallucinations or illusions, logical and goal-directed thought process and association, thought content showed passive thought of wishing he was dead without intent or plan, and no homicidal ideation. However, an early October 2012 VA mental outpatient notes shows the Veteran reported a violent altercation with a member of his family. Mental status examination results show the Veteran to be tall, slim, neat, studious-appearing, tearful several times in the interview, psychomotor activation with constant knee shaking and tremulousness, normal speech rate, rhythm and volume, mood was depressed and frightened, affect was anxious, thought process was circumstantial but easily redirected, thought content showed no suicidal ideation or history of attempt, although he showed homicidal ideation with fear of intent and would do it "with my hands," no audio/visual hallucinations or delusions endorsed, cognition/memory were not assessed, and insight and judgment were fair to poor. Overall results from numerous mental status examinations from February 2012 through July 2013 for various presentations to VA, with the exceptions above, to include anger management, showed the Veteran alert and oriented to time, place and person, mood euthymic (sad in February 2012, in April 2012, tearful and in October, "pretty good"), affect congruent, good eye contact, voice normal rate, rhythm, and volume, hygiene and grooming good, thought process linear, thought content appropriate to topic with no psychosis evidenced, no suicidal ideation/homicidal ideation, behavior organized and cooperative, memory and cognition appeared intact, limited insight, fair and good judgment but also impulsive, and an average fund of knowledge. In some examinations, there was psychomotor fidgeting. In October 2013, the Veteran admitted himself to VA acute psychiatric admission for thoughts of self-harm. He reported he had no plan to hurt himself or take his life but he did have thoughts, specifically mentioning thoughts to "slit my throat." He said he expressed these thoughts out of feeling "sorry for myself." He had never tried to kill himself, only acted irresponsibly and putting himself in dangerous situations. He specifically talked about driving when really intoxicated in the past. He further reported he did not "feel good about myself" and had not for the past 4 years. The admission note showed mental status examination results of alert and oriented to time, place and person, cooperative and reasonable, grooming appropriate, but the Veteran exposed himself to the nurse and the reporting psychologist while being interviewed, but agreed to cover up himself quickly, speech and language were intact, depressed mood with anger, but more sadness, affect congruent with mood, no hallucinations or illusions, normal and coherent thought process and association, no unusual thought content, passive suicidal ideation without plan, impulsive and impaired insight and judgment, and an average fund of knowledge. Later mental status examination results for this episode showed the Veteran lying in bed, covered with sheets, thin young male, long but well-groomed beard, good hygiene, fluent speech with normal rate and tone, "Great" and "Stressed" mood, wide-ranged affect, at times congruent with mood (he laughed when talking of his life stressors), thought content showed no active suicidal ideations, no audio/visual hallucinations, logical, linear and goal oriented thought process, good insight, and fair judgment. After admission in August 2014 to VA for "alcohol dependence/acute EtOH," a VA social worker noted mental status examination results of the Veteran dressed in hospital attire, alert and oriented, normal speech rate, volume and tone, good eye contact, depressed mood with cautious optimism, affect congruent with mood, and logical, future oriented thought process. The Veteran stated some passive suicidal ideation with no current intent or plan, such as at times he feels as though "it would be easier if he did not wake up." When prompted, the Veteran described this sentiment as a sense of hopelessness or emotional exhaustion. However, he also stated emphatically that "[s]uicide is selfish, and not something that [he] would do," citing his own experience of the loss of close friends due to suicide. The Veteran did not endorse homicidal ideation, hallucinations and stated nothing to indicate a delusional state. His insight and judgment were fair. A second treatment provider in August 2014 noted mental status examination results of the Veteran being somewhat disheveled, bearded, casual attire, cooperative, feeling ill and excusing himself to the restroom a couple of times to vomit. His speech showed normal rate and amplitude. His mood was anxious, depressed, forlorn, passive thoughts regarding not wanting to be here but no suicidal plan or intent voiced, rather hopeless and grief stricken, tearful at times. His affect was "as noted, forlorn, sad." His thoughts were relevant, with no loosening, no delusions or audio/visual hallucinations, his judgment was impulsive and his insight was fair. Other than various substance dependence, the treatment provider's diagnoses included mood disorder, primarily depressive and anxiety NOS, r/o [rule out] PTSD regarding losses, childhood issues, and cluster B traits. On discharge, the Veteran expressed interest in returning to group therapy. He reported his sleep as good, noting he has been sleeping more than usual, specifically more frequent naps. His appetite was decreased, finding himself less hungry. His mood was "[g]reat" recently but also stressed secondary to job demands. The Veteran reported episodes lasting a few days of an elevated mood, acting out in ways he typically would not, e.g., driving to Chicago "out of the blue" and walking around by himself, no sexual deviation at this time and he feels that he is not manic, because when he has seen a manic individual, he says these episodes are not the same. The Veteran exhibited no visual or auditory hallucinations, although occasionally he sees shadows out of the corner of his eyes or hears sounds which perhaps are not there, but he never hears voices. November 2014 VA social work notes contain mental status examination results showing Veteran dressed in casual attire, cooperative and friendly demeanor, speech has normal rate and volume, oriented to time, place and person , able to express himself well, able to express his emotions in session, mood was anxious, tearful at times, affect was congruent with mood, thought content was logical and goal-directed, no self-directed violence or suicidal ideation, expressed hopefulness at this time due to support of others in the domiciliary care program, and showed good memory, insight and judgment. November 2014 through January 2015 VA treatment notes show mental status examination results as increased grooming and clean appearance, steady, even gait, direct gaze, calmer that day, less fidgeting, but constant nervous type tapping of his feet, no abnormal movements, normal speech rate, rhythm and volume, cooperative and pleasant attitude, mood reported to be depressed, less so after November, but still very anxious and having "daily" panic attacks, appropriate affect, slightly constricted due to anxiety, otherwise stable, frequent nightmares, intact and logical thought processes, and fund of knowledge is appropriate to this situation. There were no auditory/visual hallucinations or delusions, showed slight paranoia, but no thought insertion or broadcasting, no reports of current thoughts of suicidal ideation and homicidal ideation, no plan, means or attempts, currently goal and future oriented, impulse control appears intact, good insight, fair judgment, and cognition appeared intact, but not formally tested. As stated above, the symptoms listed in the General Rating Formula are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of symptoms, of their effects or of an equivalent occupational and social impairment which would justify a higher rating. Therefore, the Board will consider when necessary whether some symptoms may be reasonably similar to or suggested by the criteria associated with the higher ratings of the General Rating Formula. However, in looking to 38 C.F.R. § 4.126 (a), the Board also notes that it "shall consider frequency, severity, and duration of psychiatric symptoms...." The Board understands that regulation, in its use of the phrase "shall consider," to require consideration of such factors. See also Vasquez-Claudio v. Shinseki, 713 F.3d 112 116-17 ("Reading §§ 4.126 and 4.130 together, it is evident that the 'frequency, severity, and duration' of a veteran's symptoms must play an important role in determining his disability level") (Fed. Cir. 2013). Consequently, in following this directive, the Board will consider the factual context regarding symptoms, that is to say, by their temporal significance and their intensity. In this stage of the appeal period, the record supports a higher evaluation at 70 percent. The Veteran reported some instances suicidal thoughts and consistently denied any plan or intent and further denied any history of attempts. Moreover, although during hospitalizations between April 2013 through December 2014 treatment providers consistently assessed Veteran's suicide risk as "not elevated," "Veteran poses no risk to self or others," "resolved and was without any suicidal intent," and "[l]ow (few risks, many protections)," the Veteran's repeated reference to suicidal thoughts of varying character and context give indication to the Board of suicidal ideation contributing prominently to occupational and social impairment with deficiencies in most areas without requiring evidence of intent, past suicide attempt, hospitalization, or other indicator of suicidality, particularly as the Board's principal, indeed most pertinent, concern in its factual determinations is its assessment of the degree of the effects of signs and symptoms on the Veteran's occupational and social impairment. See Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017) (Board is required to perform a holistic analysis in which it assesses the severity, frequency and duration of the signs and symptoms of a veteran's service-connected mental disorder, quantifies the level of occupational and social impairment caused by those signs and symptoms, and assigns an evaluation that most nearly approximates that level of occupational and social impairment). The record overall for this period, in containing some reports by the Veteran of passive ruminations about death or being dead, in fact does indicate frequency, duration or severity of reports of suicidal ideation and, in conjunction with the Veteran's pronounced symptoms of depression, therefore shows occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The next higher rating under the General Rating Formula is for 100 percent for total occupational and social impairment, due to associated symptoms. As set forth above, such symptoms under the General Rating Formula would be similar to or suggested by 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, one's own occupation or own name. These are symptoms of total disability. However, the record in this period does not typify reports or findings of symptoms reasonably similar to grossly impaired thought processes, diminished communication abilities or grossly inappropriate behavior, as well as any inability to perform activities of daily living, disorientation of any sort or persistent hallucinations. Although in this period the Veteran gave one report in August 2014 of occasional instances of "seeing shadows out of the corner of his eyes or hear[ing] sounds that maybe are not there but never voices," one report, tentatively made and uncertain in detail, does not reasonably amount to "persistent" hallucinations. The foregoing does not indicate "total" occupational and social impairment. In the period from November 5, 2015, the record shows in a December 2015 VA psychology outpatient note the Veteran reported the following: significant, persistent anxiety; persistent anger; ongoing depressed mood; not often leaving his house; no trust in others; memories of his assaults; frequent nightmares (average of 5 nights per week) of being "pinned down" and attacked; avoidant behavior (often through substance use); avoided crowds, stores, gas stations; experienced hypervigilance and persistent fear ("I'm afraid of being attacked"); frequent outbursts of anger, often involving property damage; and feelings guilt and self-blame regarding his abuse. The Veteran further reported significant symptoms of depression, which the treatment provider characterized as "above and beyond that accounted for by a PTSD diagnosis;" minimal appetite (but he also has an ulcer); persistent fatigue; difficulty concentrating/focusing; frequent thoughts of worthlessness; ongoing passive suicidal ideation without intent, plan or active elements; no motivation/interest in activities; and denied history of suicide attempts or non-suicidal self-injury. The treatment provider noted no mania, audio/visual hallucinations or other history of trauma, abuse or neglect. On mental status examination, results showed the Veteran was oriented to time, place and person, cooperative and reasonable, grooming appropriate, normal speech rate/rhythm, intact language, anxious mood, congruent affect, no audio/visual hallucinations, normal and coherent thought process, no unusual thought content, no suicidal or violent ideation, good insight, judgment and memory, and an average fund of knowledge. The treatment provider diagnosed PTSD; persistent depressive disorder, with intermittent major depressive episodes, with current episode; severe cannabis use disorder; and alcohol use disorder, in sustained remission (since 2014). A January 2016 VA psychology outpatient note contains mental status examination results showing the Veteran to be alert and attentive, oriented to time, place and person, cooperative and reasonable, grooming appropriate, normal speech rate and rhythm, intact language, mood was anxious, affect congruent with mood, no hallucinations or illusions, normal and coherent thought process and association, no unusual thought content, no suicidal or violent ideation, good insight and judgment, intact memory, and an average fund of knowledge. In July 2016, the Veteran presented to VA with suicidal ideation and an attempt at hurting himself with a knife during an argument with his girlfriend. The acute psychiatric admission note shows the Veteran's report of the incident. Mental status examination results show the Veteran in pajamas, comfortable in chair, hair disheveled with beard (somewhat unkempt), normal gait, cooperative, at times tearful, and some fidgeting (left leg, right hand). He had good eye contact, compulsions, sad mood, sad affect, and no abnormal movements or compulsions. He had regular speech rate, rhythm and tone, with a linear thought process. His thought content showed suicidal ideation present that day but with no plan, no homicidal ideation, fair insight, and fair judgment. An in-patient psychiatry note later that day shows mental status examination results of well-groomed, slumped in chair, normal gait, cooperative, no fidgeting or abnormal psychomotor movements noted, normal speech rate, rhythm and volume, positive and happy affect, mood much improved, no suicidal ideation or homicidal ideation, linear thought process, intact memory, appears oriented, fair judgment, and good insight. From the second week of July 2016 through April 2017, mental status examinations showed the following: Alert and oriented to time, place and person, mood euthymic, affect congruent, good eye contact, voice normal rate, rhythm, and volume, hygiene and grooming good, thought process linear, thought content appropriate to topic with no psychosis evidenced, no suicidal ideation/homicidal ideation, behavior organized and cooperative, and memory and cognition appeared intact. The Veteran was afforded a VA examination for PTSD in April 2017, in which the examiner first noted that Veteran's symptoms do not meet the diagnostic criteria for PTSD under DSM 5 criteria. Nonetheless, she diagnosed persistent depressive disorder and polysubstance-use disorder in full sustained remission. The examiner found occupational and social impairment, with reduced reliability and productivity. She noted the Veteran's reports of enjoying fishing, being outdoors, camping, and hiking, he maintains his relationships with his grandparents, father and stepmother, he maintains his social relationship with at least one friend, and he has had sporadic employment since the November 2012 examination. The Veteran also reported he has enjoyed jobs when he does not have to interact with other people, he tends to leave positions rather than be terminated and he relies on his family for financial assistance. The Veteran further reported an "up and down, inconsistent," mood, irritability making him "snappy" occasionally, "pretty good" sleep (averaging 8-10 hours), recently having dreams the content of which he does not remember, but which induce feelings of helpless and being out of control, poor appetite, feelings of worthlessness and guilt, but he denied hopelessness and helplessness. He reported past suicidal ideation, most recently in July 2016, when he tried to cut his neck, but denied current suicidal thoughts, plan or intent. He endorsed anxiety but denied hypervigilance, stating this is "a lot better" than at the time of his prior examination. He said he startled to unexpected noises/touch, which lasted about 20 seconds. He reported past panic attacks, but managed 4 near-panic episodes this past year by sitting and engaging in controlled breathing. He had crying spells, difficulty trusting others (particularly authority figures). He avoided answering the phone at times, preferring a text message first telling him what the conversation will be, and had no alcohol or drugs in the past year. The examiner found symptoms associated with the Veteran's diagnoses to be depressed mood, anxiety, suspiciousness, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances, including work or a worklike setting. He behavioral observations show alertness, no confusion, normal eye contact, casual dress, appropriate grooming and hygiene, fluent and appropriate speech content, with no word-finding problems or paraphasic errors, orientation appeared grossly intact, mood appeared anxious with broad affect, appropriate timing of smiles, intermittently shaking legs, and the Veteran denied suicidal ideation, homicidal ideation, audio/visual hallucinations, and delusions. At the end or her report, the examiner remarked that markers of mental health complaints support the Veteran's reported physical assault during active service. However, "while he may have met full criteria for the diagnosis at some point in the past, currently, the Veteran does not report the full symptomatology required for a diagnosis of PTSD as a result of the MST [military sexual trauma] due to lack of sufficient re-experiencing and cognitive symptoms," but does continue to report symptoms of service-connected persistent depressive disorder, which "render moderate effects on functioning as evidenced by limited social support and inconsistent employment history in the context of maintenance of a few supportive interpersonal relationships." In its March 2019 decision, the Board granted service connection for PTSD and remanded the Veteran's claim for an increased rating. The Board could not address it until the Agency of Original Jurisdiction (AOJ) implemented the grant of PTSD and assigned a rating. The AOJ requested another VA examination, which the Veteran underwent in April 2019, in which the examiner diagnosed both persistent depressive disorder and PTSD, noting symptoms attributable to each diagnosis could not be differentiated and separated. She found occupational and social impairment with reduced reliability and productivity. She noted the Veteran's reports of failure to complete errands, communicates poorly, is irritable, but his relationship with his fiancée has improved with the birth of his son and he strives to set a good example by controlling irritability. He also reported he is in contact with his father daily and with his stepmother and grandparents, he maintains contact with 3 to 4 friends a few times a month, he engages in activities with a neighbor, and he has contact with a mentor in a veterans mental-health counseling organization. Concerning activities of daily living, the Veteran reported he completes regular household tasks, self-care, manages his finances, paid the past year's rent, although an unknown trigger prevented him in the last 3 months, his parents have since provided financial support since the 2017 examination, and he enjoys collecting silver from stores, walking his dogs, fishing, canoeing, hiking, spending time with his family, and engages daily in summer activities. The Veteran further reported, he has had 4 jobs since the prior examination, but left each job for various reasons, to include using his cell phone at lunch, feeling "harassed" by co-workers regarding their comments about his pregnant fiancée, and he struck a co-worker because of opinions regarding the military. He reported not missing any work for mental health reasons in this first job, missing one week in the second job due to panic attacks. In a third seasonable job he works long hours as a foreman and his employer accommodated his request to work alone. He experienced anxiety 70 percent of the time when interacting with customers, other times not, but also vomited approximately 3 times a week before work due to anxiety. He denied missing any work due to mental health reasons, and he intended to attend a school of machine-operation training. The Veteran describes his mental health as "just healthy enough to be productive," describes himself as "miserably sufficient" and denies any suicidal attempts. He reported daily feelings of anxiety, lasting half the day, he vomits when anxious, anxiety is triggered by low confidence for handling situations. decreased trust in others since his hazing during service, daily intrusive memories of such hazing, which induce rage, sadness and anxiety, listing from 20 minutes to 1 or 2 days. He also reported thought avoidance and panic attacks (i.e., difficulties breathing, chest pain, shakiness, sweating), which occurred approximately 3 times a month, triggered by difficult social interactions. The Veteran reported irritability and anger, occurring 3 to 5 times a day and lasting for 10 minutes to an hour, triggered by the behavior of others (e.g., driving), difficulties keeping his temper (e.g., breaking things, verbal arguments), occurring once a week, and worrying about his anger escalating. He further reported feelings of hopelessness and worthlessness, guilt regarding financial difficulties, and increased sleep problems. He sleeps 4 to 8 hours per night, but had difficulty falling and staying asleep. He had excessive worries about scenarios of danger to his fiancée, as well as nightmares twice a week regarding the same. He had "zilch" appetite, "no energy," concerns with concentration and attention, and motivation problems. The Veteran reported no audio/visual hallucinations, decreased suicidal ideation since his son's birth. He had current passive suicidal thoughts without plan or intent a few times per month. If they increased in frequency or severity, he would contact his father or VA. He had no homicidal ideation and no alcohol abuse since July 2016, and no drug use. The examiner found associated symptoms of depressed mood, anxiety, panic attacks that occur weekly or less often, chronic sleep impairment, and disturbances of motivation and mood. Behavioral observations consisted of psychometric testing. This showed the Veteran was punctual, clean and well-groomed, casually dressed, with adequate appearance and self-care skills. He had no abnormal behavior, appropriate eye contact, normal social comportment. He was oriented to time, place and person, with logical and relevant responses and no evidence of psychosis. He had no audio/visual hallucinations, good to fair attention and concentration, an intact memory, and adequate frustration tolerance. He denied suicidal ideation or homicidal ideation. He wakes at 6:30 am, retires at 9:00 pm, completes home tasks, and feeds his son and lays him down for a nap. The examiner noted that testing showed severe levels of depression, severe symptoms of trauma associated with PTSD and mental not physical concerns have a significant deleterious effect on functioning. Although opining the Veteran meets the criteria for PTSD, she noted his medical record shows he has demonstrated increased stability in mental health symptoms since the prior examination, indicated by the Veteran, although taking no medications, reporting in his last VA appointment he felt the happiest he had in years. She concluded: [F]unctional impairments include social restriction, isolation, reduced ability to complete tasks efficiently and intermittently strained interpersonal relationships. These functional impairments are impacted by anxiety, avoidance and irritability. In spite of his mental health concerns, [the Veteran] has maintained employment since his last exam, has not missed time for mental health symptoms with his current employer, maintains recreational activities and cares for his son and himself independently. The rating criteria for the current 70 percent evaluation, either directly or by their similarity, sufficiently addresses the Veteran's symptoms, particularly regarding greater isolation and anxiousness. In the April 2019 VA examination, the Veteran reported that, although having left 4 jobs since his prior examination, he had not missed any work for mental health reasons in 3 of the 4 jobs, even though he described in great detail severe anxiety at the prospect of interacting with other persons. Nonetheless, he worked as a foreman and reported to the examiner his intention to attend a school for machine-operation training. Moreover, he reported he enjoys collecting silver from stores, walking his dogs, fishing, canoeing, hiking, spending time with his family, and engaging daily in summer activities. Although he presented to VA in July 2016 with suicidal ideation and a reported instance of "cutting" his neck, the record in the appeal period does not offer a similar instance of self-harm. This does not rise to a level of frequency and severity of a "persistent danger of hurting" himself. Significantly, in the April 2019 examination, the Veteran further reported decreased suicidal ideation since his son's birth. As stated, although the Veteran's difficulties in interaction are pronounced, his job performance indicates determined efforts to stay employed which, with his reported activities, interests and plans, are not plausibly similar to, and do not reasonably suggest, total occupational and social impairment. The Board has carefully considered the Veteran's extensive reports to treatment providers and examiners as they appear throughout the record. The Board is well aware that lay persons are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran is competent to provide statements of symptoms which are observable to his senses and there is no reason to doubt his credibility. Nonetheless, his lay evidence in turn must be weighed against other evidence, as all relevant evidence of varying kinds must be considered. The Veteran's reports to examiners and treatment providers give highly detailed information of the Veteran's current symptoms at various times. However, as a factual determination by the Board, in the period of treatment and examination between 2011 and 2020, the findings of VA mental health professionals, made after noting and considering the very same reports by the Veteran, are consistent in the identification of symptoms relevant for rating purposes. The Board therefore assigns more probative value to the findings of the numerous treatment providers, as well as the VA examiners, as almost all are psychiatric specialists who conducted their examinations and interviews during in-person sessions with the Veteran, they thoroughly reviewed the Veteran's medical history and their findings therefore are adequate for VA rating purposes. See generally Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in assessing the adequacy of an opinion is whether the examiner was informed of the relevant facts in rendering a medical opinion). For the reasons stated and based on the objective medical evidence, the Board finds the preponderance of the evidence supports an initial disability evaluation of 70 percent, but no higher, prior to November 5, 2015 for persistent depressive disorder and no higher thereafter for PTSD, with persistent depressive disorder. Even though the Veteran has experienced some periods of stability and improvement, resolving doubt in his favor, a 70 percent rating is warranted for the entire time period on appeal. EMILY TAMLYN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Franke, 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.