Citation Nr: 21010431 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 17-31 849 DATE: February 24, 2021 ORDER Entitlement to an increased evaluation higher than 30 percent for posttraumatic stress disorder (PTSD) is denied. FINDING OF FACT The Veteran’s PTSD has been manifested by no more than occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks. CONCLUSION OF LAW The criteria for an evaluation higher than 30 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from March 1968 to March 1970. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously remanded by the Board in October 2020 for further development, to include a VA PTSD examination. The Board finds substantial compliance with the October 2020 remand directives. A Supplemental Statement of the Case was issued in January 2021. This appeal has been advanced on the docket pursuant to 38 C.F.R. § 20.900(c). Increased Rating Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Psychiatric disorders, however diagnosed, are rated under the General Rating Formula for Mental Disorders, and the criteria under this formula shall be considered no matter which diagnostic code is assigned. Under the General Formula for Mental Disorders, the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). Furthermore, when evaluating the level of disability arising from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. As such, the Board will consider both the Veteran's specific symptomatology as well as the occupational and social impairment associated with the rating code to determine whether an increased evaluation is warranted. 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). The Veteran’s PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. DC 9411 directs for evaluation under the General Formula for Mental Disorders. The Board will list the criteria for ratings of 30, 50, 70, and 100 percent under the General Formula, as they are pertinent to the current claim on appeal. A 30 percent rating is assigned under DC 9411 for PTSD manifested by occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks (although generally functioning satisfactorily with routine behavior, self-care, and conversation normal) due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted under DC 9411 for PTSD 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, and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned under DC 9411 for PTSD manifested by 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), or an inability to establish and maintain effective relationships. The maximum rating available of 100 percent is assigned under DC 9411 for PTSD manifested by 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, and memory loss for names of close relatives, own occupation, or own name. Entitlement to an increased evaluation higher than 30 percent for PTSD The Veteran contends his PTSD warrants a 100 percent evaluation. Turning to the evidence of record, in a Primary Care Mental Health Integration note from January 2016, the Veteran did not respond to attempts to engage him in conversation. He seemed “startled and worried, responding with yes/no answers.” His wife noted that he was forgetful, talks to himself all day, has worsened irritability, and an increase in nightmares. On mental status examination, he was casually dressed. Behavior was uncooperative, with poor eye contact. Affect was flat. Cognition was unable to assess. The Veteran was provided an initial VA Mental Health evaluation in January 2016. The Veteran was noted to have poor hearing and was not wearing his hearing aids for the evaluation. He was described as a poor historian, and much of the history was obtained from his wife and after a review of his chart. The Veteran denied feeling depressed, and noted he sleeps good sometimes. He endorsed nightmares and flashbacks, but was unable to provide much detail about this. When asked if he was anxious or worried a lot, he responded “maybe a little anxious.” The Veteran’s wife reported he talks to himself, but when asked if he was seeing or hearing anyone else in the room during the examination, he did not respond. The Veteran’s wife reported her main concern was his increased irritability at home. She also noted his memory has been poor for “years,” but it seems to be getting worse. On mental status examination, he had fair grooming and minimal eye contact, with his head hanging looking down for the majority of the interview. Speech was slowed, low volume, hard to understand at times, significant latency, and often did not answer questions at all. Affect was flat, non-reactive. Thought processes were noted as difficult to assess, given his limited speech and paucity of thought. Insight and judgment were impaired. He scored 11/30 on the Mini-Mental Status Exam (MMSE). Upon clinical evaluation, there was findings of psychomotor slowing, with profound latency in responding, lack of response, and minimal eye contact. The examiner indicated that a neurological disorder would be reasonable given the significant cognitive and motor slowing on examination. His low score on the MMSE could suggest more of a primary cognitive problem rather than a pseudodementia, as he did provide effort on the examination. This could represent a dementia process. A diagnosis of unspecified neurocognitive disorder was provided, and PTSD by history. The Veteran underwent a VA neuropsychological evaluation in March 2016 to evaluate his current cognitive status in order to assist with diagnostic clarification. The evaluation consisted of a clinical interview, review of records, and a Montreal Cognitive Assessment (MoCA). The Veteran was diagnosed with unspecified neurocognitive disorder, other stress and trauma related disorders (subthreshold PTSD), and unspecified depressive disorder. The Veteran attended the evaluation with his wife and daughter. The Veteran reported his memory as “not good.” He noted that “things get away from him,” although he could not provide examples of what he forgets. He was unable to report his dates of military service or the number of siblings he had. The Veteran’s wife reported that her primary concern was that her husband often “talks to himself,” when alone in a room. The Veteran’s wife and daughter reported that he appears to be talking to someone. When asked about this, the Veteran reported that he is “talking thoughts aloud” and not talking to anyone in particular. The Veteran’s wife also reported her husband is forgetful, primarily with short-term tasks, sad, depressed, and will often isolate himself. Both the wife and daughter mentioned the Veteran’s irritability and anger, off and on for the past 5-6 years. The Veteran reported instances of irritability and anger and also somatic depressive symptoms (e.g., sleep problems, variable appetite/weight loss, variable energy levels); however, he denied any anxiety symptoms. During the examination, the Veteran indicated that he was independent in basic activities of daily living, including helping with some household tasks and driving his wife to her medical appointments. He reported sustaining a head injury in Vietnam and he was told by a VA provider “he had nerve damage in [his] head” as a result. The examiner noted TSH, B12, and folate levels were within normal limits in March 2016. The examiner noted the Veteran was dressed in casual clothing, with adequate grooming and hygiene. His speech had slow rate, low volume, and significant latency in responding to interview questions. His affect was flat. Mood appeared dysthymic. Hearing was markedly impaired, but he did wear his hearing aids. He was fully oriented to self (name, date of birth, and age), and partially oriented to place (correct state, VA hospital, but not name the city). He was partially oriented to date and was able to name two recent U.S. presidents. The MoCA was administered and the Veteran scored 7/30. Due to the very impaired performance on that cognitive screening measure and apparent difficulty engaging with test tasks, a more comprehensive test was not administered. The examiner noted that the Veteran’s scores on cognitive screening measures (11/30 on the MMSE in January 2016 and 7/30 on the MoCA in March 2016) suggest moderate to severe cognitive impairment. His “engagement/effort during these evaluations appeared compromised, evidenced in long latencies in responding and apparent difficulty following test instructions. This may be due, at least in part, to hearing impairment and anxiety.” The examiner noted that his recent medical encounters suggest that he has experienced functional and cognitive decline, but “the extent is difficult to establish due to his limited engagement in objective testing and other evaluation procedures.” The etiology may include vascular risk factors (history of suboptimally controlled hypertension) and anxiety/affective symptoms (subclinical PTSD, poor insight and coping skills). In the context of the very limited engagement during the evaluation, “symptom exaggeration cannot be ruled out.” At a May 2016 VA mental health evaluation, the Veteran reported memory problems and feeling depressed at times. The Veteran reported Sertraline helps him feel calmer and his wife reported it has helped some of his irritability, but at times, he is still easily angered. A diagnosis of neurocognitive disorder, depressive disorder unspecified, and Vitamin D deficiency were noted. On mental status examination, he was dressed in casual clothing. He made good eye contact and was cooperative. Speech was mumbled, but able to understand. Mood was “ok.” Affect was constricted, grimacing and looking perplexed at times, however, he was more engaged during this interview. He denied homicidal or suicidal ideations. Judgment and insight were fair. Cognition was impaired. The examiner noted that since starting Sertraline, there was notable improvement. Speech was no longer latent, and he answered questions appropriately. Examiner noted MMSE or MoCA would be completed at next follow-up appointment. Sertraline would be increased to 100mg to further target depression. In a June 2016 VA visit, the Veteran’s cognitive impairment was listed as mild, and he was highly functioning at this point. The Veteran was working as a crossing guard without any issues and he was approved to continue driving and working. It was requested he wear his hearing aids at all times. See VA Medical Record Addendum, June 2016. A VA Mental Health visit from September 2016 noted the Veteran drove himself to the appointment and did not get lost. However, the Veteran did report he sometimes forgets where he is driving to. Conversation was noted as difficult, because the Veteran left his hearing aids in the car. The Veteran was working two hours a day as a crossing guard for an elementary school. Sleep was reported as better overall, but he has to get up to urinate. He reported he was no longer having nightmares. Mood was pretty good overall, but he mentioned he can sometimes become irritated by his family. Occasional brief depression was noted, but no suicidal or homicidal ideations. On mental status examination, he had good grooming and hygiene, was casually dressed. He was cooperative and responsive. Affect was mildly restricted. Thought processes were logical and linear. He denied any suicidal or homicidal ideations, visual hallucinations, or delusions. Sensorium impairment was noted. The psychiatrist noted that the Veteran’s overall PTSD symptoms were stable and/or decrease with his cognitive impairment. No mental health concerns were noted from the evaluation. He noted that the Veteran “still retains many functional capacities.” See Mental Health Note, September 2016. The Veteran was afforded a VA PTSD examination in October 2016. The examiner opined that it was not possible to determine any mental disorder diagnosis or comment on functional impairment or distress without resorting to mere speculation. Notably, the examiner felt it “was unclear if the Veteran was unable or unwilling to participate fully in the interview, as there were inconsistencies in his functioning, his cognitive abilities, and behaviors. In addition, objective psychological testing was suggestive of poor cognitive effort or malingering of cognitive deficit.” The Veteran was listed as “minimally cooperative” during the interview and testing. His report of symptoms was vague, and he appeared to have “significant difficulty answering questions. There were long delays when responding to even basic questions… Overall, he was considered a questionable informant.” The examiner stated that the Veteran was “administered a well standardized measure for symptom validity and cognitive effort that relies upon simple testing procedures passed by all but the most severely cognitively demented individuals.” The Veteran’s scores “reflected below chance level performance on all test trials. Per the test’s administration manual and normative data, any score at or below 44 on test trials is suggestive of poor cognitive effort or malingering of cognitive deficit.” The Veteran’s scores were well below the recommended cutoff and below chance level performance. The examiner noted that responding in such a below chance performance fashion requires intact recognition memory abilities, as well as executive control abilities to inhibit the correct response and monitor task performance over time. The Veteran’s behavior during the examination was noted as inconsistent with information about his current functioning. The Veteran’s behavior during the exam was listed as “suggestive of severe cognitive impairment such that he appeared unable to respond to basic questions about his name, occupation, and place of birth. At times, he appeared drowsy, confused, and disengaged. He provided very little information about his daily activities, his personal history, or mental health symptoms.” His wife was present and helped to provide additional information. However, he drove himself and his wife to the appointment, and works as a crossing guard. His wife reported he does so well at his job that the school system called him to return to work as soon as a school near his home had an opening. In addition, he is able to complete activities of daily living without problems. No diagnosed traumatic brain injury was reported. It was noted the Veteran was not wearing his hearing aids during the exam and had left them in the car “which has been consistent behavior at medical appointments per CPRS records.” He denied having problems hearing during the examination, and often responded with correct information, suggesting he was able to hear the questions being asked. The examiner noted a review of all relevant lay evidence, records available via the VA electronic medical records (CPRS), and the Veteran’s e-folder. A VA Mental Health visit from January 2017 noted the Veteran gets up at 4 a.m. when he works as a crossing guard, but otherwise sleeps well. The Veteran reported no longer having nightmares. Mood was “overall good.” He was not wearing his hearing aids. Sertraline 100mg was noted as his medication and the Veteran reported he feels like it helps him. He was also to continue Zoloft. On mental status examination, he was casually dressed, and had good grooming and hygiene. No suicidal or homicidal ideations, visual hallucinations, or delusions were noted. Affect was mildly restricted. He was cooperative, responsive, but not very articulate overall. Thought processes were noted as logical and linear. A diagnosis of PTSD, cognitive impairment was noted. Although the Veteran was positive for cognitive impairment, the psychiatrist noted he did not do a MoCA test because the Veteran was not wearing his hearing aids so he could not hear the instructions. The assessment would be administered at the next visit. A VA Mental Health visit from March 2018 noted that the Veteran drove himself to the appointment and did not get lost. He was employed as a crossing guard, working two hours a day on school days. He described his sleep as “so-so,” having to get up often to urinate. No bad nightmares since the last visit were noted. Active medications were Sertraline 100mg and Zoloft. He reported the medication helped both his mood and nerves. The examiner noted he was casually dressed, with good grooming and hygiene. Affect was mildly restricted, thought form was logical, linear. He was noted as not very articulate overall. He denied any suicidal or homicidal ideations, visual hallucinations, or delusions. A diagnosis of PTSD, cognitive impairment was noted. A MoCA evaluation was to be conducted at the next visit. A VA Mental Health visit from October 2019 noted the Veteran did not wear his hearing aids to the appointment but does have them. He drove himself and wife to the appointment and did not get lost. His wife reported he was more irritable, but also thinks he does not take his mood medications. The examiner noted he has not had a refill since April 2018, so he was to restart Sertraline 100mg. He presented with good hygiene and grooming and was dressed casually. No suicidal or homicidal ideations, visual hallucinations, or delusions were noted. A PTSD with mild cognitive impairment was reported. A MoCA was to be conducted at the next visit, when he is wearing his hearing aids. A VA Mental Health visit from February 2020 noted both the Veteran and wife agreed that he is doing better on his medication. He is less irritable and anxious. The Veteran drove himself and his wife to the appointment and did not get lost. No change in his sleep was reported, and he gets up often to urinate. No bad nightmares since the last visit. Mood was reported as “mostly good, occasional low mood but does not last long.” It was reported the Veteran’s daughter does most of the shopping and cooking, and the Veteran will help clean around the house. The Veteran’s wife handles the finances. Sertraline 100mg was noted. On mental status examination, he was casually dressed with good grooming and hygiene. His affect was mildly restricted. Thought processes were logical and linear. He denied any suicidal or homicidal ideations, visual hallucinations, or delusions. The examiner noted the Veteran is back on medication and doing a bit better. Mild cognitive impairment (MCI) testing was last done in 2016. Again, the psychiatrist held off on administering the MoCA, as the Veteran’s hearing aids were not working well. In June 2020, the Veteran submitted a private medical opinion on direct service connection, providing a positive nexus opinion. The private examiner further opined that the Veteran’s current PTSD impairment is one of total social and occupational disability. The private examiner reported that no valid mental health evaluation could be completed due to the Veteran’s mental confusion, inability to respond to details of his history, and due to long waits after questions as he searched for answers. The private examiner did not contribute these symptoms to malingering or exaggeration, as noted in his last VA examination. The private examiner reported there is no way the Veteran should be driving a car or operating machinery. The private examiner noted “available records were reviewed,” but did not specify which records were reviewed in making his determination. See Attorney Correspondence, June 2020. Pursuant to the October 2020 Board remand, the Veteran was afforded a VA PTSD examination in January 2021. Ultimately, the examiner concluded that the Veteran’s PTSD symptoms had not increased from those documented in 2011 and 2016. Symptoms included depressed mood and mild memory loss. A diagnosis of PTSD and other neurocognitive disorder were noted. The examiner highlighted inconsistencies in the record. For his PTSD diagnosis, the examiner commented that on the PCL-5, a 20 item self-report of PTSD symptoms, the Veteran endorsed moderate to extreme symptoms. However, upon prompting to provide specific examples, he became confused and “gave vague, rambling responses, and appeared to tire.” In addition, because he complained of memory problems, he was given the Mini-Mental State Examination (MMSE), which screens for differing memory deficits. On this test, he struggled with the year, eventually answering correctly with prompts. However, he remembered how much money his joint income decreased with his wife’s death, down to the penny. Regarding his 2016 neurocognitive disorder diagnosis, the examiner commented that the Veteran’s performance today was similar to that described in the 2016 examination where he “failed” significant portions of a memory test but exhibited no symptoms on others. His 2016 diagnosis of unspecified neurocognitive disorder was due to his unconventional symptom formulation. In other evaluations, symptom exaggeration and “malingering” have been proposed. Notably, this clinician had similar thoughts. As did previous examiners, the Veteran’s reported symptoms and his presentation during the evaluation made an assessment somewhat difficult. He struggled with his hearing aids, eventually taking one out, making conversation difficult. The examiner opined that the Veteran’s mental health symptoms caused occupational and social impairment with reduced reliability and productivity. In reaching this conclusion, the examiner noted that the Veteran was a poor historian regarding his symptoms. The Veteran complained of memory problems during the evaluation, but at other times knew specific dates and times, including the date of his wife’s death and the exact amount of his loss of income due to her death. The examiner noted that the “Veteran’s presentation waxed and waned.” In addition, “at times, he presented as tired and confused and others as alert and engaged.” When asked about his mood, he stated it was “good,” but he “needed money.” A diagnosed traumatic brain injury was noted shown in the records reviewed. Of note, the Veteran is no in receipt of service connection benefits for any residuals of a traumatic brain injury. The examiner noted a review of the Veteran’s file, including relevant records such as his separation examination in 1970, his initial PTSD evaluation in April 2011, his 2016 VA PTSD Compensation and Pension examination, and his 2016 Neuropsychological examination. The examiner noted the Veteran was adequately dressed and groomed, and drove himself to the appointment. The Veteran reported he regularly shops for groceries and supplies. Additionally, he is capable of managing his own finances. The examiner reported that since the death of the Veteran’s wife in August 2020, the Veteran currently resides with his adult daughter. He lost his part time job as a crossing guard in April 2020 due to COVID, so he spends his days working in his workshop, driving around looking at things, and shopping. Prior to COVID, he worked two hours a day on school days working as a crossing guard. The Veteran reported that he has not underwent any mental health treatment since 2018. Prior to that, he saw a psychiatrist in 2016 and was prescribed Zoloft. He denied any suicidal or homicidal ideations, or psychiatric hospitalizations since his last evaluation. He is currently not taking psychotropic medications. The Veteran did report sleep problems, as he needs to get up frequently to urinate. He reported getting 6-8 hours of sleep per night, and naps during the day. Applying the relevant criteria, the Board finds that an evaluation in excess of 30 percent is not warranted. Here, the question of rating for PTSD is complicated by the Veteran’s poor memory, hearing issues, and concentration during evaluations. However, the symptoms described by the Veteran, the treatment records, and the findings of the VA examiners who conducted his examinations reflect symptoms that most nearly approximate a 30 percent rating. Specifically, the Veteran had depressed mood, anxiety, and mild memory loss, such as forgetting dates, directions, or recent events. He also had symptoms that are not listed with a specific rating. Specifically, the Veteran had irritability and nightmares. The nightmares are similar to chronic sleep impairment, which is contemplated by the 30 percent rating. The Veteran’s irritability is similar to depressed mood, anxiety which are also contemplated in the 30 percent rating. Proper self-care, including grooming and hygiene were noted throughout the appeal period. Additionally, he was found to pose no threat of danger or injury to himself or others throughout the appeal process. Regarding occupational impairment, prior to COVID, the Veteran was able to maintain employment as a crossing guard at a local elementary school. This position was noted consistently during mental health evaluations. As it relates to his ability to establish and maintain relationships, the evidence indicates the Veteran is capable of maintaining social functioning. The Veteran was married for over 30 years, before his wife passed in August 2020. He has three adult daughters, one of which he currently resides with. During his January 2021 PTSD examination, the Veteran reported that his other adult daughters reside locally, and he sees them, but with reduced frequency due to COVID. Throughout the period on appeal, there has been no indication his relationship with his family has suffered due to his mental health symptoms, other than his noted occasional irritability and the reports he talks to himself. The 30 percent rating contemplates the impact of the Veteran’s symptoms on his social relationships, including those with family members. Moreover, although the Veteran may have had symptoms such as impaired cognitive thinking, memory loss, and difficulty in understanding complex commands, symptoms contemplated by a 50 percent rating, the evidence taken as a whole, presents a disability picture indicative of a 30 percent evaluation. In this regard, the Board acknowledges the low 11/30 on the MMSE during the January 2016 VA Initial Mental Health Evaluation. The examiner noted affect was flat and suggested the possibility of a cognitive problem. In March 2016, during the Veteran’s neuropsychological evaluation, his score of 7/30 suggested moderate to severe cognitive impairment. However, the examiner noted that the extent of his impairment is difficult to establish due to his limited engagement in objective testing and other evaluation procedures. The examiner also noted that symptom exaggeration could not be ruled out. Further, standardized MoCA testing could not be administered during several VA mental health evaluations because the Veteran would not wear his hearings aids during the examinations. The record contains numerous VA opinions and one private medical opinion. When reviewing medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). Accordingly, the Board attaches the most significant probative value to the October 2016 and January 2021 VA opinions, as they appear to be well-reasoned, detailed, consistent with other evidence of record, and included accurate background of the Veteran. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Each of the VA examiners reviewed the Veteran’s claims file (or e-folder). However, the June 2020 private medical provider noted “available records were reviewed,” but did not specify which records were reviewed in making his determination. Furthermore, the different VA examiners’ respective findings were consistent with each other in how they determined that the Veteran did not meet the criteria for the next higher rating for PTSD. Each VA examiner found signs of malingering symptomatology. The June 2020 private medical opinion is the only inconsistent opinion. Although the private medical opinion supported a 100 percent rating for PTSD, the opinion was conclusory, did not describe the Veteran’s symptoms in detail to assign an appropriate rating, and referenced no standardized testing. The Board has considered the June 2020 private opinion that supported a 100 percent rating. However, a review of the evidence does not show total occupational and social impairment as contemplated by a 100 percent schedular evaluation. Therefore, the Board places very low probative weight to the opinion. The examiner made findings of total social and occupational impairment with no reference to specific examples. The Veteran was accompanied to his many VA appointments by his wife, and on at least one occasion, his daughter. This illustrates his ability to maintain social functioning. For a 100 percent evaluation, there must be total occupational impairment. Prior to COVID restrictions in April 2020, the Veteran was working. In addition, the record does not show any evidence of persistent delusions, grossly inappropriate behavior, persistent danger of hurting self or others, or an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene). The Veteran has consistently denied suicidal or homicidal ideations and has presented with good hygiene and grooming during ongoing mental health evaluations. Additionally, the Veteran has been able to perform activities of daily living, including managing his finances, shopping, and driving. During his January 2021 VA examination, he noted he drives regularly to local shops. Therefore, total social and occupational impairment is simply not supported by the evidence of record. In contrast to the private opinion, separate VA mental health professionals have consistently described suspected malingering during examinations. In determining the weight to be assigned to evidence, the Board notes that credibility can be affected by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996). The VA examiner during the October 2016 PTSD examination noted the Veteran’s behavior during the examination was inconsistent with information about his current functioning. Upon examination, it was suggestive he had severe cognitive impairment, yet he drives and currently holds employment. Similarly, the examiner during the January 2021 PTSD examination noted inconsistencies with the Veteran’s behavior and memory problems, giving the example the Veteran struggled with what year it was, but knew the exact amount his income was decreased due to his wife’s death. This suggests that the Veteran was an unreliable historian. It is important for the Veteran to understand that the Board has not discounted his statements. However, a review of the entire record, including the Veteran’s statements to medical providers, support a 30 percent evaluation. In evaluating the Veteran’s increased rating claim, the Board is aware that the symptoms listed under the 30 and 50 percent rating are essentially examples of the type and degree of symptoms for that rating, and that the Veteran need not demonstrate those exact symptoms to warrant a higher rating. However, the record does not establish that the Veteran’s PTSD results in 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, or difficulty in establishing and maintaining effective work and social relationships, warranting a 50 percent rating. The Board notes that although the January 2021 examiner marked the box for occupational and social impairment with reduced reliability and productivity, which is indicative of a 50 percent rating, she ultimately concluded that the Veteran’s PTSD symptoms had not increased and the 30 percent rating evaluation is appropriate for his symptoms. Therefore, the Board places more weight on her determination based on the Veteran’s symptoms, than on the box checked. The above-cited competent and credible evidence establishes that the Veteran’s PTSD was manifested by symptoms such as irritability, memory loss, nightmares, depressed mood and confusion. Collectively, these symptoms are of the type, extent, severity, and frequency indicative of occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks (although generally functioning satisfactorily with routine behavior, self-care, and conversation normal). The assignment of a disability rating of 30 percent is in recognition of the moderate occupational and social impairment caused by the Veteran's mental health symptoms. Accordingly, entitlement to the next higher evaluation of 50 percent is not warranted. As such, the Board finds that the preponderance of the evidence is against an evaluation higher than 30 percent for the appellate period. H.M. WALKER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Krista Johnson, 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.