Citation Nr: 21076101 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 17-57 819 DATE: December 22, 2021 ORDER Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with major depression, opiate dependency in remission prior to February 17, 2021 is denied. Entitlement to an initial disability rating of 70 percent for PTSD with major depression opiate dependency in remission from February 17, 2021 to June 4, 2021, is granted. Entitlement to an initial disability rating in excess of 70 percent for PTSD with major depression opiate dependency in remission from June 4, 2021 is denied. FINDINGS OF FACT 1. Prior to February 17, 2021 the severity, frequency, and duration of the Veteran's PTSD symptoms most closely approximate the criteria for a 50 percent rating productive of occupational and social impairment with reduced reliability and productivity. 2. From February 17, 2021, the severity, frequency, and duration of the Veteran's PTSD symptoms most closely approximate occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent prior to February 17, 2021, for PTSD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for a disability rating of 70 percent from February 17, 2021 for PTSD are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from June 1969 to March 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a July 2015 rating decision by a U.S. Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded this matter for additional development in April 2021. The claim was remanded to obtain an addendum opinion regarding whether the Veteran experienced occupational and social impairment with deficiencies in most areas or total social and occupational impairments. In January 2008, the Veteran submitted a claim of entitlement to service connection for PTSD. In April 2009, the RO denied service connection for PTSD. The Veteran did not appeal this decision. In December 2014, the Veteran requested that her claim of entitlement to service connection for PTSD be re-opened. In July 2015, the RO granted service connection for PTSD with major depression, opiate dependency in remission and assigned a 50 percent rating effective from December 30, 2014. In October 2021, the RO granted entitlement to a disability rating of 70 percent for posttraumatic stress disorder (PTSD) with major depression, opiate dependency in remission from June 4, 2021. The Veteran contends that the severity of her PTSD and major depression is more consistent with an increased rating. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). 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 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; or memory loss for names of close relatives, own occupation or own name. 1. Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with major depression, opiate dependency in remission prior to February 17, 2021. Review of the medical records reveal that the Veteran attended behavioral health outpatient group therapy upon the recommendation of Health Care Prescription Monitoring Program (HPMP). See Medical Treatment Records. The Veteran indicated that she was seeking to regain her Nurse Practitioner and/or RN license to return to work. At the time of the appointment, the Veteran was employed as a server at a local restaurant and lived at home with her adult daughter. She was prescribed medication by her psychiatrist and reported being on a taper down program for one of them. She denied any current suicidal or homicidal ideation. The Veteran attended multiple group therapy sessions. See Medical Treatment Records. In October 2014, the Veteran reported relationship difficulties. She reported a fight with her two daughters over the weekend. She indicated that she has had poor relationships because when she was abusing substances previously, she tended to disappear and would oftentimes be less tolerant and forgiving. She noted that she lost custody of her children and divorce as a consequence of her substance use. At a session in November 2014, the Veteran noted triggers for her substance abuse. She indicated boredom, stress, her sister, and travel, specifically on an airplane or a hotel where they have little bottles, are triggers for her. At a February 2015 appointment, the Veteran appeared for group therapy an hour late and engaged in group exercise. She shared that her children were not affected by her substance abuse and that she had no feelings about it because they were uninvolved. At another therapy group session in February 2015, the Veteran shared that she needed to find a sponsor and that she was fired/quit her job because she and her boss had a disagreement. The Veteran was insistent that she needed to move to Georgia to be closer to her daughter as soon as possible. The Veteran submitted a Disability Benefits Questionnaire DBQ) completed by her psychiatrist. See Disability Benefits Questionnaire. The clinician indicated that she had been treating the Veteran for opiate dependency since September 2013. See Correspondence. In addition to opiate dependency, the Veteran is also diagnosed with PTSD and ADHD. The clinician found that the Veteran has occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The clinician found the Veteran experiences instability and avoidance from her PTSD and her nursing license difficulties and financial problems stems from opiate dependence. The clinician noted the Veteran experienced symptoms of depressed mood, anxiety, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and inability to establish and maintain effective relationships. The clinician opined that Veteran's disorders contribute to personality problems that manifest as irritability, mood instability, and temper outburst. The Veteran takes medication for her mental health conditions, though she was tapering off one of them at the time of the examination. In July 2015, the Veteran was afforded a VA examination. See July 2015 VA Examination. The examiner noted the Veteran's diagnoses of PTSD and major depression, opining that the Veteran's level of occupational and social impairment was impaired with occasional decreased in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The examiner noted that the Veteran experienced irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects, problems with concentration, and sleep disturbance. The Veteran presented with persistent and exaggerated negative beliefs or expectations about herself, others, or the world, a persistent negative emotional state, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, and persistent inability to experience positive emotions. Unfortunately, no symptoms were selected in the symptoms portion of the examination. The examiner determined that the Veteran required continued treatment for PTSD and major depression and to maintain substance abuse sobriety and did not appear to be any threat of danger or injury to self or others. In February 2017, the Veteran appeared for a scheduled visit, noting that she was last seen in July 2016. The Veteran reported that she was working at Home Depot. She reported her mood as "ok," her appetite as "ok," and sleep as "good." She shared her physical energy level was "ok" and that she actively exercises. She does not drink anymore, and her concentration was good with medication. In May 2017, the Veteran presented for a scheduled visit. The practitioner noted that she was last seen February 2008 and had since gotten her nursing license reinstated. She shared that her mood is "ok," her appetite is "good," and her sleep is "ok" with medication. She shared that she actively exercises and that her concentration is good with medication. She shared no anhedonia and that she does not drink anymore. In July 2017, the Veteran presented at the walk-in clinic requesting a refill of her medications. She denied suicidal ideation, homicidal ideation, or hallucinations. She was described as having a bright affect with an appropriate mood. In July 2017, the Veteran submitted another privately completed DBQ. See July 2017 VA Examination. The clinician noted the Veteran's diagnosis of PTSD and indicated that the Veteran did not qualify for a diagnosis of ADHD. He opined that the mental disorder was productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The clinician found that the Veteran's symptoms included a depressed mood, anxiety, suspiciousness, panic attacks more than once a week, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, chronic sleep impairment, disturbance of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances, including work or a work like setting. In addition to completing the DBQ, the clinician also submitted an opinion letter. See July 2017 Correspondence. In this, the clinician reviewed the Veteran's work, social, and medical history and rendered an opinion. At the time of the examination, the Veteran indicated that she was working as a waitress and part-time at Home Depot. She shared that she "hates the waitress job" as it makes her "irritable," having to deal with rude people and conflict with her bosses. The Veteran described reckless and self-destructive behavior including drug use and driving fast, and states that she continues to drive fast and "take chances" a couple times in the past month. She reported hypervigilance every time she goes out of the house, sitting with her back to the wall, making sure nobody is behind her, and not letting anybody could get close to her. The Veteran described startled reactions to sudden movements and noises around her by being "ready to take cover" approximately 5 times in the past month. She also reported problems with concentration and focus, with difficulty remembering names and misplacing things, burning food on the stove, forgetting to take medication, losing time, and track of content or TV problems. She does not have trouble sleeping but does not have nightmares approximately once a week. She also recounted a couple episodes over the past month of dissociative depersonalization where she felt separated from herself while working. The Veteran shared that she has constant mood swings, bad to worse and emotional lability with temper. She indicated that she was tired of going through all of this and her mood is a fake good mood, and she says to herself "let me not kill anybody at work today." She indicated anger problems and feelings of harm toward others but denied any history of assaults. She denied any obsessions, compulsions, paranoid ideas, or hallucinations. She indicated that in the past she had interpersonal relationships and was outgoing, in her 20s that changed, and she is now detached, avoidant, and has no friends. She presented as fairly oriented to time and place and person. The clinician found that the Veteran still had a diagnosis of PTSD, depression, a chronic anger state disorder, a subtle but noticeable cognitive disorder, which was undiagnosed and uninvestigated. The clinician described the Veteran as careless, restless, emotionally unstable, agitated, and hostile, maintaining only a marginal life adjustment. A Mental Health Physician Note in September 2017 indicated that the Veteran reported her mood as "okay. There was no depression, anxiety, or manic symptoms. She denied suicidal or homicidal ideations, and any hallucinations or delusions. She reported being able to handle her daily stressors. She presented as cooperative, with normal eye contact, and appropriately dressed and groomed. See CAPRI Records. At another mental health treatment appointment in October 2017, the Veteran reported that she was doing well. She denied depression, anxiety, manic symptoms suicidal ideations, homicidal ideations, and paranoia. The Veteran reported that she continues to be able to handle her daily stressors. She also appeared motivated to restart her nursing career and displayed an overall positive outlook. She presented appropriately dressed and groomed, was cooperative, euthymic, and oriented. At a December 2017 mental health physician appointment, the clinician noted that the Veteran missed her appointment last month and her labs. The Veteran appeared for her appointment appropriately dressed, groomed, and cooperative. She indicated that she does not like her jobs and that she has been "stressed" due to her nursing licensing and finances. She denied mania, suicidal ideation, homicidal ideation, and paranoia. The Veteran was seen again in November 2018, where she reported that her depressive symptoms had been under control lately. She shared some external stressors such as taking classes, working two jobs, applying for jobs, and getting her nursing license reinstated. She expressed that she was anxious and had "baseline guilt" but that she feels this is normal. She indicated that she has nightmares about 3 times per week and experiences some hypervigilance and discomfort in crowds. She denied manic symptoms, hallucinations, suicidal ideation, and homicidal ideation. In February 2019, the Veteran shared that her depressive symptoms had been under good control lately, she did not report suicidal or homicidal ideation. She reported continued nightmares 2 to 3 times per week and wanting to avoid large crowds. She denied any hypervigilance or aversion to loud noises. She reported that her PTSD is manageable, fair energy, concentration, interest, appetite, and sleep. She presented as appropriately dressed and groomed, cooperative, and reported a good mood. At a mental health appointment in April 2019, the Veteran shared that her nursing license had been reinstated and that she started working in March as a nurse again. She is enjoying her work, sharing that she is working for the first time with a mental health population. She aspires to eventually become a travel nurse. She has a one-year-old granddaughter who she loves spending time with. However, she also shared that she continues to have tension in her relationship with her oldest daughter, which she attributes to differing political views. She is living in an apartment currently and hopes to move into a home with a yard for her two dogs. Her mood and sobriety are reportedly stable. She appeared appropriately dressed and groomed, alert and oriented, mildly anxious, denied delusions and hallucinations. In May 2019, the Veteran indicated she has taken a job as a nighttime nurse. She shared that her mood is "good", and her depressive symptoms have been under control. She denied anhedonia, suicidal ideation, homicidal ideation, and hypervigilance. She reported experiencing nightmares 2 to 3 times a week and avoiding large crowds, she denied hypervigilance. She was appropriately dressed and groomed. In August 2019, she reports that her depressive symptoms continue to be well controlled. She is still working the night shift three nights per week and her schedule flips to days the rest of the week. This causes her to have poor sleep and low energy occasionally, but overall, it feels manageable to her. She denied any suicidal ideation, homicidal ideation, and feelings of helplessness or hopelessness. She has nightmares between one and three times a week, more frequently when she feels stressed overall but finds them manageable and not disruptive to sleep. The Veteran admitted some avoidance of large crowds and denied any hypervigilance or aversion to loud noises. At the time of the appointment, the Veteran indicated her symptoms are well managed, and reports compliance with all meds. In November 2019, the Veteran indicated that she was doing fairly well with current medication regimen. She continues to work as a nightshift nurse and babysits her granddaughter once a week. She reported occasional avoidance of large crowds and denied any hypervigilance or aversion to loud noises. She denied any recent stressors and shared that she wants to work as a nurse practitioner when the restriction is removed. She endorsed a good mood and appetite and did not report any feelings of helplessness or hopelessness, suicidal ideation or homicidal ideation. She reported that her symptoms are well managed and wants to continue her same treatment. In December 2020, the Veteran presented for a follow-up, noting that she was doing fairly well on her medication. She continues to work as a nurse on the nightshift 3 nights a week and babysits her three-year-old granddaughter once a week. She denied any recent stressors and is still waiting for the restriction to be withdrawn from her license, so she can work as a Nurse Practitioner again. She indicated a good mood, no suicidal ideation, no homicidal ideation, and denied feelings of helplessness or hopelessness. She denied tobacco, alcohol, or recreational drug use. At the time of this appointment, the Veteran had a negative screening for PTSD, suicide, alcohol use, and depression. In February 2021 the Veteran attended a mental health appointment where she reported continued work as a nurse. She indicated that the night shift is tough, so she wanted a new job. She presented as appropriately dressed and groomed, cooperative, with an appropriate affect, no suicidal or homicidal ideations and no delusions. Analysis When making a decision, the Board must consider all the evidence of record, to include lay statements. 38 U.S.C. § § 5107(b), 7104(a); 38 C.F.R. § 3.303(a). On February 17, 2021 the Veteran attended a Board hearing. The Veteran reported that she has been back to work since approximately 2018, noting that she angers easily and has conflict with co-workers and sometimes patients. The Veteran testified that she can offend co-workers and has gotten into trouble for losing her temper with patients. The Veteran has attention problems, which makes her constantly nervous because she is worried she has forgotten to do something. She shared that there are days when she has to take three or four days off at a time because she is unable to bring herself to leave the house and go into work. She indicated that she has two cats and two dogs and that she is more comfortable with animals than with humans. She does not have much of a social life or romantic relationships. The Veteran shared that she struggles maintaining friendships but did share that she has one friend that she works with and that they talk before her shift. But mostly, she interacts with her two daughters who live nearby and her granddaughter. The Veteran feels that even there, she struggles, she sometimes misses holidays. She shared that she is not settled into her house, everything in bins and blankets over the furniture. The Veteran testified that her depression gets in the way of her unpacking or decorating her house. She does listen to politics on the radio, and she tries to go to the gym but oftentimes finds that she makes a list and cannot carry it out. The Veteran testified to working 36-hour weeks, starting in 2018 as she had to go to Virginia to re-instate her license in order to practice in Georgia. The level of impairment required for a disability rating of 50 percent contemplates 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, 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. The level of impairment required for a disability rating of 70 percent contemplates 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; or inability to establish and maintain effective relationships. Throughout the period on appeal prior to February 17, 2021, the Veteran frequently reported irritability and feelings of anxiousness and depression. The Veteran expressed an improvement in symptoms when placed on medication. The mental status examinations consistently described her as cooperative with good hygiene and grooming, suggesting the ability to maintain personal appearance and hygiene. She also presented with speech within normal limits and organized thoughts without signs of psychosis. The Veteran did report nightmares, which is indicative of chronic sleep impairment. While the Veteran reported depression, anxiety and panic attacks at various times, the evidence reveals that she was still able to participate in activities such as working as a waitress, at Home Depot, and as a nurse, taking classes, and babysitting her granddaughter. Occupationally, the Veteran was employed for the majority of the period before the Board. While she was working towards getting her nursing license re-instated, she was employed part-time as a waitress and at Home Depot. From approximately 2018, the Veteran has worked full-time as a nurse on the night shift, which she indicated was difficult as it impacted her sleep schedule. However, the Veteran was able to maintain and continue consistent employment at this position for several years. There is no indication that this employment is marginal or in a protected setting. Thus, while the Veteran may have some difficulties in occupational settings, the overall evidence reveals that she is able to function independently, appropriately, and effectively, as well as adapt to stressful circumstances prior to February 17, 2021. Socially, the Veteran maintained familial relationships prior to February 17, 2021. While at times during the appeal, the Veteran had conflicts with her daughters, she did move from Virginia to Georgia to live closer to them. At points, she lived with one of her daughters and also regularly babysat her granddaughter. Thus, while the Veteran may have some difficulties in social settings, she is able to establish and maintain effective familial relationships and appropriately interact at medical appointments. The evidence of record includes reports of impaired impulse control, which is contemplated by a 70 percent rating in addition to irritability and anger issues when things do not go her way. The Veteran's impaired impulse control is displayed by her difficulty controlling her temper resulting in verbal arguments at work. Despite these reports, the VA examiners and treating clinicians consistently found that the Veteran was not a danger to herself or others and the mental status examinations repeatedly described her as pleasant and cooperative with fair to good insight and judgment. Significantly, the Veteran has maintained familial relationships and regularly babysits her granddaughter which suggests she is able to control her irritability, anger, and temper. The Board notes that the Veteran alleged altercations and difficulty getting along with specific family members. However, the record does not reveal any additional reports of altercations just general allegations of irritability and anger. There are no periods of violence reported. As previously noted, the Veteran's impaired impulse control includes driving fast and previous drug abuse. Throughout the appeal period, the Veteran has denied substance abuse. Despite her reported fast driving, she completed activities of daily living, to include self-care and was consistently described as well-groomed and cooperative in the mental status examinations. There is no violence accompanied by the reported impaired impulse control. Notably, the Veteran did submit a July 2017 DBQ wherein the examiner felt that the Veteran's functioning more closely resembled a 70 percent rating. At this examination, the Veteran shared that she was irritable, having conflicts at work, driving quickly, experiencing hypervigilance every time she left the house, and experiencing a startled response. The clinician described the Veteran as careless, restless, emotionally unstable, agitated, and hostile, maintaining only a marginal life adjustment. However, the Board finds the clinical records are more probative than the 2017 private DBQ. Based on the consistency of the reported statements prior to and subsequent to the 2017 DBQ, the DBQ appears to be an outlier. The July 2017 DBQ found that the Veteran's symptoms included a depressed mood, anxiety, suspiciousness, panic attacks more than once a week, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, chronic sleep impairment, disturbance of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances, including work or a work like setting. Specifically, the Veteran indicated that she hated her job, making her irritable dealing with customers and bosses. The Veteran described reckless and self-destructive behavior, reported hypervigilance every time she goes out of the house, and described startled reactions. She also reported problems with concentration and focus, with difficulty remembering names and misplacing things, burning food on the stove, forgetting to take medication, losing time, and track of content or TV problems. She also recounted a couple episodes over the past month of dissociative depersonalization where she felt separated from herself while working. Notably, the Veteran reported less severe symptoms at both previous and subsequent mental health appointments. In February 2017, the Veteran appeared for a scheduled mental health visit, noting that she was last seen in July 2016. The Veteran reported that that she was working at Home Depot. She indicated her mood was "ok," her appetite as "ok," and sleep as "good." She shared her physical energy level was "ok" and that she remains active, exercising regularly. In July 2017, the Veteran presented for a refill of her medications. She was described as having a bright affect with an appropriate mood. She denied suicidal ideation, homicidal ideation, or hallucinations. At a September 2017 mental health appointment, the Veteran reported her mood as "okay" and reported being able to handle her daily stressors. She had no depression, anxiety, or manic symptoms and denied suicidal or homicidal ideations, and any hallucinations or delusions. Again, at an October 2017 appointment, the Veteran denied depression, anxiety, manic symptoms suicidal ideations, homicidal ideations, and paranoia. The Veteran also shared that she continued to be able to handle her daily stressors. Similarly, in November 2018, and February 2019, the Veteran indicated that she had external stressors but denied depressive symptoms. She reported that her symptoms were well-maintained and reported a good mood. Routinely at each of these appointments, she presented as cooperative, with normal eye contact, and appropriately dressed and groomed. Additionally, while the Veteran shared that she was experiencing dissociative depersonalization at her 2017 private DBQ, this is the only time the Veteran alleged any experience of dissociative depersonalization in the record, as such it is afforded limited probative value. The Board has considered the statements provided by the Veteran in the 2017 DBQ and finds that the statements are inconsistent with the treatment records and thus, limiting the reliability of the statements offered in support of her claim for benefits. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (the Board can consider bias in lay evidence and conflicting statements of the veteran in weighting credibility); Caluza v, 7 Vet. App. at 511. Therefore, while the Veteran displayed difficulties with impaired impulse control to include anger, irritability, difficulties with her temper and verbal arguments, the record does not reveal any periods of unprovoked irritability or anger with periods of violence as described by the 70 percent rating. The Veteran's PTSD also does not warrant a 100 percent rating as the Veteran has neither total occupational impairment nor total social impairment. The Veteran's ability to maintain relationships for the entirety of the appeal period supports a finding she is able to maintain control of her impulses, to include anger, irritability, and her temper. The Veteran was able to perform activities such as grooming, working as a waitress and a nurse, babysitting, and visiting family. Notably, the Veteran is a registered nurse who has specifically worked in a mental health specialization. While the Veteran may be credible to describe the particular symptoms which she experiences, determining the exact extent of disability requires specialized testing and medical knowledge or training. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran has not advanced any specific diagnoses or theories of entitlement, though has indicated she believes she meets the criteria for the next higher disability rating. Although the Veteran may believe that she meets the criteria for the next higher disability rating, her complaints along with the medical findings do not meet the schedular requirements for a 70 percent rating prior to February 17, 2021. The rating schedule contemplates the Veteran's mental health complaints and difficulties in the rating criteria. Accordingly, the statements submitted by the Veteran at her medical appointments are afforded more weight as the Veteran is providing information to her doctors in pursuance of treatment. As such, the Board finds that the frequency and severity of the Veteran's impaired impulse control, anger and irritability issues, and difficulty with her temper resulting in verbal arguments is more consistent with criteria contemplated by the 50 percent rating. Therefore, when considering the overall severity, frequency, and duration of the Veteran's symptoms throughout the appeal period, the Board finds that her symptoms result in no more than an occupational and social impairment with occasional with reduced reliability and productivity consistent with a 50 percent rating. 2. Entitlement to a disability rating in excess of 70 percent for posttraumatic stress disorder (PTSD) with major depression, opiate dependency in remission from February 17, 2021. In June 2021, the Veteran was afforded another VA examination. See June 2021 VA Examination. The examiner found that the Veteran had diagnoses of PTSD and major depressive disorder. The Veteran indicated that on her days off she does not do much else outside of feeding her dogs. All of her energy is used to finish her three-hour shifts, which she likened to secretary work. She shared she is having trouble adapting to the admission process and charting system. She recognizes that she is more irritable than others about the issues. The examiner found the mental disorder to be productive of have occupational and social impairment with reduced reliability and productivity. The Veteran shared that she does not have much of a social life, though does get to watch her granddaughter at times and shared she presently has a relationship with her daughter. She indicated over the past three years she lived alone with her dog, moved in with her daughter, and now has a separate apartment. She shared that she does have personality problems but that she is still able to make a little money. The Veteran arrived on time for the evaluation and presented herself appropriately. Noted to be relatively articulate and bright, throughout the evaluation she was appropriate, attentive, and responsive to the examiner's questions. The examiner found symptoms of depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, panic attacks more than once a week, near continuous panic or depression affecting the ability to function independently, appropriately, and effectively, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, impairment of short and long-term memory, flattened affect, difficulty in understanding complex commands, 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, obsessional rituals which interfere with routine activities, intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. Ultimately, the examiner determined that the Veteran's PTSD does not cause total social and occupational impairment as the Veteran is able to work to some degree and that she has intermittent contact with her daughter and granddaughter, who live next door. In July 2021, the Veteran attended another mental health treatment appointment. She reported her medication was helpful and that she continues to work as a nurse. She is no longer on probation and has a full unrestricted license. She shared that her daughter is supportive, and her granddaughter is also close to her. She endorsed a good mood, appetite, and focus. She denied any feelings of helplessness or hopelessness, suicidal ideation, homicidal ideation, or substance abuse. In October 2021, the Veteran was afforded another VA examination. The examiner noted the Veteran's diagnoses of PTSD and major depressive disorder. The examiner opined that the mental disorder was productive of occupational and social impairment with deficiencies in most areas, such as work school, family relations, judgment, thinking and mood. At the time of the examination, the Veteran had recently lost her job as a nurse after being employed there for two years. "I was fired after several disagreements at work - I have trouble keeping my mouth shut - if I see a problem - I tell it and that makes people angry." She shared that while it was difficult, she was able to obtain another job at a rehabilitation center as a staff nurse. The Veteran reported she was nervous about having a daytime job as having a nighttime shift had changed her sleep schedule. She indicated that she had been depressed, worse since losing her job. She has trouble convincing herself to exercise and then feels guilty. At times, she did not want to bathe or get dressed but if she has to go somewhere, she will bathe and dress up. She reported hypervigilance and avoiding crowds, noting a frequent feeling of impending doom. She reported she has difficulty handling stress, and the examiner noted that individuals suffering from PTSD may be irritable and easily upset; tend to avoid things and people that arouse distressing memories. The examiner found that the Veteran is able to maintain employment and function socially on a limited basis, therefore she did not qualify for total social and occupational impairment. Occupationally, the Veteran was employed as a nurse in a mental health unit until July 2021. She reported having a disagreement with her boss, at which point she lost her job. In October 2021, she shared that while it was difficult, she was able to obtain another job at a rehabilitation center as a staff nurse that she would be starting once the paperwork went through. Thus, while the Veteran has difficult in adapting to stressful circumstances, she does not have total occupational impairment from February 17, 2021. She maintained the one job for several years and obtained another job relatively soon after leaving prior employment. Socially, the Veteran reported an ongoing relationship with her family members. She indicated that she regularly babysits her granddaughter, and, at her Board hearing, shared that she is working to foster a positive relationship and memories with her granddaughter. She also has continued her relationships with her daughters, living nearby or with them. The Veteran also shared that she feels more comfortable around animals, having two dogs and two cats of her own at home. Thr Board notes that the Veteran reported suicidal ideation following her recent job loss in July 2021; however, this report appeared to be only a temporary response to her job termination. At all other medical appointments prior to this statement, the Veteran repeatedly denied suicidal or homicidal thoughts or intention. The record consistently shows that the Veteran was not found to be a danger to herself and others by the examiners and clinicians of record. There is no evidence of any suicidal plans or attempts by the Veteran. As such, the Veteran's report has been considered but due to the lack of frequency of such a higher rating is not warranted on that basis. To the extent that the Veteran had difficulty in adapting to stressful circumstances and suicidal ideation, this is compensated for in the 70 percent initial evaluation which the Board has found to be appropriate. Notably, the Veteran is a registered nurse who has specifically worked in a mental health specialization. While the Veteran may be credible to describe the particular symptoms which she experiences, determining the exact extent of disability requires specialized testing and medical knowledge or training. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran has not advanced any specific diagnoses or theories of entitlement, though has indicated she believes she meets the criteria for the next higher disability rating. Although the Veteran may believe that she meets the criteria for the next higher disability rating, her complaints along with the medical findings do not meet the schedular requirements for a 100 percent rating from February 17, 2021 as per the Veteran's own statements she maintains employment and familial relationships. The Board finds that the evidence overall demonstrates the level of impairment associated with the next higher rating of 70 percent, which contemplates an occupational and social impairment with deficiencies in most areas. If the Board finds that the positive and negative evidence relating to a Veteran's claim are in "approximate balance," then the placement of the risk of non-persuasion on the VA dictates a finding in favor of the claimant. Ortiz v. Principi, 274 F.3d 1361 (2001). A 100 percent rating has not been warranted during the appeal period, however. The evidence does not support a finding that the Veteran's psychiatric illness has caused total occupational and social impairment. The Veteran has not exhibited gross impairment in thought processes and communication. The evidence indicates that the Veteran has been oriented, and has not experienced hallucinations, delusions, or psychosis. The evidence indicates isolation but has not shown grossly inappropriate behavior or an inability to perform activities of daily living to include personal hygiene requirements. The evidence generally indicates intact memory, judgment, and insight. In short, despite the Veteran's severe symptoms, she has not exhibited during the appeal period the type of emotional and cognitive impairment reserved for a total rating. The Board notes that in October 2021, the Veteran reported that she will not bathe or get dressed for several days, which is similar to an inability to perform activities of daily living to include personal hygiene requirements. However, the severity, frequency, and duration of the Veteran's lack of maintenance of personal hygiene has not risen to the level contemplated by the 100 percent disability rating. At the same examination, the Veteran shared that if she has to go somewhere, she will bathe and get dressed up. As such, the Veteran's report of difficulty with personal hygiene has been considered but due to the lack of frequency and inconsistency of such a higher rating is not warranted on that basis as the evidence does not show that the Veteran has an inability to perform activities of daily living. In sum, the Board notes that, despite her difficulties, the Veteran maintained familial relationships and maintained employment for most of the appeal period. See 38 C.F.R. § 4.130. As such, a preponderance of the evidence is against the assignment of a 100 percent rating for mood disorder. See Gilbert and Alemany, both supra. G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board V. Schmidt 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.