Citation Nr: A21019643 Decision Date: 12/09/21 Archive Date: 12/09/21 DOCKET NO. 190808-19560 DATE: December 9, 2021 ORDER Entitlement to an initial rating higher than 50 percent for service-connected unspecified anxiety disorder ("anxiety disorder") is denied. FINDING OF FACT Throughout the appeal period, the Veteran's anxiety disorder was manifested by one instance of passive suicidal ideation; some impaired impulse control with no periods of violence; irritability; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week when stateside; some memory loss; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; suspiciousness; and chronic sleep impairment, productive of occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW The criteria for entitlement to an initial rating higher than 50 percent for service-connected anxiety disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9413. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1972 to February 1974; from January 2002 to January 2003; from August 2003 to February 2005; from April 2006 to May 2007; and from December 2010 to April 2011. This case comes before the Board of Veterans' Appeals (Board) on appeal of a July 2019 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In August 2017, the President signed into law the Veterans Appeals Improvement and Modernization Act of 2017 (Appeals Modernization Act or AMA), Pub. Law 115-55, which created a new claims and appeals process for pursuing VA benefits. As the claim on appeal has been subject to both the pre-AMA (legacy) and AMA appeals processes, a brief summary of the procedural history of this case is provided. In April 2016, the RO issued a rating decision denying service connection for anxiety disorder (claimed as posttraumatic stress disorder (PTSD)), to which the Veteran filed a timely Notice of Disagreement (NOD). Prior to the issuance of a Supplemental Statement of the Case (SOC), VA invited the Veteran to participate in the Rapid Appeals Modernization Program (RAMP), a temporary program allowing early participation in the new appeals process before the AMA became effective in February 2019. In February 2018, the Veteran submitted his RAMP opt-in election form and chose the Higher-Level Review option. In June 2018, VA notified the Veteran that his appeal of the RO's denial of this claim had been removed from the legacy appeal system. The Veteran's decision to opt-in to RAMP resulted in an October 2018 rating decision, which granted service connection for anxiety disorder with an evaluation of 30 percent, effective November 19, 2015. In November 2018, the Veteran timely appealed the rating decision to the Board and elected the Direct Review option. See November 2018 Statement in Support of Claim. In January 2019, the Board remanded the matter to correct a pre-decisional duty to assist error, and the RO issued a July 2019 rating decision, which increased the Veteran's rating for service-connected anxiety disorder to 50 percent, effective May 23, 2019. In August 2019, the Veteran timely appealed this rating decision to the Board and again elected the Direct Review option. See August 2019 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement). When a claimant seeks appellate review through the Board's Direct Review docket, the Board may only consider the evidence of record at the time of the rating decision on appeal. See 38 U.S.C. § 7113(a). As the Veteran properly appealed the July 2019 rating decision, the Board considers the evidence of record at the time of that decision. Since the July 2019 rating decision, additional evidence was added to the claims file. The Board cannot consider this evidence in connection with the increased rating claim for anxiety disorder. The Veteran may file a Supplemental Claim and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. The Board issued a decision on this matter in March 2020, granting an initial 50 percent rating for the service-connected anxiety disorder and denying a rating higher than 50 percent throughout the appeal period. The Veteran appealed the decision to the U.S. Court of Appeals for Veterans Claims (Court). Pursuant to a joint motion for partial remand (JMPR) granted by the Court in June 2021, the portion of the March 2020 decision denying a rating higher than 50 percent throughout the appeal period was vacated, and the matter was remanded for the Board to provide an adequate statement of reasons and bases. The Board notes that the RO has yet to fully implement the full initial increased rating of 50 percent granted in the March 2020 Board decision. Specifically, the RO, rather than fully implementing the grant, instead granted a 50 percent rating, effective January 31, 2017, only partway through the appeal period. In accordance with the March 2020 decision, the RO must fully implement the Board's grant of an initial rating of 50 percent for the entire period on appeal, dating back to the Veteran's November 19, 2015 service connection claim. Separately, the Board is aware that the Veteran has a diagnosis of PTSD, which is not service-connected. However, the Board has considered all of the Veteran's mental health symptoms in evaluating his service-connected anxiety disorder. See Mittleider v. West, 11 Vet. App. 181 (1998). If the Veteran wants to seek service connection for PTSD, he may file a Supplemental Claim. Increased Rating The Veteran seeks an initial rating higher than 50 percent for his service-connected anxiety disorder, which is rated under 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name cause total occupational and social impairment. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a Veteran's symptoms, but it must also make findings as to how those symptoms impact a Veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran's impairment must be "due to" those symptoms, a Veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. The Board finds that a rating higher than 50 percent for the Veteran's service-connected anxiety disorder is not warranted for any portion of the period on appeal. In making this finding, the Board has considered Dr. M.C. and Dr. K.L.'s assessments and opinions, the VA examinations, as well as the Veteran's treatment records and lay statements. The Veteran's VA treatment records, which document the course of his anxiety disorder treatment throughout the appeal period, are associated with the claims file. At a May 2015 psychological assessment, the Veteran indicated that he had been married 34 years and had two children. He reported symptoms of avoidance, hypervigilance, hyperarousal, intrusive recollections, reactivity to triggers, isolation, withdrawal, difficulty being in exposed situations or positions, and difficulty with crowds. He denied any audio or visual hallucinations and past or current suicidal or homicidal ideation. The psychologist diagnosed him with PTSD, dysthymia, pain disorder associated with both psychological factors, and a general medical condition. Regarding behavior, the psychologist observed that he was neatly dressed and groomed, demonstrated pleasant and cooperative affect, exhibited fluent speech and goal-directed communication, and was alert and oriented to time, place, person, and situation. A week later, per a telephonic social work encounter, the Veteran reported being irritable and hyperaroused and denied suicidal ideation. He discussed his upcoming one-year deployment and indicated that he felt like he did not fit in and needed to be somewhere that made sense to him. His social worker observed that his mood seemed euthymic and his thinking was clear and goal-directed. At a July 2015 VA primary care physical examination, the Veteran reported that he and a friend decided to check on each other because they decided to quit alcohol six months prior. Per a PTSD screening, he denied having nightmares and/or intrusive thoughts, avoidance, hypervigilance, and feelings of detachment. His provider observed that he was alert, fairly composed, and exhibited intact and coherent speech and thought processes, and documented that he denied suicidal or homicidal ideation. At an April 2018 VA primary care physical examination, the Veteran reported that he had been working in Afghanistan and would return to the U.S. only for a month once every several months. He indicated that he was physically active, quit drinking alcohol over a year ago, and did not have any suicidal or homicidal ideation. Per depression and suicide screenings, he denied having little interest or pleasure in doing things, feeling down or depressed, having feelings of hopelessness, and having any thoughts of taking his own life. His provider noted that he had possible dysthymia and insomnia, observed that he was fairly composed, and noted that he exhibited coherent and intact speech and thought processes. The Veteran was afforded two VA examinations assessing the nature and severity of his overall psychiatric symptoms in March 2016 and May 2019. The Board notes that the March 2016 examination was an initial PTSD evaluation rather than a more general mental disorders evaluation; however, as the findings documented therein also relate to the Veteran's anxiety disorder, this examination is still probative. Separately, the Veteran has submitted two psychological assessments, which he personally obtained in January 2017 and May 2019. At the time of the March 2016 VA examination, the Veteran had been married for 34 years and stated that his wife was more of a friend than a spouse. He indicated that he has acquaintances, as his friends "are either retired or dead," and described his activities and leisure pursuits as "work," adding that he doesn't have time for hobbies. He reported working as a physician's assistant as a contractor overseas since June 2015, having left his previous joa physician's assistant for an orthopedic surgeon as contracting was where he felt at home. The Veteran reported some psychiatric symptoms, including difficulty falling asleep and staying asleep, short temper, and recurring nightmares at least twice a week. The examiner documented that the Veteran experienced anxiety, chronic sleep impairment, and circumstantial, circumlocutory, or stereotyped speech as symptoms of his anxiety and alcohol use disorders. The examiner determined that the severity and duration of the Veteran's symptoms resulted in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during period of significant stress, or, symptoms controlled by medication. The examiner documented that the Veteran convincingly denied any ideas or plans of self-harm or harm to others, but did not document any behavioral observations. In January 2017, the Veteran obtained and submitted an assessment completed by Dr. M.C. addressing his claims for both obstructive sleep apnea (which is no longer before the Board) and PTSD. The assessment was conducted telephonically while he was working in Afghanistan. Dr. M.C. summarized the Veteran's treatment for, and reported symptoms of, PTSD and/or anxiety disorder, and stated that since 2002, the Veteran had experienced symptoms of irritability, anger, mood lability, volatility, social isolation, nightmares, depression, periods of dissociation, and escalated alcohol utilization while in the states, which had escalated exponentially, increasing in intensity, frequency, and severity. Dr. M.C. concluded that the Veteran exhibited all criteria necessary for a PTSD diagnosis pursuant to the DSM-V, specifically determining that the Veteran's statements demonstrated the following symptoms: Intrusive symptoms, including distressing dreams and memories, multiple dissociative reactions, prolonged psychological distress, and physiological reactivity. Avoidance symptoms, including avoidance of distressing memories and external reminders. Negative alterations in cognitions and mood, including persistent negative emotional state with feelings of guilt, shame, and incapability of functioning normally as a civilian, feelings that the world is dangerous and unpredictable, and lack of participation in previously significant activities. Marked alterations in arousal and reactivity including irritability, hypervigilance, severely exaggerated startle response, problems with concentration, and severe sleep disturbance. Across his discussion of the Veteran's symptoms, Dr. M.C. determined that the Veteran was unable to leave the house, socialize with others, engage with his wife, participate with his children, interact with civilians in any reasonable fashion, and had themes of suicidal ideation and hopelessness, but no active thoughts of harm. Dr. M.C. specifically noted that the Veteran "described himself as doing perfectly fine while overseas in a warzone," but also noted that he had tried and failed, on at least three occasions, to transition to civilian life. Regarding behavior and other observations, Dr. M.C. observed that the Veteran was cooperative and appropriate during the interview, did not express any delusions, and exhibited normal speech, no agitation or impulsivity, dysphoric and dysthymic affect, and normal thought processes and cognitions. Dr. M.C. opined that the Veteran's symptoms "are extraordinarily severe and only appear to be mitigated when he is in the only environment where life feels comfortable, a warzone," separately noting that "[c]ertainly, by November 2015 the veteran had become profoundly socially and occupationally impaired[,] incapable of functioning in a civilian world." The Board finds the January 2017 assessment and opinion by Dr. M.C. to be of limited probative value. While Dr. M.C. appears to have reviewed most, if not all, relevant medical records and lay statements in the Veteran's claims file, and included lengthy discussion of the Veteran's reported social impairment, his findings are conclusory and unaligned with a finding of severe occupational and social impairment, despite his opinion as such. Dr. M.C. repeatedly indicated that the Veteran was unable to function in social settings and barely capable of leaving his house, and noted that when forced to engage in civilian life, the Veteran was volatile, irritable, angry, paranoid, socially isolated, hypervigilant, avoidant, and incapable of even basic and simple interpersonal interactions. Some of these symptoms are noted throughout the Veteran's treatment records; however, the Veteran's treatment records, which primarily relate to in-person rather than telephonic visits, document no behavioral issues approaching incapability of even basic and simple interpersonal interactions. Even more, Dr. M.C. failed to discuss in what way the Veteran was "incapable of even basic and simple interpersonal interactions," instead repeating the same conclusion that he was merely incapable of it, which appears to have stemmed from the Veteran's lay determination of such rather than Dr. M.C.'s own medical opinion. Separately, Dr. M.C. opined that the Veteran had become "profoundly socially and occupationally impaired" and his symptoms mitigated only while he is in a warzone, despite his reference to the Veteran's wife's statement that he works 105 days on and 35 days off, essentially spending the majority of his time living and working in an environment that the Veteran himself stated that he was "perfectly fine" in. At no point in his assessment did Dr. M.C. reconcile how the Veteran's social and occupational impairment was "profound[]" when, per the Veteran's reports and Dr. M.C.'s own statement, these symptoms were mitigated more than half the time. As such, the Board affords Dr. M.C.'s opinion little probative value due to its conclusory and inconsistent nature. The Board recognizes, though, that Dr. M.C.'s overall assessment is still probative of the Veteran's variety of symptoms while stateside, including, as noted above, irritability, anger, mood lability, volatility, social isolation, nightmares, depression, periods of dissociation, and escalated alcohol utilization. Separately, the Board finds some of the Veteran's reports documented in Dr. M.C.'s assessment probative of the severity of his psychiatric symptoms and resulting occupational and social impairment; however, the Board notes that in a few instances, the Veteran reported on both his symptoms and his resulting impairment (e.g. describing himself as "thoroughly and completely nonfunctional" upon returning from overseas). The Board acknowledges the Veteran's education and training as a physician's assistant, and that he is certainly competent to report some things, including symptoms of his anxiety disorder that come to him through his senses; however, he has not shown that he has specialized education or training in psychiatrics such that he is competent to determine the overall level of impairment resulting from his symptoms. See Layno v. Brown, 6 Vet. App. 465, 469-470 (1994); Jandreau v. Nicholson, 492 F.3d 1372, 1376-1377. Therefore, his reports of his resulting impairment are afforded less probative value than the objective psychiatric medical evidence of record. At the time of the May 2019 examination, the Veteran had been married for 37 years and reported having significant problems with his wife and no social support. He reported working as a physician's assistant overseas on and off since June 2015, typically home only twice a year for 30 days at a time, though he noted that he had been on "workman's comp" since breaking his foot in March 2019. He also noted that he considers his reported symptoms, discussed below, as helpful when working overseas. As related to his alcohol use disorder, he reported drinking a fifth of a bottle of wine nightly "to get started," and if he was still angry, he would drink another fifth of a bottle. The Veteran reported psychiatric symptoms, including irritability and anger, sweating, palpitations, racing heart, short temper, and irrationality, and noted that these symptoms occur two to three times a week but did not occur when overseas. He denied symptoms of depression, including hopelessness, worthlessness, and any self-esteem problems while overseas. The examiner documented that the Veteran experienced anxiety, suspiciousness, panic attacks more than once a week, and difficulty in establishing and maintaining effective work and social relationships as symptoms of his anxiety and alcohol use disorders, separately noting that the Veteran has some mild problems with concentration and some reports of memory problems (though the examiner determined that the medical records do not evidence significant problems with memory). The examiner also noted that there was no noted cognitive symptomology or deficits in the medical record. The examiner determined that the severity and duration of the Veteran's symptoms resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. Regarding behavior, the examiner observed that the Veteran had fair hygiene and grooming, appeared suspicious and attempted to commandeer the evaluation, required redirection stay on topic and exhibited euthymic mood, agitated affect, and normal speech. The Veteran denied any suicidal or homicidal ideation and auditory or visual hallucinations. The May 2019 examiner also provided a medical opinion addressing the resulting occupational and social impairment from the Veteran's service-connected anxiety disorder in more detail. She determined that at the time of the evaluation, the Veteran's mental conditions did not significantly interfere with his ability to function in an occupational environment, and he reported no impairments in his occupational functioning. She further noted the Veteran's reports that his symptoms dissipate in a hostile zone while working overseas and that he has some difficulty interacting in a social environment due to his mistrust of nonmilitary personnel, angry disposition, and avoidance of crowds, which may result in some difficulties interacting with nonmilitary individuals. The day before the May 2019 VA examination, the Veteran obtained and submitted a psychological assessment completed by a VA psychologist, Dr. K.L., whom he briefly served with in the Florida National Guard. Dr. K.L. documented the Veteran's reported symptoms, including avoidance, hypervigilance, hyperarousal, intrusive recollections, reactivity to triggers, isolation, withdrawal, anger and irritability, insomnia, and difficulty with crowds or being in exposed positions/situations. Dr. K.L. concluded that the Veteran exhibited all criteria necessary for a PTSD diagnosis pursuant to the Clinician-Administered PTSD Scale (CAPS-5) under the DSM-V, specifically determining that the Veteran's statements demonstrated the following symptoms: Intrusive symptoms, including severe recurrent memories, moderate recurrent distressing dreams, severe dissociative reactions twice per week, extreme intense prolonged psychological distress at least 15 times in the month prior, and severe marked physiological response. Avoidance symptoms, including extreme avoidance of distressing memories occurring every day, several times a day and extreme avoidance of external reminders. Negative alterations in cognitions and mood, including severe inability to remember two to three important aspects of the traumatic event, severe persistent and exaggerated negative beliefs about oneself or others, moderate persistent and distorted cognitions about the cause of the traumatic events, severe persistent negative emotional state, severe markedly diminished interest or participation in significant activities, extreme feelings of detachment or estrangement, and severe persistent inability to experience positive emotions. Marked alterations in arousal and reactivity, including extreme irritable behavior and angry outbursts, moderate reckless or self-destructive behavior, extreme hypervigilance, markedly elevated exaggerated startle response, severe problems with concentration, and extreme sleep disturbance. As to marked alterations in arousal and reactivity, the Board notes that the Veteran reported, and Dr. K.L. documented, a statement that the Veteran "can't work anymore," "can't retain new information," and that the only work for him "here" as a physician's assistant seems to be primary care. Regarding behavior and other observations, Dr. K.L. observed that the Veteran was neatly dressed and casually groomed with clean personal style, presented as alert and oriented to time, place, person, and situation, demonstrated a good fund of recent knowledge, became emotionally agitated while recounting traumatic events but was redirectable and able to calm himself, and provided consistent and tempered responses demonstrative of his maturity. He further noted that the Veteran credibly denied any auditory or visual hallucinations, past or current suicidal or homicidal ideation, and/or any history of suicide or homicide attempts. Dr. K.L. ultimately opined that the Veteran "is clearly experiencing a [s]evere level of emotional distress at this point with [s]evere impact on his vocational, social, educational and intimate life." He noted that the Veteran provided medical records for review, and much of the Veteran's reports were backed by official documentation, but did not specifically note whether he reviewed the Veteran's complete treatment records, prior VA examinations, and/or his statements submitted to VA. Dr. K.L. also noted that the Veteran submitted typewritten summaries of recent past events; however, it is unclear if these summaries are statements previously submitted to the Board or new summaries not associated with the claims file. The Board finds the May 2019 psychological assessment by Dr. K.L. to be of limited probative value. First, the evidentiary value of Dr. K.L.'s opinion is reduced by his failure to identify and specifically cite or discuss supporting or contradicting evidence in the Veteran's treatment records, prior VA examination, and/or prior statements submitted to VA and is reduced by the overall unclear extent of records he was provided to review in making his overall opinion. To be adequate, a medical opinion must (1) be based upon consideration of the veteran's prior medical history; (2) describe the disability in sufficient detail so that the Board's "evaluation of the claimed disability will be a fully informed one," Ardison v. Brown, 6 Vet. App. 405, 407 (1994) (quoting Green v. Derwinski, 1 Vet. App. 121, 124 (1991); and (3) "support its conclusion with an analysis that the Board can consider and weigh against contrary opinions." Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Here, Dr. K.L. did not cite any records, examinations, or statements, and merely noted that he reviewed records provided by the Veteran. This failure either to cite or to discuss treatment records and/or the prior VA examination from the period on appeal suggests that the opinion is not based on full consideration of the Veteran's prior medical history. Second, the evidentiary value of Dr. K.L.'s opinion is further reduced by the conclusory nature of his findings. While Dr. K.L. opined that the Veteran's emotional distress has a "[s]evere impact on his vocational, social, educational and intimate life," and quoted statements from the Veteran which he determined represented varying symptoms of different severity and frequency, he did not explain how he came to this conclusion. For instance, despite this conclusion, the Dr. K.L. included no discussion of occupational impairment, with the only reference of occupational impairment limited to the Veteran's inconsistent report of not being able to work. Dr. K.L. did not reconcile, nor even reference, the Veteran's reports in his treatment records and at a prior VA examination that he "feels at home" while working overseas and describes it as somewhere that made sense to him with his report at the assessment that he could no longer work. See Swann v. Brown, 5 Vet. App. 229, 233 (1993) (Board may reject a medical opinion because other facts present in the record contradict the facts provided by the veteran that formed the basis for the opinion). Moreover, the Board notes that the occupational impairment determination within Dr. K.L.'s conclusion is drastically different than the May 2019 VA examiner's occupational impairment determination made only a day later. Whereas Dr. K.L., documented the Veteran's reports of occupational impairment and determined that there was a severe impact on the Veteran vocational and educational impairment, the May 2019 VA examiner determined that the Veteran's anxiety disorder did not significantly interfere with his ability to function in an occupational environment, and noted that the Veteran reported no impairments in his occupational functioning. Separately, the Board notes that Dr. K.L. did not reference the General Rating Formula for Mental Disorders in making his findings and conclusion, and he did not make any conclusion aligned with it. While his lack of reference to or reliance on the General Rating Formula for Mental Disorders does not reduce the probative value of his opinion in and of itself, it further muddles what factored into his conclusion that the Veteran's emotional distress has a "[s]evere impact on his vocational, social, educational and intimate life." As such, the Board finds that the conclusory nature of Dr. K.L.'s findings, the inconsistency of his conclusions with the VA examination and opinion provided only a day later, and his failure to address any of the Veteran's prior treatment records or his prior VA examination undercut his overall opinion as to the severity of the Veteran's occupational and social impairment. Nonetheless, the Board finds some of the Veteran's statements documented in Dr. K.L.'s assessment to be probative of the severity of his psychiatric symptoms and indicative of his resulting occupational and social impairment. Specifically, the Board finds that the Veteran's statements directly quoted in the evaluation report align with symptoms such as some impaired impulse control with no evidence of unprovoked irritability with periods of violence, panic attacks more than once a week, some memory issues and problems with concentration, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and chronic sleep impairment. The Board acknowledges the Veteran's representative's argument that the May 2019 VA examiner did not take into account all symptoms associated with PTSD that affect the Veteran's social and occupational abilities as the type of VA examination provided (i.e. a general mental disorders examination rather than a PTSD examination) did not accurately reflect the Veteran's symptomatology. However, as noted above, the Veteran is not currently service-connected for PTSD, and service-connection for PTSD is not before the Board. If the Veteran is seeking service-connection for PTSD, he should file a Supplemental Claim. Nonetheless, the Board has considered all mental health symptoms reported by the Veteran and documented in the objective medical evidence of record in determining whether a higher rating is warranted. The Board has also considered statements submitted by both the Veteran and his wife. In a February 2017 statement, the Veteran stated that after every tour, his anxiety level would increase and his relationships with others would degrade. He reported issues with his temper, irritability, anger, and not wanting to interact with others, and indicated that he was constantly on alert, did not have many friends, could not relate to others, was stressed, was constantly aware of his surroundings, and worked to escape his thoughts. He noted that his relationship with his wife had suffered. In another February 2017 statement, the Veteran's wife reported that he was always on alert; could not be around people or in crowds; could not get together with friends or neighbors; could not tolerate someone bumping into him; would react if he startled and go into "attack mode"; was unpredictable; had a temper; had a strained relationship with his kids; was restless; and had issues with memory. After review and weighing of the lay and medical evidence, the Board finds that the severity, frequency, and variety of the Veteran's anxiety disorder symptoms, including irritability, circumstantial, circumlocutory, or stereotyped speech, panic attacks more than once a week when stateside, some memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, suspiciousness, and chronic sleep impairment, resulted in occupational and social impairment with reduced reliability and productivity from the start of the appeal period. In making this conclusion, the Board found the treatment records particularly probative and the January 2017 and May 2019 assessments less probative, as these records document contemporaneous reports of symptoms and behavioral observations, whereas the assessments, particularly the May 2019 assessment, relied significantly on history of symptoms reported by the Veteran. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (holding that contemporaneous evidence has greater probative value than history as reported by a claimant). The Board also found the May 2019 VA examination probative, as it was based on a complete review of the Veteran's claims file, accurately addressed the Veteran's work situation, and provided detailed discussion of the Veteran's symptoms, behavior, and overall occupational and social impairment. The Board found the January 2017 and May 2019 assessments and opinions to be of limited probative value for the reasons detailed above. The Board recognizes that the Veteran reported, and the objective medical evidence of record noted, some symptoms aligned with the 70 percent rating criteria, but finds that the occupational and social impairment resulting from his symptoms, viewed in the cumulative, does not expand to deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. For instance, as to "neglect of personal appearance and hygiene," while the May 2019 VA examiner categorized the Veteran's hygiene and grooming as "fair," there are no other indications of any deficiencies in hygiene or grooming in the record, and he was observed as neatly dressed and groomed on two other occasions. Additionally, while the January 2017 and May 2019 assessments may have implied that the Veteran's anxiety symptoms include "near-continuous panic or depression affecting the ability to function independently, appropriately and effectively" while stateside, this symptom is not evidenced in the Veteran's contemporaneous treatment records. Instead, as the evidence consistently indicates that the Veteran's symptoms dissipate when he is overseas, such that he describes himself as "perfectly fine," and as he worked overseas for the majority of the time throughout the appeal period, the Veteran's panic and depression does not approach "near-continuous." Similarly, while the Veteran and his wife have reported that the Veteran has impaired impulse control (such as when he reported closing his 25-year-old bank account over a rude employee), there is no evidence of unprovoked irritability with periods of violence. As to suicidal ideation, the Board notes that the 70 percent rating criteria do not distinguish between active and passive suicidal ideation and that, in some cases, the mere presence of suicidal ideation (ranging from passive thoughts of one's own death to active thoughts of engaging in suicide-related behavior), may cause occupational and social impairment with deficiencies in most areas. See Bankhead v. Shulkin, 29 Vet. App. 10 (2017). The key word in that finding from the Bankhead decision is "may" which is merely suggestive. Thus, the Court declined to hold that the presence of suicidal ideations automatically entitles a veteran to a 70 percent evaluation under the rating criteria in every situation. Here, the Board finds that the Veteran's single reference to passive suicidal ideation at the January 2017 assessment, compared to his consistent denial of suicidal ideation across VA treatment and examinations, is insufficient to make the Veteran's overall symptoms and impairment more closely approximate the next-higher, 50 percent rating criteria for any portion of the appeal period. The Veteran's single report and several denials of suicidal ideation, taken as a whole, and considered alongside his 34-year marriage at the start of the appeal period and continued employment as a physician's assistant, indicate that the impact of any passive suicidal ideation, as well as his other psychiatric symptoms, does not warrant a rating higher than 50 percent. The Board also recognizes, as previously referenced, that the symptoms listed in the rating criteria are not exhaustive, and symptoms contemplated by lower rating criteria may represent a higher rating depending on their frequency, severity, and duration. See Mauerhan, 16 Vet. App. at 442; Vazquez-Claudio, 713 F.3d at 118. Here, while there is evidence of depressed mood, problems with concentration, increased irritability and volatility, paranoia, suspiciousness, social isolation, avoidance, nightmares, problems with efficiency at work related to sleepiness, lack of energy, fatigue, difficulty interacting with nonmilitary individuals, angry disposition, and memory problems, these symptoms are not of such frequency, severity, or duration such that a higher rating is warranted. Again, the Veteran, VA examiners, and Dr. M.C. have all indicated that the Veteran's symptoms mitigate or dissipate while working overseas, which he does for 105 days at a time with 35 days off between rotations. While the Veteran's symptoms may be more frequent, more severe, and last longer when the Veteran is stateside, because the Veteran is stateside only (approximately) a third of the time, this frequency, severity, and duration while stateside does not warrant a higher rating. (Continued on the next page) Even more, it is not symptoms alone that warrant a certain rating, but the resulting impairment. While the Veteran may have experienced some symptoms contemplated by a 70 percent rating, and symptoms of higher frequency, severity, and duration while stateside, the overall evidence demonstrates that he has been able to maintain a job as a physician's assistant and a marriage of more than 34 years. The evidence does not demonstrate the level of impairment associated with a 70 percent or higher rating. The Veteran reported only one instance of passive suicidal ideation, and the overall evidence indicates that the Veteran's anxiety disorder has not manifested as obsessional rituals, intermittently illogical/obscure/irrelevant speech, impaired impulse with periods of violence, spatial disorientation, difficulty in adapting to stressful circumstances with work or a worklike setting, and/or inability to establish and maintain effective relationships, nor has the Veteran's anxiety disorder manifested as any symptoms contemplated by a 100 percent rating. Accordingly, the Board finds that throughout the appeal period, the Veteran's anxiety disorder manifested as occupational and social impairment with reduced reliability and productivity as contemplated by a 50 percent rating. The Board further finds that the Veteran's anxiety disorder did not manifest as occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood as required by the next higher rating, and his symptoms were not of such severity or variety to indicate that the resulting occupational and social impairment is not fully contemplated by a 50 percent rating. RAY BARTO SLABBEKORN, JR. Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Tierno The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.