Citation Nr: A21018317 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 201008-111295 DATE: November 17, 2021 ORDER Entitlement to an initial rating higher than 30 percent for service-connected posttraumatic stress disorder (PTSD) prior to August 7, 2019 is denied. Entitlement to a 50 percent rating, but no higher, for service-connected PTSD from August 7, 2019 onward is granted. Entitlement to a rating higher than 50 percent for service-connected PTSD throughout the appeal period is denied. FINDINGS OF FACT 1. Prior to August 7, 2019, the Veteran's PTSD was manifested by depressed mood, anxiety, suspiciousness, chronic sleep impairment, nightmares, intrusive reminders of past trauma, hypervigilance, trust difficulties, altered worldview, survivor guilt, and some social isolation and avoidance. 2. From August 7, 2019 onward, the Veteran's PTSD was manifested by chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, obsessional rituals sometimes interfering with routine activities, and some neglect of personal appearance and hygiene. 3. At no point during the period on appeal has the Veteran's PTSD been manifested by deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, or by total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating higher than 30 percent for the service-connected PTSD prior to August 7, 2019 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. The criteria for entitlement to a 50 percent rating, but no higher, from August 7, 2019 onward have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 3. The criteria for entitlement to a rating higher than 50 percent for the service-connected PTSD throughout appeal period have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1964 to July 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2020 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) following a request for higher level review of a February 2020 rating decision. In August 2019, the Veteran submitted VA Form 20-0995, Decision Review Request: Supplemental Claim, requesting review of a September 2018 rating decision based on new evidence. In February 2020, the agency of original jurisdiction (AOJ) issued a new rating decision continuing the Veteran's existing 30 percent rating for PTSD. In April 2020, the Veteran submitted VA Form 20-0995, Decision Review Request: Higher-Level Review, and requested review of the February 2020 rating decision. In September 2020, the agency of original jurisdiction (AOJ) issued the higher-level review decision on appeal, which found that an increased evaluation of the service-connected PTSD is warranted from November 25, 2019, the date of the most recent VA PTSD examination. The Veteran submitted VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) (NOD) in October 2020, appealing the September 2020 rating decision to the Board and electing the Direct Review option. When a claimant seeks appellate review through the Board's Direct Review docket, the Board may only consider the evidence of record at the time of the rating decision on appeal. See 38 U.S.C. § 7113(a). By selecting the Board's Direct Review option, the Veteran opted for a closed evidentiary record; therefore, the Board can consider only the evidence of record at the time of the February 2020 rating decision. Since the February 2020 rating decision, additional evidence was added to the claims file. The Board cannot consider this evidence in connection with the increased rating claim for PTSD. The Veteran may file a Supplemental Claim and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. Due to the complex procedural nature of this matter, the Board must clarify the period on appeal, which extends to February 3, 2016, the effective date of service connection for PTSD. By way of background, the Veteran filed a VA Form 21-0958, Notice of Disagreement (NOD) in July 2016 as to the June 2016 rating decision, which granted service connection for PTSD and awarded a 30 percent evaluation. Following this filing, and prior to receiving a Supplemental Statement of the Case (SSOC) as to his claim, he opted-in to the Rapid Appeals Modernization Program (RAMP), a temporary program allowing early participation in the new appeals process before the AMA became effective in February 2019. Per his RAMP opt-in election form, the Veteran elected the Higher-Level Review option. VA notified the Veteran that his appeal of the June 2016 rating decision had been removed from the legacy appeal system in July 2018, and in September 2018, the RO issued a higher-level review rating decision. In August 2019, in response to the September 2018 rating decision, the Veteran's representative submitted VA Form 646, Statement of Accredited Representative in Appealed Case, and stated that the Veteran is appealing the September 2018 rating decision, with the relief sought including, in part, an increased rating for the service-connected PTSD from February 3, 2016 onward. His representative separately submitted VA Form 20-0995, Decision Review Request: Supplemental Claim a few weeks later, included a private medical evaluation of the Veteran's PTSD, and referred to the filing as a "Notice of Disagreement." While the Board recognizes that the Veteran's representative sought to have these filings construed as notices of disagreement but did not file on the standardized form, and 38 C.F.R. § 19.21 requires that Veterans file a notice of disagreement in response to a rating decision on a standardized form, the Board also notes that RAMP temporarily altered the appeal procedures for Veterans while VA transitioned to the AMA system. Here, attached to the September 2018 rating decision, the Veteran received a notification letter detailing review rights under RAMP and informing him that he could "follow the application requirements outlined below to seek further review until the new decision review system becomes effective on or after February 14, 2019, at which time [he] may select different lanes for each issue and will have to follow the application requirements of the new system." The review options included filing a Supplemental Claim, requesting Higher-Level Review, and filing an Appeal to the Board. Although the Veteran's representative characterized the August 2019 filings as notices of disagreement, which would have been improper for failure to use the standardized form, the submission of VA Form 20-0995, Decision Review Request: Supplemental Claim allowed review of the Veteran's claim to continue under RAMP. Accordingly, although the Veteran did not file a valid notice of disagreement within one year of notification of the September 2018 rating decision, he nonetheless properly followed the procedure outlined by VA as to RAMP and continuously pursued his increased rating claim for PTSD. As such, the Board will address the present matter as an appeal for an initial increased rating and will consider evidence from February 3, 2016, the date of service connection, to February 7, 2020, the date of the rating decision on appeal. Increased Rating The Veteran seeks an initial rating higher than 30 percent for service-connected PTSD prior to November 25, 2019 and higher than 50 percent thereafter. His PTSD is rated under 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events) cause 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). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name cause total occupational and social impairment. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a Veteran's symptoms, but it must also make findings as to how those symptoms impact a Veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran's impairment must be "due to" those symptoms, a Veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. 1. Entitlement to an initial rating higher than 30 percent prior to August 7, 2019 for service-connected PTSD is denied. After a review of the lay and medical evidence, the Board finds that an initial rating higher than 30 percent is not warranted prior to August 7, 2019. The Veteran was afforded a VA PTSD examination in June 2016 to assess the severity of his PTSD symptoms. At the time of this examination, the Veteran had been married for 47 years with one son and three grandchildren. He described his relationship with his wife as "excellent," referring to her as his rock, and his relationship with his son as good, and reported having a close relationship with his siblings. He reported working as a correctional officer from 1969 to 1982, medically retiring following a hostage incident, and subsequently serving as a caregiver for his parents and sister. The Veteran reported multiple symptoms related to his PTSD, including: chronic sleep impairment, feeling on edge, and experiencing nightmares. He noted that he had been attending therapy to help himself relax, seeking help after speaking with a fellow servicemember about memories from Vietnam. The examiner documented that the Veteran experienced depressed mood, anxiety, and chronic sleep impairment as symptoms of his PTSD. The examiner determined that the severity and duration of the Veteran's symptoms resulted in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during period of significant stress, or, symptoms controlled by medication. Regarding behavioral observations, the examiner noted that the Veteran was alert and oriented to time, place, person, and purpose, casually dressed and well-groomed, and exhibited normal speech, dysphoric tearful mood, normal cognitive function, normal thought processes, and intact insight and judgment. The Veteran denied recent suicidal or homicidal ideation, denied any hallucinations or delusion, and the examiner noted that no obsessions, compulsions, or phobias were detected. Both VA and private treatment records are associated with the claims file from the start of the appeal period and document the Veteran's overall PTSD symptoms and observations of his behavior and mental status. The Board notes that the Veteran's VA treatment records include only limited discussion of his PTSD and behavior. In January 2016, the Veteran called VA's Veterans Crisis Hotline and reported that he was struggling with flashbacks, sleep disturbances, mood swings, depression, withdrawal, and isolation, noting that his nightmares and flashbacks started three to four months prior. He denied any recent suicidal ideation, but reported that he had experienced suicidal ideation "a few years back." The Veteran also began receiving treatment at the Vet Center in January 2016 and consistently attended group therapy and appointments there through November 2016. He reported experiencing insomnia, nightmares, intrusive reminders, depression, anxiety, and self-isolation as symptoms of PTSD at his initial visit, and his wife separately reported that he is always on edge, hates crowds, and is irritable with her and their grandchildren. Across several visits, he reported having a strong marriage with his wife, being involved in church, attending his grandchildren's school events, and traveling to the Vietnam Memorial Wall and Fort Myer, Virginia with fellow servicemembers. At the start of the Veteran's Vet Center treatment, his provider noted that he had not previously been prescribed medication for his mood, but had been recently prescribed Zoloft and Remeron at different points by his VA provider. In March 2016, he reported that his mood and sleep both improved with medication, and his wife observed how much more relaxed he was. In April 2016, his provider noted that his psychotropic medications had helped significantly with symptom reduction. In May 2016, he reported improvement of his PTSD symptoms, having been able to attend his grandson's choral program for the first time and tolerating other events. In July 2016, he reported that his mood was continuing to improve and that he was becoming more social, especially in activities with his wife. However, across two August 2016 visit, he reported increased PTSD symptoms, which his provider documented as depression, re-experiencing, insomnia, anxiety, and isolation. The Veteran consistently denied any suicidal or homicidal ideation throughout his Vet Center treatment. In March 2016, the Veteran's Vet Center provider submitted a statement to VA detailing his treatment and participation in the program. His provider stated that his presenting PTSD symptoms include anxiety and depression, nightmares and intrusive memories, hyperarousal, hypervigilance, trust difficulties, altered worldview, survivor guilt, social isolation, and avoidance, and despite the considerable progress he has made in counseling, his trauma reactions persist for him. While the Veteran's treatment records, both VA and private, from November 2016 onward are limited, his providers documented general observations as to his mental status and behavior, consistently noting that he presented as alert and oriented to time, place, and person with normal affect. See, generally, Private Treatment Records from October 2018 to July 2019. At a July 2018 neurosurgery and spine consultation, his provider documented that he denied anxiety, depression, and/or inability to concentrate. See July 2018 B.N.S.C. Note. Separately, per a VA depression screening, he denied having little interest or pleasure in doing things; feeling down, depressed, or hopeless; or having suicidal thoughts in the past two weeks. Per a PTSD screening, he reported having nightmares and/or intrusive thoughts, avoidance, hypervigilance, feelings of detachment, and feelings of guilt or self-blame in the past month, and he again denied any suicidal ideation. See May 2019 Primary Care Note. The Board has considered the Veteran's lay statements from this portion of the appeal period. In March 2016, the Veteran provided background as to what he felt triggered his PTSD, detailing the 1982 prison escape and hostage situation that was involved in while working as a corrections officer and noting that following the incident was the first time he was treated for what he called "shell shock." He reported that he forced his way through his monsters until he began experiencing nightmares, night sweats, periods of anxiety, and sleeplessness seven months prior. His wife also submitted a statement and detailed his history of psychiatric symptoms, noting that since he began receiving treatment at the Vet Center and began taking medication, he has slept at night without nightmares. In his July 2016 Notice of Disagreement, the Veteran stated that based on his social impairment, anti-social behavior, fear of crowds, wanting to be alone, mood swings, inability to cope with difficult and stressful situations, and sometimes bad judgment, he felt as though he should have received a higher PTSD rating. Prior to August 7, 2019, the severity, frequency, and variety of the Veteran's symptoms, taken in light of the level of impairment resulting from these symptoms, most closely approximated the symptoms and impairment contemplated by a 30 percent rating. The Board notes that the Veteran reported some symptoms contemplated by the 50 percent rating criteria, such as impaired judgment and difficulty in adapting to stressful circumstances; however, while the Veteran, as a lay person, is competent to report some things, including symptoms of his PTSD that come to him through his senses, his reports must be taken in tandem with medical observations and the overall impairment resulting from her symptoms. See Layno v. Brown, 6 Vet. App. 465, 469-470 (1994); Jandreau v. Nicholson, 492 F.3d 1372, 1376-1377. Therefore, his reports are afforded less probative value than the objective psychiatric medical evidence of record. Regardless, it is not symptoms alone that warrant a certain rating, but the resulting impairment. While the Veteran reported symptoms contemplated by a higher rating, as discussed above, these symptoms were not documented in his VA or private treatment records or at his June 2016 VA examination. The Veteran's remaining symptoms are consistent with a 30 percent rating. The medical evidence indicates that the Veteran experienced symptoms such as depressed mood, anxiety, suspiciousness, chronic sleep impairment, nightmares, intrusive reminders, hypervigilance, trust difficulties, altered worldview, survivor guilt, and some social isolation and avoidance. The lay and medical evidence, taken together, demonstrates that while he experienced occupational and social impairment due to her PTSD symptoms, he was able to maintain a marriage that he described as "excellent," maintain close relationships with his siblings, serve as a caregiver for his parents and sister, attend church and other events, and remain active in his grandchildren's lives, all of which suggest that his PTSD did not manifest as occupational and social impairment with reduced reliability and productivity. While he may have had difficulties with depressed mood, anxiety, chronic sleep impairment, and some instances of hypervigilance and irritability, those symptoms are encompassed by the assigned 30 percent rating. Accordingly, the Board finds that, prior to August 7, 2019, the Veteran's PTSD did not manifest as occupational and social impairment with reduced reliability and productivity as required by the next higher rating, and his symptoms were not of such severity or variety to indicate that they are not fully contemplated by a 30 percent rating. 2. Entitlement to a 50 percent rating, but no higher, for service-connected PTSD prior to November 25, 2019 is granted. 3. Entitlement to a rating higher than 50 percent for service-connected PTSD throughout the appeal period is denied. After a review of the lay and medical evidence, the Board finds that a 50 percent rating, but no higher, is warranted from August 7, 2019 onward, the date of a factually ascertainable increase. In August 2019, the Veteran submitted a private medical evaluation detailing his psychiatric symptoms and including a private examiner's opinion as to the severity of his PTSD. In the evaluation report, the examiner, Dr. C.M., documented the Veteran's history of PTSD treatment, most of which is detailed in the previous section. Dr. C.M. documented that the Veteran endorsed a multitude of psychiatric symptoms and provided citations to the Veteran's interview statements as related to several of the listed symptoms. She specifically determined that the Veteran's statements demonstrate the following: Intrusive symptoms, including recurrent thoughts, traumatic nightmares, intense or prolonged distress after exposure to traumatic reminders, and marked physiologic reactivity after exposure to trauma-related stimuli. Avoidance symptoms, based on the Veteran's reports of avoiding television shows that remind him of the war, staying home all the time, not wanting to go out, and avoiding calls from a fellow veteran who only wants to talk about the war, which she categorized as "near-complete isolation." Negative alterations in cognitions and mood, including negative beliefs or expectations, negative emotional state, markedly diminished interests, and alienation. Trauma-related alterations in cognitions and mood, including irritability, hypervigilance, exaggerated startle response, and sleep disturbance. Severe functional impairment, based on a need to follow a routine, memory issues, and occasional reminders to shower due to lack of energy and/or motivation. Following her general overview of these symptoms and the Veteran's statements, Dr. C.M. opined that the Veteran's PTSD is severe and has at least as likely as not caused him occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood due to symptoms such as obsessional rituals which interfere with routine activities; near-continuous depression affecting the ability to function independently, appropriately and effectively; impaired impulse control; neglect of personal appearance and hygiene; and difficulty in adapting to stressful circumstances (including work or a worklike setting). The Board finds Dr. C.M.'s medical evaluation and opinion to be of limited probative value and the Veteran's statements documented therein to be of greater probative value. Although Dr. C.M. determined that the Veteran experiences symptoms such as near-continuous depression affecting the ability to function independently, appropriately and effectively; impaired impulse control; and neglect of personal appearance and hygiene, these symptoms are not shown in the evidence of record and do not necessarily align with the Veteran's statements directly quoted in the evaluation report or his symptoms documented in VA and private treatment records. Dr. C.M. did not point to evidence of near-continuous depression affecting the ability to function independently, appropriately and effectively, specific instances of impaired impulse control, or neglect of personal appearance and hygiene beyond occasional lack of motivation to shower, and, while there is potential evidence of obsessional rituals based on the Veteran's statements, she categorized these statements as evidence of hypervigilance and startle response. Dr. C.M. did not provide the basis of her assessment as to these symptoms, and, for her findings in which there is some, albeit limited, evidence of record demonstrating such symptoms (e.g. obsessional rituals which interfere with routine activities and neglect of personal appearance and hygiene), she does not specify the frequency in which these symptoms occur or the severity of them. The Board finds that the conclusory nature of Dr. C.M.'s findings, particularly including her failure to specifically discuss the symptoms she listed from the General Rating Formula for Mental Disorders despite determining that these symptoms are present, undercuts her overall opinion as to the severity of the Veteran's occupational and social impairment. Moreover, the Board notes that Dr. C.M.'s summation of the Veteran's wife's March 2016 statement is misleading, which further reduces the probative value of her opinion. Specifically, as discussed in the section above, the Veteran's wife submitted a statement detailing the Veteran's history of psychiatric symptoms, with most of her statement focused on the Veteran's symptoms soon after his 1969 discharge from service. She stated that "[h]e was very nervous walking back and forth jumping from back fire [sic] of cars and when he was sitting his legs were shaking and at night he would have dreams and sweats," and continued by stating that whenever she questioned him about his behavior, "he kept silent," "was drinking alcohol and smoking marijuana all the time," and "was out of control." The Veteran's reports in his treatment records make clear that he has not abused alcohol or drugs in several years. See January 2016 Vet Center Progress Note (noting that the Veteran does not abuse alcohol now); June 2016 VA Examination (noting that the Veteran stopped using cannabis and alcohol about 10 years prior); November 2019 VA Examination (noting that the Veteran quit drinking "cold turkey" after service). Due to the organization of the Veteran's wife statement, it does not appear that she was reporting current or recent observations, but rather observations of the Veteran's behavior soon after his discharge from service. While the Board has considered the Veteran's wife's observations as to his recent symptoms, as discussed in the prior section, the Board finds that Dr. C.M.'s reliance on his wife's observations of his behavior soon after his 1969 discharge without recognizing that these observations are not current further reduces the probative value of her opinion. Nonetheless, the Board finds the Veteran's statements documented in Dr. C.M.'s evaluation report to be probative of the severity of his psychiatric symptoms and resulting occupational and social impairment. Specifically, the Board finds that the Veteran's statements directly quoted in the evaluation report align with symptoms such as chronic sleep impairment, mild memory loss, disturbances of motivation and mood, obsessional rituals sometimes interfering with routine activities, and some neglect of personal appearance. Based on the Veteran's statements documented in the August 2019 private medical evaluation and the limited treatment records documenting behavioral observations in the year prior to the period on appeal, the Board finds that the Veteran's occupational and social impairment resulting from his PTSD caused reduced reliability and productivity beginning on August 7, 2019, the date of his interview with Dr. C.M. After considering the evidence, the Board finds that a 50 percent rating, but no higher, is warranted for this portion of the appeal period due to symptoms such as chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, obsessional rituals sometimes interfering with routine activities, and some neglect of personal appearance and hygiene. The Board finds that a rating higher than 50 percent for the Veteran's service-connected PTSD is not warranted for any portion of the period on appeal. In making this finding, the Board has considered Dr. C.M.'s evaluation report and the November 2019 VA examination (discussed in more detail below), as well as the Veteran's prior treatment records and June 2016 VA examination. The Veteran was afforded a VA examination to assess the nature and current severity of his PTSD in November 2019, based on which the RO increased his PTSD rating from 30 percent to 50 percent, effective November 25, 2019. At the time of the examination, the Veteran had been married since 1969 with an adult son, and he described his marriage as good and his relationship with his son as excellent. He reported that his social network consists of his wife, son, and siblings. The Veteran reported multiple symptoms related to his PTSD, including: frequent nightmares, flashbacks, and intrusive thoughts; avoidance of crowded places; hypervigilance as to surroundings; diminished interest in activities; withdrawing from others; sleep disturbances; irritable mood; negative thoughts about his time in service; and a history of suicidal ideation but no current suicidal or homicidal ideation. The examiner separately documented that the Veteran experienced depressed mood, anxiety, chronic sleep impairment, and mild memory loss, such as forgetting names, directions, or recent events as symptoms of PTSD. The examiner determined that the severity and duration of the Veteran's symptoms resulted in 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. Regarding behavioral observations, the examiner noted that the Veteran was oriented to time, place, and person; appropriately dressed and well-groomed; pleasant to work with; coherent and logical; exhibited adequate language skills; and presented as mild mannered. Based on the Veteran's lay statements and the combined medical evidence, the Board finds that the severity, frequency, and variety of the Veteran's PTSD symptoms, taken in light of the level of resulting occupational and social impairment, most closely approximate a 30 percent rating prior to August 7, 2019 and a 50 percent rating thereafter. The cumulative evidence demonstrates that the Veteran has been able to maintain relationships with his wife, siblings, son, and grandchildren, and while he experienced some symptoms contemplated by a 70 percent rating from August 7, 2019 onward, such as obsessional rituals which interfere with routine activities and neglect of personal appearance and hygiene, these symptoms were not of such severity or frequency to result in occupational and social impairment with more than reduced reliability and productivity. While the Veteran demonstrated severe symptoms throughout the period on appeal, the overall evidence was not reflective of total occupational and social impairment. The evidence viewed from a longitudinal perspective persuasively shows that the Veteran's PTSD disability picture also did not more nearly approximate the criteria for a 100 percent rating during this period. Accordingly, a rating higher than 50 percent is not warranted throughout the period on appeal. M. Mills Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Tierno 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.