Citation Nr: 21009649 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 14-22 485 DATE: February 23, 2021 ORDER Entitlement to an increased rating in excess of 10 percent for right knee osteoarthritis with meniscal tear is denied. Entitlement to an increased rating in excess of 50 percent prior to July 17, 2015 for posttraumatic stress disorder (PTSD) is denied. Entitlement to an increased rating of 70 percent, but no higher, from July 17, 2015 to February 10, 2020 for posttraumatic stress disorder (PTSD) is granted. Entitlement to a rating in excess of 70 percent since February 10, 2020 for PTSD is denied. FINDINGS OF FACT 1. The Veteran’s right knee disability has not manifested to flexion limited to 60 degrees or less, extension limited to 5 degrees or more, ankylosis, or fibula and tibia impairment. 2. Prior to July 17, 2015, the probative evidence of record shows the Veteran’s PTSD was primarily manifested to 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 impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 3. From July 17, 2015, the Veteran’s PTSD has manifested by occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking or mood due to such symptoms as suicidal ideation; near continuous panic or depression affecting the ability to function independently, appropriately, and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; inability to establish and maintain effective relationships; mild memory loss; and occasional hallucinations. CONCLUSIONS OF LAW 1. The criteria for an increased rating in excess of 10 percent for right knee osteoarthritis with meniscal tear have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.105, 3.344, 4.71a, Diagnostic Codes 5256-5263. 2. The criteria for an increased rating in excess of 50 percent prior to July 17, 2015 for posttraumatic stress disorder (PTSD) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.125, 4.126, 4.130, Diagnostic Code 9411. 3. The criteria for an increased rating of 70 percent, but no higher, from July 17, 2015 to February 10, 2020 for posttraumatic stress disorder (PTSD) have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.125, 4.126, 4.130, Diagnostic Code 9411. 4. The criteria for a rating in excess of 70 percent since February 10, 2020 for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.125, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from March 1969 to October 1970. In a March 2018 Board decision, the Board granted a rating of 50 percent for the entire appeal period for the Veteran’s PTSD and remanded his increased rating claim for right knee disability. The Veteran appealed the Board’s decision with respect to the assigned rating for PTSD to the United States Court of Appeals for Veterans Claims (Court) and in an April 2019 Joint Motion for Partial Remand (JMPR), the Court granted the parties’ motion to vacate the March 2018 decision only to the extent of the denied rating in excess of 50 percent for PTSD and remanded the case to the Board. The claims were again brought before the Board in September 2019 and August 2020 and were remanded for further development. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran’s service-connected disability adversely affects his/her ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Additionally, when 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). In a claim for a greater original rating after an initial award of service connection, all of the evidence submitted in support of the veteran’s claim is to be considered. See Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2. However, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. See Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). Further, when evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). Lastly, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran’s capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126 (a) (2019). When evaluating the level of disability from a mental disorder, VA also will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (b). 1. Entitlement to an Increased Rating: Right Knee Osteoarthritis with Meniscal Tear The Veteran service-connected right knee disability is currently rated as 10 percent disabling under Diagnostic Code (DC) 5260 for limitation of flexion. Diagnostic Code 5260 provides for a non-compensable rating where flexion is limited to 60 degrees; a 10 percent rating where flexion is limited to 45 degrees; a 20 percent rating is warranted where flexion is limited to 30 degrees; and a 30 percent rating is warranted where flexion is limited to 15 degrees. See 38 C.F.R. § 4.71a, DC 5260. In March 2011, the Veteran received a VA examination and reported an increase in severity and frequency of pain, especially with activities. He reported that the pain was an aching and full pain that was shooting at times. He reported difficulty in sitting for long periods and more stiffness. His symptoms were noted as causing a mild impact on daily activities. He reported occasionally taking Aleve for pain. The Veteran’s symptoms were noted as pain, giving away, stiffness, popping, decreased speed of joint motion, and tenderness. There was no instability, weakness, incoordination, subluxation, effusion, or locking episodes. There were no flare-ups of joint disease. The Veteran was noted as being able to stand more than one hour but less than 3 hours, and able to walk more than one fourth of a mile but less than a mile. His gait was antalgic. His range of motion (ROM) was forward flexion to 95 degrees, and extension was normal. There was no objective evidence of pain following repetitive motion or limitations following three repetitions. There was no joint ankylosis or meniscus abnormality. In August 2012, the Veteran was provided another VA examination. The Veteran reported difficulty in sitting for long periods and difficulty with prolonged standing or walking. He reported flare-ups that occurred when walking down hills. The Veteran’s ROM was forward flexion to 120 degrees with pain and no limitation in extension. The Veteran was able to perform repetitive testing with at least three repetitions and did not suffer additional loss in ROM after. The Veteran did suffer from additional loss due to pain on movement. There was pain on palpation noted. The Veteran did not suffer from recurrent subluxation or dislocation or shin splints. Joint stability testing was normal. The Veteran was not found to have any meniscal conditions. Tenderness over the medial side of the knee was noted. The Veteran did not have need for assistive devices. The Veteran received another VA examination in September 2017. The Veteran did not report flare-ups. He did report having functional loss or impairment in not being able to move as fast as he used to. He also reported difficulty standing or stooping and pain with driving long distances. The Veteran’s ROM was noted as all normal. There was no evidence of pain on weight bearing, localized tenderness or pain on palpation, and no crepitus. The Veteran was able to perform repetitive testing with at least three repetitions and did not suffer from additional loss or limitation of ROM following repetitions. The examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time. The examiner noted he was unable to determine if pain, weakness, fatigability, or incoordination significantly limited the Veteran with repeated use over a period of time without resorting to mere speculation due to not observing the Veteran following repeated use over time. Additional contributing factors were noted as disturbance of locomotion and interference with standing. The Veteran also related pain with extended walking and standing. The Veteran had full muscle strength. There was no muscle atrophy or ankylosis. There was no history of recurrent subluxation, recurrent effusion, and no joint instability. The Veteran was noted to have a right meniscal tear. The Veteran did have regular use of a brace and stated that it helps with stability. There was no evidence of pain on passive ROM or pain when joint is used in non-weight bearing. In September 2019, the Veteran received a VA examination. The Veteran reported pain after standing for long periods of time, which he does as a church greeter for sometimes for 3 hours at a time. He reported pain that was dull and achy and feeling like his knee might give away when descending stairs or inclines. He did not report catching or locking on inclines. He reported that some walking hurts at times and not at others. The Veteran reported that his knee condition has consistently progressed and there is no period of time where his right knee does not hurt him, and therefore, marked no for flare-ups as his pain is constant with occasional locking of his knee. The Veteran reported functional loss pain in full extension, full flexion and prolonged standing. The Veteran’s range of motion (ROM) was forward flexion to 125 degrees and normal extension. Pain was noted on both flexion and extension and caused functional loss. There was evidence of pain with weight bearing and localized tenderness. There was objective evidence of crepitus. The Veteran was able to perform repetitive testing with at least three repetitions with no functional loss. The examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time. Pain, and fatigue did significantly limit the Veteran with repeated use over time and decreased his forward flexion to 90 degrees. The Veteran had full muscle strength. There was no muscle atrophy and no ankylosis. He did not have recurrent subluxation, recurrent effusion, lateral instability, or joint instability. The Veteran did have a meniscal tear condition with frequent episodes of joint locking and pain. The Veteran did not have use of assistive devices. There was pain on passive range of motion. However, there was no evidence of pain on non-weight bearing. In January 2020, the Veteran was seen at the VA Medical Center. The Veteran complained of right knee pain and swelling. He reported feeling like his knee would buckle especially while going downstairs or getting out of his truck. He reported having several episodes of knee popping that is not painful, but alarming with some tightness. He reported that Aleve helps when the pain gets bad, which is usually after standing for long periods of time. There was no catching or locking. Upon examination, there was no swelling or erythema. Quad atrophy was noted. There was mild tenderness over the medial patella border. His forward flexion was to 130 degrees with pain and normal extension. There was no instability or pain with stressing. Upon review of the evidence, the Board finds that a rating in excess of 10 percent for the Veteran’s right knee condition due to limitation of motion is not warranted. The Veteran at no time has had flexion limited to 30 degrees or less, nor did he have less than full extension, ankylosis of the knee, cartilage removal, impairment of his tibia and fibula, or genu recurvatum, which would warrant consideration of a higher or additional separate rating under another Diagnostic Code for the Knee and Leg. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5259-5263. Further, although the Veteran has had occasional need for a brace, the Veteran has consistently had normal strength and has not reported a constant need for assistive devices. The Board has also considered whether a separate rating is warranted under Diagnostic Code 5257. However, there has been no evidence of subluxation, and all of the Veteran’s joint stability tests during the appeal period have been normal. While the Veteran reported feeling like his knee would give way or buckle while going downstairs or getting out of his truck, there is no indication that his knee has actually given way or been unstable during the appeal period. Therefore, a separate rating under Diagnostic Code 5257 is not warranted. Regarding Diagnostic Code 5258, the Board acknowledges that the Veteran had a right meniscal tear during the appeal period. The evidence showed frequent episodes of joint locking and pain, but there was no evidence of any episodes of effusion throughout the entire appeal period. While the Veteran’s right knee meniscal tear had manifest some of the symptoms contemplated by Diagnostic Code 5258, it had not manifest as all of the symptoms in the rating criteria. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision means that all of the conditions listed in the provision must be met). Therefore, a separate rating for dislocated cartilage is not warranted under Diagnostic Code 5258. The Board recognizes that the Veteran has been found to be additionally limited due to pain, fatigue, and/or disturbance of locomotion. However, the Board notes that the Veteran does not currently meet the requirement of flexion being limited to at least 45 degrees as needed for a 10 percent rating, and his additional pain, fatigue and limitation of motion were considered to afford the Veteran a 10 percent rating for his right knee disability. The Board has also considered his statements of popping and a feeling his knee will buckle and/or lock while going downstairs. However, the Board notes that the Veteran reported no pain with the popping and has reported no instances of falling. Thus, the Board finds that the requirements of DeLuca were already considered and met in the rating provided. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca at 202. The Board also acknowledges the Veteran’s assertions that he is entitled to a higher rating because his symptoms are worse. The Board recognizes that lay persons are competent to provide medical opinions on some medical issues. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). However, the Board has considered the Veteran’s statements and finds them credible and consistent with the rating assigned. In light of the foregoing, the Board concludes that a rating in excess of 10 percent for right knee osteoarthritis with meniscal tear is not warranted. The benefit of the doubt doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). 2. Entitlement to an Increased Rating: PTSD The Veteran’s service-connected PTSD is rated as 50 percent disabling prior to February 10, 2020 and as 70 percent disabling thereafter under Diagnostic Code (DC) 9411 of the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, DC 9411 (2019). Under DC 9411, a 50 percent disability rating is warranted when there is 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. Id. A 70 percent disability rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. Finally, a 100 percent disability 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. Id. The Veteran submitted a statement in December 2014. The Veteran stated that he had not sought treatment for his “issues” because he felt embarrassed to talk about them. He had not shared his history or symptoms with his family members because he did not want to worry them, and he felt that sharing these symptoms would impact how he was perceived as “man of the house.” He stated that 1.5 years prior he had renewed a friendship with someone he served with in Vietnam, and who was present during a traumatic event in November 1969. He stated that this fellow veteran always wanted to talk about this traumatic event, and that it was a request the Veteran could not refuse. He stated that yet another veteran who was present during the traumatic event found him on the internet and contacted him and requested that he provide information and photographs for a book. The Veteran agreed to write down his memories, and he stated that this resulted in nightmares, flashbacks, and constant recollection of this event. He reported it has caused him to live it all over again and he has thoughts and visions of his experience day and night. The Veteran reported that he was a hunter and had loved to hunt for a number of years, and even enjoyed watching television shows about hunting. However, since his renewed recollections of the traumatic event, he could no longer handle watching hunting shows or participating easily in hunting. He stated he tried to go hunting, but he felt regret after killing the deer. The Veteran thought of reaching out to the pastor at his church but was finding it a struggle to talk to anyone. He stated he felt “inadequate as a man” that he was allowing his trauma to impact his life. The Board notes that a number of the Veteran’s lay statements address similar feelings and symptoms. The Veteran is very upset that he no longer enjoys activities he used to enjoy, and, in fact, is emotional or disturbed by hunting. This was a large part of his enjoyment and pastime that he feels he can no longer participate in. He also described how he perceived his newfound emotional reactions to hunting as emasculating. In January 2015, the Veteran was provided a VA examination. The examiner noted the Veteran’s PTSD 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. The Veteran reported he felt that he had a good marriage and that he got along quite well with his wife. He also felt he got along well with his children, and he had four grandchildren nearby that he was able to spend time with. He reported enjoying hunting, fishing, and volunteering at his church. He indicated that he had friends and family, and an overall good support system. The Veteran stated that he was no longer excited about hunting, and he felt sad for the animals that are killed, but that he feels obligated to participate for the sake of his grandson. The Veteran stated that he was retired and he currently volunteers as a union representative for the state. He stated that he expresses his anger in ways that are disruptive to the family. The Veteran was not receiving any mental health treatment and he was not prescribed any medications for the management of his mental health. The Veteran’s overall symptoms were depressed mood and anxiety. The Veteran was fully oriented and had adequate hygiene and appearance. His speech was normal, and he denied suicidal and homicidal ideation or intent. His thought process was linear and there was no evidence of a thought disorder. His attention and concentration were intact. When asked about his symptoms, the Veteran stated that he was trying to manage his PTSD symptoms without treatment. He acknowledged that he had a friend who frequently wanted to talk about their war experience, and it made the Veteran uncomfortable. He endorsed having intrusive thoughts more regularly, and the Veteran was tearful when discussing these memories. He stated he was unsure of how to tell his stories to others, and that he wished to not talk about them. He continued to have some nightmares, dependent on triggers. He would become “sad” when his memories are triggered. As his one traumatic experience occurred in November 1969, he tends to become more emotional and had increased episodes of re-experiencing during the holiday season. He endorsed continued symptoms of negative alterations in cognitions and mood, as well as arousal. He endorsed guilt and stated that he was easily irritated and annoyed. His sleep was variable, but on good nights he was able to sleep 7 to 8 hours. The examiner noted that the Veteran was pleasant and cooperative and was forthright in providing the information in the current report. The examiner noted that the Veteran’s symptoms continue to result in mild range impairment. In July 2015, the Veteran submitted a statement. The Veteran reported not having much medical information due to not wanting to discuss his issues with anyone and being embarrassed. He stated that he does not think about killing himself; however, he does ask “God” to take his life often. He reported being angry easily and trying to control it. The Veteran reported that the examiner did not give him the opportunity to explain how his in-service trauma still affects him. He described how it has affected the things he used to enjoy such as hunting, watching television, and doing things with family members. He reported not being able to watch anything where something or someone is killed. He reported reliving his trauma daily. In August 2015, the Veteran was seen at the VA medical center. The Veteran reported an increase in intrusive thoughts. He reported he recently met with two friends from his service and it triggered memories. He reported difficulty sleeping and not taking medication. The Veteran had not experienced any delusional grandiosity, hyper-religiosity, hyper-sexual thoughts, or period of euphoria lasting 7 days or more. The Veteran reported taking about 1 to 2 hours to fall asleep at night and waking up 2 to 5 times a night. He reported staying awake for 1 to 2 hours once awoken. He reported having nightmares about once a month or rarely. He reported waking up earlier than he wanted several times a week. The Veteran was noted as having moderate sleep impairment. The Veteran then underwent a suicide risk assessment. The Veteran had no paranoid delusions, no auditory hallucinations, and no visual hallucinations. He did not have any substance abuse. The Veteran reported not having feelings of hopelessness about the present or future and not having thoughts about taking his own life. He reported not having a plan to take his life and never attempting suicide. The physician noted the Veteran’s warning signs were feeling trapped like there was no way, withdrawing from friends, family, and society, as well as anxiety and agitation. Factors that decreased the Veteran’s risk were positive social support, sense of responsibility to family, life satisfaction, positive coping skills, positive problem-solving skills, reality testing ability, and active participation in treatment planning. The Veteran was determined to be a low risk level for suicide. The Veteran was noted to be neatly groomed. He was alert and oriented to person, place, time, and situation. His attitude was collaborative and unguarded. His mood was depressed and anxious. His affect was blunted and congruent with mood. His thought process was goal-directed and logical. His speech was soft and quiet. The examiner noted the Veteran had increasing depression due to increased intrusive thoughts, as well as sleep problems. The Veteran did not want medication or counseling. In July 2016, the Veteran was provided a psychological evaluation. The Veteran reported an increase in his symptoms, to include an increase in distress. He reported not discussing any of his trauma with his family and was unsure how to tell his grandson he was uncomfortable with hunting. He reported hunting caused him to have emotional distress associated with his memories. The Veteran again reported that he did not want medication but stated he would consider possible therapy options. The psychologist noted the Veteran was pleasant, attentive, and cooperative. His speech was goal-directed, and his thought processes were logical and rational. He had no current suicidal or homicidal ideations. His affect was somewhat dysthymic and consistent with reported mood. There was no evidence of any psychotic symptoms. His insight and judgment were good. In an August 2016 letter, the Veteran reported that he relived the event in service several times every day. He expressed wonder at why he was allowed to live instead of a fellow servicemember, and it made him want God to take him out of this world every day. He indicated that he did not believe himself to be suicidal, but he did desire to die at times. He reiterated that he was too embarrassed to share the traumatic events with family and friends. An August 2017 letter from the Veteran described the impact of the in-service trauma as preventing him from enjoying things that he once did and that he had a desire for God to take him out of the world. He had a fear of sharing this with his friends because of memories he didn’t want to have. He indicated that dying would be a relief. In September 2017, the Veteran was afforded another examination. The examiner noted the Veteran’s PTSD caused occupational and social impairment with reduced reliability and productivity. The Veteran reported still being married to his second wife. However, he reported that it has not been easy and thinks a lot of it is due to himself. He reported having a “really good” relationship with his daughter, and an improving relationship with his stepson. He reported having a real good relationship with two of his grandchildren. He stated that he has friends. He reported not having interest in hunting anymore. He does continue to work in his yard and volunteer at church every week, which he enjoys. He complained of not understanding why he can’t think of any positive thoughts of his time in Vietnam. The Veteran’s overall symptoms were depressed mood, anxiety, suspiciousness, chronic sleep impairment, and disturbances of motivation and mood. The Veteran was oriented to all spheres. His speech was normal in rate and rhythm. His hygiene and appearance were adequate. His mood was pleasant with congruent affect and he was noted as tearful at times. His thought processes were linear and there was no evidence of a thought disorder. He denied any current suicidal or homicidal ideations, plans, or intents. His attention and concentration appeared intact. The Veteran was found capable of handling his own financial affairs. The examination report included information of non-psychological testing that was performed. The examiner noted that the Veteran’s overall level of functioning appeared to have somewhat worsened since his last examination. The examiner found the Veteran appeared to function with moderate range impairment with reduced reliability and productivity. The examiner noted that the Veteran would benefit from having a mental health provider to talk to. In December 2017, the Veteran was seen at the VA medical center for a psychological evaluation. The Veteran complained of more frequent intrusive thoughts. He reported experiencing the events his in-service trauma daily, with more details being remembered. The Veteran showed slight psychomotor agitation when discussing his trauma. He reported irritability and “snapping” about “little things.” He reported this has caused marital issues. He denied any physical violence. He reported passive thoughts of suicide in the form of thinking he was better off dead. He reported being able to experience happiness sometimes. He described avoidance of people and instances of extreme irritability towards others while driving. He reported his mood as feeling down. He reported waking from his sleep often and only getting 4 or 5 hours of sleep a night. He did not report nightmares. He reported his energy level as low and a lack of desire to engage in his hobbies anymore. The Veteran did not report feelings of hopelessness or thoughts of taking of his own life. He reported no plan or attempts to kill himself. The Veteran’s appearance was well kempt. He was oriented to person, place, and time. His attitude was cooperative, and his behavior was calm. His speech was normal in tone, rate, and volume. His mood was dysthymic. His affect was stable and congruent with his mood. His thought process was linear, organized, and tangential. His thought content was appropriate to mood and circumstances. He reported hallucination in the form of movement in the corner of his eyes. He denied homicidal ideation. He reported impaired recent memory of train of thought, names, and time. His attention was attentive. His judgment was impaired in his ability to make routine decisions. The Veteran was not found to be a suicide risk. The Veteran received another psychological evaluation in August 2018. The Veteran reported being on an antidepressant. He denied any suicidal or homicidal ideations. He was dressed appropriately and well groomed. His thought content was of his physical ailments and fatigue. The Veteran was disoriented to time. His attitude was cooperative yet guarded. His behavior was calm. His speech was normal in tone, rate, volume, and amount. His mood was dysphoric. His thought process was linear, organized, and goal directed. His thought content was appropriate. He denied hallucinations and homicidal ideations. His memory was impaired to recent memory. His insight was fair with self-awareness. His judgment was normal. In a June 2019 letter, the Veteran reported that he had issues with anger and that he had put his wife through “living hell” at times. He stated that so many times he wanted to die and leave this world, that everyone would be better off without him, and that he had asked God to let him die. He indicated that killing himself would make things worse and that he wished to instead get killed in an accident or have a sudden death from some illness. In October 2019, the Veteran was seen at the VA medical center. The Veteran was oriented to person, place, time, and situation. He was casually dressed and well groomed. His mood was anxious to irritated. His speech was tangential. He endorsed thoughts of suicide but denied plans or intent to harm himself or others. He denied current delusions or hallucinations. The Veteran reported heightened levels of anxiety and depression. He reported a time many years ago where his daughter walked in on an episode where he planned to kill himself. He reported his reason for wanting to die was to end his suffering and his reason for living was his family, kids, and grandkids. He reported finding it helpful to have someone to talk about his feelings. The Veteran reported feelings of wishing he were dead. He reported no thoughts of actually killing himself or intentions or plans. In February 2020, the Veteran was provided a VA examination. The examiner noted the Veteran’s condition caused occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, and thinking and/or mood. The Veteran reported living with his wife off and on, and his marriage currently not being comfortable. He reported getting easily angered with their dog. He reported still attending church regularly and friends he still spoke to at church. He reported having intrusive memories throughout the day and recalling more details. He reported that when he has these vivid memories he gets down and depressed. He reported feelings of guilt and tightness in his body. He reported not participating in his hobbies anymore and not being proud of his service anymore. He denied active suicidal thoughts but stated that “death doesn’t scare him.” He reported a lot of passive suicidal thoughts. He stated his daughter as one of the reasons he would never plan a suicide. He reported crying spells and being angry most of the time. He reported being easily angered and anger outbursts that can range from two to three times a week to once a couple of weeks. He reported yelling, swinging arms, and cussing a lot. He reported feeling numb often and that his concentration was terrible. He reported seeing movement out of the corner of his eyes several times a week and when it occurs, it brings him to be alert. He reported his PTSD as an 8 out of 10, with 10 being extreme. He reported feeling like a failure. The Veteran’s overall symptoms were depressed mood, anxiety, suspiciousness, chronic sleep impairment, flattened affect, disturbance of motivation and mood, persistent delusions and hallucinations, and neglect of person appearance and hygiene. The Veteran was casually dressed and fairly groomed. His beard was disheveled. He was oriented to person, place, time, and situation. His speech was appropriate in rate, rhythm, and volume. His thoughts were linear and logical. His eye contact was fair. His mood was depressed, and his affect was flat and congruent to mood. He did not exhibit memory problems or psychosis during the evaluation. His insight and judgment were fair. The Veteran was found capable of handling his own financial affairs. The examiner noted that mental state testing showed the Veteran had no cognitive impairment. However, results were indicative of severe depression. After review of the evidence of record, the Board finds that rating in excess of 50 percent prior to July 17, 2015 is not warranted. During this period, the Veteran’s PTSD was primarily manifested by depression, anxiety, chronic sleep impairment, hypervigilance, irritability, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Further, while the Veteran has difficulty in adapting to stressful circumstances and work situations, the evidence consistently shows that the Veteran has not experienced obsessional rituals which interfered with routine activities; speech that was illogical, obscure, or irrelevant; spatial disorientation; neglect of personal appearance and hygiene, or near-continuous panic affecting the ability to function independently, appropriately and effectively. Although the Veteran reported depression throughout the period, it did not manifest to the level of severity of being near-continuous and affecting the Veteran’s ability to function independently, appropriately, and effectively. In fact, the Veteran reported continuing to go to church and perform yard work during this period. While the Veteran had problems relating to others, he did not demonstrate a complete inability to establish and maintain effective relationships, as he reported having a good relationship with his wife, daughter, and grandson, and reported enjoying spending time at church. Further, while he reported being irritable and easily angered, the Board notes the Veteran did not report any outbursts, instances of violence, or legal issues during this period. Additionally, the Veteran was noted as having normal speech, thought processes, and judgment. He also did not report hallucinations or delusions and was always noted as being oriented. Therefore, the Board does not find that the overall frequency, severity, and duration of the Veteran’s PTSD rises to the level of severity as needed for a 70 percent or 100 percent rating. However, the Board finds that a 70 percent rating from July 17, 2015 is warranted. From July 17, 2015, the Veteran began reporting an increase in irritability to the point of having outbursts and consistently reported suicidal passive thoughts, including in July 2015, August 2016, August 2017, December 2017, June 2019, and October 2019. Moreover, the Veteran began to report memory impairment and occasional hallucinations during this period. The Veteran further reported a diminished relationship with his wife and was occasionally noted as having impaired judgment and being disoriented to time. Thus, the Board finds that overall evidence of record shows the Veteran’s symptoms rise to the level of deficiencies in most areas from July 17, 2015. However, the Board finds that the evidence of record does not support a rating of 100 percent at any time during the pendency of the appeal. While the Veteran had problems relating to others, he has maintained a relationship with his wife, albeit strained, his daughter, and two of his grandchildren, as well as reported having friends at church. The Veteran has also consistently been found to be cooperative with primarily good judgment and thoughts intact. Although the Veteran was reported as having a disheveled look during his February 2020 examination, the Veteran has consistently been noted as being appropriately dressed and groomed, to include during the aforementioned examination, as well as during his routine VA medical center visits. Thus, the Board finds the majority of the evidence does not show that the Veteran had intermittent inability to perform activities of daily living. Further, the Veteran has reported continuing to watch television and participate in church. The Board recognizes that the Veteran has endorsed suicidal passive ideation. However, the Veteran has consistently reported no intent or plans, and often denied any suicidal ideation during his VA treatment visits, thereby not demonstrating that he was a persistent danger to himself. The Board acknowledges the Veteran’s statements that he has angry outbursts; however, there has been no evidence of violence or irrational behavior, nor has the Veteran demonstrated that he was/is a danger of hurting others. Further, these occurrences do not appear to have grossly impaired the Veteran in his thought process/communication or caused grossly inappropriate behavior. The Board recognizes that the Veteran has sometimes endorsed hallucinations. However, the Board notes that the majority of the evidence of record does not show that these occurrences rise to the level of being persistent, as the Veteran has predominantly denied any hallucinations during his treatment visits and did not report persistent hallucinations in his most recent examination in February 2020. He also has only been noted as being disoriented to time once and has always been found to be oriented to person, place, and situation. He further has never endorsed homicidal ideation and has only been noted as having mild recent memory loss. Thus, the Board finds that a 100 percent rating is not warranted. The Board also acknowledges the Veteran’s assertions that he is entitled to a higher rating because his symptoms are worse. The Board recognizes that lay persons are competent to provide medical opinions on some medical issues. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). However, the Board has considered the Veteran’s statements and finds them credible and consistent with the ratings assigned. Accordingly, the Board concludes that a rating in excess of 50 percent prior to July 17, 2015 for PTSD is not warranted. However, a rating of 70 percent, but no higher, from July 17, 2015 is warranted. The benefit of the doubt doctrine has been considered in this determination. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). JENNIFER HWA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Negron, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.