Citation Nr: 21071916 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 14-38 181 DATE: December 1, 2021 ORDER Entitlement to a rating in excess of 50 percent prior to October 9, 2019 for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to a rating in excess of 20 percent for residuals of fracture of neck C5 compression with degenerative arthritis is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to May 31, 2017 is remanded. FINDING OF FACT Prior to October 9, 2019, the Veteran's PTSD symptoms resulted in, at most, occupational and social impairment with reduced reliability and productivity with no evidence of greater impairment. CONCLUSION OF LAW The criteria for entitlement to a rating in excess of 50 percent prior to October 9, 2019 for PTSD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130; DC 9201-9440. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served in the United States Army from June 1977 to September 1977 and from May 1978 to August 1979. These issues come before the Board of Veterans' Appeals (Board) on appeal from multiple rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). In October 2017, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. The transcript is of record. The issues on appeal were before the Board in October 2020, at which time it denied the following: (1) entitlement to a rating in excess of 20 percent for the Veteran's neck disability, (2) entitlement to a rating in excess of 50 percent for PTSD prior to October 9, 2012, and (3) entitlement to a rating in excess of 70 percent for PTSD from October 9, 2012 onward. Thereafter, the Veteran appealed this decision to the Court of Appeals for Veterans Claims (the Court). In July 2021, a Joint Motion for Partial Remand (JMPR) was granted by the Court, vacating the Board decision regarding the Veteran's neck rating and PTSD rating prior to October 9, 2019, and remanding these issues back to the Board for additional development. 1. Entitlement to a rating in excess of 50 percent prior to October 9, 2019 for PTSD. The Veteran contends that his psychiatric symptoms are more severe than the ratings currently assigned. His claim for compensation was received by VA in December 2012. A January 2014 rating decision granted service connection for PTSD and assigned a 50 percent rating effective December 20, 2012. He timely appealed this determination to the Board. Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321 (a), 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a "staged" rating is required. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). VA adjudicators must consider whether to assign different ratings at different times during the rating period to compensate the Veteran for times when the disability may have been more severe than at others. The United States Court of Appeals for Veterans' Claims (the Court) since has extended this practice even to established ratings, not just initial ratings. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing Gilbert, 1 Vet. App. at 54). The Veteran's PTSD symptoms are currently rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. Ratings are assigned according to the manifestation of particular symptoms. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. A 100 percent rating is warranted 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. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. The "such symptoms as" language of the diagnostic codes for mental disorders in 38 C.F.R. § 4.130 means "for example" and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). However, as the Court also pointed out in that case, "[w]ithout those examples, differentiating a 30% evaluation from a 50% evaluation would be extremely ambiguous." Id. The Court went on to state that the list of examples "provides guidance as to the severity of symptoms contemplated for each rating." Id. Accordingly, while each of the examples needs not be proven in any one case, the particular symptoms must be analyzed in light of those given examples. Put another way, the severity represented by those examples may not be ignored. From December 2011 to October 8, 2019 The Veteran contends that he is entitled to an increased rating for his service-connected PTSD. The Veteran's PTSD has been rated as 50 percent disabling during this appeal period. The Board finds that the symptomology associated with PTSD more nearly approximates the criteria for a 50 percent rating. Therefore, his claim for an increased rating must be denied. Factual History Associated with the claims file are numerous clinical records dated during the appeal period which include the Veteran's reported symptomology as well as results of mental status examinations. The results of the mental status examinations are consistent in demonstrating that the Veteran was observed to be his stated age, dressed appropriately in casual attire, was well groomed, and had good hygiene. He was noted to be cooperative and made good eye contact. No psychomotor agitation, retardation or tremors was observed. Speech was found to be fluent and normal in rate, rhythm, and tone. Thought process was found to be linear with no evidence of flight of ideas, loosening of association or thought blocking. The Veteran consistently denied suicidal/homicidal ideation, paranoia, overt delusions, or hallucinations. He was found to be oriented to person, place, year, month, and day. Concentration and insight were observed to be intact. Insight and judgment were found to be good. Affect was euthymic and congruent. A September 2011 VA treatment record noted the Veteran experiencing improved anxiety symptoms. Mood was described as "I've been better." An October 2011 VA treatment record noted the Veteran feeling anxious and depressed, difficulty concentrating, and not being able to take care of his son due to the financial constraints. Mood was described as "I'm down." A subsequent October 2011 VA treatment record noted the Veteran reporting feelings of depression, anxiety, and struggling with his finances and his son. Mood was described as "I'm down." A November 2011 VA treatment record noted the Veteran reported continued depressed/anxious mood, poor sleep, and poor concentration. Mood was described as "I'm down." A December 2011 VA treatment record noted the Veteran feeling between, with improved sleep and appetite. Mood was described as "I'm feeling better." A January 2012 VA treatment record noted the Veteran's "up and down" mood, with low motivation, concentration, and energy. However, he endorsed good sleep patterns and intact appetite. Mood was described as "I'm feeling better." A February 2012 VA treatment record noted the Veteran reporting poor sleep, low motivation, poor concentration, and low energy. Mood was described as "I'm still depressed." A March 2012 VA treatment record noted the Veteran sleeping more and experiencing an improved appetite. Mood was described as "I'm alright." An April 2012 VA treatment record noted the Veteran expressing anger towards his son's mother. He also reported ongoing financial constraints, but described how he might not be able to return to work due to memory and concentration issues. Mood was described as "I'm alright." A subsequent April 2012 VA treatment record noted the Veteran's mood as "pretty good" and denied any history of aggressive behaviors. The Veteran appeared lethargic and described being fatigued due to lack of sleep. Motor behavior was found to be normal. Attention and concentration were found to be adequate. Response latency was observed to be within normal limits. Speech was observed to be spontaneous, clear, fluent, and grammatical with a normal rate, rhythm, and volume; no notable word finding difficulties were observed. Thinking was observed to be logical and coherent. Eye contact was appropriate. Insight and judgment were found to be intact. Mood was described as euthymic with a full affect range. When asked about current news events, he was able to spontaneously report specific details related to recent national news stories. He reported specific details regarding a recent shooting. He also provided rich details regarding the last two series played by the Red Sox, including their opponents and scores. The examiner noted that there was evidence to suggest that the Veteran did not put forth complete and consistent effort across the evaluation, and therefore neuropsychological test results are not believed to be valid. A May 2012 VA treatment record noted the Veteran reexperiencing childhood and military trauma, as well as knee pain. Mood was described as somewhat down. A subsequent May 2012 VA treatment record noted the Veteran doing better in terms of mood and social situation. Mood was described as "I'm alright." Another subsequent May 2012 VA treatment record noted the Veteran doing well. Mood was described as "I'm alright." A July 2012 VA treatment record noted the Veteran experiencing increased anxiety and panic symptoms associated with an increase in the severity of his chronic pain. Mood was described as "I'm alright." A September 2012 VA treatment record noted the Veteran feeling depressed and having sleep difficulties due to physical pain. He did endorse improved anxiety symptoms with increase in medication dosage. Mood was described as "depressed." An October 2012 VA treatment record noted the Veteran feeling significantly depressed and anxious for the past month, as he continued to struggle with his physical pain. Mood was described as "anxious." A November 2012 VA treatment record noted the Veteran's mood being unchanged from the previous appointment, with significant knee pain, impaired sleep, weight gain. Mood was described as "depressed." A December 2012 VA treatment record noted the Veteran sleeping better, but continued to experience nightmares. Mood was described as "depressed." A January 2013 VA treatment record noted the Veteran' sleep difficulties (including returning nightmares) and feeling more depressed due to his finances. Mood was described as "depressed." A February 2013 VA treatment record noted the Veteran experiencing vivid dreams, but denied nightmares. He endorsed improved sleep. Mood was described as "depressed." A subsequent February 2013 VA treatment record noted the Veteran reported anxiety attacks, nervousness, cold hands, and heart racing. However, he denied shortness of breath, chest pain, headaches, dizziness, nausea, vomiting, and abdomen pain. Mood was described as "depressed." A March 2013 VA treatment record noted the Veteran reporting an improved mood, but continued to struggle with anxiety. Mood was described as "ok." A subsequent March 2013 VA treatment record noted the Veteran denying sleep difficulties and was otherwise "doing well." Mood was described as "ok." An April 2013 VA treatment record noted the Veteran endorsed good sleep patterns, increased energy during the day, and reported that increased socialization at work has helped with his mood. Mood was described as "better." A May 2013 VA treatment record noted the Veteran sleeping better and having an overall good mood. Mood was described as "good." The Veteran underwent a VA examination in May 2013. He was diagnosed with PTSD. He reported staying in touch with family members and having a good relationship with his 16 year old son. He did not report any major interference with activities of daily living (ADLs) as a result of his mental health symptoms. He endorsed better temperament control, but endorsed "terrible" memory, attention, and concentration. He explicitly denied suicidal/homicidal ideation, but endorsed self-isolation when feeling depressed. He denied panic attacks, obsessive thoughts or compulsive or ritualistic behaviors, hallucinations, ideas of reference, paranoia, thought insertion, mania or hypomania. He endorsed feelings of anxiety over "little things." He denied any alcohol use or abuse. The following symptoms were observed by the examiner: depressed mood; anxiety; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. The examiner found that the PTSD symptoms led to occupational and social impairment with reduced reliability and productivity. A mental status examination was conducted. The Veteran was found to be oriented to person, place, time, and situation. He was observed to be clean, neatly groomed, and appropriately dressed. Behavior was observed to be appropriate to the situation. Mood was described as mildly dysphoric, with an appropriate affect. Speech was observed to be spontaneous, fluent, and normal in rate, rhythm, volume, and prosody. No evidence was observed regarding word-finding difficulties. Concentration was observed to be intact. Thought process was found to be linear, coherent, logical, and goal directed, with no evidence of flight of ideas, loose associations, or thought derailment or blocking. Abstract thinking, insight, and judgment were observed to be ok. A June 2013 VA treatment record noted the Veteran reporting minor panic attacks up to three times a day over the past two months, lasting about 10 to 15 minutes in duration. Mood was described as "good." A July 2013 VA treatment record noted the Veteran "doing okay," but continued to experience distressing nightmares and ongoing anxiety and panic episodes. Mood was described as "good" with a euthymic, congruent affect. The Veteran denied suicidal/homicidal ideation, paranoia, overt delusions, or hallucinations. A September 2013 VA treatment record noted the Veteran feeling "a little removed" and quieter, with continued episodes of anxiety and panic. Mood was described as "good." VA treatment records in October 2013 and December 2013 noted the Veteran reported "up and down" moods; however, he denied suicidal/homicidal ideation, paranoia, overt delusions, or hallucinations. He was found to be oriented to person, place, year, month, and day. Concentration and insight were observed to be intact. Insight and judgment were found to be good. A subsequent December 2013 VA treatment record noted the Veteran's "better" moods. Mood was described as dysphoric with a euthymic, congruent affect. Thought process was found to be linear with no evidence of flight of ideas, loosening of association or thought blocking. VA treatment records dated in January 2014 and February 2014 noted the Veteran's reported stable mood due to medication. In addition, he reported periods of elevated moods with extra energy and racing thoughts, as well as a history of over-spending and racking up credit card debt. Mood was described as dysphoric, with an appropriate, congruent affect. Behavior was observed to be appropriate, cooperative, and pleasant. The Veteran denied suicidal/homicidal ideation, hallucinations, delusions, or paranoia. VA treatment records in March 2014 and April 2014 noted the Veteran "having no energy to do anything" since November. However, he endorsed his continued sobriety from alcohol and illicit drug use, as well as spending more time with his son. Mood was described as euthymic, with an appropriate, congruent affect. Behavior was observed to be appropriate, cooperative, and pleasant. The Veteran also denied suicidal/homicidal ideation, hallucinations, delusions, or paranoia. VA treatment records in May 2014 and July 2014 noted the Veteran feeling a little better and having more energy during the day. Mood was described as "sad, depressed," with an appropriate, congruent affect. Behavior was observed to be appropriate, cooperative, and pleasant. The Veteran also denied suicidal/homicidal ideation, hallucinations, delusions, or paranoia. A September 2014 VA treatment record noted the Veteran reporting that "my sister is dying" and being very upset by it. Mood was described as "sad, tearful," with an appropriate, congruent affect. Behavior was observed to be appropriate, cooperative, and pleasant. The Veteran also denied suicidal/homicidal ideation, hallucinations, delusions, or paranoia. An October 2014 VA treatment noted the Veteran being able to spend time with his sister before she died. Mood was described as "sad, depressed," with an appropriate, congruent affect. Behavior was observed to be appropriate, cooperative, and pleasant. The Veteran also denied suicidal/homicidal ideation, hallucinations, delusions, or paranoia. A November 2014 VA treatment record noted the Veteran actively grieving for his recently passed sister. Mood was described as "sad, tearful," with an appropriate, congruent affect. A December 2014 VA treatment record noted the Veteran being very reflective about the loss of his sister. Mood was described as "sad, tearful," with an appropriate, congruent affect A January 2015 VA treatment record noted the Veteran still grieving and being very reflective on the loss of his sister. Mood was described as "sad, tearful," with an appropriate, congruent affect. Behavior was observed to be appropriate, cooperative, and pleasant. The Veteran also denied suicidal/homicidal ideation, hallucinations, delusions, or paranoia. A March 2015 VA treatment record noted the Veteran's reports of sleep difficulties, keeping to himself after work, and "frequently" feeling down. Mood was described as "up and down" with an appropriate, congruent affect. Behavior was observed to be appropriate, cooperative, and pleasant. The Veteran also denied suicidal/homicidal ideation, hallucinations, delusions, or paranoia. An April 2015 VA treatment record noted the Veteran's better sleep patterns, but overall mood was described as "not great." However, behavior was observed to be appropriate, cooperative, and pleasant. The Veteran also denied suicidal/homicidal ideation, hallucinations, delusions, or paranoia. A May 2015 VA treatment record noted the Veteran's reports of a long history of anxiety and depression that began during childhood. Mood was described as "alright" with a ranging, appropriate affect. Thought process was observed to be linear, logical, and goal directed. The Veteran further denied suicidal/homicidal ideation, delusions, hallucinations, or illusions. A June 2015 VA treatment record noted the Veteran feeling a little more anxious and nervous, and endorsed ongoing sleep difficulties. Mood was described as "anxious, nervous" with an appropriate, congruent affect. Behavior was observed to be appropriate, cooperative, and pleasant. The Veteran further denied suicidal/homicidal ideation, hallucinations, delusions, or paranoia. A July 2015 VA treatment record noted the Veteran feeling more irritable and shorter tempered. Mood was described as "ok but still somewhat anxious, nervous" with an appropriate, congruent affect. An August 2015 VA treatment record noted the Veteran's ongoing sleep issues. Mood was described as "not too bad" with an appropriate, congruent affect. Behavior was observed to be appropriate, cooperative, and pleasant. The Veteran denied suicidal/homicidal ideation, hallucinations, delusions, or paranoia. VA treatment records dated in September 2015 and December 2015 noted the Veteran tolerating his medication regimen well, which he reported finding moderately helpful. Mood was described as "calm, alright" with an appropriate, congruent affect. Behavior was observed to be appropriate, cooperative, and pleasant. The Veteran denied suicidal/homicidal ideation, hallucinations, delusions, or paranoia. A March 2016 VA treatment record noted the Veteran endorsing some depressive symptoms, but denied discrete depressive symptoms of major depressive disorder. In addition, he endorsed time limited anxiety symptoms, but denied a history of panic attacks. He was observed to be cooperative, pleasant, appropriate, and engaging. Mood was described as "same" with a constricted, but euthymic affect. The Veteran denied hallucinations or symptoms of psychosis, as well as suicidal/homicidal ideation, paranoia, or violent thoughts. An April 2016 VA treatment record noted the Veteran feeling "Ok I guess," but still felt burdened by low mood, chronic pain, and disrupted sleep. He denied use of alcohol or illicit drugs. Mood was described as "Ok I guess" with a constricted, but euthymic affect. A June 2016 VA treatment record noted the Veteran's increased depressive symptoms due to increased physical pain. Mood was reported as "alright, could be better without pain" with a congruent affect. He denied suicidal/homicidal ideation. He endorsed anxiety symptoms, but that it was well controlled. An August 2016 VA treatment record noted the Veteran having more emotional energy ("feeling the feelings") both positive and negative. He reported better sleep patterns and improved concentration, appetite, and energy. Mood was described as "real good" with a full range, euthymic affect. The Veteran denied hallucinations or symptoms of psychosis, as well as suicidal/homicidal ideation, paranoia, or violent thoughts. A subsequent August 2016 VA treatment record noted the Veteran's continued sleep difficulties, but concentration, appetite, and energy levels were found to be "OK." Mood was described as "OK" with a constricted, but euthymic affect. A September 2016 VA treatment record noted the Veteran's decreased appetite due to pain medication, but "fine" concentration and energy levels. Mood was described as "pretty good" with a full range, euthymic affect. The Veteran denied hallucinations or symptoms of psychosis, as well as suicidal/homicidal ideation, paranoia, or violent thoughts. An October 2016 VA treatment record noted the Veteran's "okay" sleep patterns, appetite, concentration. Energy levels were reported to vary due to pain complaints. Mood was described as "Ok" with a full range, euthymic affect. A December 2016 VA treatment record noted the Veteran had a "good" appetite, no issues with concentration or energy, and similar sleep patterns as previously reported. Mood was described as "Ok" with a full range, euthymic affect. The Veteran denied hallucinations or symptoms of psychosis, as well as suicidal/homicidal ideation, paranoia, or violent thoughts. VA treatment records dated in January and February 2017 noted the Veteran denying any problems with energy, concentration, alcohol use, or illicit drug use. Mood was described as "good" with a full range, euthymic affect. The Veteran denied hallucinations or symptoms of psychosis, as well as suicidal/homicidal ideation, paranoia, or violent thoughts. The Veteran underwent a second VA examination in June 2017. He was diagnosed with PTSD. He reported being in a relationship of two years that was generally positive and supportive. He also reported experiencing symptoms of panic, anxiety, avoidance, anhedonia, hypervigilance, insomnia, poor concentration and memory, irritability, and emotional numbing. He further reported that he keeps people at a distance, even his girlfriend, whom he will see once or twice a week. He reported that his irritability has been an issue as he gets unnecessarily angry at little issues. He admitted that he does not manage conflict or frustration well and will quickly dismiss himself from stressful circumstances. He also admitted calling out of work up to three times per month because of insomnia and anxiety. He denied any alcohol or illicit substance use. The following symptoms were noted by the examiner: depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances, including work or a worklike setting. The examiner found that the PTSD symptoms were productive of occupational and social impairment with reduced reliability and productivity. A mental status examination was conducted. The Veteran arrived on time and was unaccompanied for the appointment. He was found to be alert and oriented to person, place, and time. Thinking was observed to be logical, linear, and goal-oriented. Speech was observed to be fluent and normal in terms of rate and volume. Auditory comprehension was within normal limits. The Veteran presented as appropriately dressed and well-groomed. He was cooperative and engaged in the session. His mood was described as anxious with a full range, congruent affect. He denied suicidal and homicidal ideation. A June 2017 VA treatment record noted the Veteran reporting continued sleep difficulties. Mood was described as "good" with a full range, euthymic affect. The Veteran denied hallucinations or symptoms of psychosis, as well as suicidal/homicidal ideation, paranoia, or violent thoughts. VA treatment records dated in October 2017 and November 2017 noted the Veteran reporting ongoing neck pain that increases feelings of depression. Mood was described as "ok" but can "get low due to pain" with a full range, euthymic affect. A February 2018 VA treatment record noted the Veteran reporting a "pretty good" mood and continued sobriety from alcohol and illicit substances. Mood was described as "pretty good" but can "get low due to pain" with a full range, euthymic affect. The Veteran denied hallucinations or symptoms of psychosis, as well as suicidal/homicidal ideation, paranoia, or violent thoughts. The Veteran testified at his October 2017 Board hearing that he experienced memory problems, concentration issues, sleep difficulties, anger issues, disagreements with coworkers, and limited patience with people. He also reported experiencing social isolation, checking the perimeter of his home, and locking the windows and doors. A May 2018 VA treatment record noted the Veteran reporting "some days I feel down and I don't want to come in... I am nervous about the day." Mood was described as "alright but sometimes I can get very nervous" with a full range, euthymic affect. A June 2018 VA treatment record noted the Veteran reporting chronic neck pain and intermittent radiating pain down his right arm that wakes him up at night. Mood was described as "alright but sometimes I can get very nervous" with a full range, euthymic affect. An August 2018 VA treatment record noted the Veteran "taking it easy" for now that he is no longer working, but may return to work in the near future. He denied any feelings of depression and any cravings for illicit substances. Mood was described as "good" with a full range, euthymic affect. The Veteran denied hallucinations or symptoms of psychosis, as well as suicidal/homicidal ideation, paranoia, or violent thoughts. A subsequent August 2018 VA treatment record noted the Veteran reporting intense physical pain that may be exacerbated by his PTSD symptoms. Mood was described as euthymic with a congruent affect. Thought content, insight, and judgment were observed to be intact. Impulse control and hygiene appeared appropriate. The Veteran denied suicidal/homicidal ideation. An October 2018 VA treatment record noted the Veteran reported his mood being "good" with no current feelings of depression or anxiety. Mood was described as "good" with a full range, euthymic affect. The Veteran denied hallucinations or symptoms of psychosis, as well as suicidal/homicidal ideation, paranoia, or violent thoughts. A subsequent October 2018 VA treatment record noted the Veteran describing several traumatic events that occurred throughout his life that continue to bother him to this day. He was observed to be highly emotionally expressive, displaying a range of emotive facial expressions throughout the session. The Veteran was tearful when experiencing anticipatory anxiety related to talking about his trauma. A November 2018 VA treatment record noted the Veteran verbalizing shame after he began crying when speaking about his past trauma. He presented as primarily anxious. He was observed to be emotionally expressive throughout the session and was tearful when talking about trauma. The Veteran denied suicidal/homicidal ideation. A subsequent November 2018 VA treatment record noted the Veteran's chronic pain continuing to be problematic for him and his ambivalence about talking about trauma and building motivation for change. He presented as primarily anxious. He was observed to be emotionally expressive throughout the session and was tearful when talking about trauma. The Veteran denied suicidal/homicidal ideation. A December 2018 VA treatment record noted the Veteran reporting a great deal of physical pain in back and neck. He presented as primarily anxious. A January 2019 VA treatment record noted the Veteran feeling "alright" and denying any feelings of depression or anxiety. Mood was described as anxious but he denied current feelings of depression with a full affect range. The Veteran denied hallucinations or symptoms of psychosis, as well as suicidal/homicidal ideation, paranoia, or violent thoughts. A March 2019 VA treatment record noted the Veteran's difficulties in talking about his various traumas. Mood was described as anxious with a somewhat constricted affect. Thought processes were observed to be logical, linear, and goal directed. The Veteran denied any suicidal/homicidal ideation. VA treatment records dated in April 2019 and August 2019 noted the Veteran denying any current feelings of depression, but complained of continued daily anxiety. Mood was described as nervous all the time but denied current feelings of depression with a full affect range. The Veteran denied hallucinations or symptoms of psychosis, as well as suicidal/homicidal ideation, paranoia, or violent thoughts. A September 2019 VA treatment record noted the Veteran's long standing neck pain, moderate depressed mood, more isolation and depressed mood secondary to pain. Mood was described as anxious and mildly dysphoric, with a congruent affect. Thought process was observed to be nontangential. The Veteran denied suicidal/homicidal ideation. A subsequent September 2019 VA treatment record noted the Veteran's "down" mood due to lack of progress he was experiencing in his knee rehabilitation. Mood was described as feeling low due to limited mobility issues with knee, with a full affect range. The Veteran denied hallucinations or symptoms of psychosis, as well as suicidal/homicidal ideation, paranoia, or violent thoughts. The Board notes that the Veteran underwent multiple group therapy sessions for mental health and substance abuse throughout the appeal period. His mood was observed to be euthymic with a full affect range. He was observed to have a good rapport with his fellow PTSD support group members. Analysis The Board finds that the evidence of record demonstrate that the Veteran's PTSD symptoms more nearly approximate the criteria for a 50 percent evaluation during this appeal period. The evidence of record demonstrates that the Veteran experiences panic attacks that occur more than once a week, some difficulty in understanding complex commands, impairment of short-and long-term memory, impaired judgment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. However, the next highest evaluation, a rating of 70 percent, is not warranted. The record does not demonstrate that the Veteran experienced intermittent illogical, obscure or irrelevant speech as a result of his PTSD symptomology during this time period. His VA treatment records and VA examinations reported the Veteran's speech to be normal. There is also no evidence of the Veteran exhibiting spatial disorientation, or a neglect of his personal appearance and hygiene. The majority of the evidence of record shows that he was found to be casually dressed and appropriately groomed at numerous times throughout the appeal period. In addition, the Veteran's VA treatment records reported his thought process to be logical and goal-directed. The evidence of record demonstrates that the Veteran denied any homicidal ideation. The Veteran reported experiencing increased irritability, some violent outbursts, and suicidal ideation during this appeal period. The Board notes that these symptoms are part of the criteria for a 70 percent evaluation. However, the Board must determine an evaluation based on the frequency, severity, and duration of psychiatric symptoms during the appeal period. In that regard, the Veteran's report of these symptoms are outweighed by the pertinent medical evidence which more nearly approximates a 50 percent rating based, in part, on the Veteran's constant and continued denials of suicidal ideation, obsessive rituals that interfere with routine activities, impaired impulse control, irritability, and unprovoked episodes of violence. Indeed, the Veteran reported controlling his temper and irritability at several points throughout this appeal period. There are unprovoked episodes of violence alleged during the pertinent time period. The Board places greater probative value on the clinician's findings and observations over the Veteran's self-reported irritability, anger issues, obsessional rituals, and suicidal ideation. The evidence also does not demonstrate that the Veteran reported any disorientation to time or place. Additionally, the evidence does not demonstrate that the Veteran has experienced any auditory or visual hallucinations. In addition, the evidence does not demonstrate that the Veteran has experienced any prolonged short term or long term memory issues. While he reported memory issues with his VA treating physicians, his memory was found to be intact during numerous evaluations. The Board places greater probative value on the finding the clinicians over the Veteran's self-reported memory loss. These clinicians conducted specific tests to determine if memory loss was present and did not find any. The Veteran has reported episodes of depression and anxiety; however, the evidence does not demonstrate near-continuous panic or depression affecting his ability to function independently, appropriately and effectively. The record reflects that the Veteran's depression and anxiety has waxed and waned throughout the appeal period. Indeed, he denied feeling depressed at several points throughout the appeal period. In addition, while he reported experiencing obsessive thoughts that interfered with his routine activities, there is no evidence or indication that the Veteran experienced obsessive thoughts which affected his employability or social interactions. He reported that he had good relationships with his son and PTSD support group members. This evidence does not demonstrate that the Veteran has an inability to establish and maintain effective relationships as a result of her PTSD. The evidence of record also demonstrates that the Veteran has not experienced any auditory or visual hallucinations, as well as any other symptoms of psychosis. In adjudicating this claim, the competence and credibility of lay statements must be considered by the Board. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Veteran contends that his PTSD symptoms warrant a higher rating. The Board acknowledges that the Veteran is competent to give evidence about what he observes or experiences. Layno v. Brown, 6 Vet. App. 465 (1994). That stated, the evidence of record does not favor a finding that the Veteran is entitled to a higher rating than the 50 percent currently assigned for his PTSD during this time period. His current symptomology is encapsulated in the current rating assigned under the Rating Schedule, with no evidence of symptomology warranting extra-schedular consideration. Based on the foregoing, the Board finds the PTSD symptomology has been productive of, at most, occupational and social impairment with reduced reliability and productivity during the entire appeal period. As such, a rating in excess of 50 percent for the Veteran's PTSD is not warranted at any time. The preponderance of the evidence is against the claim and the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107 (b). REASONS FOR REMAND 1. Entitlement to a rating in excess of 20 percent for residuals of fracture of neck C5 compression with degenerative arthritis. In the July 2021 JMPR, the parties agreed that the Board erred in relying on an inadequate VA examination report. The Veteran was provided a VA spine examinations in October 2019. The parties to the JMPR agreed that although the VA examiner performed range of motion testing, there was no indication that passive, weight bearing, and non-weight bearing testing was done per the Court's holding in Correia v. McDonald, 28 Vet. App. 158 (2016). For these reasons the parties agreed that the VA examination conducted in October 2019 was inadequate. Thus, the JMPR directed the Board to remand the Veteran's claim to obtain a new, adequate examination in compliance with 38 C.F.R. § 4.59 as required by the Court's holding in Correia, 28 Vet. App. 158 (2016). 2. Entitlement to a TDIU prior to May 31, 2017 is remanded. The Veteran contends that he is unable to work as a result of her service-connected disabilities. The Board notes that the RO granted TDIU in an April 2020 rating decision. However, TDIU was only granted effective May 31, 2017, and the Veteran has had pending increased rating claims since 2009. A TDIU claim, either expressly raised by a veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Therefore, the issue of a TDIU prior to May 31, 2017 is still pending before the Board. The Veteran's TDIU claim is inextricable intertwined with the neck claim being remanded by the Board. As such, the Board finds that the TDIU claim must be remanded as well. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (issues are inextricably intertwined when a decision on one issue would have a significant impact on another issue). The matters are REMANDED for the following action: 1. Obtain updated VA and/or private treatment records to the extent possible. If such records are unavailable, the Veteran's claims file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159 (e). 2. Once the above has been completed to the extent possible, schedule the Veteran for a VA examination to determine the current severity of his service-connected neck disability. The evidence of record must be made available to and reviewed by the examiner. The examination report must include a notation that this record review took place. All necessary testing should be conducted. In particular, the examination must include tests of all applicable ranges of motion in active motion, passive motion, weight-bearing, and non- weight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. In addition, if the examination is not conducted during a flare-up, the examiner must attempt to ascertain information, such as frequency, duration, characteristics, severity, and functional loss (due to pain, weakness, fatigability, or incoordination) regarding any flare-ups by alternative means. The examiner must provide an estimate of functional loss in terms of range of motion based on the Veteran's statements, available medical records, and other relevant sources. In rendering this opinion, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. The examiner is not to improperly discount the Veteran's lay statements or rely solely on an absence of medical evidence in the record to support his or her conclusions. A complete rationale must be provided for all opinions presented. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J.T. Massey, 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.