Citation Nr: 21077288 Decision Date: 12/29/21 Archive Date: 12/29/21 DOCKET NO. 17-28 652A DATE: December 29, 2021 ORDER New and material evidence having been received; the claim of entitlement to service connection for posttraumatic stress disorder (PTSD) is reopened. Entitlement to service connection for PTSD is denied. Entitlement to an initial rating in excess of 70 percent, but no higher, for adjustment disorder with mixed anxiety and depressed mood, persistent (claimed as PTSD) prior to March 9, 2015, is granted. Entitlement to an initial rating in excess of 70 percent for adjustment disorder with mixed anxiety and depressed mood, persistent (claimed as PTSD) from March 9, 2015, is denied. FINDINGS OF FACT 1. In a final decision issued in June 2010, the RO denied the Veteran's claim of entitlement to service connection for PTSD. 2. Evidence added to the record since the June 2010 prior final denial is not cumulative or redundant of the evidence of record at the time of the prior decision and raises a possibility of substantiating the Veteran's claim for a service connection for PTSD. 3. The competent evidence reflects that the Veteran's PTSD symptoms are part of the Veteran's adjustment disorder with mixed anxiety and depressed mood, persistent and not manifested by symptoms of a separate diagnosis. 4. For the entire period on appeal, the Veteran's adjustment disorder with mixed anxiety and depressed mood, persistent, is productive of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. CONCLUSIONS OF LAW 1. As new and material evidence has been received since the issuance of a final June 2010 rating decision, the criteria for reopening the claim of entitlement to service connection PTSD have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 2. The criteria for entitlement to service connection for PTSD have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.304; 4.125. 3. For the period prior to March 9, 2015, the criteria for an assignment of a rating of 70 percent, but no higher, for service-connected adjustment disorder with mixed anxiety and depressed mood, persistent, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.126, 4.130, Diagnostic Code (DC) 9440. 4. For the period from to March 9, 2015, the criteria for an assignment of a rating in excess of 70 percent for service-connected adjustment disorder with mixed anxiety and depressed mood, persistent, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.126, 4.130, Diagnostic Code (DC) 9440. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 2008 to November 2008. In a March 2019 correspondence, the Veteran's representative revoked his representation as the Veteran's representative on all claims pending before VA. In February 2021, the Veteran did not appear for his Board videoconference hearing. As such, his request for a Board hearing is deemed withdrawn. In a September 2021 correspondence, the Veteran was notified that his representative withdrew his representation of the Veteran in all pending claims before the Board. As such, the Veteran was advised that if he would like to appoint a new representative, he has 30 days to do so. The Veteran was notified that if he does not respond, VA will assume that the Veteran is not seeking a new representative and elects to represent himself. As the Veteran did not response to this letter, the Board has determined that the Veteran seeks to continue the appeal without appointing a representative. In a March 2019 rating decision, the issue of entitlement to a total disability rating based on unemployability (TDIU) due to service-connected disabilities, was granted for the entire period on appeal. Given such, as this reflects a full grant of this benefit, there remain no issue at controversy. I. New and Material Evidence In order to reopen a claim which has been denied by a final decision, a claimant must present new and material evidence. 38 U.S.C. § 5108; 38 C.F.R. § 3.156 (a); see also Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001) (regardless of action taken by RO, Board must determine whether new and material evidence has been received subsequent to an unappealed RO denial). New and material evidence means evidence not previously submitted to agency decisionmakers; which relates, either by itself or when considered with previous evidence of record, to an unestablished fact necessary to substantiate the claim; which is neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and which raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). To reopen a previously disallowed claim, new and material evidence must be presented or secured since the last final disallowance of the claim on any basis, including on the basis that there was no new and material evidence to reopen the claim since a prior final disallowance. See Evans v. Brown, 9 Vet. App. 273, 285 (1996). For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, "credibility" of newly presented evidence is to be presumed unless evidence is inherently incredible or beyond competence of witness). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." In determining whether this threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened by triggering VA's duty to assist. See Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010). At the onset, the Board acknowledges that in April 2015, military personal records were associated with the file after the June 2010 last prior final denial with respect to the Veteran's claim to reopen service connection for PTSD. Thus, the Board has considered whether reconsideration of the claim is warranted under 38 C.F.R. § 3.156 (c). VA regulation provides that, at any time after VA issues a decision on a claim, if VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim, notwithstanding paragraph (a) of the same section (which defines new and material evidence). 38 C.F.R. § 3.156 (c). In this case, the newly-associated service records are not relevant to claims on appeal as they do not go to proving an unsubstantiated fact. Here, with respect to the Veteran's claims for a PTSD, the Veteran's claim was denied for a lack of competent evidence supporting an in-service stressor and a nexus between such stressor and PTSD. Upon review, the newly associated military personnel records do not reflect competent evidence supporting an in-service stressor and a nexus between such stressor and PTSD. Given such, these records do not relate to an unestablished fact necessary to substantiate the Veteran's claim. Additionally, some of the military personal records are not relevant as they are duplicative. Accordingly, reconsideration of the Veteran's claim under 38 C.F.R. § 3.156 (c) is not required based upon the additionally-received service records. PTSD Here, in a June 2010 rating decision, the RO denied the Veteran's claim for service connection for PTSD for a lack of an in-service stressor and a nexus opinion linking an asserted current disability to service. This decision is final, as the Veteran did not appeal this decision. In September 2012, the Veteran submitted a claim to reopen his claim for PTSD. The evidence of record at the time of the final prior denial in June 2010 included, inter alia, the Veteran's service treatment records, lay statements, buddy statements, and VA medical records. Specifically, the evidence of record at the time of the last prior final denial established that in September 2003 the Veteran was treated for PTSD. Therefore, as the Veteran has established a current disability, the issues before the Board are whether the evidence obtained since the June 2010 prior final denial establishes that the Veteran's verified in-service stressors are related to his PTSD. The evidence submitted and obtained since the June 2010 prior final denial includes the updated VA treatment records, Veteran lay statements, VA examination, and military personnel records. Upon review, the Board finds that this evidence is both new and material sufficient to reopen the Veteran's claim. The evidence is "new" as it had not been previously considered by VA, and the evidence is "material" because it relates to unestablished facts necessary to substantiate the underlying service connection claim. Specifically, the Veteran noted he saw someone die during service as an in-service stressor. As this evidence relates to an unestablished fact, in-service stressor, reopening of the claim is in order. Shade, 24 Vet. App. 110. II. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013). Service connection may be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). PTSD At the onset, the Board notes that the Veteran's VA treatment records reflect that he has been treated for PTSD symptoms. However, in a September 2014 VA examination report for PTSD, the VA examiner noted that the Veteran's psychiatric symptoms are associated with adjustment disorder with mixed anxiety and depressed mood, persistent. The Veteran is service connected for this psychiatric disability. In fact, the VA examiner opined that there is insufficient evidence to support a separate diagnosis of PTSD. Furthermore, the VA examiner opined that the Veteran reported no clear military traumas sufficient to support a diagnosis of PTSD. The Veteran did not appear to meet the criteria for PTSD. Rather, the examiner opined that the evidence supports that the Veteran's in-service stressor, a back injury, led to his chronic difficulties with anxiety and depression. Given such, the Board finds that the Veteran does not have a separate diagnosis of PTSD. Here, the evidence reveals that the Veteran's PTSD symptoms are part of adjustment disorder with mixed anxiety and depressed mood, persistent and the Veteran is already service connected for adjustment disorder with mixed anxiety and depressed mood, persistent. Consequently, because a separate pathology does not exist, then service connection for PTSD, which encompass the same symptoms as his already service-connected adjustment disorder with mixed anxiety and depressed mood, persistent, would not be warranted as this would constitute impermissible pyramiding. See 38 C.F.R. § 4.14 (the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided.); see also Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994) (pyramiding is rating the same physical manifestations of a disability under two separate diagnostic codes). The Board concludes that the Veteran does not have a current separate diagnosis PTSD and has not had a separate diagnosis of PTSD at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 5107(b); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303 (a), (d). In light of the above, the Board finds that the probative evidence of record does not demonstrate that the Veteran has a separate diagnosis of PTSD, and that the first element of service connection has not been met. In the absence of evidence of a separate and distinct diagnosis, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223.225 (1992); 38 C.F.R. § 3.385 (for VA purposes, "impaired hearing will be considered to be a disability" only when hearing loss examination results reach certain auditory thresholds). The existence of a current disability is the cornerstone of a claim for VA disability compensation. Degmetich v. Brown, 104 F. 3d 1328 (1997). The evidence must show that the Veteran currently has the disability for which benefits are being claimed. Given that the Veteran does not have a separate diagnosis of PTSD, which is the cornerstone of any service connection claim, the remaining elements of service connection will not be addressed. To the extent that the Veteran's general notice of disagreement with the RO's denial of service connection for PTSD reflects that the Veteran contends that he has a separate diagnosis of PTSD, the Board finds that due to the complexity of the issue, where it encompasses a complex medical determination, the Veteran is not competent to make such a finding, especially where there is no evidence of record that he has the requisite medical background to make such a finding. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2010). Essentially, the medical opinion by a medical professional trained to make diagnoses related to mental health disabilities is more probative than the Veteran's lay statement. Again, the September 2014 VA examiner opined that the Veteran does not have a separate diagnosis of PTSD. Accordingly, the Veteran's claim for PTSD is denied. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable. III. Increased Rating Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, in Fenderson, the Court noted an important distinction between an appeal involving a Veteran's disagreement with the initial rating assigned at the time a disability is service connected. Where the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection to consider the appropriateness of "staged rating" (i.e., assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson, 12 Vet. App. at 126; see also Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, in a January 2015 rating decision, service connection for adjustment disorder with mixed anxiety and depressed mood, persistent, was granted with a 50 percent rating under the General Rating Formula for Mental Disorders, 38 C.F.R. § 4.130, DC 9440, effective September 25, 2012. In the present case, as the Veteran timely filed a Notice of Disagreement contesting the initial rating, the Veteran is appealing the original assignment of disability evaluation following the award of service connection for his mental health disorder. In such a case, it is not the present level of disability, which is of primary importance, but rather the entire period since the effective date of the grant of service connection is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. See Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). In an April 2017 rating decision, the Veteran's mental health disability rating was increased to 70 percent effective March 9, 2015. With respect to the period on appeal, the Veteran's mental health disability rating is effective September 25, 2012. Therefore, the period on appeal begins on September 25, 2012. Under the provisions for rating psychiatric disorders, a 50 percent disability rating requires evidence of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when there is 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.). A 100 percent rating is warranted when there is 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. 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 a rating 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 a rating solely on the basis of social impairment. 38 C.F.R. § 4.126. The evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including (if applicable) those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). See Mauerhan, 16 Vet. App. 436. Factual Background As discussed above, the period on appeal beings on September 25, 2012. At the onset, the Board notes that the Veteran's Social Security Administration (SSA) disability records were obtained and are part of the Veteran's claims file. For background purposes, as the medical records are dated in prior to September 24, 2012, SSA determined that the Veteran's is disabled, per SSA regulations, due to impairments, to include as due to anxiety and depression. See SSA Disability Determination and Transmittal. Significantly, while the Board notes that SSA determinations are not binding on VA, the Board has reviewed these records for purposes of understanding the Veteran's background. Turing to the remaining evidence of record, the Board notes that in October 2012 VA medical treatment records, the Veteran reported panic attacks and a low tolerance for frustration. With respect to behavioral observations, the examiner noted that the Veteran's mental status was within normal limits. The Veteran was appropriately dressed. His mood was noted as generally euthymic. There was no evidence of suicidal or homicidal ideation. The Veteran noted he it was "very difficult" to take care of things at home and get along with others. See October 31, 2012 VA medical records. Also, October 2012 VA medical records reflect that the Veteran got married in October 2012 and reported that his wife was very supportive. He reported that he slept well with medications. Mental status examination revealed that the Veteran had limited eye contact; regular speech; mood was noted as "better"; affect was noted as dysphoric and constricted; and he was alert to person, place, and time. This cognitive ability was intact, and insight and judgment were fair. See October 31, 2012 VA medical records. In a December 2012 mental health note, the VA examiner contacted the Veteran via telephone and the Veteran reported no suicidal or homicidal ideation. In a January 2013 VA medical note, the examiner noted that the Veteran was last seen on October 31, 2012. The Veteran reported that he was doing "fair." The Veteran reported that he continued to struggle with anxiety, irritability, and hypervigilance. The Veteran reported no suicidal or homicidal ideation. Mental status examination revealed the Veteran was well maintained, and grooming and hygiene were appropriate. He was pleasant and cooperative. Eye contact was fair. His speech was regular. His affect was mildly dysphoric and congruent with mood. In a January 2013 VA medical record, the Veteran was contacted regarding missed appointments. He reported that he was having difficulty with transportation. The Veteran reported no acute distress, and no suicidal or homicidal ideation. In a March 2013 VA medical note, the Veteran reported 45 minutes late for his appointment. He reported he was "still not doing well." He reported he continued to struggle. He reported a divorce from his new wife. He described ongoing issues with dysphoria, anxiety, tremulousness, intrusive thoughts, hypervigilance, and irritability. He had a tendency toward isolation. He continued to have sleep difficulties, with persistent nightmares. The Veteran denied suicidal or homicidal ideation. Mental status examination revealed that the Veteran was appropriately groomed and dressed. He exhibited fair eye contact. He appeared to be agitated. His speech was normal. He was alert to person, place, and time. His cognitive ability was intact. In a May 2013 VA mental health note, the VA examiner noted the Veteran exhibited depressed mood, anxiety, sleep problems, nightmares, amotivation, anergia, intrusive thoughts, flashbacks, hyperstartle, hypervigilance, avoidance, and isolation. In an October 2013 VA mental health note, the Veteran reported that he still heard someone calling his name often. He reported that he was sad about losing his career. He was an EMT and Flight EMT for 21 years. He felt like his 21 years of experience were a waste. The VA examiner noted that the Veteran exhibited depressed mood, anxiety, sleep problems, nightmares, amotivation, anergia, intrusive thoughts, flashbacks, hyperstartle, hypervigilance, avoidance and isolation. In a March 2014 VA mental health note, the Veteran reported he was doing better. He denied any suicidal or homicidal ideation. In a May 2014 VA mental health note, a caller called to inform the Veteran's doctors that the Veteran was abusing his psychiatric medications. In an August 2014 VA mental health note, the Veteran reported feeling alright. He denied any suicidal or homicidal ideations. The examiner noted improvement in the Veteran's sleeping problems. In a September 2014 VA examination for PTSD, the VA examiner noted the Veteran did not have a diagnosis for PTSD. The VA examiner diagnosed the Veteran with adjustment disorder w/ mixed anxiety and depressed mood, persistent (chronic). The VA examiner noted that despite the Veteran's inconsistent statements with respect to being a combat veteran, it was very clear that the Veteran's occupational and psychosocial functioning had deteriorated since his time in service. The Veteran's mental health disability was productive of occupational and social impairment with reduced reliability and productivity. The VA examiner noted the Veteran exhibited the following symptoms: depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, and difficulty in establishing and maintaining effective work and social relationships. With respect to behavioral observations, the VA examiner noted that the Veteran had nightmares, fear of crowds, loud noises, and got agitated very easy. The Veteran denied any difficulties with violence toward others since his military discharge. The Veteran's mental status examination revealed that the Veteran appeared adequately groomed. The Veteran was alert. He was orientated to person, place, time, and situation. His attitude was anxious, cooperative, and appropriate. He appeared very tense. His affect was restricted and anxious. His mood was quite anxious and tense. His speech was normal in volume. Thought process was logical. The Veteran denied delusions. The Veteran reported that he heard his name a lot. He was not sure if it was in his dreams. However, he reported that he sat up in bed and talked to people who are hurt or dead. He reported panic attacks. The Veteran reported chronic sleep impairment. He did not exhibit any inappropriate behavior, obsessive or ritualistic behavior. The Veteran denied suicidal or homicidal ideations. The Veteran's memory appeared grossly intact. With respect to social functioning, the Veteran reported that he married his first wife in 1995. They had one daughter together. They separated after one year. He married his second wife in 2001. This marriage lasted six years. The Veteran reported visitation with his daughter had been limited over the years. The Veteran reported he married his third and current wife in 2014. He reported a good relationship with her. He was otherwise estranged from his family. He reported he isolated himself from everyone other than his wife and her kids. He denied any regular social contacts. He reported that he did not go out anymore. He reported that he only had one friend. The Veteran did not belong to any groups, clubs, organizations, or churches. The VA examiner noted this was moderate impairment of social functioning. With respect to occupational functioning, the Veteran reported no gainful employment since 2009. The Veteran reported he began receiving SSA disability benefits for his back and hip problems in 2009, and had not worked since. The Veteran reported that he felt that his psychiatric and physical disabilities made it so he was unable to find and maintain gainful employment. In February 2015 VA medical records, the Veteran reported that he separated from his wife and was having a hard time. The Veteran reported that his anxiety has improved. In a March 9, 2015 medical record, the Veteran reported having nightmares, not leaving the house, and isolating himself. In an April 2015 mental health record, the Veteran denied suicidal and homicidal ideation. The Veteran reported that he was "based to square one" with his anxiety. The Veteran reported that he "blacked out" but refused any treatment. He reported that his mood was "all over the place." The Veteran reported that he did not feel his symptoms were severe enough to warrant more intense services at this time. In a July 2015 VA mental health note, the Veteran reported nightmares, anxiety, sleep problems, flashbacks, hyperstartle, hypervigilance, avoidance, and isolation. The record reflects that the Veteran's last treatment for psychiatric condition was in July 2015. The Board notes that throughout his course of mental health treatment, the VA medical records reflect that the Veteran missed several appointments and after July 2015 stopped attending mental health treatment. In an April 2019 VA Form 9, the Veteran's representative at that time, contended that the Veteran's psychiatric condition maintained the same severity since the Veteran filed his claim in September 2012. Accordingly, the representative stated that the Veteran requested a 70-percent rating for the entire period on appeal. Prior to March 9, 2015 Based on the foregoing evidence, the Board finds that for period on appeal, the Veteran's adjustment disorder with depression most nearly approximated the criteria for a 70-percent rating for period prior to March 9, 2015. Based on the foregoing, prior to March 9, 2015, the Board finds the Veteran's psychiatric disability was manifested by symptoms such as depressed mood, anxiety, panic attacks, chronic sleep impairment, flattened affect, and inability to establish and maintain effective relationships. As such, the Veteran exhibited symptoms that meet the criteria of both the 50-percent and 70-percent ratings. The Board notes that while the RO determined that March 9, 2015 is the date in which the Veteran exhibited symptoms of a 70-percent rating, the Board finds that the Veteran exhibited these symptoms prior to March 9, 2015. The Board acknowledges that during this period on appeal, the Veteran's mental health symptoms reflect symptoms that fall under the 50 and 70 percent rating criteria. However, although the intensity of the individual symptoms varied throughout the period on appeal, and at times the Veteran reported an improvement of his symptoms, the chronic nature of the duration and frequency of the Veteran's mental health symptoms, despite a prolonged course of medical treatment, reflected that the severity of the Veteran's mental health symptoms. Specifically, one of the symptoms listed under the 70-percent criteria is the inability to establish and maintain effective relationships. Significantly, the Board notes that the Veteran had been married three times, with each marriage ending in divorce. Furthermore, the Veteran noted that he was estranged from his family. He reported that he did not go out, he was not part of any clubs or organizations, and preferred to be alone. The evidence consistently supported the Veteran's inability to establish and maintain effective relationships. Furthermore, with respect to this occupational functioning, the evidence reflected that the Veteran had not been gainfully employed since 2009. This was in part due to his anxiety and depression. The Veteran reported that he heard his name being called often, even though no one was present. This increased the Veteran's paranoia, and resulted in deficiencies in his ability to work. The Veteran reported that he felt that his psychiatric and physical disabilities made it so he was unable to find and maintain gainful employment. When looking at the duration, frequency, and severity of the Veteran's symptoms the Board finds the Veteran's psychiatric disability had consistently been manifested by occupational and social impairment with deficiencies in most areas due to symptoms such disturbances of motivation and mood, difficulty in establish and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and the inability to establish and maintain effective relationships. Given such, resolving doubt in favor of the Veteran, the Board finds that the Veteran's psychiatric disability more closely reflected a 70-percent rating for the period prior to March 9, 2015. In other words, throughout the period on appeal the Veteran's psychiatric disability more closely approximates the criteria of a 70-perecnt rating. Entire Period on Appeal A maximum 100 percent rating is not warranted at any time during the period on appeal as the Veteran did not exhibit symptoms such as grossly inappropriate behavior, persistent delusions, persistent danger of hurting himself or others, intermittent inability to perform daily living, disorientation to time living or place, memory loss of close relatives, own occupation or own name. Although the Veteran reported that he heard his name being called often, the Board notes that this symptom, while having an effect on his occupational functioning, has not been shown to be productive of total occupational or social impairment. In other words, there is no evidence that the Veteran's possible hallucinations of hearing his name being called had had any effect on his failed marriages or his estranged familial relationships. Also, while the Board finds that hearing his name being called was productive of deficiencies in occupational functioning, as contemplated by the 70-percent rating, there is no evidence that the Veteran is totally impaired from this symptom. While the Veteran reported that he got angry easily, there is no evidence that the Veteran was an imminent threat to himself or others. In fact, the September 2014 VA examination report shows that the Veteran denied any difficulties with violence toward others since his military discharge. The medical records do not show that the Veteran exhibited symptoms of grossly inappropriate behavior; intermittent inability to perform daily living; disorientation to time living or place; memory loss of close relatives, own occupation, or own name. As discussed above, the Veteran's orientation was always noted to be within normal limits. Importantly, in all the VA medical records of record, the Veteran was able to answer questions about his name and occupation. As such, the evidence does not support both total occupational and social impairment. Therefore, a rating in excess of 70-percent for the entire period on appeal is not warranted. The Board notes that subsequent to the September 2014 VA examination, the RO made several attempts to schedule an updated VA examination. However, the Veteran failed to report to all the examinations. The record does not establish, nor does the Veteran contend, good cause for failing to report to these VA examinations. Thus, with respect to the VA's duty to assist, while VA made several attempts to schedule an updated examination, because the Veteran failed to report for these examinations without good cause, any further attempts to schedule an examination would be futile. Consequently, the Board finds that VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. (Continued on the next page) As the preponderance of the evidence is against the Veteran's claim, the benefit-of-the-doubt doctrine is not applicable, and his claim must be denied. 38 U.S.C.§ 5107 (b); 38 C.F.R. § 3.102. L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Abdelbary, 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.