Citation Nr: 21015575 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 15-17 888 DATE: March 17, 2021 ORDER The appeal for service connection for the Veteran’s left knee disability, having been granted in full, is dismissed. Service connection for bilateral hearing loss is denied. For the period on appeal prior to October 19, 2020, an increased initial evaluation of 70 percent, but no greater, for the Veteran’s service-connected acquired psychiatric disability, to include post-traumatic stress disorder (PTSD) and persistent depressive disorder, is granted. For the period on appeal from October 19, 2020, an increased evaluation in excess of 70 percent for the Veteran’s service-connected acquired psychiatric disability, to include post-traumatic stress disorder (PTSD) and persistent depressive disorder, is denied. FINDINGS OF FACT 1. The appeal for service connection for the Veteran’s left knee disability was granted in an August 2020 rating decision. 2. There remains no question of fact or law to be decided by the Board concerning the question of service connection for the Veteran’s left knee disability. 3. The Veteran currently does not have bilateral sensorineural hearing loss to an extent recognized as a disability for VA purposes. 4. For the entire period on appeal, the Veteran’s service-connected acquired psychiatric disability, to include post-traumatic stress disorder (PTSD) and persistent depressive disorder, is productive of a disability level that more nearly approximates occupational and social impairment with deficiencies in most areas, to include work, family relations, judgment, thinking, and mood, but does not result in total social and occupational impairment. CONCLUSIONS OF LAW 1. There being no question of fact or law to be decided by the Board, the appeal of the issue of entitlement to service connection for a left knee disability is dismissed. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The criteria for entitlement to service connection for bilateral hearing loss have not been satisfied. 38 U.S.C. §§ 1101, 1110, 1112, 1154, 5107, 7104; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.385, 4.85. 3. For the period on appeal prior to October 19, 2020, the criteria for an increased evaluation of 70 percent for the Veteran’s service-connected acquired psychiatric disability, to include post-traumatic stress disorder (PTSD) and persistent depressive disorder, have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § § 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Codes 9411, 9433. 4. For the period on appeal from October 19, 2020, the criteria for an increased evaluation in excess of 70 percent for the Veteran’s service-connected acquired psychiatric disability, to include post-traumatic stress disorder (PTSD) and persistent depressive disorder, have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § § 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Codes 9411, 9433. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the U.S. Army from June 1979 to June 1999. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2010 rating decision issued by a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). The Veteran testified before the undersigned at a hearing held in February 2018; a transcript of that hearing is of record. In January 2019, the Board remanded the Veteran’s claim for further development, including the procurement of additional VA examinations to evaluate his bilateral hearing loss and psychiatric claim. To the extent that the directed VA examination reports have been procured, the Board finds that substantial compliance with its remand directives pertaining to the Veteran’s bilateral hearing loss and psychiatric claims has been accomplished. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Service Connection 1. The appeal for service connection for the Veteran’s left knee disability, having been granted in full, is dismissed. The Veteran perfected an appeal to the Board seeking service connection for a left knee disability by submitting a timely Notice of Disagreement in October 2011. Subsequently, an August 2020 rating decision granted service connection for a left knee disability effective April 5, 2010. Thus, the issue sought on appeal has already been granted and there remains no further controversy of fact or law. The appeal is, therefore, dismissed. See 38 U.S.C. § 7105. 2. Service connection for bilateral hearing loss is denied. The Veteran contends that he is entitled to service connection for bilateral hearing loss that was proximately caused by his active military service, to include his exposure to hazardous military noise during service. In this regard, service connection is warranted where the evidence of record demonstrates that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of a pre-existing injury suffered or disease contracted in the line of duty during active military service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Disorders diagnosed after discharge may be found to be service-connected where all the evidence, including that pertinent to service, establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). Service connection for a disability requires competent and credible evidence of the following: (1) the existence of a current disability; (2) the existence of the disease or injury in service; and (3) a relationship or nexus between the current disability and any injury or disease during service. See Hickson v. West, 12 Vet. App. 247, 252 (1999). A presumption of service connection attaches to certain diseases enumerated in 38 C.F.R. § 3.309(a). In this case, sensorineural hearing loss is categorized as an organic disease of the nervous system under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258, 271 (2015). Where a veteran has served for at least ninety days during a period of war or after December 31, 1946 and develops an enumerated chronic disease to a compensable degree within one year from the date of separation from service, such disease shall be presumed to have been incurred or aggravated in service even though there is no evidence of such disease during the period of service. See 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In order to establish a chronic disease in service, a veteran must show a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “chronic.” See 38 C.F.R. § 3.303(b). When the disease identity is established, there is no requirement of an evidentiary showing of continuity. See id. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. See id. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. See id. Continuity of symptomatology is only applicable to those diseases recognized as “chronic” for VA purposes. See Walker v. Shinseki, 708 F.3d 1331, 1338-1339 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.309(a). Service connection for impaired hearing shall only be established when hearing status as determined by audiometric testing meets specified puretone and speech recognition criteria. Audiometric testing measures puretone threshold hearing levels (in decibels) over a range of frequencies (in Hertz). See Hensley v. Brown, 5 Vet. App. 155, 158 (1993). The determination of whether a veteran has a hearing loss disability is governed by 38 C.F.R. § 3.385, which provides that, for the purposes of applying the laws administered by VA, impaired hearing will be considered a disability only where one of the following is established: (1) the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; (2) the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 hertz are 26 decibels or greater; or (3) speech recognition scores using the Maryland CNC Test are less than 94 percent. See 38 C.F.R. § 3.385. The threshold for normal hearing ranges between zero to 20 decibels and higher threshold levels indicate some degree of hearing loss. See Hensley, 5 Vet. App. at 157. A veteran may establish direct service connection for a hearing disability that initially manifests several years after separation if the evidence of record demonstrates a causal relationship between the veteran’s current hearing disability and the injury or disease suffered in service. See id. at 164; 38 C.F.R. § 3.303(d). Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board shall afford the claimant the benefit of the doubt. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. Where the evidence is in relative equipoise, the claimant shall prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). The preponderance of the evidence must weigh against the claim in order to warrant its denial. See Alemany v. Brown, 9 Vet. App. 518, 519-20 (1996). After careful review of the evidence of record, the Board finds that the Veteran currently does not suffer from bilateral hearing loss to an extent recognized as a disability for VA purposes. In August 2020, the Veteran was afforded his most recent VA audiological examination which reflected bilateral hearing thresholds of 25 decibels or lower in all frequencies from 500 Hertz to 4000 Hertz, and speech recognition measured as 96 percent in the right ear and 98 percent in the left ear. All of these measurements fall short of the VA criteria for a hearing disability as set forth above. See 38 C.F.R. § 3.385. Accordingly, the Board finds that the Veteran has not manifested bilateral hearing loss to an extent recognized as a disability for VA purposes at any time during the period on appeal, and in the absence of competent evidence of a current disability, service connection cannot be awarded. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); 38 C.F.R. § 3.385. Accordingly, the Veteran’s service connection claim for bilateral hearing loss must be denied. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Increased Ratings 3. For the period on appeal prior to October 19, 2020, an increased initial evaluation of 70 percent, but no greater, for the Veteran’s service-connected acquired psychiatric disability, to include post-traumatic stress disorder (PTSD) and persistent depressive disorder, is granted. 4. For the period on appeal from October 19, 2020, an increased evaluation in excess of 70 percent for the Veteran’s service-connected acquired psychiatric disability, to include post-traumatic stress disorder (PTSD) and persistent depressive disorder, is denied. The Veteran’s service-connected acquired psychiatric disability, to include PTSD and persistent depressive disorder, is currently evaluated under the criteria of Diagnostic Code 9411 as follows: (1) 30 percent disabling November 27, 2013; (2) 50 percent disabling from May 8, 2020; and (3) 70 percent disabling from October 19, 2020. See 38 C.F.R. § 4.130. The Veteran contends that the current severity of his service-connected acquired psychiatric disability warrants an increased evaluation of 100 percent; however, for the entire period on appeal, the Board finds that a preponderance of the evidence of record weighs against a finding that an increased evaluation in excess of 70 percent for the Veteran’s service-connected acquired psychiatric disability is warranted in this case, as the record does not reflect that the Veteran suffers from total occupational and social impairment due to his service-connected psychiatric condition. The VA General Rating Schedule for mental disorders, including major depressive disorder, provides for a noncompensable evaluation where a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. See id. A 10 percent rating contemplates occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. See id. A 30 percent rating contemplates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). See id. 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; impairment 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. See id. A 70 percent evaluation contemplates 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 worklike setting); and inability to establish and maintain effective relationships. See id. A 100 percent evaluation contemplates total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. See id. The VA Secretary recently amended the portion of the Schedule for Rating Disabilities dealing with psychiatric disorders and the associated regulations to remove outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and replaced them with references to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). The DSM-V eliminated the DSM-IV’s reliance upon GAF scores, and accordingly, the Board will no longer afford GAF scores any probative value. See Golden v. Shulkin, 29 Vet. App. 221, 224-25 (2018). Evaluation under Section 4.130 is symptom-driven; therefore, symptomatology should be the primary focus when assigning a rating to a given mental health disability, and the frequency, severity, and duration of a veteran’s symptoms must play an important role in determining the appropriate disability rating. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). Significantly, the list of symptoms under the rating criteria is meant to be illustrative, not exhaustive; thus, the Board need not find all or even some of the listed symptoms in order to award a specific disability rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). In fact, it is the level of the veteran’s occupational and social impairment that determines the appropriate disability rating under Section 4.130; accordingly, if the evidence of record demonstrates that the veteran suffers from symptoms listed in the rating criteria or symptoms of a similar severity, frequency, and duration that cause occupational or social impairment equivalent to the criteria for a particular rating, then the corresponding rating shall be assigned. See id. at 443; see also Vazquez-Claudio, 713 F.3d at 117. In addition to the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran’s capacity for adjustment during periods of remission must also be considered, and the evaluation must rest upon all the evidence relating to occupational and social impairment, not solely the examiner’s assessment of the level of disability at the moment of the examination. See 38 C.F.R. § 4.126(a). Further, when evaluating the level of disability for a mental disorder, the extent of social impairment must be considered, but the evaluation shall not be assigned solely on the basis of social impairment. See 38 C.F.R. § 4.126(b). As stated above, in June 2014, the Veteran was awarded service connection for an acquired psychiatric disability, to include post-traumatic stress disorder (PTSD), with an initial evaluation of 30 percent, effective November 27, 2013, which was subsequently increased to 50 percent, effective May 8, 2020, and to 70 percent effective October 19, 2020. Effective dates for disability ratings shall generally be the day following separation from active service or the date entitlement arose if the claim is received within one year of separation from service; otherwise, the effective date shall be the date of receipt of the claim, or the date the entitlement arose, whichever is later. See 38 U.S.C. § 5110; 38 C.F.R. § 3.400(b)(2)(i). When determining when the entitlement arose, an effective date for benefits can be no earlier than the date the disability at issue first manifested. See DeLisio v. Shinseki, 25 Vet. App. 45, 52 (2011). In this case, the Veteran filed his claim for service connection on November 27, 2013. Therefore, the Board has considered whether the Veteran’s service-connected psychiatric symptoms warrant an increased evaluation from November 27, 2013. The Veteran contends that the severity of his PTSD symptoms warrant an evaluation in excess of 30 percent for the period on appeal from November 27, 2013, in excess of 50 percent for the period on appeal from May 8, 2020, and in excess of 70 percent for the period on appeal from October 19, 2020. After careful review, and for the reasons set forth below, the Board finds that, for the period on appeal prior to October 19, 2020, an increased evaluation of 70 percent for the Veteran’s service-connected acquired psychiatric disability, but no greater, is warranted. However, for the period on appeal from October 19, 2020, the Board further finds that a preponderance of the evidence of record weighs against a finding that an increased evaluation in excess of 70 percent is warranted in this case, as the Veteran’s service-connected acquired psychiatric disability does not result in total social and occupational impairment. Throughout the entire period on appeal, the evidence of record reflects that the Veteran’s psychiatric symptoms included the following: depressed mood; irritability; chronic sleep impairment; nightmares; avoidance; social isolation; anhedonia; hypervigilance; exaggerated startle response; impaired impulse control; and suicidal ideations. In April 2014, the Veteran was afforded a VA psychiatric examination which culminated in a report diagnosing the Veteran with PTSD and persistent depressive disorder found likely to be related to his combat service in Somalia and to manifest the following symptoms: depressed mood; anxiety; suspiciousness; chronic sleep impairment; recurrent distressing dreams; intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; persistent avoidance; negative alterations in cognitions and mood; persistent and exaggerated negative beliefs or expectations; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; irritable behavior and angry outbursts; hypervigilance; and exaggerated startle response. The April 2014 VA examination report also notes the Veteran’s report of the following: (1) he divorced his spouse in 2001 but they remarried some years later; (2) his adult son lives at home, and his adult daughter lives out of the home; (3) he has been written up a work “a couple of times;” (4) the prescription medication for his nightmares is not effective, resulting in intermittent awakenings and causing him to get “very little sleep some nights;” (5) when he has been unable to sleep for two to three days he takes a sick day, but he still cannot sleep well; (6) he cannot deal with a lot of noise and prefers that the house be quiet; and (7) he avoids attending family activities and sometimes does not answer the phone. The April 2014 VA examination report further notes as follows: (1) the Veteran manifested a dysphoric mood during the examination; (2) the Veteran made little eye contact and appeared both tired and inattentive; and (3) the Veteran denied suicidal or homicidal ideations. In February 2016, the Veteran underwent a psychiatric examination by a private psychiatrist (Dr. L) which culminated in a report (Dr. L’s February 2016 Report) confirming the Veteran’s diagnosis of PTSD and finding the following symptoms: depressed mood; anxiety; suspiciousness; flattened affect; guilt; nightmares two to three times per week; physical aggression while sleeping; daily intrusive thoughts; flashbacks; avoidance; reduced activity; fatigue; numbing; isolation; anhedonia; feelings of detachment or estrangement from others; restricted range of affection; sense of foreshortened future; chronic sleep impairment; irritability; angry outbursts; impaired concentration; hypervigilance; exaggerated startle response; cognitive impairment; poor self-esteem; helplessness; hopelessness; loss of employment opportunities; social withdrawal; loss of interest in sex; alcohol abuse; panic attacks weekly or less often; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; mild memory loss (such as forgetting names, directions, recent events; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; inability to establish and maintain effective relationships; difficulty in adapting to stressful circumstances (including work or a worklike setting); neglect of personal appearance and hygiene; auditory and olfactory hallucinations; paranoia; and claustrophobia. Dr. L’s February 2016 Report further indicates the following: (1) the Veteran’s triggers include crowds; leaving the house; smells; loud noises/fireworks; being touched; and being close to people; (2) the Veteran had been married for thirty-one years, including after a 2001 divorce caused by the Veteran’s increasingly isolative state since 1994; (3) the Veteran has two adult children and one close friend; (4) he does not engage in activities outside his home; (5) he can drive but does not leave his car; (6) he has been working full time as a business training consultant for the past twelve years; (7) he is frequently out of the office on flexible sick leave and has been increasing his amounts of leave as his symptoms have worsened; (8) he previously worked as a truck driver, car salesperson, and office clerk; (9) he was fired or suspended from a prior job for a driving accident; (10) he considered suicide more than one year prior stating that he feels his family would be better off without him and he assumed he would “just die from stress or a heart attack;” (11) he is easily tearful and overwhelmed; (12) he wishes he had been a better father and husband; and (13) he sometimes uses wine to go to sleep. In May 2016, the Veteran was afforded another VA psychiatric examination which culminated in a report confirming the Veteran’s diagnosis of PTSD and finding the following symptoms: depressed mood; anxiety; suspiciousness; avoidance; chronic sleep impairment (one to two hours per night); nightmares three to four times per week; hypervigilance “all the time;” exaggerated startle response almost daily; intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; persistent, distorted cognitions about the cause or consequences of the traumatic event; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; irritable behavior and angry outbursts; disturbances of motivation and mood; and reports of never being in a “happy mood.” The May 2016 VA examination report also notes the following: (1) the Veteran has been married twice to the same woman, first in 1983, then divorced for one to two years in early 2000; (2) he has two children and “maybe one friend;” (3) he sometimes visits his adult daughter in Orlando; (4) he sometimes goes to church; (5) he lives with his spouse and his adult son; (6) he has been employed full-time as business training consultant for past thirteen to fourteen years; (7) he has been prescribed sleep medication (prazosin) for nightmares and also receives individual therapy treatment; and (8) he denied suicide attempts, self-harm, or harm to others or plans. In August 2017, the Veteran underwent another psychiatric examination by a private psychologist (Dr. D) which culminated in a report (Dr. D’s August 2017 Report) confirming the Veteran’s diagnosis of dysthymic disorder and somatic symptom disorder and finding the following symptoms: depressed mood; anxiety; suspiciousness; chronic sleep impairment; auditory hallucinations (noise, door knocks, bell ringing); nightmares; hypervigilance; suspiciousness; ease of startle; crying; impaired focus; irritable behavior and angry outbursts; intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; persistent avoidance; negative alterations in cognitions and mood; persistent and exaggerated negative beliefs or expectations; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; exaggerated startle response; flattened affect; social withdrawal; reduced activity; fatigue; poor self-esteem; helplessness; hopelessness; guilt; loss of employment opportunities; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); disturbances of motivation and mood; inability to establish and maintain effective relationships; difficulty in adapting to stressful circumstances (including work or a worklike setting); impaired impulse control; persistent delusions or hallucinations; neglect of personal appearance and hygiene; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); regular suicidal ideation (“they’d be better off without me”); denial of any suicidal intent or plan; anhedonia and lack of interest in shopping with his spouse, playing sports, or enjoying time with his family due to his chronic pain in foot and irritated scalp. Dr. D’s August 2017 Report further indicates the following: (1) the Veteran has been married twice to the same spouse for more than thirty years; (2) he has two adult children with whom he has contact; (3) he lives with his spouse and his adult son; (4) he keeps in touch with his siblings; (5) he completed college after he separated from service; (6) he has been employed for the past fifteen years as a business services specialist; (7) he has experienced some conflict with co-workers due to his “physical issues;” (8) he has been diagnosed with PTSD which is being treated with group counseling, individual counseling, and prescription medication for nightmares (prazosin); (9) he confirmed that he has had suicidal ideations but no intent or plan; and (10) his mobility is “severely diminished” due to chronic pain. In May 2020, the Veteran was afforded a third VA psychiatric examination during the period on appeal which culminated in a report confirming the Veteran’s diagnosis of PTSD, as well as persistent depressive disorder, secondary to PTSD, and finding the following symptoms: depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; avoidance; depressed affect; chronic sleep impairment; intrusive thoughts; nightmares; hypervigilance; hopelessness; worthlessness; marked physiological reactions; persistent and exaggerated negative beliefs; auditory hallucinations; impaired motivation; persistent, distorted cognitions about the cause or consequences of the event; persistent negative emotional state; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement; exaggerated startle response; and suicidal ideation. The May 2020 VA examination report also notes the following: (1) the Veteran still lives with his spouse and adult son; (2) he reports that he gets along with his family, although it is “rough because of” his “situation;” (3) he has one long-distance friend; (4) does not do activities, go out, or participate in family outings; (5) he has been employed for eighteen years as a business service specialist; (6) he has been reprimanded both verbally and in writing at work; (7) last year he “got into it” with a colleague, and VA treatment records reflect that he was transferred to a different office due to his conflict with a colleague; (8) he reports that he tries to work forty hours per week but he often takes sick leave; (9) he reports sleeping six hours per night; (10) he reports that he wakes up in the middle of the night due to “hearing things,” then he “gets his gun” and walks around, but no one is there; (11) he does not want to be a “burden” to his family; (12) when around others he experiences sweating, numbness, tingling; (13) sometimes he needs reminders to drive; (14) he is able to interact with colleagues, though others generally leave him alone; and (15) he arrives early to work, closes his door, and does not interact with customers. The May 2020 VA examination report further indicates that the Veteran’s psychiatric condition may impair his ability to interact with coworkers, supervisors, and the public and may impair his ability to maintain a regular schedule. Moreover, although the Veteran has worked for his employer for the prior eighteen years, his employer has made certain accommodations, such as allowing the Veteran to change locations and to close his office door daily. In December 2020, the Veteran underwent an additional psychiatric examination by a private psychologist (Dr. C) which culminated in a report (Dr. C’s December 2020 Report) confirming the Veteran’s diagnosis of PTSD and finding the following symptoms: depressed mood; anxiety; suspiciousness; chronic sleep impairment; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; flashbacks; apathy; rage; noise sensitivity; lack of empathy; nightmares; fatigue; intrusive thoughts; emotional detachment; social isolation; crowd avoidance; anhedonia; impaired motivation; hypervigilance; mood swings; irritability; angry outbursts, to include being physically aggressive with his spouse and his son; mild memory loss (such as forgetting names, directions, recent events; impairment of short- and long-term memory); flattened affect; impaired judgment; impaired abstract thinking; gross impairment in thought processes or communication; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships; inability to establish and maintain effective relationships; impaired impulse control (such as unprovoked irritability with periods of violence); persistent delusions or hallucinations; neglect of personal appearance and hygiene, to include staying in bed for days at a time neglecting nutrition and hygiene; often neglects appearance and hygiene; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); olfactory hallucinations of dead or burning bodies and foul odors; auditory hallucinations of people talking; a belief that people are following him; and suicidal ideation without plan or intent. Dr. C’s December 2020 Report further indicates the following: (1) the Veteran has been married for thirty-six years despite being divorced and remarried to the same spouse; (2) he has worked for the same employer for the past eighteen years; (3) he has a history of workplace confrontations with co-workers and supervisors, as well as poor job performance; (4) he has been moved to different departments and locations due to his difficulties getting along with others; (5) he has received verbal and written reprimands due to aggressive behavior and has had frequent absences due to difficulty being around people; (6) due to the chronic and consistent nature of the Veteran's psychiatric symptoms, it is unlikely that his condition will change, and his PTSD is considered static and permanent in nature; (7) the Veteran's persisting psychiatric symptoms preclude his ability to interact with superiors, coworkers, and customers; (8) he will be unable to remember and follow instructions, to use judgment, to show insight or to think abstractly, to concentrate, or to work in a loosely supervised situation; and (9) he will require little interaction with the public. In January 2021, the Veteran was afforded a fourth VA psychiatric examination during the period on appeal which culminated in a report confirming the Veteran’s diagnosis of PTSD and finding the following symptoms: increased depression to include sadness and thoughts of death with no current suicide or homicidal ideation, intent or plan; feelings of hopelessness, anxiety and worry; racing and ruminating thoughts; nightmares; flashbacks; hypervigilance; intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; avoidance; persistent and exaggerated negative beliefs or expectations; persistent, distorted cognitions about the cause or consequences of the traumatic event; persistent negative emotional state; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; persistent inability to experience positive emotions; irritable behavior and angry outbursts; exaggerated startle response; impaired concentration; suspiciousness; panic attacks that occur weekly or less often; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; impaired judgment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work like setting; impaired impulse control, such as unprovoked irritability with periods of violence; and passive hallucinations consisting of thinking he is hearing someone outside his house. The January 2021 VA examination report further indicates the following: (1) the Veteran was alert and oriented to person, place, situation, and time and demonstrated fair attention and concentration; (2) his mental flexibility appeared to be fair as he was able to complete simple tasks of serial calculations without errors; (3) he denied any suicidal or homicidal ideations at the time of the evaluation; (4) he is currently married and reported his PTSD has impacted the marriage, including his anger, irritability, paranoia, and fear, causing his spouse to move “to another room;” (5) he continues to experience hypervigilance and passive hallucinations consisting of thinking he is hearing someone outside his house, prompting him to call the police, but no one is there; (6) he has been told that if he continues to “abuse” the law enforcement system, he will be charged; (7) he has been pulled over in the last few weeks due to speeding; (8) he reports no social support network and is not involved in any social activities; (9) he reports difficulty remembering his daughter’s birthday; (10) he reports a “good relationship” with his adult son; (11) he has been employed for the last eighteen years as a business service specialist; (12) he reports that his mood has impacted his ability to get along with others as he is often getting into confrontations; (13) his difficulties at work have resulted in his transfer to several other departments; (14) he reports that he often feels like he is being treated unfairly at work and has missed several days of work because of his performance; and (15) he currently receives mental health treatment at VA, to include psychiatric medication management of trazadone; duloxetine; prazosin; and lamotrigine and biweekly psychotherapy. The Veteran also testified before the undersigned at a February 2018 Board hearing that he was experiencing more irritability issues, including difficulty getting along with people and adapting to stress. In addition, the Veteran further testified that he continues to suffer from the following: nightmares; night sweats; impaired memory; hypervigilance, including perimeter checks on the house; social isolation; crowd avoidance; and thoughts that his family “would probably be a lot better off” without him. In light of the foregoing evidence, the Board finds that an evaluation of 70 percent, but no higher, during the entire period on appeal is warranted in this case, because the frequency, severity, and duration of the Veteran’s symptomatology resulted in social and occupational impairment in most areas, particularly with respect to his continued nightmares and sleep impairment, his restricted social relationships, his irritability and impaired impulse control, his inability to form productive working relationships or to focus on job-related tasks, and his persistent mood dysregulation. See 38 C.F.R. § 4.130. The Board notes that the June 2014, May 2016, May 2020, and January 2021 VA psychiatric examinations culminated in reports assessing the Veteran’s service-connected acquired psychiatric disability as less than 70 percent disabling despite the Veteran’s report of recurrent suicidal ideations and hallucinations, among other symptoms resulting in occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, and mood. In contrast, the Board finds the Veteran’s competent and credible testimony regarding his current symptomatology to carry significant probative weight, including his report of his recurrent suicidal ideations and his chronic nightmares, sleep impairment, and impulse control, as well as the Veteran’s continued conflicts at work, which have necessitated certain accommodations by his employer and which were found by Dr. C to limit his employment performance as follows: (1) precluding his ability to interact with superiors, coworkers, and customers; (2) impeding his ability to remember and to follow instructions; (3) impairing his ability to use judgment, to show insight, or to think abstractly; (4) impairing his ability to concentrate or to work in a loosely supervised situation; and (5) rendering him unable to interact with the public on more than an minimal basis. See Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017). Accordingly, in light of the foregoing lay and medical evidence, the Board finds that an evaluation of 70 percent, but no higher, during the entire period on appeal is warranted in this case, because the frequency, severity, and duration of the Veteran’s symptomatology during this period resulted in social and occupational impairment in most areas, particularly with respect to his work, family relations, judgment, thinking, and mood. See 38 C.F.R. § 4.130. However, in so finding, the Board further finds that at no time during the pendency of the appeal have the criteria for a 100 percent rating for an acquired psychiatric disability been satisfied or approximated. See 38 C.F.R. § 4.130, Diagnostic Codes 9411, 9433. The Veteran’s examination and treatment records consistently reflect the absence of any reports or observations of gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; or a memory impairment of such severity that he could not remember highly learned material such as his own name or the names of close relatives. Moreover, the evidence of record reflects that the Veteran has maintained steady employment, albeit with certain accommodations, and that the Veteran has maintained close familial relationships with his current spouse for approximately the last thirty-seven years, as well as with his adult children. See id; See 38 C.F.R. § 4.130. Accordingly, in light of the foregoing, the Board finds that a preponderance of the evidence of record weighs against a finding that the Veteran’s psychiatric symptoms resulted in total social impairment as contemplated by Section 4.130 for a total disability rating, and in so finding, the Board determines that the severity of the Veteran’s psychiatric symptomatology does not more nearly approximate the level of disability contemplated by a 100 percent rating. See Vazquez-Claudio, 713 F.3d at 117-118. As set forth above, a total disability rating under Section 4.130 requires an ultimate factual conclusion that the level of the Veteran’s psychiatric symptomatology resulted in both total occupational and total social impairment; however, the evidence in this case does not support a finding that the Veteran’s familial or occupational relationships were totally impaired as contemplated by a total disability rating, as he remains both married and employed. See 38 C.F.R. § 4.130. Therefore, the Board finds that the Veteran’s psychiatric symptomatology more nearly approximates the rating criteria contemplated by the 70 percent disability rating rather than the 100 percent rating, and a rating of 100 percent is not warranted at any point during the period on appeal. Instead, a maximum evaluation of 70 percent, and no higher, during the entire period on appeal is warranted in this case, due to the frequency, severity, and duration of the Veteran’s symptomatology resulting in social and occupational impairment in most areas, particularly in employment, family relations, judgment, and mood. See id. Consideration has also been given the potential application of diagnostic codes for other mental disorders, including persistent depressive disorder. See 38 C.F.R. § 4.130, Diagnostic Codes 9433. However, the Board finds no basis upon which to assign increased or additional ratings for the Veteran’s acquired psychiatric disability at any point during the period of appeal, as the totality of the Veteran’s psychiatric symptoms have been encompassed in the current evaluation. Accordingly, the Board finds that an award of additional evaluations under Section 4.130 would constitute the sort of impermissible pyramiding proscribed by VA regulations for conditions that are duplicative or overlapping with the symptomatology of another condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); 38 C.F.R. § 4.14. Thus, all potentially applicable diagnostic codes have been considered, and there is no basis to assign an evaluation in excess of the rating assigned herein for the Veteran’s disability. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). In addition, the Board is not required to address additional issues unless specifically raised by the Veteran or reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017). Accordingly, because neither the Veteran nor his representative has raised any other issue concerning the Veteran’s psychiatric disability, and no other issues have been reasonably raised by the record, the Board finds that a disability rating of 70 percent, but no greater, for the Veteran’s service-connected acquired psychiatric disability throughout the entire period on appeal is warranted in this case. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board H. Marsdale 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.