Citation Nr: 21014000 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 18-11 648 DATE: March 11, 2021 ORDER The claim of entitlement to an evaluation of 70 percent for posttraumatic stress disorder (PTSD) is granted. REMANDED The claim of entitlement to an evaluation in excess of 70 percent for PTSD is remanded. The claim of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDING OF FACT The Veteran’s PTSD manifested in occupational and social impairment with deficiencies in most areas, due to symptoms such as suicidal and homicidal ideation. CONCLUSION OF LAW The criteria for entitlement to an evaluation of 70 percent for PTSD have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Code (Code) 9411 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 2003 to April 2009. In February 2021, the Veteran testified at a video teleconference hearing before the undersigned Veterans Law Judge. Service connection for PTSD was granted upon rating decision in April 2011. A 30 percent rating was assigned. This appeal ensued following a December 2016 rating decision wherein the 30 percent rating was increased to 50 percent, effective October 8, 2015, the date that the Veteran’s intent to file was received. Entitlement to an evaluation in excess of 50 percent for PTSD. Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity caused by the given disability. Separate diagnostic codes (DCs) identify the various disabilities. 38 U.S.C. § 1155 (2012); 38 C.F.R. § Part 4 (2020). When a question arises as to which of two ratings applies under a particular code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7 (2020). After careful consideration of the evidence, any reasonable doubt remaining, including degree of disability, is to be resolved in favor of the Veteran. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 4.3 (2021). When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Veteran’s PTSD is currently rated at 50 percent under the General Rating Formula for Mental Disorders (General Formula). 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). This may be 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 worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Code 9411 (2020). Suicidal ideation alone, that is, a veteran’s thoughts of his or her own death or thoughts of engaging in suicide-related behavior, may cause occupational and social impairment with deficiencies in most areas, and thus may be sufficient to warrant a 70 percent rating. Bankhead v. Shulkin, 29 Vet. App. 10, 20 (2017). During his February 2021 Board hearing, the Veteran reported suicidal ideations throughout the appeal period (the last 5-6 years). He also had homicidal thoughts and exhibited aggressive behaviour such as throwing rocks at cars who were making bad turns. He was easily infuriated by the “stupid” behaviour of others. The severity of his intermittent rages was also noted by multiple lay statements of record as submitted by friends and family. As a result, the Board finds that the Veteran’s PTSD has manifested in occupational and social impairment with deficiencies in most areas, and entitlement to a 70 percent evaluation is warranted. REASONS FOR REMAND 1. The claim of entitlement to an evaluation in excess of 70 percent for PTSD is remanded. The Veteran’s most recent VA examination for his PTSD occurred in November 2016. Since that time, he has indicated that his disability has worsened. See February 2021 Board hearing. Because it has been over 4 years since the last VA examination, remand for a contemporaneous examination is required to assess the current severity of his service-connected disability. See Green v. Derwinski, 1 Vet. App. 121 (1991); see also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). 2. The claim of entitlement to TDIU is remanded. Because the TDIU and PTSD claims are inextricably intertwined, TDIU must be remanded concurrently. See Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) should obtain all updated relevant treatment records (private and VA) and associate them with the claim file. 2. After the development in the first instruction is completed, the AOJ should arrange for an examination of the Veteran to assess the current severity of his service-connected PTSD. The examiner must review the entire record (including this remand) in conjunction with the examination and note such review was conducted. The examiner should provide a full description of the disability and report all signs and symptoms associated with the Veteran’s disability. (Continued on next page)   3. If upon completion of the above action the issues remain denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Hal Smith, 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.