Citation Nr: 21067096 Decision Date: 11/03/21 Archive Date: 11/03/21 DOCKET NO. 17-16 947A DATE: November 3, 2021 ORDER A 50 percent rating for posttraumatic stress disorder (PTSD), prior to April 25, 2017, is granted. FINDING OF FACT The Veteran's PTSD more closely approximates occupational and social impairment with reduced reliability and productivity throughout the entire appeal period. CONCLUSION OF LAW The criteria for a rating of 50 percent, but no higher, for PTSD, prior to April 25, 2017, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130 DC 9411. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty from August 1969 to March 1971. The claim for an increased rating for PTSD prior to April 25, 2017, was previously before the Board in February 2019, at which time the Board denied the claim. The Veteran appealed the Board's denial to the United States Court of Appeals for Veterans Claims (Court). In a December 2019 Joint Motion for Partial Remand (Joint Motion), the parties determined that the Board's denial of this claim should be vacated, and the matter remanded to comply with the instructions in the Joint Motion. Increased Rating for PTSD The Veteran contends that his PTSD signs and symptoms warrant an initial rating in excess of 30 percent prior to April 25, 2017. In a March 2018 statement, the Veteran's attorney contended that a higher rating was warranted because the medical evidence showed that the Veteran exhibited increased irritability, difficulty with dealing with people, hypervigilant behaviors at night, isolating behaviors, intense nightmares that occurred three to five times per week, and auditory hallucinations. VA has adopted a Schedule for Rating Disabilities (Schedule) to evaluate service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R., Part IV. Disability evaluations assess the ability of the body as a whole, the psyche, or a body system or organ to function under the ordinary conditions of daily life, to include employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule represent the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The percentage ratings are generally adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the disability. Id. In disability rating cases, VA assesses the level of disability from the initial grant of service connection or a year prior to the date of application for an increased rating and determines whether the level of disability warrants the assignment of different disability ratings at different times over the course of the claim, a practice known as "staged ratings." The Veteran appealed the initially assigned disability rating for PTSD; thus, the appeal period is from February 3, 2014, until April 25, 2017, at which time a 100 percent disability rating was assigned for this disability. In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104 (a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran's service-connected psychiatric disability has been evaluated under 38 C.F.R. § 4.130 as 30 percent disabling under the General Rating Formula for Mental Disorders, which assigns ratings based on particular symptoms and the resulting functional impairments. See 38 C.F.R. § 4.130, DC 9411. The General Rating Formula is as follows: A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. A 70 percent rating is assigned 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. A 50 percent rating is assigned for 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; difficulty in establishing and maintaining effective work and social relationships. A 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. The symptoms associated with each rating in 38 C.F.R. § 4.130 are not intended to constitute an exhaustive list; rather, they serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Thus, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the DCs. See id. VA must consider all symptoms of a veteran's disorder that affect his or her occupational and social impairment. See id. at 443. If the evidence demonstrates that a veteran has symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the DC, the appropriate, equivalent rating will be assigned. Id. In this regard, VA shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and a veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126. Although VA considers the level of social impairment, it does not assign an evaluation based solely on social impairment. Id. VA must consider all of the Veteran's symptoms and resulting functional impairment as shown by the evidence in assigning the appropriate rating and will not rely solely on the examiner's assessment of the level of disability at the moment of examination. See id. The Veteran filed a claim for service connection for a psychiatric disorder in February 2014. Here, the relevant evidence includes a February 2014 PTSD consultation wherein the Veteran reported passive suicidal ideation but denied plan or intent. He had reported having auditory hallucinations earlier that same month. A February 2014 VA psychiatry medication management note showed that the Veteran was married for 42 years to his wife, with whom he lived, and that they had two children. He did not have a history of suicide attempts and no psychiatric hospitalizations. He stated that he was retired and happy in his retirement. He reported that he enjoyed working in the yard and building and repairing things. He endorsed having symptoms of nightmares from Vietnam at least three times per week. He stated that he did not like to socialize or go anywhere in crowds. He also reported that he had problems with irritability, isolating behaviors, hypervigilance, and intense nightmares three-to-five times per week. He rated his depression symptoms as a five out of a possible ten (or 5/10) on the depression scale. Similar symptoms were noted in an April 2014 VA psychiatry medication treatment record, which showed the Veteran's complaints of depression, which he rated as 5 /10 on a depression scale. He reported problems with irritability and self-isolating at home. The VA clinician stated that the goal was to work on nightmares with medication. The Veteran also reported hypervigilance at night and "intense nightmares" three to five times a week. His depression had been much worse prior to the medication sertraline, which he had started taking. Mental status examination of the Veteran showed neat and clean hygiene, good eye contact, clear speech, talkative, psychomotor activity within normal limits, no suicidal or homicidal ideation, and full orientation. The Veteran reported hearing voices, which were "not decipherable," and reported hypervigilance, but no history of mania or manic episodes, no reported memory problems, normal reality testing, good insight, and intact judgment. The VA clinician stated that the Veteran "is improving with current medications." The medical professional determined that the Veteran had some mild symptoms or some difficulty in social, occupational, or school functioning but generally functioning pretty well with some meaningful interpersonal relationships. The Veteran was advised to restart taking prazosin at night for his reported nightmares and to continue taking sertraline. In an August 2014 VA treatment record, the Veteran reported that he was "doing well with the sertraline." He reported experiencing occasional depression, which he rated as 5 -6/10 on a depression scale. He also reported fewer nightmares "than in the past." The mental status examination showed clean and neat hygiene, direct eye contact, clear speech, talkative, psychomotor activity within normal limits, no suicidal or homicidal ideation, full orientation, reported hearing voices that were "not decipherable," reported "frequently checking locks," no mania or manic episodes, no issues with memory, normal reality testing, good insight, and intact judgment. He reported sleeping four to six hours per night. During the January 2015 VA examination, the Veteran reported that he did not trust people and preferred to keep himself fairly isolated. He stated that he was content in the company of his wife and/or children, but that they occasionally socialized with other people. The examiner noted that the Veteran's PTSD appeared to interfere with his socialization in that he preferred to avoid people, and that there was interference with work in that he was irritable and intolerant, although the examiner noted that the Veteran was retired. The Veteran reported that he was disillusioned and upset with society in general, but not depressed per se. The examiner noted that the Veteran recovered from prostate cancer seven years ago, and that he had a stroke when he was 55 years old, which affected his right side of the body and possibly short-term memory. He had symptoms of suspiciousness, chronic sleep impairment, and mild memory loss, such as forgetting names, directions, or recent events. He stated that he was taking sertraline and prazosin medication. Following the psychiatric examination, a review of the Veteran's records, and notation of his self-reported symptoms and history, the examiner determined that the Veteran appeared to have a mild case of PTSD. The examiner also determined that the Veteran's PTSD signs and symptoms amounted to occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. Office notes from February 2015 show the Veteran continued to hear voices. In an April 2015 VA outpatient note, the Veteran stated that he was still having nightly nightmares, but that they were not as intense as before. A mental status examination of the Veteran showed neat and clean hygiene, direct eye contact, psychomotor activity within normal limits, clear speech, talkative, no suicidal or homicidal ideation, reported hopeless thoughts were "present at times," full orientation, no auditory hallucinations, less frequently checking locks, no mania or manic episodes, normal reality testing, good insight, and intact judgment. In a June 2015 VA treatment record, the Veteran reported that his nightmares "are much better." The Veteran's wife stated that he was smiling more and was doing better. His nightmares were less intense and less frequent but still occurred three times a week. Mental status examination of the Veteran was unchanged except for reported hypervigilance whereby he was checking the perimeter more than ten times a day. The Veteran was advised to increase his dosage of prazosin for nightmares. In a December 2015 VA treatment record, the Veteran stated that he was doing fine with the current medications. A mental status examination of the Veteran was unchanged except for no hopeless thoughts present and checking the perimeter multiple times a day. The Veteran also reported that he was "hearing voices at times but cannot make out what they are saying," He reported six to seven hours of sleep a night with nightmares three to four times a week, which did not last long. In a September 2015 VA treatment note, the Veteran reported that he "hears voices at times but cannot make out what they are saying." He complained of the same issue in February 2016. In a March 2016 treatment record, the Veteran and his wife reported that he was "doing about the same" as previously. He rated his depression as 5 /10 on a depression scale. He reported that nightmares were still present but more subtle. Both the Veteran and his wife agreed that his memory problems were related to a recent stroke. Mental status examination of the Veteran and the diagnosis were unchanged from December 2015. The Veteran was advised to increase his dosage of prazosin for nightmares. In May 2016 and August 2016 VA treatment records, the Veteran reported vague auditory hallucinations. Furthermore, he stated in the August 2016 treatment record that he was a little depressed and noted that he slept five to seven hours per night with nightmares three or more nights a week but with less intensity. He had two to three daytime flashbacks per week. He denied anhedonia. He reported lower energy and tiring more quickly. He denied any suicidal or homicidal ideation, symptoms of mania, or manic episodes. Mental status examination of the Veteran showed he was dressed casually, good grooming and hygiene, steady gait, no abnormal movements, normal speech, no paranoia or delusions, logical, goal-oriented, and organized thought process, no flight of ideas or looseness of associations, no visual hallucinations, not responding to internal stimuli, intact concentration and attention, full orientation, grossly intact remote and recent memory, and good insight and judgment. The Veteran was advised to start taking perphenazine "for hallucinations or anger issues." In October 2016, the Veteran again stated, "I am a little depressed." He also complained of anxiety, vague hallucinations, and irritability. In particular, he stated that his auditory hallucinations occurred "every night" and could occur in the daytime as well if he was in a quiet setting. The Veteran reported that perphenazine, which was prescribed to treat his hallucinations and anger, had been beneficial. He reported better sleep. His wife reported that he was calmer. He rated his depressed mood as 4 /10 on a depression scale. His anger was getting better, and he slept about five to seven hours per night with nightmares of about three or more nights per week but not as intense. He had daytime flashbacks three to four times a week in the previous two to three weeks. He denied anhedonia, suicidal ideation or plan, symptoms of mania, or manic episodes. He reported hearing unintelligible auditory hallucinations mostly at nighttime but also during the daytime if in a quiet setting. Mental status examination of the Veteran showed he was dressed casually, appropriate grooming and hygiene, a steady gait and no abnormal movements, normal speech, no paranoia or delusions, logical, goal oriented, and organized thoughts, no flight of ideas or looseness of associations, not responding to external stimuli, intact concentration and attention, full orientation, grossly intact remote and recent memory, and good insight and judgment. In January 2017, the Veteran reported that he was sleeping better and getting more hours of sleep. He rated his depression as 4 /10 and his anxiety as 5 /10 "if wound up." He experienced anxiety a few times a day. He denied any suicidal ideation, homicidal ideation, or auditory or visual hallucinations. The mental status examination was unchanged from October 2016. The Veteran was advised to continue taking all of his medications prescribed to treat his service-connected PTSD symptoms. A January 2017 VA treatment note reflects that the Veteran reported hallucinations occurring "every night" and sometimes during the day as well. He described the voices as sounding like "people talking in the distance, but unintelligible. He says it is similar to how they could hear nearby village people talking while pt [patient] was in military." In a VA outpatient treatment record, dated April 19, 2017, which was less than one week prior to the April 2017 VA examination that was the basis for the award of a 100 percent rating for PTSD, the Veteran stated that he still was tired from recent surgery. He again reported that his nightmares were less intense. He stated that he had intermittent irritability. He slept six to seven hours on some nights and four to five hours on some nights "but not as often." He denied any daytime auditory hallucinations and any visual hallucinations "of any kind" although he reported hearing voices at night when it was quiet, and he was trying to go to sleep. He also denied any suicidal or homicidal ideation. Mental status examination of the Veteran showed he was dressed casually, good grooming and hygiene, a steady gait, no abnormal movements, normal speech, no suicidal or homicidal ideation, no paranoia or delusions, logical, goal-oriented, and organized thoughts, no flight of ideas or looseness of associations, no auditory or visual hallucinations, not responding to internal stimuli, intact attention and concentration, full orientation, grossly intact remote and recent memory, and good insight and judgment. Based on the above, and resolving reasonable doubt in favor of the Veteran, the Board finds that a 50 percent rating is warranted, prior to April 25, 2017. However, the Veteran's overall disability picture prior April 25, 2017, does not support a rating in excess of 50 percent. In this regard, the record shows that his disability is primarily manifested by complaints of depression and anxiety, nightmares, irritability, and auditory hallucinations as detailed above. The VA treatment records dated prior to April 25, 2017, show that the Veteran consistently reported feelings of depression and anxiety and experiencing nightmares, ongoing irritability, and on several occasions that he had auditory hallucinations, which he described as hearing indecipherable voices when it was quiet. However, the frequency, severity, and duration of these complaints does not show that he had persistent delusions or hallucinations. See 38 C.F.R. § 4.126. Rather, this evidence shows that the Veteran's reported PTSD symptoms were managed successfully with medications throughout this time period. The Veteran also reported to his VA treating clinicians that his nightmares improved in terms of becoming less frequent and less intense after he began taking additional medications to treat them. These treatment records also show that the Veteran's wife reported improvements in his mood during this time period. Mental status examinations of the Veteran were consistent with the Veteran's reported improvement in his PTSD symptoms as well prior to April 25, 2017. Additionally, the Veteran's complaints of self-isolating at home, including in the February 2014 VA psychiatric medication management note and the January 2015 VA examination report, did not amount to social impairment with reduced reliability and productivity. Rather, the record shows that the Veteran has been retired during the appeal period, and he reported that he was happy in his retirement, which is documented in the February 2014 VA treatment record. Additionally, the January 2015 VA examiner noted that the Veteran was content in the company of his wife and/or children and that they occasionally socialized with other people. This is evidence against a finding that the Veteran had difficulty in establishing and maintaining effective work and social relationships. Furthermore, although the Veteran was noted to have mild memory loss, such as forgetting names, directions, or recent events, during the January 2015 VA examination, the VA examiner attributed these symptoms to the Veteran's stroke. Likewise, both the Veteran and his wife agreed that the Veteran's memory impairment was due to his stroke, as documented in the March 2016 VA treatment record. Additionally, in the January 2015 VA examination report, when asked which of the following criteria best summarized the Veteran's level of occupational and social impairment, the examiner checked "occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication," which is the criteria that falls under the 10 percent rating. While the adjudicator makes the determination of what evaluation is warranted for the service-connected PTSD, the examiner's conclusion that the Veteran's psychiatric disorder was summarized best by the criteria described under the 10 percent evaluation is evidence against a finding that the Veteran's psychiatric disorder causes occupational and social impairment with reduced reliability and productivity. Moreover, the evidence shows that the Veteran's speech was normal and his remote and recent memory was grossly intact throughout this time period. He repeatedly denied any suicidal ideation and he consistently had good grooming and hygiene and was dressed appropriately during this time period. Although the Veteran reported that he frequently checked the perimeter during the day, it appears that this reported symptom went away after his medication was increased by his VA treating clinician. The Board acknowledges and has considered the Veteran's reports of auditory hallucinations. However, the Board does not find that this warrants a higher rating. Although persistent hallucinations are listed as a symptom to consider under a 100 percent disability rating, there is no evidence in the record that the Veteran's hallucinations have any impact on his social or occupational functioning. Similarly, the Board has considered the notation of passive suicidal ideation. However, the Board finds that such thoughts do not support the award of a 70 percent rating. The Veteran's noted suicidal thoughts appear to have occurred in isolation. Indeed, suicidal ideation was denied on multiple occasions, and the evidence does not show that the Veteran's PTSD is productive of symptoms causing occupational and social impairment with deficiencies in most area. The Board reiterates that the criteria set forth in the rating formula for mental disorders are examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, the Board's analysis focuses on the resulting social and occupational impairment due to the current severity, frequency, and duration of his symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). Therefore, the Board finds that the Veteran's occasional suicidal ideation and auditory hallucinations, even when considered together, do not rise to the level of frequency, duration, or severity to warrant a rating in excess of 50 percent. In sum, the Board finds that a disability rating of 50 percent, but no higher, is warranted for the Veteran's PTSD, prior to April 25, 2017. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.Z., 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.