Citation Nr: 21014612 Decision Date: 03/15/21 Archive Date: 03/15/21 DOCKET NO. 16-52 700 DATE: March 15, 2021 ORDER Effective from September 10, 2015, entitlement to an initial disability rating of 70 percent for posttraumatic stress disorder (PTSD) is granted. FINDING OF FACT For the entire period on appeal, the Veteran's PTSD has been manifested as occupational and social impairment with deficiencies in most areas; but not total occupational and social impairment. CONCLUSION OF LAW Effective from September 10, 2015, the criteria to establish entitlement to an initial disability rating of 70 percent for PTSD have been met. 38 U.S.C. § 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.4, 4.7, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service in the United States Army from November 1979 to November 1982. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a December 2015 rating decision. In December 2020, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript from that proceeding is associated with the claims file. 1. Entitlement to an initial disability rating for PTSD in excess of 50 percent. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C. § 1155. The evaluation of a service-connected disorder requires a review of a veteran's entire medical history regarding that disorder. 38 U.S.C. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, 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. Evidence to be considered in an appeal from an initial disability rating was not limited to that reflecting the then current severity of the disorder. Fenderson v. West, 12 Vet. App. 119 (1999). In cases where an initially assigned disability evaluation has been disagreed with, it is possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Fenderson, 12 Vet. App. at 126-27; Hart v. Mansfield, 21 Vet. App. 505 (2007). Such separate disability ratings are known as staged ratings. The Veteran's service-connected PTSD has been evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411; however, the actual criteria for rating the Veteran's disability are set forth in a General Rating Formula for evaluating psychiatric disabilities other than eating disorders. See 38 C.F.R. § 4.130. The Veteran has been in receipt of an initial 50 percent rating for PTSD effective from September 10, 2015. A 50 percent rating is assigned 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. A 70 percent rating is assigned 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is assigned for 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, or for the Veteran's own occupation or name. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact occupational and social impairment. Vasquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, as all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear the veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vasquez-Claudio, 713 F.3d at 118. The Board acknowledges that psychiatric examinations frequently include the assignment of a global assessment of functioning (GAF) score. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (5th Ed) (DSM-5) has been officially released, and 38 C.F.R. § 4.130 has been revised to refer to the DSM-5. The DSM-5 does not contain information regarding GAF scores. Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders to remove outdated references to the DSM-IV and replace them with references to the DSM-5. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). VA adopted as final, without change, the interim final rule and clarified that the provisions of the final rule did not apply to claims that were pending before the Board, this Court, or the U.S. Court of Appeals for the Federal Circuit on August 4, 2014, even if such claims were subsequently remanded to the agency of original jurisdiction. See 80 Fed. Reg. 14,308 (Mar. 19, 2015). While GAF scores are included in the Veteran's medical records, the Board will not consider GAF scores in determining the outcome of this case. See Golden v. Shulkin, 29 Vet. App. 221 (2018) (finding GAF scores to be unreliable indicators of functional impairment not useful in rating psychological disabilities). Prior to the beginning of the appeal period, a February 2015 VA treatment record noted that the Veteran was unemployed and divorced. He had been referred to the Recovery Support Program/Continuum of Care in January 2015 following a brief stay in the PER related to alcohol use disorder and depression. The Veteran had maintained sobriety while at Continuum, and he had completed Substance Abuse Treatment Program (SATP) treatment. He had also loosely developed a plan with his mental health treatment coordinator for further VA treatment. The Veteran expressed hesitancy about returning to his sister's home while awaiting treatment at VA, and he was referred for the Partial Hospitalization Program (PHP) with sober housing at Stonington Institute. A subsequent February 2015 VA treatment record noted that the Veteran was leaving for the Center for Integrated Residential Care for Addictions (CIRCA) at VA in Brockton, Massachusetts. The Veteran reported that he had remained sober while living at his sister's home. Later in July 2015, a VA treatment record reported that the Veteran had been admitted to the Compensated Work Therapy/Transitional Residence (CWT/TR) program upon referral from the Boston Healthcare System Resources for Enhancing All Caregivers Health (REACH) program on a voluntary basis. Another entry noted that this admission would be for a 6 to 12 month period, and a transitional residence that addressed housing was a facet of programming. The focus of the Veteran's admission was maintaining sobriety, employment, and housing. The Veteran would be assigned a CWT position. The Veteran was noted to have a longstanding history of alcohol use disorder that had progressed somewhat over the past few years and impacted his family/work, etc. The Veteran had completed CIRCA and REACH programs at the Boston Healthcare System and prior Substance Use Disorder (SUD) treatment with VA in Newington, Connecticut. The Veteran did not have a history of prior suicide attempts, and he had experienced a positive response to his current treatment. The mental status examination showed that the Veteran was alert and oriented, cooperative and reasonable, and he had normal speech. His language was intact, and mood was euthymic with a congruent affect. There was no evidence of perceptual disturbance, abnormal thought process or content, or suicidal or violent ideation. The Veteran's insight and judgment were good, and his memory was intact. Another July 2015 VA treatment record noted that the Veteran had been married and divorced twice. Although he denied a current relationship, he reported being close with his three children and two grandchildren. The Veteran was residing in Care House in New Haven, Connecticut since the beginning of January 2015, nad he described this setting as a controlled sober living environment with a case manager on site. Regarding the Veteran's employment history, he previously worked at the United States Postal Service (USPS) for 24 years until he was released from employment in 2011 after missing three months of work due to mood and alcohol use. The Veteran reported that he last drank alcohol in January 2015. Prior to that point, he had been drinking approximately 12 beers a day since 2003. He reported that he stopped drinking a few times during this period, and his heavy drinking in 2003 was preceded by his divorce. His longest period of sobriety had been the past several weeks. A subsequent July 2015 VA Vocational Rehabilitation consultation noted that the Veteran was being assigned to Food Service in the Transitional Work (TW) program. He would begin the assignment in July 2015. A July 2015 Vocational Rehabilitation initial evaluation noted that it was not the Veteran's first admission to CWT. He previously participated in Transitional Work (TW) as a participant in the REACH program the Brockton VA Medical Center (VAMC). The Veteran had a high school education. The interview revealed that the Veteran's primary barriers to work were active psychological symptoms, no long-term stable residence, and feeling anxious in the performance of his job. The Veteran's general work goal was obtaining full-time competitive employment. His future employment plans included working as a substance abuse counselor/case worker/social worker for young veterans. The Veteran was assigned to a kitchen aid position, and he was going to work Monday through Friday, from 6:30 am to 3:00 pm, beginning on July 10, 2015. He would be paid 9.00 dollars an hour for hours worked. A subsequent July 14, 2015 VA treatment record noted that the Veteran had requested a transfer from the Kitchen Aid position to the Sanitation Aid position. The Veteran reported that he was claustrophobic and needed a larger environment in which he could work. The Veteran would begin this new position on July 15th and work Monday through Friday, from 6:00 am to 2:30 pm. A July 2015 mental health intake note stated that the Veteran was a low risk to self. He had good insight into his problems, and he was actively addressing the problems. The Veteran's strengths included his expressed desire/motivation for change, good use of treatment in the past, interest in vocational development, support of family and/or friends, desire to be sober, ability to maintain instrumental activities of daily living, and capability of independence. His limitations included homelessness, unemployment, substance abuse/dependence, and financial deficit. The record stated that the Veteran's psychiatric history did not include any formal treatment for psychiatric concerns in a VA setting, but there had been some on and off therapy for depression in the past from non-VA providers. In addition to the previous reports regarding his social relationships, he also stated that he was close with his siblings. The Veteran reported having a good group of friends, and a good support network. A subsequent Vocational Rehabilitation note continued to identify active psychological symptoms as a barrier, but specifically noted lack of motivation. In August 2015, a VA treatment record noted that the Veteran reported feeling very groggy in the morning and having a dry mouth. The record indicated that the Veteran had changed the recommended dose of hydroxyzine from 25 milligrams four times a day to 50 milligrams twice a day. The Veteran had believed that taking this medication would prevent his anxiety despite the fact that he reported feeling anxiety all the time. The assessment was alcohol use disorder and depression. In September 2015, a VA treatment record noted that the Veteran met with a peer support specialist to assist with the construction of a resume. The specialist had been working with the Veteran on several occasions on the resume, and the work was nearing completion. The Veteran was thankful for these services. Another September 2015 entry indicated that a specialist was able to assist the Veteran with two online applications through the employment website USAJOBS. A September 2015 CWT note stated that the Veteran felt as though he was going backwards, and he wondered if he should stay or leave the program. He had feelings of resentment toward several residents at the TR. He was reluctant to confront these individuals for fear of them acting out towards him. The Veteran spoke of his range of methods for dealing with situations, i.e., avoidance to confrontation. The provider discussed the role of being assertive rather than sarcastic or aggressive. The provider also noted that the Veteran's inclination to leave the program could be viewed as being avoidant. A September 2015 VA psychology note indicated a formal PTSD diagnosis was pending. The provider recommended for the Veteran to continue with psychotherapy and focus on his interlocking problems of trauma, substance use disorder, and depression. The Veteran discussed his plans for the upcoming months, and the record stated that he was due for his 6-month review at his CWT/TR residence in January. The Veteran hoped to be approved for another 6 months. He was working on applying to be trained as a CPA with the hopes of working on a VA campus. The impression noted that the Veteran was in good spirits, but he felt vulnerable to things falling apart after participating in so many programs. The idea of losing the structure of the residence was particularly worrisome to him. The Board notes that although this record identified the Veteran's career goal as working as a CPA (certified public accountant), a subsequent October 2015 record clarified that he was interested in becoming a certified nursing assistant (CNA) and eventually, a caseworker. An additional October 2015 VA treatment record noted that the Veteran disclosed the difficult reactions he had experienced with various family members. The provider stated that some family members were perhaps struggling to understanding addiction recovery, while others might resent his efforts. The Veteran did not indicate that was at current risk of injury to himself or others. An October 2015 Vocational Rehabilitation note stated in the summary and impression that the Veteran had been performing well in his assignment as reported by his on-site supervisor. He performed assigned tasks in the required timeframe and always produced a good product. The Veteran reported being responsible and having no anxiety on the job. He reported that his confidence had been improved now that he had been on the job for several months and felt familiar with his responsibilities. he had been working to update his resume. Another October 2015 entry stated that the Veteran was working in CWT and reported having no adverse side effects from medications. He was no longer feeling groggy in the morning, and his sleep and appetite were good. The record stated that he was casually dressed with good personal hygiene. He was alert and oriented as well as cooperative during the interview. There were no deficiencies in speech or memory, his mood was euthymic, and his affect was full and appropriate. There were also no homicidal or suicidal ideations, hallucinations, or delusions. His insight and judgment were fair. Later in October 2015, a record noted that the Veteran had applied for two jobs online with FedEx and UPS. In November 2015, a VA treatment record reported that the Veteran had attended an interview for an employment opportunity with a local market and believed the interview went well. The Veteran understood he might be eligible for the United States Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH) Program if he obtained the position, and he was excited about this possibility. However, he still wished to pursue federal employment if he accepted this position. A November 2015 psychology note stated that the Veteran reported managing a stressor in a way he felt good about. Although he had left a meeting with a counselor abruptly after his request for a pass was denied due to lack of financial planning, he later accepted the feedback and planned to call the counselor to let her know he understood. The Veteran also raised concerns related to his military sexual trauma. In this regard, he discussed two situations with one involving an incident when he felt that a CNA at his CWT placement was attracted to him, and a second incident when he felt repelled by a veteran who introduced a transgender person as his fiancée. Although he had a history of letting stressful events provide an excuse to relapse, he was monitoring this behavior. Another November 2015 custodial note stated that the Veteran had plans to apply for a part-time custodial position with the local market. The provider believed that his computer skills were quite limited. In November 2015, a CWT note stated that the Veteran was struggling with taking responsibility to make the changes necessary to move forward with his recovery. He had been developing goals such as applying for jobs before taking a nap when he returned from work. The provider noted that he would readily avoid versus accept responsibility for making changes, noting that he reported not knowing why he did not follow through. The Veteran wanted to see his doctor to discuss his struggle with attitude. A subsequent November 2015 CWT note stated that the Veteran continued to resist making the necessary to progress with his treatment and ensure a continued stay in the CWT/TR program. He admitted to not following through with suggestions to develop a resume or create a savings plan. Although the Veteran expressed interest in training to become a CNA to help others, the vocational rehabilitation specialist stated that he was advised to first focus on helping himself. In December 2015, a record noted that the Veteran had completed his resume and was encouraged to apply for the custodial position in which he had expressed an interest. Also in December 2015, a record reported that the Veteran had applied for a VA position as a motor vehicle operator. Later in December 2015, a CWT note stated that the Veteran's 6 month stay would end in January 2016. In terms of meeting the requirements for a possible extension, the Veteran had struggled with missing appointments, not completing assigned tasks, not saving money, and honestly looking at the changes necessary for his recovery. He admitted to having problems with procrastination, but he did not follow through with suggestions to address this issue. He had been able to remain free of substances, and he had been a good worker in the Transitional Work Experience (TWE) program. The Veteran was told that he would be able to continue with all aspects of treatment as an outpatient, but he would not be able to remain in treatment at the TR. The Veteran would be made aware that in order to remain until January, he would be expected to follow up on program guidelines. The specialist would attempt to assist the Veteran with his transition to the community if he was interested. A subsequent social work group note reported that the Veteran discussed his January discharge from the TR, and his eyes filled with tears as he described feeling angry and sad about the discharge. The Veteran was comfortable at the TR and wanted to continue in transitional sober house somewhere else. He had called his VA provider to ask about a possible referral. Later in December 2015, a specialist informed the Veteran that if he could obtain full or part-time employment prior to his discharge date in January, they could negotiate the length of his stay. The Veteran was provided with a VA examination to evaluate his psychiatric disability in December 2015. The examiner opined that the Veteran had occupational and social impairment with reduced reliability and productivity. The diagnoses were PTSD; major depressive disorder, mild; and generalized anxiety disorder. However, the examiner found that it was not possible to differentiate what symptoms were attributable to each diagnosis. The examiner explained that there was substantial overlap in symptoms between major depressive disorder and PTSD. Both shared problems with concentration, sleep, pervasive negative emotions, and anhedonia. There is also substantial overlap between generalized anxiety disorder and PTSD, including persistent negative emotional state (e.g., irritability/anger, anxiety), difficulty concentrating, and sleep disturbance. Symptoms of weight change and psychomotor retardation/agitation were more likely to be associated with depression; whereas, avoidance of stimuli related to the Veteran's trauma, re-experiencing and hyperarousal symptoms are more likely associated with PTSD. Worry about multiple topics is due to generalized anxiety disorder. The examiner also noted that it was not possible to differentiate what level of impairment was attributable to each diagnosis, noting that the Veteran was impaired by all the diagnoses. In light of the examiner’s opinions, the Board finds that all of the Veteran's psychiatric symptoms are attributable to his service-connected PTSD. See Mittleider v. West, 11 Vet. App. 181 (1998). Regarding the Veteran's social functioning, the examiner noted that the Veteran had been divorced twice, and he had three children. The Veteran was currently unemployed and engaged in VA CWT. He was working 40 hours a week as a janitor at VA. He had only missed one day of work in the past 12 months. The Veteran worked complete shifts and did not have any trouble doing any aspect of the job. Regarding his interactions with others on the job, the Veteran reported that they were pretty good. The Veteran described himself as social and noted that he tried to get along with everyone. He had not been subject to any disciplinary actions. Prior to this employment, the Veteran had been employed for 24 years as a mail processor for the United States Postal Service (USPS). This position ended in 2011 when the Veteran was fired or missing work. The Veteran reported that he experienced depression in that employment position and did not report for work or respond to his employer during his last three months of employment. The Veteran was treating his symptoms with medication and therapy, but he did not find either treatment to be too helpful. The Veteran symptoms included a depressed mood, disturbances of motivation and mood, and anxiety. He also experienced a chronic sleep impairment and difficulty in establishing and maintaining effective work and social relationships. The examiner also found that he had an intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. During the interview, the Veteran was appropriately dressed and groomed and well-engaged, but he had a constricted affect. The examiner found that he was capable of managing his financial affairs. The examiner separately noted the Veteran's report that approximately 50 percent of the time, he had feelings of irritability and anger as well as anxiety and nervousness. The Veteran also reported that he was always sad, estimating that he had felt a depressed mood/sadness approximately 75 percent of the time since the time since the 1990's. His last break in depression occurred approximately two months ago when he was working on his resume and things were going well for him in terms of efforts to find work. Later in December 2015, a VA psychology note stated that the Veteran met the criteria for PTSD. His symptom presentation was unusual in that its main manifestation related to strong, negative feelings about gay people that dated to his military sexual trauma as the perpetrator was a gay male. He had other significant difficulties that related to PTSD of an unknown extent, including a long history of substance use disorder and problems maintaining housing and employment. A subsequent December 2015 psychology note stated that the Veteran's medication might need to be adjusted as he had multiple and conflicting thoughts on what happened to his ability to move forward with planing. He had lost motivation due to the length of time he had spent working on his resumes and his belief that he had been discouraged from pursuing a path to work as a peer specialist. He noted that one of his roommates informed him the previous day that the Veteran "just shut down" after returning home. Vocational Rehabilitation notes in January 2016 revealed that the Veteran interviewed for a janitorial position at a local school, and he was scheduled to meet for continued routine vocational assistance until he attained employment. In January 2016, a HUD-VASH program note stated that the Veteran's diagnoses included PTSD and depression. The Veteran reported, "I have my days" when asked how well his symptoms were controlled. He had been sober for a year. Although there was some history of suicidal thinking, there were no current symptoms. He also had some history of domestic violence with his first wife, but nothing since that time. There was no other assaultive behavior. The Veteran was working in CWT and looking for competitive employment. The provider stated that his CWT would likely end when his time at the TR ended. The Veteran wanted to learn computer skills. A January 2016 psychiatry note documented the Veteran's report that his mood had changed. He did not feel motivated, and he did not want to do anything. The Veteran's PTSD was stable at that time. A separate psychology note from the same day stated that the Veteran was able to stay at the TR longer, but it was unclear why the decision was made. The provider stated that the Veteran tended to "dig in" when efforts were made to see how he could move forward. Later in January 2016, a VA mental health social worker note stated that the Veteran was working CWT in housekeeping. He attended church at least three times a week and found it helpful and supportive in maintaining sobriety. The Veteran also had a great deal of anger related to his military sexual trauma that was triggered in his daily life. He did not report homicidal or suicidal ideation. A subsequent January 2016 Vocational Rehabilitation note stated that the Veteran had not been checking his e-mail for notifications regarding submitted employment applications. He reported being too busy working on his car to check e-mails, call employers back, or use the computer lab for job searches. He later admitted that he tended to forget to check his e-mail. In February 2016, the Veteran reported feeling down as he was not offered a peer support position for which he had applied. The Veteran denied attempting to reschedule a canceled appointment with a personnel service company, and the specialist stated that he "gave the look of attitude to this." The Veteran reported being unable to find the phone number, but he told the specialist he would call later once the specialist located the phone number for him. In February 2016, a Vocational Rehabilitation note stated that the Veteran discussed the anxiety and stress of looking for employment and housing at the same time. The Veteran had completed an application for a position at a hardware store and called the hiring manager. He also planned to submit a federal application for a sanitation position. The Veteran was service-connected, working in housekeeping, and obtaining good reviews from his supervisors. Later in February 2016, a homeless telephone contact noted that the Veteran requested contact after recently cancelling an appointment to attend an interview at the hardware store. However, the Veteran reported that he did not believe he could accept the position if offered as it involved working from afternoons until the evening, and the Veteran felt that working late and night shifts contributed substantially to his alcoholism. A prospective apartment he had visited also reminded him of an apartment where he drank heavily and from which he had been evicted. Later in February 2016, a Vocational Rehabilitation note stated that the Veteran had declined the position at the hardware store as someone in his CWT work in sanitation had informed him of an employment opportunity with VA in housekeeping. In a subsequent Vocational Rehabilitation note in February 2016, the Veteran reported that the benefits of a federal job included his ability to retire with a pension after three years due to his prior 27 years of employment with USPS. A subsequent February 2016 Vocational Rehabilitation note indicated that the Veteran was scheduled for an interview for the VA housekeeping position in March. He had been told by his Sanitation supervisor that "he was in." In March 2016, a VA treatment record noted that the Veteran had an interview for a position on that campus that he felt went well. Later in March 2016, the Veteran reported that he had been offered a job at the VA medical Center as a housekeeper and accepted the job. He was very excited as he had been performing the position as a TWE and really enjoyed the work. The specialist noted that a plan was made to provide ongoing support as the Veteran moved to fulltime federal employment. Later in March 2016, a HUD-VASH program note stated that the Veteran was no longer in the program as he exceeded the income guideline after obtaining the job in housekeeping. The Veteran reported that he had been seeing his family and helping his brother with his house. Another March 2016 HUD-VASH program note stated that the Veteran was no longer interested in applying to be a peer specialist due to his new position with VA. The assessment noted a broad range of affect, an increase in positive affect, and maintenance of sobriety. He did not endorse suicidal or homicidal ideation. On March 18, 2016, the Veteran was discharged from HUD-VASH. In March 2016, a social work group note stated that the Veteran reported feeling enraged with his son and daughter-in-law due to their rude interactions with Veteran's family members. He acknowledged his own issues with anger. The provider noted that looking at personal issues rather than remaining preoccupied with others was a challenge for the Veteran and other group members. Also in March 2016, a Vocational Rehabilitation discharge note summarized that the Veteran had been placed in the transitional work program in July 2015, and he initially worked in the kitchen before being transferred to sanitation. He was scheduled to begin working in sanitation as a full-time federal employee in April 2016. The Veteran reported that he was appreciative that Vocational Rehabilitation services had helped him to rejoin the workforce. The Veteran was in the process of finding his own apartment. He would continue to live at the TR until he located an apartment, but the record indicated that he was not intended to stay later than July. In May 2016, a VA psychology note stated that the diagnoses were PTSD and substance use disorder in full sustained remission. The Veteran was finally feeling ready to leave the TR and manage his own household. In June 2016, a pass status note reported that the Veteran was actively looking for an apartment. He planned to stay with his bother after his discharge the next week if an apartment did not become available before then. On July 1, 2016, a Vocational Rehabilitation note stated that the Veteran would complete his year in the CWT/TR program on July 7, 2016. The Veteran had since obtained gainful employment in Sanitation as a federal employee. He also had aspirations to further educate himself to work towards a goal of becoming a peer specialist. The record added that the Veteran had re-connected with his siblings, children, and grandchildren. He was also on good terms with his ex-wife. The Veteran had not yet found an apartment, and he continued to plan to stay with his brother. He had made much progress with insight into his character flaws and was taking steps to improve himself. He planned to continue in aftercare with CWT/TR and mental health care appointments. A July 5, 2016 addendum noted that the Veteran requested for be discharged on that date as he had been able to borrow a truck to move the rest of his belongings. In July 2016, the Veteran reported that it had been a challenge to live outside of the TR. He had a longer commute, he was not attending as many meetings, and he did not enjoy living with his brother. He was also aggravated by his children as he felt that they did not respect him as much as they should. The provider stated that he was doing well considering it was his first time living outside the program in almost 1.5 years. In August 2016, a psychology note stated that the Veteran's pattern of dealing with family stressors was to initially respond to hurt with anger and fantasies of retaliation. However, he typically came up with a more mature response after thinking things over. He had recently thought of not keeping his promise to ready a car for his son after feeling aggravated by his ex-wife, and he instead made plans to go with his brother to work on it. In November 2016, a VA psychology note stated that the Veteran had plans to go to the union as he felt disrespected by his boss. He later discussed whether there were other ways to approach the issue. The provider stated that the Veteran had a strong visceral reaction to being disrespected which was likely due to the fact that that he had encountered a lot of disrespect when he was drinking. A November 2016 psychiatry follow-up note stated that the Veteran reported doing alright. He was not drinking and trying to stay positive. His PTSD symptoms were stable with no adverse side effects from medications. The mental status examination showed that the Veteran was casually dressed with good personal hygiene. He was alert and oriented, pleasant, and cooperative. His speech was goal directed, his affect was full and appropriate, and his memory appeared to be intact. There were no homicidal or suicidal ideations, and no hallucinations or delusions. His insight and judgment were fair. The depression screen showed that for several days, the Veteran had little interest or pleasure in doing things; and he felt down, depressed, or hopeless. In December 2016, a VA psychology note stated that the Veteran was moving in with another man in recovery at the end of the month. Later that month, a psychology note stated that the Veteran was not able to move to the apartment due to credit problems. The Veteran was going to church regularly and spending time with family. He provided them with some financial help, and he knew he needed to focus more on righting his own finances. The provider indicated that he was being avoidant in this area. In January 2017, a VA psychology note stated that the Veteran had spoken with a VA employee in Newington who offered to help him with a transfer there. In February 2017, a psychiatry note documented the Veteran's report that he was doing well, but he did not know if he needed stronger medication as he sometimes fell into a depression. He noted that the depression did not last long. The Veteran was maintaining sobriety, and his PTSD symptoms were stable. The provider noted that the Veteran's mood was dysphoric, and the remaining mental status evaluation findings were largely unchanged from those previously noted. A February 2017 psychology note stated that the Veteran reported having a tough week, and his frayed nerves were evident. A couple of guys at work had been "teasing" the Veteran about his sexual orientation issues by blowing him kisses or calling him "Cupcake," and the Veteran found this behavior extremely offensive and something he did not need to tolerate. Fellow staff members had also been giving him a hard time about their perception that he left early or did not report to work when there was a threat of snow. The Veteran was going to consider options related to sexual harassment. Later in February 2017, a psychology note stated that the Veteran was in a "funk" as he was still living with his brother and did not feel he was making progress getting out of debt. In March 2017, a psychology note stated that the Veteran reported he might be able to transfer to a housekeeping position in Newington. Although this position would be close to family, he found the thought of leaving Northampton to be wrenching. Despite his sadness at leaving, he was basically doing well and looking forward to the future. No risk factors were noted. In April 2017, a VA psychiatry note stated that the Veteran reporting doing pretty well. His sleep was disturbed, but not too bad. His appetite was also pretty good with stable PTSD symptoms. The Veteran's mood was mildly anxious, but there were no other notable changes in the mental status examination findings. In May 2017, the Veteran described a "near miss" on a relapse. He and his wife went into a bar he previously frequented to escape the rain, and he felt a powerful urge to drink. The Veteran was able to overcome this urge by going to an Alcoholics Anonymous meeting. In June 2017, a psychology note stated that the Veteran was doing very well and indicated that he had accepted the job in Newington. The Veteran was a bit sad to be leaving, but he basically felt good about everything he had accomplished. He also brought in a list of all his creditors and the monthly payments he had agreed to make, and the provider indicated that she provided validation for the Veteran having tackled a problem after years of putting it off. During the December 2020 Board hearing, the Veteran reported that he was still working in a VA housekeeping position in Newington. Consistent with the information in the VA treatment records, the Veteran explained that he had transferred to this position from his prior employment with VA in Northampton. However, the Veteran indicated that he had plans to retire from his current position due to his feelings of not wanting to be around others. The Veteran indicated that colleagues had asked him for rides, but he found himself unable to help as he did not want to be around them. The Veteran confirmed that the circumstances of his job were increasing his anxiety and some of his other symptoms. The perpetrator of his military sexual trauma had been African American, and some of the current social justice movements in the country were increasing his anxiety. He was having nightmares and problems sleeping that left the Veteran feeling tired during the day. The Veteran indicated that he also felt unable to relax unless he was by himself. He ate lunch alone in his car rather than in the breakroom as the breakroom was frequented by several African American employees. The Veteran was still living with his brother. He denied going to places such as restaurants, indicating that he primarily went to work or to visit his granddaughters and grandson. The Veteran avoided stores. He tried to do his shopping at night when there was less chance of a crowd and did his best to avoid eye contact when in a store. The Veteran also parked far away from stores in an attempt to control who was close to him. The Veteran also felt the need to roll up his windows, check his mirrors, and lock his car doors whenever he saw an African American man due to feelings of fear. The Veteran noted that when he was working in the lobby area of the pharmacy at VA, he was afraid of the patients who came in as some would be angry. The Veteran indicated that he sought to distance himself from any type of confrontation. The Veteran additionally described having memory and concentration issues with frequent difficulties in completing tasks. In addition, the Veteran was easily frustrated. Feelings of frustration could make the Veteran begin to hyperventilate, feel angry, and feel anxious. The Veteran also often had difficulty following along in conversations. Although he still had anger issues, the Veteran currently had a tendency to walk away from a confrontation. However, the Veteran's representative noted that the Veteran had informed him that if murder was legal, there would be a lot of murders. The Veteran expressed regret that he had shared this thought with the representative. He felt that he was able to keep his anger under control. The Veteran also denied having thoughts of hurting himself. Although the Veteran indicated that he changed his clothes after returning home from work, he reported that he typically showered only twice a week. The Veteran also stated that he did nothing more than sit in his chair after work. The Veteran additionally stated that he had no interest in eating more than once a day, and he had lost his previous interest in bowling and watching sports. The Veteran had no other hobbies. Although the Veteran indicated that he had initially planned to retire on a specific day December, he reported that there was a problem with his paperwork. He did not indicate that he had any set retirement date at the time of the Board hearing, and there has been no further evidence added to the claims file to indicate that he is no longer employed in his housekeeping position at VA. After reviewing the foregoing evidence, the Board finds that a 70 percent disability rating for his PTSD is warranted for the entire appeal period. During this period, the Veteran demonstrated difficulty in adapting to stressful circumstances, including at work. PTSD symptoms related to avoidance and lack of motivation also impaired his ability to function independently, appropriately, and effectively. As early as July 2015, the Veteran was noted feel anxious in the performance of his job and described as lacking motivation. In August 2015, the Veteran reported feeling anxious all the time. Records in September 2015 also indicated that the Veteran was avoidant and that he was reluctant to confront others with whom he was having difficulties. Although the Veteran denied having anxiety on the job in October 2015, the Veteran also indicated that he was reliant on the structure of his TR program at that time to deal with stressors. Beginning in November 2015, the Veteran also reported having difficulty coping with certain interactions with his coworkers regarding sexual orientation as the subject was a trigger related to his military sexual trauma. The Veteran was also noted to be struggling with his attitude, accepting responsibility for making changes, and following through on the goals he needed to accomplish to transition towards living on his own. The Veteran was still feeling a depressed mood, disturbances of motivation and mood, and anxiety at the time of the December 2015 VA examination, and the Veteran indicated that these symptoms of depression and anxiety were present at least 50 percent of the time. These symptoms affected the Veteran’s functioning such that the Veteran was noted to “just shut down” after work in December 2015. The Veteran’s difficulty with anxiety in his search for employment and housing during this period was also well-documented in the record. Although the Veteran was eventually able to obtain full-time employment with VA in April 2016, his Board hearing testimony indicated that he continued to lack motivation to do anything after work. The subsequent records continued to indicate that the Veteran’s symptoms of avoidance of situations that caused anxiety or reminded him of military sexual trauma also continued to affect his functioning at work and in his free time. The record indicates that the Veteran sought to transfer to employment at another VA facility after he faced harassment from coworkers regarding his military sexual trauma-related difficulty with issues concerning sexual orientation. The Veteran additionally reported during the December 2020 Board hearing that his avoidance of confrontation affected his ability to perform his duties in areas where he might encounter angry veterans. The Veteran’s feelings of fear of African Americans as a result of his military sexual trauma also led the Veteran to avoid joining his colleagues for lunch, and his apprehension of crowds influenced his decisions regarding when to shop and where to park his car. Although several records during the appeal period indicated that the Veteran had good hygiene, both the December 2015 VA examination report and the Veteran’s December 2020 Board hearing testimony describing infrequent showers indicated that he did experience periods of neglect of personal appearance and hygiene. The Veteran displayed some, but not all, of the symptoms listed as examples under the 70 percent rating criteria. Although the Board has considered the December 2015 VA examiner’s determination that the Veteran experienced occupational and social impairment with occupational and social impairment with reduced reliability and productivity, the Board finds that the symptoms reported by the Veteran are of greater severity than those associated with a 50 percent disability rating. Resolving all doubt in favor of the Veteran, the Boards finds that the overall level of impairment during this period is consistent with occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. During the Board hearing, the Veteran and his representative indicated that they would be satisfied with the grant of a 70 percent rating for PTSD. Consequently, discussion of whether a rating higher than 70 percent is warranted for PTSD is unnecessary. Cf. AB v. Brown, 6 Vet. App. 35, 39 (1993) (a veteran is presumed to be seeking the maximum possible rating unless he indicates otherwise). In light of the evidence discussed above, and resolving all reasonable doubt in favor of the Veteran, the Board finds that a 70 percent disability rating for the Veteran's PTSD, but no higher, is warranted for the entire period on appeal. 38 U.S.C. § 5107(b). GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K.C. Spragins, 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.