Citation Nr: 21070081 Decision Date: 11/23/21 Archive Date: 11/23/21 DOCKET NO. 17-31 827 DATE: November 23, 2021 ORDER Reopening of service connection for a low back disorder is granted. Service connection for lumbar spine arthritis is granted. For the increased rating period on appeal from December 17, 2013 to April 18, 2018, an increased disability rating of 70 percent for the service-connected major depressive disorder with posttraumatic stress disorder (PTSD) is granted; for the increased rating period on appeal from December 17, 2013, a rating in excess of 70 percent is denied. FINDINGS OF FACT 1. A February 2013 Department of Veterans Affairs (VA) Regional Office (RO) rating decision denied service connection for a low back disorder, finding no nexus between the low back disorder and service. No Notice of Disagreement nor new and material evidence was received within one year. 2. Evidence received since the February 2013 rating decision pertains to a nexus between the low back disorder and service. 3. The Veteran has present diagnoses of spondylosis and degenerative disc and facet disease (lumbar spine arthritis). 4. Symptoms of lumbar spine arthritis have been continuous since service separation. 5. For the increased rating period on appeal from December 17, 2013 to April 18, 2018, the severity, frequency, and duration of the service-connected PTSD symptomatology most nearly approximated deficiencies in most areas, and did not more nearly approximate total occupational and social impairment. CONCLUSIONS OF LAW 1. The February 2013 rating decision denying service connection for a low back disorder became final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. 2. Evidence received since the February 2013 rating decision is new and material to reopen service connection for a low back disorder. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for lumbar spine arthritis have been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. Resolving reasonable doubt in the Veteran's favor, for the increased rating period on appeal from December 17, 2013 to April 18, 2018, an increased disability rating of 70 percent, and no higher, for the service-connected PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 43, 4.7, 4.126, 4.130, Diagnostic Code 9434-9411. 5. For the entire increased rating period on appeal from December 17, 2013, the criteria for an increased disability rating in excess of 70 percent for the service-connected PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 43, 4.7, 4.126, 4.130, Diagnostic Code 9434-9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant, had active duty service from November 1982 to November 2002. The instant matters are on appeal from VA RO rating decisions. Regarding the low back disorder, a February 2014 rating decision denied service connection for low back pain on the basis of no new and material evidence, and the Veteran filed a new claim on March 31, 2014 for entitlement to service connection for low back pain, supplying a nexus statement. That claim was denied in a May 2014 rating decision. Regarding the psychiatric disability, a November 2014 rating decision continued the 30 percent disability rating and a January 2018 rating decision increased the disability rating to 50 percent, effective December 17, 2013 (date of claim for increase). A February 2019 rating decision established a staged rating of 70 percent from April 18, 2018 (date of receipt of a Disability Benefits Questionnaire from the treating psychiatrist). The instant matters have been before the Board of Veterans' Appeals (Board) previously. In March 2019, the matters were remanded to obtain outstanding Social Security Administration (SSA) disability records. As the records have since been obtained, there has been substantial compliance with the terms of the remand and adjudication can proceed. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Reopening Legal Criteria Generally, a claim that has been denied may not thereafter be reopened and allowed based on the same record. Accordingly, the first determination is whether a final decision has been reached. 38 U.S.C. § 7105. If there is a final decision, then the question becomes whether new and material evidence has been presented or secured with respect to a claim that has been disallowed. 38 U.S.C. § 5108. "New" evidence is defined as existing evidence not previously submitted to agency decision makers. 38 C.F.R. § 3.156(a). "Material" evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. When the veteran seeks to reopen a claim based on new evidence, VA must first determine whether the evidence is "new" and "material." Evidence must be both new and material. See Smith v. West, 12 Vet. App. 312 (1999). New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened. 38 C.F.R. § 3.156(a). It must raise a reasonable possibility of substantiating the claim. Id. If the Board determines that the evidence submitted is both new and material, it must reopen the claim and evaluate the claim in light of all the evidence. Justus v. Principi, 3 Vet. App. 510, 512 (1992). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly received evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA Secretary's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. Regardless of the RO's determination as to whether new and material evidence had been received, the Board must address the issue of the receipt of new and material evidence in the first instance because it determines the Board's jurisdiction to reach the underlying claims and to adjudicate the claims de novo. See Woehlaert v. Nicholson, 21 Vet. App. 456, 460-61 (2007) (citing Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996)). If the Board determines that the received evidence is both new and material, it must reopen the case and evaluate the claim in light of all the evidence. Justus, 3 Vet. App. at 512. Such evidence is presumed to be credible for the purpose of determining whether the case should be reopened; once the case is reopened, the presumption as to credibility no longer applies. Id. at 513. 1. Reopening of Service Connection for a Low Back Disorder is Granted. The Veteran contends that there is new and material evidence to support service connection for a low back disorder. See August 2014 Notice of Disagreement (providing a lay statement as to the onset of symptoms during service and attaching various medical documents); March 2014 Nexus Statement. A February 2013 rating decision denied service connection for a low back disorder, finding no nexus between the low back disorder and service. No Notice of Disagreement nor new and material evidence was received within one year, so the rating decision became final. 38 U.S.C. § 7105. Evidence received since the February 2013 rating decision pertains to a nexus between the low back disorder and service, as the Veteran has provided an updated nexus statement from a VA treating physician. See March 2014 Nexus Statement. The evidence is new, in that it was not before previous adjudicators. It is material, in that it pertains to the possible existence of a nexus between service and a present disability. See 38 C.F.R. § 3.156(a). Accordingly, new and material evidence has been received to reopen service connection for a low back disorder. Service Connection Legal Authority Direct Service Connection Service connection can be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection generally requires competent evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. Chronic Disease Presumptive Service Connection Lumbar spondylosis and degenerative joint disease are a form of arthritis and are therefore a "chronic disease" under 38 C.F.R. § 3.309(a); accordingly, 38 C.F.R. § 3.303(b) applies. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For these reasons, the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on "chronic" symptoms in service and "continuous" symptoms since service are applicable. Id. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then, generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Where a veteran served 90 days or more of active service, and certain chronic diseases become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). 2. Service Connection for a Low Back Disorder is Granted. The Veteran seeks service connection for a low back disorder. The evidence shows current diagnoses of lumbar spondylosis, chronic back pain, and degenerative joint and facet disease. See March 2014 Nexus Statement (providing the diagnoses of chronic back pain and degenerative joint and facet disease); April 2016 X-ray Results (providing the diagnosis of lumbar spondylosis). Accordingly, the present disability requirement has been met. After a review of all the evidence, lay and medical, the Board finds that the evidence is at least in equipoise as to symptoms of lumbar spine arthritis starting during service and being continuous since service separation. The Veteran sought treatment for back pain three times during service. See May 1988 Service Treatment Record; October 1988 Service Treatment Record; March 1999 Service Treatment Record. The Veteran also marked "yes" to recurrent back pain or any back problem on the June 2002 Report of Medical History at separation, which is a contemporaneous to service report of medical problems that existed at the time of the report or that had previously existed. Although there was an x-ray at the time that was normal and the VA examiner commented on the June 2002 Report of Medical History that the lower back pain was mechanical, symptoms of arthritis (pain) do not have to manifest to the degree that they are diagnosed as arthritis during service for purpose of chronic disease presumptive service connection. The point of the presumption is to note that the symptom began during service, was continuous since service separation, and was later diagnosed as arthritis. With respect to continuous post-service symptoms, the evidence shows that the Veteran complained of mild low-grade back pain at a March 2003 VA examination, less than six months after service separation. Although in November 2007 the Board denied the appeal for service connection for low back pain because there was no listed disability, the claim and appeal supports the assertion that the pain was chronic since service. The evidence also demonstrates that when the Veteran sought treatment for back pain subsequently to the claim, he described the pain as being chronic since when he had difficulty working out in the military carrying things. See March 2011 VA Treatment Record. Additionally, in his August 2014 Notice of Disagreement, the Veteran sated that he has problems in the lower back that started when he was in the service due to the strenuous physical activity that was required. Although the March 2014 Nexus Statement was supporting a direct service connection theory, the physician's statement supports the Veteran's assertion that strenuous physical activities caused the lumbar spine arthritis. Resolving reasonable doubt in the Veteran's favor, the Board finds that the symptoms of lumbar spine arthritis were continuous since service separation; accordingly, the criteria are met for presumptive service connection for the chronic disease of arthritis (38 C.F.R. § 3.303(b)). 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Board acknowledges that there is a direct service connection opinion that weighs against a direct nexus between the in-service injuries and the post-service diagnosis; however, as the Board is granting presumptive service connection for lumbar spine arthritis on a chronic disease presumptive basis, a direct service connection theory of entitlement has been rendered moot, leaving no question of law or fact to decide. See 38 U.S.C. § 7104. PTSD Rating Legal Criteria 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. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The Secretary of VA, acting within the authority to adopt and apply a schedule of ratings, chose to create one general rating formula for mental disorders. 38 U.S.C. §§ 501, 1155; 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 psychiatric disorders, there can be no doubt that the Secretary of VA anticipated that any list of symptoms justifying a particular rating would in many situations be either under- or over-inclusive. The Secretary's use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (1992). 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 diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment. See 38 C.F.R. § 4.126. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. The schedular rating criteria rate by analogy psychiatric symptoms that are "like or similar to" those explicitly listed in the schedular rating criteria. See Mauerhan, 16 Vet. App. at 443. The Federal Circuit has embraced the Mauerhan interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (2013), the Federal Circuit held that VA "intended the General Rating Formula to provide a regulatory framework for placing veterans on a disability spectrum based upon their objectively observable symptoms." The Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Under Diagnostic Code 9434-9411, a 50 percent rating will be 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, disturbance of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A 70 percent rating will be 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), and inability to establish and maintain effective relationships. Id. A 100 percent schedular rating contemplates 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. Id. 3. An Increased Disability Rating of 70 Percent from December 17, 2013 to April 18, 2018 for PTSD is Granted The Veteran is currently in receipt of a 50 percent disability rating for the service-connected PTSD from December 17, 2013 to April 18, 2018, and a 70 percent disability rating from April 18, 2018 onward. The Veteran is also in receipt of a total disability rating due to individual unemployability (TDIU) from February 9, 2015 onward, which is the day after he terminated employment as a meter reader. After a review of all the evidence, lay and medical, the Board finds that the lay and medical evidence more nearly approximates the criteria for a 70 percent disability rating for the entire period on appeal, but no higher. The evidence demonstrates that for the entire period on appeal, the severity, frequency, and duration of the psychiatric symptomatology most nearly approximated deficiencies in most areas, but did not more nearly approximate total occupational and social impairment. For the entire rating period on appeal, the Veteran has been in active psychiatric and psychological treatment, so there is ample documentation as to the nature of the Veteran's psychiatric disorder, namely that he experiences PTSD, depression, and alcohol use disorder. For the majority of the period on appeal, the Veteran has taken five psychiatric medications to assist with the psychiatric symptomatology and, for the most part, has reported that they are helpful. See, e.g., December 2013 VA Treatment Record (stating that he has had fewer nightmares and flashbacks with medication and feels that medication has helped); May 2015 VA Treatment Record (stating that he cut back his drinking and has fewer nightmares and flashbacks because medication has helped). The evidence demonstrates that the Veteran had one psychiatric inpatient hospital admission during the period that is currently rated at 50 percent disabling. From January 22, 2015 through January 26, 2015, the Veteran was treated because he had harmful thoughts toward anyone (like or similar to suicidal ideation), it appeared that he was going to hurt someone but denied thoughts of hurting himself (like or similar to suicidal ideation), and was experiencing hopelessness and helplessness (like or similar to disturbances of motivation and mood). His mood was depressed and anxious and his memory and concentration were impaired. Despite the severity of symptoms, however, he was oriented in time, place, and person, and not experiencing auditory or visual hallucinations. Subsequent to the hospital admission, the Veteran reported to a private psychologist, Dr. A.D., that he had become so angered during his psychiatric visit that he made statements about hurting others and experienced a breakdown in the psychiatrist's office, leading to the admission. The severity, frequency, and duration of symptoms associated with the hospitalization is part of the evidence that suggest a higher 70 percent disability rating, as suicidal ideation is only contemplated by the 70 percent criteria. See Bankhead v. Shulkin, 29 Vet. App. 10, 20 (2017). It is also worth noting that subsequent to the hospital admission, the Veteran terminated employment because he felt work had been a substantial trigger for the symptoms. See February 2015 VA Treatment Record. The outpatient VA psychiatrist has stated in a May 2019 Psychiatric/Psychological Impairment Questionnaire that the symptoms during the early rating period on appeal included memory loss for names of close relatives, own occupation, or own name, deficiencies in family relations, persistent irrational fears, persistent delusions or hallucinations, deficiencies in work or school, gross impairment in thought processes or communication, depression affecting the ability to function independently, appropriately, and effectively, neglect of personal appearance and hygiene, intermittent inability to perform activities of daily living, deficiencies in mood, difficulty in adapting to stressful circumstances, intrusive recollections of a traumatic experience, disorientation to time or place, irritability, inability to establish and maintain effective relationships, deficiencies in judgment, intermittent suicidal ideation, floods of hypervigilance, hyperstartle, nightmares, and flashbacks. The outpatient VA psychiatrist stated that the Veteran was markedly limited in all aspects related to possible employment and was not capable of performing gainful employment. The outpatient VA psychiatrist's own treatment notes do not reflect the extreme degree of impairment that the outpatient VA psychiatrist suggested existed in the May 2019 Psychiatric/Psychological Impairment Questionnaire, most notably in the areas of cognition, memory, and appearance. The notes do demonstrate that the Veteran dealt with PTSD and depression symptomatology, including alcohol problems, nightmares (like or similar to chronic sleep impairment), depression, anxiety, and flashbacks (like or similar to disturbances of motivation and mood). However, the mental status exams reveal that the Veteran was alert, calm, cooperative, spoke at a normal rate and volume, usually was euthymic, usually had a broad affect, usually displayed normal attention, concentration, and memory, did not display auditory or visual hallucinations, had fair insight and judgment, and was oriented in all spheres. These records were made at the time that the psychiatrist was observing the Veteran and would have guided the treatment recommendations, rather than being a document generated for disability compensation purposes. As such, the Board finds that their probative value outweighs that of the May 2019 Psychiatric/Psychological Impairment Questionnaire. The Board recognizes that the psychiatrist submitted an additional statement that was designed to explain the conclusions of the May 2019 Psychiatric/ Psychological Impairment Questionnaire. In a March 2021 letter, the psychiatrist stated that the psychiatric symptoms worsened over the course of treatment and that the Veteran had several stressors occur, which contributed to his symptoms worsening, including memory. The outpatient psychiatrist noted that there were difficulties at work when one of his coworkers found the body of a deceased child, that the Veteran's daughter was physically assaulted, that his son-in-law committed suicide, and that the Veteran began to drink alcohol excessively, all of which led to increasing symptomatology and worsening memory. This statement supports the 70 percent rating, which in itself reflects significant occupational and social impairment, but still does not warrant a total occupational and social impairment conclusion. When the Veteran initially filed the appeal for an increased disability rating, a VA examiner initially opined that the Veteran had occupational and social impairment due to mild or transient symptomatology that decrease work efficiency and ability to perform occupational tasks only during periods of significant stress or that symptoms were controlled by medication. See August 2014 VA Examination. The August 2014 VA examiner observed the symptoms of depressed mood, anxiety, chronic sleep impairment, mild memory loss, and difficulty in establishing and maintaining effective work and social relationships. In response to the August 2014 examination, the Veteran submitted a November 2014 statement by his wife that stated that his symptoms were worsening, that he demonstrated nightmares, and that he had changing moods and anger (like or similar to depressed mood). The wife wrote that they have to be careful when they go out because the Veteran thinks someone might attack him and that he in general wants to stay at home. She explained that she has to take him to his appointments and order him to do basic activities like shaving or combing his hair. She also explained that sometimes the Veteran does not want to go to work, so she will drive him to his job and pick him up because he did not feel comfortable driving. The Veteran also submitted a May 2015 Psychiatric/Psychological Impairment Questionnaire by the outpatient VA psychiatrist, which largely reached the same conclusions as the previously discussed May 2019 Psychiatric/Psychological Impairment Questionnaire (significant cognitive and behavioral disorientation issues and total occupational impairment). The Veteran submitted a September 2015 Disability Benefits Questionnaire by the same provider that also opined as to total occupational and social impairment; however, notwithstanding the overall characterization of severity, the actual symptomatology and degrees of social and occupational impairment that the Veteran has, as shown by the weight of the lay and medical evidence, most nearly approximates that of the 70 percent disability rating. Symptoms included depressed mood, anxiety, suspiciousness, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances including work or a work-like setting, and inability to establish and maintain effective relationships. Accordingly, the Board concludes that the September 2015 Disability Benefits Questionnaire is consistent with the finding that a 70 percent disability rating, but no higher, is warranted for the entire increased rating period on appeal. Because of the conflict between the August 2014 VA Examination and the observations provided by the VA outpatient psychiatrist, the RO asked a neuropsychologist to provide an updated VA examination to attempt to resolve the discrepancy. In a January 2018 VA Examination, the neuropsychologist reviewed the Veteran's mental health treatment and records. The January 2018 neuropsychologist found that the diagnoses of PTSD, major depressive disorder, and alcohol use disorder were still well-supported. The January 2018 neuropsychologist noted also that the Veteran continued to be married to his spouse, though there were issues with intimacy and communication. The Veteran also noted continued contact with his adult children and with six grandchildren. The January 2018 neuropsychologist explained that the Veteran left his employment as a meter reader after he experienced increasing difficulties with irritability and frustration intolerance with coworkers and customers, that the Veteran resigned voluntarily from the position, though he felt as though his job was in jeopardy at times, and that the Veteran took some college classes. The symptoms that the January 2018 neuropsychologist found included depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, flattened affect, 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, and suicidal ideation. The January 2018 neuropsychologist found that, although mood and affect were overtly anxious and moderately depressed, there was no evidence of loose associations, blockages of thought, or any other indicators of major mental disorder. While the Veteran reported subjective visual and auditory hallucinations, further questioning and interview suggested they were largely pseudo-hallucinations. The Veteran's mental status exam was within normal limitsin keeping with that observed by the outpatient VA psychiatrist. Because of the conflicting observations, the January 2018 neuropsychologist administered psychometric testing related to malingering and found that the Veteran produced a very high score, endorsing highly infrequent, bizarre, and unusual symptoms of mental illness. The score was at a level that suggested his self-report is "less than fully reliable in terms of symptoms frequency and intensity." The Veteran appeared heavily invested in the notion that he was permanently damaged and altered by his symptomatology. The January 2018 neuropsychologist opined that the Veteran was more significantly impaired than what the previous VA examiner had concluded, but less so than what the outpatient VA psychiatrist suggested, finding that the Veteran demonstrated an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The January 2018 neuropsychologist suggested that the treating VA psychiatrist may have been placed in a challenging position where he felt the need to advocate for his client and also noted that the treating VA psychiatrist did not have access to the malingering psychometric test results. The results of the January 2018 VA Examination place a cautionary note on the report given by the Veteran as to his symptomatology. In May 2018, the VA treating psychiatrist wrote another letter that stated that he has been treating the Veteran for approximately ten years and that the Veteran had to resign from his job because of his psychiatric issues, which included anger, depression, flashbacks, and nightmares that led to interpersonal issues at work. The VA treating psychiatrist stated that he does have a good rapport with the Veteran, but that the relationship is based on the knowledge that the psychiatrist must be honest and candid with his condition, treatments, and prognosis and would not write any document regarding his condition that he was not convinced was accurate and precise. Overall, the Board finds that the level of occupational impairment is significant, as evidenced by the fact that the Veteran quit his job following his hospitalization (which supported the grant of a TDIU). Socially, however, the evidence still demonstrates that the Veteran has social relationships with his wife, children, and grandchildren. Although there is reportedly strain in these relationshipsas noted by the wife's statement in support of his claim for an increased ratingthe Veteran is not totally socially impaired. For example, over the course of his treatment, the Veteran has been an active participant in group therapy, accepting and giving feedback. While the evidence approximates the criteria for a 70 percent disability rating for the service-connected PTSD from December 17, 2013 to April 18, 2018, at no time does the evidence approximate total social and occupational impairment required for a 100 percent rating. J. PARKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Smith, 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.