Citation Nr: 21069866 Decision Date: 11/22/21 Archive Date: 11/22/21 DOCKET NO. 17-62 125A DATE: November 22, 2021 ORDER Entitlement to an initial rating of 100 percent for posttraumatic stress disorder with major depressive disorder with obsessive compulsive features (PTSD) is granted. FINDING OF FACT The occupational and social impairment manifested by the Veteran's PTSD most closely approximates total for the entire period on appeal. CONCLUSION OF LAW The criteria for an initial rating of 100 percent for PTSD have been met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Codes 9411, 9434 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active naval service from August 2000 to April 2005. This case comes before the Board of Veterans' Appeals (Board) on appeal from a November 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge in March 2021. A transcript of that hearing has been added to the record. This case was previously before the Board in May 2021, at which time it was remanded for additional development. The case has now been returned to the Board for further appellate action. Increased Rating PTSD The Veteran asserted that she should have a 100 percent rating for her PTSD as her symptoms are worse than those contemplated by the currently assigned rating. At a September 2016 VA examination, the Veteran reported that she was currently married and lived with her husband and young son. She reported she also had a daughter from a prior relationship who lived with her father. The Veteran reported that she stopped working approximately one year prior due to anxiety attacks. The Veteran reported that she had been working in insurance claims at the time, and had completed a Master's Degree in criminal justice. The Veteran reported that her traumatic experiences caused difficulty in her marriage, as she had a hard time forgiving everything, and had a negative attitude. The examiner noted that the Veteran experienced recurrent recollections, nightmares, dissociative reactions, intense or prolonged psychological distress at exposure to external and internal cues, marked physiological reactions to external and internal cues, avoidance, persistent and exaggerated negative beliefs or expectations, distorted cognitions as a result of her traumatic experiences, persistent negative emotional state, markedly diminished interest or participation in significant events, feelings of detachment or estrangement from others, persistent inability to experience positive emotions, irritability, angry outburst, reckless or self-destructive behavior, exaggerated startle response, problems with concentration, and sleep disturbances. Upon mental status examination, the Veteran was noted to be alert, oriented, and in no acute distress at the time of the assessment. The examiner noted the Veteran's symptoms included depressed mood; anxiety; suspiciousness; panic attacks more than once a week; near continuous panic or depression affecting her ability to function independently, appropriately, or effectively; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; memory loss for names of close relatives, own occupation, or own name; flattened affect; impaired judgement; disturbances in motivation and mood; difficulty in establishing and maintaining effective work and social relationships; inability to establish and maintain effective relationships; suicidal ideation; obsessional rituals which interfere with routine activities; impaired impulse control, such as unprovoked irritability with periods of violence; and neglect of personal hygiene. The examiner diagnosed PTSD and major depressive disorder with compulsive features, and noted that it was not possible to differentiate which symptoms were attributable to each diagnosis in light of the significant overlap in symptomatology. The examiner found that the Veteran's level of occupational and social impairment was characterized as deficiencies in most areas. At her March 2021 hearing before the Board, the Veteran reported that she had been able to return to the workplace, but only was able to work part time even though the position was flexible and allowed her to take time off when her mental health required it. She reported that she had not been able to connect with a therapist at the VA Medical Center, and had recently sought private psychotherapy. She reported that her symptoms of panic had continued to progress to the point where she went to the doctor over a year prior thinking she was experiencing a heart attack, but was ultimately found to have extreme anxiety. The Veteran reported having thoughts of self-harm, and difficulty falling and staying asleep. She reported that she was in the process of getting divorced, and that she had a strained relationship with her son, and he preferred to be with his father. She reported that she felt isolated, did not have a social life, and had completely withdrawn from friends. At a July 2021 VA examination, the Veteran reported that she was divorced in April 2021, after eight years of marriage. She reported that she had two children, but reported strained relationships with both children. She reported that she was estranged from her father, spoke to her mother approximately once per month, and was in touch with a couple of her seven siblings. She reported that she had friends, but that she did not participate in any social activities. She reported that she was still working part-time as a nurse, but was unable to work full-time due to being overwhelmed. She reported that she had gotten a verbal warning regarding her rigid and aggressive behavior in the workplace, and was worried about losing her position. She reported that she felt like she needed to work to keep from getting more depressed, but that she did not think she would ever again be capable of full-time employment. She reported suicidal ideation and plan, but no attempt. She reported difficulty falling asleep and staying asleep; daily depression with sadness, crying spells, loss of appetite, loss of hair, self-isolation, avoidance, low energy, hopelessness, and helplessness; anxiety where she wakes up with panic attacks, hypervigilance, restlessness, being on edge, an inability to relax, and at least daily panic attacks. She reported being irritable, and that she had obsessive rituals regarding cleanliness and obsessive thoughts that interfered with her ability to move about her day. She reported significant memory impairment and forgetfulness. Upon mental status examination, the Veteran was noted to casually and appropriately dressed and groom. She was noted to be pleasant and cooperative. Her mood was euthymic, and she had a sense of humor. The examiner noted she was oriented x4, made good eye contact, and had an appropriate affect. The examiner noted that there was nothing unusual about her speech, motor activity, or thought processes. The examiner noted that she exhibited symptoms of depressed mood; anxiety; suspiciousness; panic attacks more than once per week; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work like setting; inability to establish and maintain effective relationships; suicidal ideation, and obsessional rituals which interfere with routine activities. The examiner noted that the Veteran was a low acute risk for self-harm, and noted that the Veteran was provided with a flier regarding the VA crisis number, and she was asked to put the phone number in her phone and on her refrigerator for easy access. The examiner strongly encouraged the Veteran to seek counseling, and to develop a safety plan for when she experienced suicidal ideations. The examiner diagnosed PTSD and major depressive disorder. The examiner noted that the Veteran's depression was a symptom of her PTSD, but that she met the criteria for a diagnosis of depression due to frequency and severity of her depression. The examiner noted that the Veteran's occupational and social impairment resulting from her PTSD was manifested by deficiencies in most areas. The Board finds that the Veteran is entitled to a 100 percent rating for her psychiatric impairment for the entire period on appeal. In this regard, the Board finds that the occupational and social impairment caused by the Veteran's PTSD more closely approximates total. In this regard, the Veteran has been shown to experience severe and chronic symptoms throughout the entire period on appeal. the Veteran has significant impairment resulting from her symptoms of depression, anxiety, irritability, memory impairment, and isolation. The Veteran has not been shown to obtain and maintain appropriate occupational or social relationships. While she does work part-time, she regularly has difficulty interacting with her co-workers due to her rigidness and aggressiveness, and has been counseled regarding her attitude. Further, there is absolutely no indication from the record that the Veteran has the occupational functioning to be successful in a competitive work environment on a full-time basis. Further, the Veteran is recently divorced, appears to have very few long-standing relationships with family or friends, and is unable to maintain good relationships with her two children. The Veteran also has regular suicidal ideation and plan, but has not made attempts. There is also an indication from the record that the Veteran is sometimes unable to maintain her personal hygiene as a result of her depressive symptoms. Further, the Veteran has significant obsessional rituals with regard to cleanliness and thoughts that often interfered with her ability to manage activities of daily living. Therefore, based on Veteran's disability picture as a whole, the Board finds that the Veteran's symptoms more closely approximate total social and occupational impairment for the entire period on appeal. Therefore, the Board finds that an initial rating of 100 percent for PTSD is warranted. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board acknowledges that the results of the VA examinations, the symptoms described in the VA examination reports, and the lay statements of record do not indicate that the Veteran has experienced all of the symptoms associated with a 50 a 100 percent rating for PTSD. Therefore, a finding that there is total occupational and social impairment is sufficient to warrant a 100 percent rating for the entire period on appeal even though all the specific symptoms listed for 100 percent ratings are not manifested. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the Board finds that the evidence for and against the claim is at least in equipoise. Therefore, the benefit of the doubt must be resolved in favor of the Veteran, and entitlement to an initial rating of 100 percent for PTSD is warranted. 38 U.S.C. § 5107 (b) (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Kristin Haddock Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Andrew Ledman II 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.