Citation Nr: 21011327 Decision Date: 03/01/21 Archive Date: 03/01/21 DOCKET NO. 11-08 792 DATE: March 1, 2021 ORDER An initial rating of 70 percent, but no higher, for posttraumatic stress disorder (PTSD) (excluding the time period from February 8, 2011, to March 31, 2011, where a temporary total evaluation due to hospitalization has been assigned) is granted, subject to the laws and regulations governing the payment of monetary awards. FINDING OF FACT Resolving all doubt in favor of the Veteran, for the entire appeal period (excluding the time period from February 8, 2011, to March 31, 2011, where a temporary total evaluation due to hospitalization has been assigned), his PTSD is manifested by symptomatology resulting in occupational and social impairment with deficiencies in most areas, without more severe manifestations that more nearly approximate total occupational and social impairment. CONCLUSION OF LAW For the entire appeal period (excluding the time period from February 8, 2011, to March 31, 2011, where a temporary total evaluation due to hospitalization has been assigned), the criteria for an initial rating in of 70 percent, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 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 August 1968 to February 1970. He is the recipient of the Combat Action Ribbon. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in April 2010 by a Department of Veterans Affairs (VA) Regional Office. In May 2012, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. The Board remanded the case in March 2014, March 2015, and October 2015 for additional development and, in a March 2016 decision, denied an initial rating in excess of 50 for PTSD. Thereafter, the Veteran appealed such decision to the United States Court of Appeals for Veterans Claims (Court). In June 2017, the Court granted the Veteran’s and the Secretary of VA’s (the parties’) Joint Motion for Remand (JMR), which vacated and remanded the Board’s March 2016 decision. The Board again denied such claim in a November 2017 decision and the Veteran subsequently appealed such decision to the Court. In February 2019, the Court granted the parties’ JMR, which vacated and remanded the Board’s November 2017 decision. Subsequently, the Board denied the Veteran’s claim in an August 2019 Board decision and the Veteran appealed such decision to the Court. In June 2020, the Court granted the parties’ JMR, which vacated and remanded the Board’s August 2019 decision. Thus, the matter now returns to the Board for further appellate review. The Board notes that additional evidence has been associated with the record subsequent to the issuance of the November 2015 supplemental statement of the case. The Veteran has not waived Agency of Original Jurisdiction (AOJ) consideration of such evidence; however, as it is irrelevant to the instant matter or contains findings that are duplicative to those previously considered by the AOJ, there is no prejudice to the Veteran in proceeding with a decision on his claim at the present time. 38 C.F.R. § 20.1305(c). Entitlement to an initial rating in excess of 50 percent for PTSD (excluding the time period from February 8, 2011, to March 31, 2011, where a temporary total evaluation due to hospitalization has been assigned). The Veteran is currently in receipt of an initial 50 percent rating for his PTSD, effective April 20, 2009, excluding the time period from February 8, 2011 to March 31, 2011 where a temporary total evaluation due to hospitalization has been assigned, effective April 20, 2009. He contends that such disability is more severe than the current assigned rating and, as such, a higher initial rating is warranted. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The Veteran’s service-connected PTSD is evaluated under the criteria of DC 9411, which provides that such disability is evaluated pursuant to the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. A 50 percent rating contemplates 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; impairments of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; 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 work like setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where 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. As the United States Court of Appeals for the Federal Circuit explained, evaluation under 38 C.F.R. § 4.130 is “symptom-driven,” meaning that “symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating” under that regulation. Vazquez–Claudio v. Shinseki, 713 F.3d 112, 116–17 (Fed.Cir.2013). The symptoms listed are not exhaustive, but rather “serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating.” Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering “not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas” - i.e., “the regulation... requires an ultimate factual conclusion as to the Veteran’s level of impairment in ‘most areas.’” Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, DC 9411. Further, when evaluating a mental disorder, the Board must consider the “frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission,” and must also “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). In Bankhead v. Shulkin, 29 Vet. App. 10 (2017), the Court held that the language of the general rating formula “indicates that the presence of suicidal ideation alone…may cause occupational and social impairment with deficiencies in most areas.” However, as recognized by the Court, VA must engage in a holistic analysis in assessing the severity, frequency, and duration of the signs and symptoms of a veteran’s service-connected psychiatric disability, and their resulting social and occupational impairment. Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations that define the term “psychosis” to remove outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and replace them with references to the recently updated DSM-5. See 79 Fed. Reg. 149, 45094 (August 4, 2014). The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the AOJ on or after August 4, 2014. VA adopted as final, without change, the interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board as of August 4, 2014, even if such claims are subsequently remanded to the AOJ. See 80 Fed. Reg. 53, 14308 (March 19, 2015). In the instant case, the Veteran’s claim was certified to the Board in April 2012 and, as such, the DSM-IV applies to his claim. In this regard, the Board notes that the DSM-5 removed reference to Global Assessment of Functioning (GAF) scores. However, as the DSM-IV governs the Veteran’s claim, such scores are relevant to the evaluation of his PTSD. A GAF score is another component considered to determine the entire disability picture for the Veteran. The GAF scale is a scale reflecting the “psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness” from 0 to 100, with 100 representing superior functioning in a wide range of activities and no psychiatric symptoms. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994)). Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. Carpenter, supra. An assigned GAF score, like an examiner’s assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a). Accordingly, an examiner’s classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered, but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126, VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995). After a review of the record, the Board finds that the Veteran is entitled to an initial rating of 70 percent, but no higher, for his PTSD. In this regard, VA treatment notes from February 2009 through March 2012 reflect that the Veteran attended both individual and group therapy sessions approximately once a week, except for February 2011 through March 2011, when the Veteran participated in an inpatient program at the Southern Arizona VA Medical Center. The Veteran indicated that he had been married once, but his wife had passed away after 10 years of marriage; he indicated that he had not dated since his wife’s death. The Veteran reported that he had three adult children who he spoke with regularly and with whom he enjoyed good relationships. The Veteran reported trouble sleeping and violent nightmares, and he indicated that he avoids crowds, but attends church regularly. The Veteran denied suicidal or homicidal ideations, delusions, or physical violence. Mental status examinations found the Veteran to be alert and oriented, his thoughts organized and his speech goal-directed. Judgment and insight appeared to be fair to good while psychosis, gross cognitive or memory deficits were not found. The VA social workers who coordinated the groups noted that the Veteran was an active and cooperative participant in the sessions. The treatment notes showed that the Veteran often appeared anxious, but communicated effectively. While GAF scores were not documented for each session, those reported ranged from 30-70 throughout the time the Veteran was a participant in the groups. A March 2009 VA treatment note indicated that the Veteran reported that he avoided crowds as he struggled with issues of irritability and anger. Specifically, he denied violence, but admitted to getting angry while driving and having confrontations with other drivers. He also denied suicidal ideation and stated that he believed that to die by suicide, one must have a lot of anger or pride and he did not feel that way. The Veteran reported a heightened startle response to being awakened suddenly and indicated that smells often triggered nightmares and flashbacks. He also stated that he was vigilant about his surroundings and checked for tire tracks and prints at and around his home. A GAF score of 50 was assigned. An April 2009 VA treatment record revealed that, with regard to his anger issues, the Veteran stated that he had “buttons” such as arrogant drivers and mailbox placement on his property. He also discussed his lifetime of “controlling” anger when he was in law enforcement and admitted to shaking after getting angry. The treating provider noted that they discussed at length the need to moderate the Veteran’s anger, and things that were lifesaving reactions in Vietnam and in law enforcement were hurting him now. A May 2009 VA treatment record indicated that the Veteran reported he was having a harder than usual time dealing with uncomfortable situations, and had some anger and disappointment in “government situation.” He also stated that he had some hypervigilance in that he did lots of checking of security of his property, and startled when somebody touched him while he was sleeping. The Veteran reported sleep problems and some hypnopompic hallucinations. However, he denied having auditory and visual hallucinations. The Veteran further reported that he occupied his days gardening, cutting firewood, riding ATVs, and doing tractor work, but still had problems with getting motivated to do things himself. The clinician noted that the Veteran’s short-term memory was fair and he had no suicidal ideation. Upon mental status examination, the Veteran was found to be oriented to time, place, and personal information. While he was anxious, his speech was found to be goal directed, and his judgment and insight appeared to be good and intact. The clinician determined that the Veteran’s PTSD symptoms were moderate to severe and assigned a GAF score of 30. In November 2009, the Veteran was afforded a VA examination in connection with his PTSD claim. At such time, the examiner noted the Veteran’s reports of hypervigilance, sleep problems, anger, avoidance, and heightened startle response. Specifically, the Veteran reported that he often walked around the house and got up at night to make sure that things were in order, and would sit in particular places and look people over before he went into a room. The Veteran also reported he frequently got angry at other people and acknowledged confrontations a few times, which occurred mostly with other drivers. He stated that he had verbal aggression in the form of yelling and screaming, but denied physical aggression at the time. The Veteran further reported that he had good relationships with his three children and his siblings. With regard to social relationships, the Veteran stated that he currently had a few friends and helped them out, and enjoyed helping his neighbors fix things. A history of trying to harm himself or others was denied. A history of violence was also denied and the Veteran reported that he was able to complete all activities of daily living such as grooming and dressing. Furthermore, mental status examination showed no impairment of thought processes or communications. The examiner indicated that there did not appear to be delusions or hallucinations present. Eye contact was found to be good and the Veteran was noted to have interacted appropriately during the session and that he displayed no inappropriate behavior. Speech was found to be logical and goal-directed, and the rate and flow were normal. There were no problems with impulse control. The examiner noted that the Veteran had previously been assigned a GAF score of 30; however, he found that his symptomatology was moderate and a GAF score of 60 was assigned. In a February 2010 statement, the Veteran reported that he suffered from nightmares frequently, had panic attacks, heard noises that were not there, could not sleep well, and had hallucinations that there were snakes or other animals in his bed. The Veteran also stated that he had not worked in five years and had no desire to work unless he could find something to do where he would not have to deal with other people. A March 2010 VA treatment record indicated that the Veteran was alert and oriented, but that he continued to report sleep disturbances. Specifically, he reported that he suffered from nightmares, night sweats, and flashbacks. The Veteran also indicated that he enjoyed motorcycle riding, swimming, and camping, and planned to do a lot of travelling with friends and family the upcoming year. The clinician noted that the Veteran was a retired policeman that worked undercover a lot and saw a lot of prescription drug abuse and fraud. The clinician also noted that the Veteran worked on the SWAT team and in the critical incident stress debriefing. In this regard, the clinician stated that it sounded like the Veteran dealt with a lot of stressful experiences on the job. Mental status examination found the Veteran to be oriented to time, place, and personal information. The Veteran was well groomed, his mood was appropriate and calm, and his thoughts were goal directed. The Veteran reported no suicidal or homicidal ideations. A GAF score of 60-70 was assigned. An October 2011 VA treatment note indicated that, while the Veteran continued to suffer from sleep disturbances, he was alert, oriented, pleasant, and appropriate. The Veteran was an active participant in the group session who gave effective feedback. A GAF score of 55 was assigned. Additionally, a March 2012 VA treatment note indicated that the Veteran reported no suicidal or homicidal ideations. He was oriented to time, place, and personal information. The Veteran was also well dressed and groomed, and he exhibited no abnormal movements. His mood was fair and his affect controlled; his thoughts and speech were goal directed and linear. In an April 2012 VA treatment record, the Veteran reported that he went out on his 4-wheeler looking for wood and was out for 6 hours. Along the way, he became extremely alert and saw a wire sticking out of the ground, like a trip wire. He realized that his subconscious saw the wire and alerted him. It took him several hours to come down from that alertness and did not sleep more than a couple of hours that night. He was hypervigilant all night long. The clinician noted a GAF score of 50. During the May 2012 Board hearing, the Veteran testified to his current symptoms and the repercussions that they caused. Specifically, he reported that he suffered from hypersensitivity, a heightened startle response, paranoia, nightmares and night sweats, and sleep disturbances. The Veteran recounted instances where his heightened startle response caused altercations between himself and other people. In particular, he stated that he grabbed and almost punched a flight attendant who had awoken him. The Veteran also testified that he got frustrated easily and was quick to anger, but never got violent and looked for “positive things.” He further testified that he avoided crowds, but that he regularly attended church. With regard to his employment history, the Veteran stated that he had worked with the department of public safety for 20 years and mostly did undercover work as a police officer. He retired for 9 years and then went back to work for the state as an investigator for the registered contractor’s office. The Veteran stated that he stayed at such job for three and a half years because he had a hard time dealing with the ineptness, laziness, and political appointments. He also stated that he turned down other jobs after being asked by sheriffs because of the “internal stuff” and not so much the public. An August 2012 VA treatment note revealed that a GAF score of 40 was assigned and reflected the Veteran’s reports of not doing well and having sleeping problems. The social worker also noted that he was alert and oriented at the time of the interview. A December 2012 VA treatment noted the Veteran’s reports that he continued to hear knocking on his door and could not figure out what it is about. The Veteran also stated that whenever the sun went behind the clouds, he saw shadows and wondered who was out there. Moreover, a January 2013 suicide risk assessment indicated that the Veteran had a low level risk of potential harm, but there was some suicidal ideation. However, the clinician noted that such ideation was limited in intensity and duration and the Veteran had no specific plan or intent to die, and self-control was intact with considerable protective factors. In a February 2013 VA treatment note, the Veteran reported that he had been having a terrible month with a lack of sleep. Specifically, he reported that his mood was poor, he had a lot of depression and nightmares, his anxiety was high, his irritability was fair, and his energy and motivation were low. He further reported that he had increased intrusive thoughts, flashbacks, feeling paranoid, but no hallucinations. However, the clinician found the Veteran to be oriented to person, place, time, and context, and that his affect was congruent. She also noted that his speech was normal and that his insight and judgment appeared to be intact. Additionally, in a March 2013 VA treatment note, the Veteran reported that he was still having sleep problems and he had irritability only when he was driving. He also reported no hallucinations and denied thoughts of suicide or homicide. A November 2013 VA treatment revealed the Veteran’s reports of auditory/olfactory hallucinations of smoke and the door knocking, but he denied any visual hallucinations. The Veteran also stated that he forgot names and set up systems to get chores and bills done. He also denied thoughts of suicide or homicide, and reported that his anxiety and irritability were low. The clinician further noted that the Veteran was well groomed, had normal speech and a controlled affect with a sad, anxious, and frustrated mood. The Veteran’s thought processes were normal, logical, and goal oriented, and that he had no delusions, no feelings of helplessness or hopelessness, and no obsessions. His judgment and insight were also good. In a January 2014 VA treatment note, the Veteran reported that he was okay and his mood was stable. He denied depression, but stated that he still was not getting much sleep and had occasional nightmares. The Veteran also reported that he had no problems with anxiety and irritability, but his energy and motivation were low. He further reported the same intrusive thoughts, flashbacks, and hypervigilance, and he denied thoughts of suicide, homicide, paranoia, and hallucinations. Upon mental status examination, the clinician noted that the Veteran was well groomed, his speech was normal and so was his thought processes and content with no delusions, no feelings of helplessness or hopelessness, and no obsessions. During a February 2014 group session, the Veteran stated that he had not really dated anyone in 15 years, but was currently dating a woman and their relationship was going well. In May 2014, the Veteran was afforded another VA examination. At such time, the examiner noted his reports that he had been prescribed psychotropic medication, and continued to receive treatment for his PTSD through group and individual therapy. The Veteran complained of frequent nightmares and night sweats. He also reported hypervigilance and a heightened startle response. Specifically, the Veteran stated that he when he hears a noise, he feels he must inspect it and wants to know what someone is doing if they are driving near his house in the early morning. The examiner noted that, while the Veteran was retired, his occupational and social impairment was characterized 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. Moreover, the Veteran reported that he had a couple of female friends that he usually saw at church and may go to lunch afterwards. He also stated that he had other police friends who he might see every once in a while. The Veteran also reported that he saw his children at least once a year and talked to them regularly on the phone. In addition, the examiner noted that the Veteran was articulate and able to answer all questions asked of him. He appeared able to complete short tasks without difficulty. The Veteran was cooperative and pleasant. The examiner noted the Veteran traveled frequently and enjoyed doing so, and was able to navigate without difficulty or needing assistance. The examiner reported that the Veteran was capable of managing change in an otherwise stable environment, and noted that the Veteran had symptoms of anxiety, suspiciousness, chronic sleep impairment, mild memory loss such as forgetting names, directions, or recent events, and disturbances of motivation and mood. As the examiner performed the examination according to the guidelines of the DSM-5 and not the DSM-IV, no GAF score was assigned. In an October 2014 addendum opinion, the May 2014 VA examiner noted that the “current [DSM-5] criteria does not include a GAF score, as such this is not able to be done for current diagnosis as there is no GAF score in the current diagnosis. Additionally, it is not possible to reconcile previous GAF scores that were given by other doctors at times between 2009 and 2011 without mere speculation.” VA treatment notes from May 2014 through December 2014 reflect that the Veteran attended both individual and group therapy sessions approximately once a week. He reported no change in his familial status or friendships, except that he began dating. The Veteran indicated that he had trouble sleeping and violent nightmares, and continued to avoid crowds, but attended church regularly. Mental status examinations found the Veteran to be alert and oriented, his thoughts organized and his speech goal-directed. Judgment and insight appeared to be fair to good while psychosis, gross cognitive, or memory deficits were not found. The VA social workers who coordinated the groups noted that the Veteran was an active and cooperative participant in the sessions. The treatment notes showed that the Veteran often appeared frustrated, but that he communicated effectively. The notes reflected that the Veteran denied any suicidal or homicidal ideations or delusions and physical violence. VA treatment notes from December 2014 through April 2015 reflect that the Veteran again attended both individual and group therapy sessions. He reported no change in his familial status or friendships. The Veteran continued to report trouble sleeping and violent nightmares, and indicated that he continued to avoid crowds. He also reported intrusive thoughts, flashbacks, and occasional paranoia. Mental status examinations found the Veteran to be alert and oriented, his thoughts organized and his speech goal-directed. Judgment and insight appeared to be fair to good while psychosis, gross cognitive, or memory deficits were not found. The Veteran’s mood was reported to be neutral to positive and he reported no delusions, hallucinations, and no suicidal or homicidal ideations and no physical violence. However, in an April 2015 VA treatment record, the Veteran reported that his current condition was probably deteriorating and he was tired all the time. The Veteran also reported that his anxiety was high and that his irritability was higher than usual, and that his energy and motivation were low. The clinician also noted that the Veteran was getting forgetful, but found that he had normal thought processes and thought content with no delusions or obsessions. Additionally, a suicidal risk assessment was completed and the clinician found that the Veteran’s current risk for potential harm was low. Specifically, she noted that he had infrequent, low intensity, and vague suicidal ideation and there was no subjective or objective evidence of intent or plan. The Veteran also had a willingness to engage in treatment and had social support from family and friends. The clinician further noted that the Veteran had no specific plan or intent to die, self-control was intact, some depressive symptoms, mild risk factors, but had considerable protective factors such as cultural, religious, or other beliefs that prohibit/discourage suicide, strong coping and problem-solving skills or optimism, strong therapeutic relationship, and was positively motivated in treatment. In May 2015, the Veteran underwent another VA examination in connection with his claim. At such time, he reported continued sleep disturbances, regular nightmares, and periodic flashbacks. He also indicated that he had difficulty remembering names. The Veteran further reported that he was “vigilant to noises, particularly at night,” and continued to think about traumatic events and respond with anxiety. He denied physical violence. The examiner found the Veteran to be “cooperative, easy to establish a rapport with, and responsive.” The Veteran’s thoughts were clear and goal directed. The examiner reported no suicidal or homicidal ideations and no psychosis. The examiner also noted that, although the Veteran was retired, his occupational and social impairment would result in 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 examiner further noted that the Veteran’s symptoms included anxiety, suspiciousness, chronic sleep impairment, mild memory loss such as forgetting names, directions, or recent events, and difficulty in establishing and marinating effective work and social relationships. As the examiner performed the exam under the guidelines of the DSM-5 and not the DSM-IV, no GAF score was assigned. The examiner noted that “GAF scores can vary tremendously between providers and are considered unreliable indicators of functioning.” In a November 2015 addendum opinion, the May 2015 examiner stated “the nature and severity of the Veteran’s PTSD is not materially different than findings that would have been made under the DSM-IV. Functioning levels, symptoms, and presentation between current examination and previous examinations are similar.” The examiner concluded that the Veteran’s PTSD was mild to moderate and that “this would correspond to a GAF of 55-65.” Subsequent treatment records indicate that, in January 2016, the Veteran reported ongoing “dreams” that impacted his mood and functioning and he expressed desire to continue counseling to address his irritability, being easily startled, paranoia, and dreams, which impacted his mood and functioning. In December 2017, the Veteran reported with depressed mood and congruent affect. He reported ongoing poor sleep patterns, nightmares, and the he could easily be awakened by a “knocking that’s not there.” He stated that he has made improved efforts to manage his reaction when he wakes up from these nightmares and auditory hallucinations with reported use of reframing negative cognitions and fears, which had been beneficial. Upon mental status examination, the Veteran had appropriate hygiene; was calm and cooperative; normal speech; linear and coherent thought process; denied suicidal and homicidal ideations; had auditory/olfactory hallucinations when first awakening; denied paranoia; did not appear to be responding to internal stimuli; and had intact insight, judgment, and memory. Subsequent VA treatment records dated through November 2020 reflect the Veteran’s reports of nightmares and depression, his denial of suicidal ideation, and a notation that he was doing well. Based on review of the forgoing evidence, the Board resolves all doubt in favor of the Veteran and finds that, for the entire appeal period (excluding the time period from February 8, 2011, to March 31, 2011, where a temporary total evaluation due to hospitalization has been assigned), the Veteran’s PTSD is manifested by symptomatology resulting in occupational and social impairment with deficiencies in most areas due to his psychiatric symptomatology, to include passive suicidal ideation; hypnopompic hallucinations; difficulty with memory and concentration; anxiety, disturbance of motivation and mood; nightmares; avoidance behavior; irritability; sleep difficulty; panic attacks; hypersensitivity; flashbacks; occasional paranoia; depressed mood; and difficulty establishing and maintaining effective work and social relationships, without more severe manifestations that more nearly approximate total occupational and social impairment. In this regard, the Board has considered the aforementioned January 2013 and April 2015 suicide risk assessments that indicated that the Veteran had a low-level risk of potential harm and there was some suicidal ideation. However, as mentioned previously, the clinician noted that such ideation was limited in intensity and duration, the Veteran had no specific plan or intent to die, and self-control was intact. The Veteran also had considerable protective factors such as cultural, religious, or other beliefs that prohibit/discourage suicide, strong coping and problem-solving skills or optimism, strong therapeutic relationship, and was positively motivated in treatment. Further, the remainder of the treatment records do not show a report of a greater level of suicidal ideation. Nonetheless, the Court has held that the language of the general rating formula “indicates that the presence of suicidal ideation alone…may cause occupational and social impairment with deficiencies in most areas.” See Bankhead, supra. Additionally, throughout the appeal period, the Veteran reported hypnopompic hallucinations that were described as hearing the door knocking, being triggered by smells, seeing snakes or other animals in his bed, and hearing other noises that he could not figure out where they were coming from. See March 2009, December 2012, November 2013, May 2015, January 2017, and December 2017 VA treatment records. He also stated that such “dreams” impacted his mood and functioning. The Board also acknowledges the Veteran’s statements of having high irritability, getting into an altercation with a flight attendant, getting violent when suddenly awoken, and having confrontations with other drivers, and his reports of having to check his surroundings, including checking tire tracks around his home. In this regard, while the balance of the evidence reflects that the Veteran’s impulse control is intact and he does not have obsessional rituals that interfere with his routine activities, such symptoms suggest a greater degree of occupational and social impairment greater than such resulting in reduced reliability and productivity. Upon consideration of the Veteran’s passive suicidal ideation, hypnopompic hallucinations, irritability, and need to check his surroundings in combination with his additional psychiatric symptoms involving difficulty with memory and concentration; anxiety, disturbance of motivation and mood; nightmares; avoidance behavior; irritability; sleep difficulty; panic attacks; hypersensitivity; flashbacks; occasional paranoia; depressed mood; and difficulty establishing and maintaining effective work and social relationships, the Board resolves all doubt in his favor and finds that the nature, frequency, severity, and duration of such symptomatology results in occupational and social impairment in most areas. In this regard, as will be discussed below, the Veteran has not worked during the appeal period, but the evidence suggests a low frustration tolerance in a work-like setting and, while he does maintain relationships with his family and a few friends, he rarely socializes and prefers not to leave the house. Moreover, the Board finds that, by resolving all doubt in the Veteran’s favor, the GAF scores assigned during the course of the appeal likewise supports such a 70 percent rating as they span from 30 to 70, which are indicative of serious to mild symptoms. In this regard, he was assigned GAF scores of 30 in May 2009, 40 in August 2012, and 50 in March 2009 and April 2012. A GAF score of 21 to 30 indicates behavior is considerably influenced by delusions or hallucinations, or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation), or inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends). See DSM-IV at 44-47. A GAF score of 31 to 40 indicates some impairment in reality testing or communications or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. Id. A GAF score of 41-50 contemplates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Id. Thus, while the Veteran was also given GAF scores that were suggestive of mild or moderate symptoms, the aforementioned GAF scores reflect serious symptoms and, in combination with the above noted symptoms and resulting occupational and social impairment, the Board finds that such scores support a 70 percent rating. However, the Board finds that a rating in excess of 70 percent for the Veteran’s PTSD is not warranted at any point during the appeal. Specifically, there is no evidence that the Veteran’s PTSD symptomatology results in intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting his ability to function independently, appropriately, and effectively; spatial disorientation; neglect of personal appearance and hygiene; inability to establish and maintain effective relationships; gross impairment in thought processes or communication; persistent danger of hurting himself or others; intermittent inability to perform activities of daily living; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. Furthermore, the Veteran’s PTSD is not shown to result in total occupational and social impairment. Specifically, the record reflects that the Veteran has maintained good relationships with his children and siblings throughout the appeal period. He also stated that he developed relationships with the members of his therapy group, and he reported that he had a few friends and enjoyed helping his neighbors fix things. During the May 2014 VA examination, the Veteran also reported that he had a couple of female friends that he usually saw at church and that they might go to lunch afterwards. He also stated that he had other police friends, who he might see every once in a while. He also traveled frequently. Additionally, the Veteran was able to maintain a long career despite his PTSD symptomatology. Furthermore, at the May 2012 Board hearing, the Veteran testified that he left his last employment due to having a hard time dealing with the ineptness, laziness, and political appointments, not his PTSD symptomatology. The Veteran also stated that he turned down other jobs after being asked by sheriffs because of the “internal stuff” and not so much the public. Thus, the Board finds that the Veteran’s PTSD is not manifested by total occupational and social impairment. The Board has also considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran’s service-connected PTSD; however, the Board finds that his symptomatology has been stable throughout the appeal period. Therefore, assigning staged ratings for such disability is not warranted. Further, neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the initial rating claim adjudicated herein. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). Therefore, the Board finds that an initial 70 percent rating, but no higher, for PTSD is warranted. Insofar as the Board has denied a higher rating, the preponderance of the evidence is against such aspect of the Veteran’s claim. Therefore, the benefit of the doubt doctrine is not applicable and such initial rating claim must otherwise be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Clark, 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.