Citation Nr: 21021344 Decision Date: 04/12/21 Archive Date: 04/12/21 DOCKET NO. 16-14 523 DATE: April 12, 2021 ORDER Entitlement to an increased evaluation in excess of 50 percent for bipolar I disorder is denied. FINDING OF FACT The Veteran’s symptoms of bipolar I disorder was manifested by depression, anxiety, chronic sleep impairment, problems with relationships, and difficulty adapting to stressful circumstances, resulting in a disability picture that more nearly approximates that of occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW The criteria for a rating in excess of 50 percent for bipolar I disorder, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.130, Code 9432. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served in active duty service with the Army from March 1988 to February 1992. This matter is on appeal from a March 2016 rating decision. The Board remanded this appeal in September 2018 for additional development. The Board notes in the September 2018 Board decision, the issues remanded by the Board was entitlement to an evaluation in excess of 50 percent for bipolar I disorder; entitlement to service connection for peripheral neuropathy and restless leg syndrome of the bilateral lower extremities; and entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). During the pendency of the appeal, a June 2020 rating decision granted service connection for peripheral neuropathy and restless leg syndrome of the bilateral lower extremities and an October 2020 rating decision granted TDIU. As such, the issue remaining on appeal before the Board is entitlement to an increased evaluation in excess of 50 percent for bipolar I disorder. Increased Rating A disability rating is determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155 ; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The Board will consider whether separate ratings may be assigned for separate periods of time based on the facts found, a practice known as “staged ratings.” Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran’s entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2017). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the “staging” of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See also Hart v. Mansfield, 21 Vet. App. 505 (2008). Bipolar disorder The Veteran is service connected for bipolar I disorder evaluated at 50 percent under Diagnostic Code (DC) 9432 effective from July 23, 2010. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran’s capacity for adjustments during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on the social and occupational impairment, rather than solely on the examiner’s assessment of the level of disability at the time of examination. The rating agency will consider the extent of social impairment but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. 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; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Lastly, a 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. See 38 C.F.R. § 4.130. The “such symptoms as” language means “for example,” and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The list of examples provides guidance as to the severity of symptoms contemplated for each rating. Id. However, this fact does not make the provided list of symptoms irrelevant. See Vasquez-Claudio v. Shinseki, 713 F.3d 112, 11617 (Fed. Cir. 2013). The Veteran must still demonstrate either the particular symptoms associated with the rating sought, or other symptoms of similar severity, frequency, and duration. Id. at 117. The Board notes that one factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the “psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness.” Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). According to the DSM-IV, GAF scores ranging between 61 to 70 reflect some mild symptoms [e.g., depressed mood and mild insomnia] or some difficulty in social, occupational, or school functioning [e.g., occasional truancy, or theft within the household], but generally functioning pretty well, and has some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect more moderate symptoms [e.g., flat affect and circumstantial speech, occasional panic attacks] or moderate difficulty in social, occupational, or school functioning [e.g., few friends, conflicts with peers or co- workers]. Scores ranging from 41 to 50 reflect serious symptoms [e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting] or any serious impairment in social, occupational or school functioning [e.g., no friends, unable to keep a job]. Scores ranging from 31 to 40 reflect some impairment in reality testing or communication [e.g., speech is at times illogical, obscure, or irrelevant] or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood [e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school]. VA has changed its regulations, and now requires use of DSM-5 effective August 4, 2014. Among the changes, DSM-5 eliminates the use of the GAF score in evaluation of psychiatric disorders. The change was made applicable to cases certified to the Board on or after August 4, 2014; and is not applicable to cases certified to the Board prior to that date. 79 Fed. Reg. 45093 (Aug. 4, 2014). As the Veteran’s case was certified to the Board after August 4, 2014, DSM-5 applies, and GAF scores are no longer used in evaluation of psychiatric disorder. Id. However, the examiner’s discussion of symptoms associated with any assigned score would still be useful in evaluation of psychiatric disabilities. The Board notes that submitted Social Security Administration (SSA) documents shows a July 2005 Administrative Law Judge (ALJ) decision granted the Veteran SSA disability due to impairments from bipolar disorder. Review of the medical treatment record shows in a November 2011 initial care evaluation, the Veteran was observed to be alert and oriented, and demonstrated an alert mood and good insight and judgement. In a December 2011, the Veteran reported that he was transferring care to VA in order to afford his medication. The Veteran reported that since his last increase in medication in June 2011, the Veteran has gone through 2 minor episodes of depression lasting 3 weeks and 5 weeks respectively. The Veteran also reported during these episodes he would have fleeting suicidal ideation and small auditory hallucinations once a month. The Veteran noted that since his increase in medication “[the Veteran] thinks he is so much better now than before he had the [medication] raised – he feels he’s much more functional now.” The Veteran reported he was married for 4 years but ended due to his bipolar disorder. The Veteran stated that he next was in a common-law relationship for 8 years with a 13-year-old daughter whom which he shares custody. The Veteran stated that he has good support from his parents and siblings. The Veteran stated that he last worked as a software developer until his bipolar disorder completed interfered with his duties. The Veteran indicated that he was receiving Social Security disability for his bipolar disorder since 2003. The Veteran reported manic and depressive episodes. The Veteran described his manic episodes lasting for days to weeks with symptoms of racing thoughts; starting many projects but not completing them; reduced need for sleep; and gambling. The Veteran noted that he filed for bankruptcy in 2009 due to incurred gambling debt. The Veteran described his depressive episodes last for weeks to months with symptoms of anhedonia; poor motivation; isolation; hypersomnia; increased appetite; and ongoing suicidal ideation. The Veteran stated that during both manic and depressive episodes he has experiences visual or audio hallucination. When asked about suicidal ideation and attempts, the Veteran denied any suicide attempts. The Veteran stated that his suicidal ideation varied for years, noting that when he is in a severe depression he would have intense suicidal ideation with some planning; but with minor depression, the Veteran would only have fleeting or flashes of suicidal ideation. The Veteran asserts that looking after his daughter has given him a lot of stability and a reason for living. The Veteran was observed to be alert, oriented, casually dressed, and groomed. The Veteran’s mood was good with a good range of affect. The Veteran demonstrated linear thought with no cognitive deficit or memory impairment. The Veteran demonstrated fair to good insight and judgement. The Veteran denied hallucinations, suicidal and homicidal ideation. The treating provider did not find the Veteran at risk to himself or others. In February 2012 the Veteran reported feeling good with one minor mixed episode. The Veteran stated that he overall had a stable mood and was currently in school taking a course in computer programing. In April 2012 the Veteran reported feeling depressed 2 weeks after his February visit, then depressed again after his March birthday where he felt that “life was half over, and I haven’t accomplished much.” The Veteran reported symptoms of low motivation and energy; anhedonia; negative self-talk; and difficulty getting out of bed. The Veteran stated that his depressions usually last 6 to 9 weeks and so his current symptoms may resolve in the next few weeks. The Veteran stated that he was in school but dropped a few courses but kept a computer programming course which he found easy due to his past experience as a computer programmer. The Veteran was observed to be alert, casually dressed, and groomed. The Veteran’s mood was depressed with constricted affect. The Veteran demonstrated linear thought with no cognitive deficit or memory impairment. The Veteran demonstrated fair to good insight and judgement. The Veteran denied hallucinations, suicidal and homicidal ideation. In a later April 2012 visit, the Veteran reported feeling better since taking new medication. The Veteran stated that he felt good on the weekend; became depressed and stayed in bed on Monday and Tuesday; and then felt good yesterday and at today’s visit. The Veteran acknowledged his mood cycles and noted that his improved mood may be due to coming out of a depression cycle. The Veteran was observed to be alert, casually dressed, and groomed. The Veteran’s mood was feeling better with constricted affect. The Veteran demonstrated linear thought with no cognitive deficit or memory impairment. The Veteran demonstrated fair to good insight and judgement. The Veteran denied hallucinations, suicidal and homicidal ideation. In June 2012 the Veteran reported feeling better and stated that he felt his bipolar disorder was stabilizing. The Veteran was observed to be alert, casually dressed, and groomed. The Veteran’s mood was feeling better with constricted affect. The Veteran demonstrated linear thought with no cognitive deficit or memory impairment. The Veteran demonstrated fair to good insight and judgement. The Veteran denied hallucinations, suicidal and homicidal ideation. In a later June 2012 visit, the Veteran reported feeling depressed lately with symptoms of low energy, motivation and isolation. The Veteran noted that his daughter has recently gone to visit her mother until August and that he was affected by this as “his whole life has been focused on looking after her.” The Veteran was observed to be alert, casually dressed, and groomed. The Veteran’s mood was depressed with constricted affect. The Veteran demonstrated linear thought with no cognitive deficit or memory impairment. The Veteran demonstrated fair to good insight and judgement. The Veteran denied hallucinations, suicidal and homicidal ideation. The Veteran was afforded an August 2012 VA examination. The Veteran reported a close relationship with his parents and was in contact with his siblings. The Veteran stated that he was previously married and then another relationship for 5 years with a 14-year-old daughter whom which he gets along. The Veteran stated that he is not in a current relationship. The Veteran stated that he was currently not work. The Veteran stated that he last worked in 2001 as a software developer but let go after hallucinations and other symptoms of his bipolar disorder interfered with his performance. The Veteran noted that he was let go from 4 to 5 other jobs due to psychiatric problems and he believes he currently cannot find any job offers due to his bipolar disorder. The Veteran noted that he returned to school in early 2012 but in mid-March suffered a depression episode after his birthday and realization that “his daughter will leave him in 4 years”; afterwards the Veteran went into “my zombie mode” and quit going to classes. The examiner found the Veteran with symptoms of depressed mood; anxiety; chronic sleep impairment; and impaired judgement. The examiner found the symptoms to result in occupational and social impairment with reduced reliability and productivity. In an October 2012 mental health note, the Veteran reported feeling better in the past several weeks and feels he has just come out of a long and intense depression that lasted for 6 months. The Veteran noted that his daughter has returned from visiting her mother, and that was a “good turning point in depression.” The Veteran noted that he would sometimes feel a little manic with panicky or racing thoughts at night. The Veteran was observed to be alert, casually dressed, and groomed. The Veteran’s mood was feeling better with constricted affect. The Veteran demonstrated linear thought with no cognitive deficit or memory impairment. The Veteran demonstrated limited to fair insight and fair judgement. The Veteran denied hallucinations, suicidal and homicidal ideation. In May 2013 the Veteran reported that during the past winter he went through a manic episode and mixed episode; the Veteran stopped his medication due to his belief that it was the cause of his episodes. The Veteran stated that he currently felt more anxious and irritable where he “felt homicidal”. The Veteran indicated that he was unsure why this happened but did note that his daughter was to go visit her mother for 2 months and felt this was a possible cause. The Veteran was observed to be alert, casually dressed, and groomed. The Veteran’s mood was stressed and depressed with constricted affect. The Veteran demonstrated linear thought with no cognitive deficit or memory impairment. The Veteran demonstrated limited to fair insight and fair judgement. The Veteran denied hallucinations, suicidal and homicidal ideation. The Veteran submitted a November 2013 mental disorder disability benefits questionnaire (DBQ) from a private provider. The Veteran reported he was married and divorced once with a 15-year-old daughter and denied having any significant relationship. The Veteran stated that he lives next door to his parents whom which along with his daughter he stated are his greatest support system. The Veteran reported having no friends and suffers anxiety when leaving home. The Veteran stated that he last worked as an independent software consultant until 2003 and began receiving Social Security disability income in 2005. The private provider found the Veteran with symptoms of depressed mood; anxiety; chronic sleep impairment; panic attacks more than once a week; near-continuous panic or depression; mild memory loss; impairment of short and long term memory; flattened affect; disturbance of motivation and mood; difficulty establishing and maintaining effective relationships; difficulty adapting to stressful circumstances; persistent delusions or hallucinations; neglect of personal appearance and hygiene; and intermittent inability to perform activities of daily living. The provider observed the Veteran’s attention was normal with variable concentration. The Veteran’s thought content was appropriate with reported overt hallucination. The Veteran’s mood was anxious and nervous with restricted affect. The provider noted the Veteran was “vague with response, suspicious and rather vigilant” during the interview. The private provider submitted a separate medical statement regarding the Veteran. The provider stated that the Veteran reported does not do the household chores regular and can go for weeks without things getting done around the house. The provider noted the Veteran struggled with maintaining personal hygiene and that his daughter has to remind him to shower and shave. The Board notes the provider referred to the Veteran’s GAF scores to indicate the severity of his symptoms; however as addressed above, the Board finds that GAF scores are no longer used in evaluating psychiatric disorders. In February 2014 the Veteran reported feeling better but recently felt more irritable as he noticed he drives more aggressively and using more coarse language; the Veteran indicated that his medication ran out in January. The Veteran also noted that his episodes were last longer where he felt depressed this past November and December 2013 before improving in January 2014. The Veteran reported that he was an in-house husband that felt claustrophobic most of the time and did not go out much. The Veteran was observed to be adequately groomed. The Veteran’s mood was anxious with concordant and modulated affect. The Veteran demonstrated linear thought with no cognitive deficit or memory impairment. The Veteran demonstrated good insight and judgement. The Veteran denied hallucinations, suicidal and homicidal ideation. In an October 2014 emergency department visit, the Veteran reported that he was out of medication and “having violent thoughts; any little thing sets me off.” The Veteran was observed to alert and oriented but reported no thoughts of harming himself or others. In a November 2014 mental health note, the Veteran reported running out of medication in October and “got really [verbally] angry] before refilling at the emergency department. The Veteran stated that otherwise he has been doing well with no major mood swings and less isolation. The Veteran was observed to be neatly groomed. The Veteran’s mood was euthymic with concordant and modulated affect. The Veteran demonstrated linear thought with no cognitive deficit or memory impairment. The Veteran demonstrated good insight and judgement. The Veteran denied hallucinations, suicidal and homicidal ideation. In April 2015 the Veteran stated it was “good and bad” and that he attends and leads a support group. The Veteran stated that for the past couple weeks he has had “terrible” energy and has become more easily agitated with little things that set him off. The Veteran reported current stressors to include getting up early to care for his parents’ dog; his daughter’s recent anxiety and depression; and his daughter’s mother trying to become more involved in his daughter’s life. The Veteran was observed to be neatly groomed. The Veteran’s mood was subdued with narrowed, reactive, and modulated affect. The Veteran demonstrated linear thought with no cognitive deficit or memory impairment. The Veteran demonstrated good insight and judgement. The Veteran denied hallucinations, suicidal and homicidal ideation. In October 2015 the Veteran stated that his depression has improved with increased medication and was experiencing stress related to his daughter’s depression and anxiety. The Veteran was observed to be neatly groomed. The Veteran’s mood was mostly euthymic with concordant and modulated affect. The Veteran demonstrated linear thought with no cognitive deficit or memory impairment. The Veteran demonstrated good insight and judgement. The Veteran denied hallucinations, suicidal and homicidal ideation. In a March 2016 form 9 statement, the Veteran reported chronic sleep impairment; hypersomnia; persistent delusions and hallucinations; near continuous panic or depression; and difficulty performing activities of daily living. In May 2016 the Veteran reported that a friend of his had recently died; the Veteran stated that he was grieving but his sadness was not out of control and he was able to do his usual activities. The Veteran noted that his daughter was doing well with her depression in treatment. The Veteran was observed to be neatly groomed. The Veteran’s mood was mostly euthymic with concordant and modulated affect. The Veteran demonstrated linear thought with no cognitive deficit or memory impairment. The Veteran demonstrated good insight and judgement. The Veteran denied hallucinations, suicidal and homicidal ideation. In November 2016 the Veteran reported his whole life was going well and that he drove his daughter to college twice a week. The Veteran noticed that while driving he has little tolerance for aggressive drivers and has increased his medication to decrease his aggression, anxiety and anger. The Veteran reported rare auditory hallucinations when he is stressed. The Veteran was observed to be neatly groomed. The Veteran’s mood was mostly euthymic with concordant and modulated affect. The Veteran demonstrated linear thought with no cognitive deficit or memory impairment. The Veteran demonstrated good insight and judgement. The Veteran denied hallucinations, suicidal and homicidal ideation. In a later November 2016 mental health note, the Veteran reported his mood was more up and down with higher anxiety and sleeping issues. The Veteran noted chronic holiday stressors and stated that while he continues to drive his daughter to college, he finds the traffic extra stressful and makes him anxious and hypervigilant. The Veteran noted that this stress would be decreasing in 2 weeks as his daughter goes on semester break and plans to obtain her driver license. The Veteran was observed to be neatly groomed. The Veteran’s mood was pleasant but anxious with reactive and modulated affect that appeared more anxious than hypomanic. The Veteran demonstrated linear thought with no cognitive deficit or memory impairment. The Veteran demonstrated good insight and judgement. The Veteran denied hallucinations, suicidal and homicidal ideation. In June 2017 the Veteran reported that “I think we hit gold.” The Veteran stated that after a rocky two months transitioning between medications that his mood has stabilized with increased concentration and emotional availability. The Veteran reported that on the new medication his hallucinations have completely resolved, he is reading more, and he plans to return to college to complete a degree. The Veteran was observed to be neatly groomed. The Veteran’s mood was pleasant and euthymic with reactive and modulated affect. The Veteran demonstrated linear thought with no cognitive deficit or memory impairment. The Veteran demonstrated good insight and judgement. The Veteran denied hallucinations, suicidal and homicidal ideation. In May 2018 the Veteran reported he was stable and currently compliant with medication. The Veteran admitted a short period of “low grade depression” in early 2018 but stated that he was now stable. The Veteran also noted that he has experienced thoughts of self-harm in the past but would never act on these thoughts because of his daughter. The Veteran noted that his hallucinations were completely resolved, and he was looking back to go back to school to obtain a higher education degree. The Veteran was observed to be in casual dress with fair grooming and hygiene. The Veteran’s mood was norm and euthymic with full affect. The Veteran demonstrated linear thought with no psychosis and good insight and judgement. The Veteran denied hallucinations, suicidal and homicidal ideation. The Veteran was afforded an August 2019 VA examination. The Veteran reported that he lives alone and is divorced with one child. The Veteran stated that he attended an online college last year where he did not get along with the professor and the interpersonal interactions “wiped me out.” The Veteran reported that he was doing well on medication. The Veteran stated that he sleeps 9 hours a day; if he sleeps too little, he becomes manic and spends money; and if he sleeps too much, he becomes depressed. The Veteran stated that for 2 to 3 weeks at a time for a total of 12 weeks he becomes depressed where he stays in bed and sleeps for 16 to 17 hours. The Veteran referred to himself having an obsessional compulsive personality where he gets fixated on something. The Veteran noted that he previously had audio and visual hallucinations but currently has none with his current medication. The examiner found the Veteran with symptoms of depressed mood; anxiety; panic attacks occurring weekly or less; chronic sleep impairment; and obsessional rituals that interfere with routine activities. The Veteran was observed with neutral mood and affect, intact concentration, insight, and judgement. The Veteran reported no hallucinations, suicidal or homicidal ideation. The examiner found the Veteran’s symptoms resulted in occupational and social impairment with reduced reliability and productivity. In December 2019 the Veteran reported that he recently moved resulting in increased stress. The Veteran stated managing his symptoms with medication, structure routine and his daughter’s service animal. The treating provider noted a history of anxiety with panic and agoraphobia which resulted in isolating behavior the impacted the Veteran’s behavior, relationship with others, and ability to engage in activities taking place outside of the home. The Veteran was observed to be alert, oriented, and well-groomed. The Veteran’s mood was better with appropriate affect. The Veteran demonstrated unremarkable thought process with normal attention and concentration. The Veteran demonstrated good insight and judgement. The Veteran denied hallucinations, suicidal and homicidal ideation. In a later December 2019 psychiatric note, the Veteran was seen to establish care after recently moving to be closer to his parents. The Veteran reported a good relationship with his parents and daughter. The Veteran stated a fear of open spaces; crowds; standing in line; and enclosed spaces with people that was improving with acclimation to the area. The Veteran reported a strong history of isolation that has improved; the Veteran stated that his neighbors have “adopted him” and would often visit him or request him to give them rides to grocery stores or appointments. The Veteran denied significant symptoms of depression but reported episodes of depression occurring 3 to 4 times a year lasting 1 to 4 weeks, most recently in April to November due to his recent relocation. The Veteran stated that his symptoms have significantly improved. The Veteran reported 1 hypomania episode a year and 1 manic episode every 5 years. The Veteran also reported a history of auditory and visual hallucinations. The Veteran reported a preoccupation with organization. The Veteran described one incident during an appointment where he rearranged an employee’s corkboard while they were away; the Veteran stated that he would still be able to continue the appointment without rearranging the corkboard and denied any other ritualistic behavior or functional impairing compulsions. The Veteran denied any psychiatric hospitalizations and indicated “significant unwillingness for involuntary hospitalization.” Regarding suicidal ideation, the Veteran reported nihilistic thoughts and during depressive episodes he has prayed to God to “take my life.” The Veteran also stated that he previously used to sleep with a gun under his pillow. The Veteran stated that he currently sleeps with pills and whisky under his pillow but “adamantly denied this was related to suicidal ideation…prevents me from having movements of weakness.” The Veteran explained that having the means so close “forces him to be resilient” and asserted that he could never commit suicide because of the impact to his parents and daughter. The Veteran was observed to be well groomed. The Veteran’s mood was mood with no lability and full range of affect with euthymic predominance. The Veteran demonstrated linear and logical thought; grossly intact memory; and no deficit to attention and concentration. The Veteran reported a history of hallucination but currently denied any hallucinations, suicidal and homicidal ideation. In a July 2020 mental health telephone note, the Veteran reported a good mood but worsening anxiety due to the pandemic, recent political situations and recent move. The Veteran was observed to be alert and oriented; demonstrated linear and logical thought; fair insight and judgement; and denied hallucinations, suicidal and homicidal ideation. Upon review of the evidence of record above, the Board finds that the Veteran’s posttraumatic stress disorder (PTSD) also claimed as anxiety and depression was manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as: anxiety, chronic sleep impairment, problems with relationships, and difficulty adapting to stressful circumstances, more nearly approximating a 50 percent rating under Diagnostic Code 9411. 38 C.F.R. § 4.130. However, the evidence does not show that the Veteran was experiencing panic attacks, suicidal ideation, impaired impulse control or near-continuous panic or depression affecting the ability to function independently, appropriately and effectively. Although the Veteran reports not having friends, the Veteran does not specify or indicate whether his symptoms contribute to this and also in December 2019 reported that his neighbors had “adopted” him and formed relationships sufficient for them to visit him and request him to give them rides to places. The Veteran has reported symptoms of irritability, aggression and anger; however, the examinations of record did not find the Veteran with symptoms of impaired impulse control nor did the Veteran state that such irritability resulted into physical outbursts or periods of violence. The Veteran has reported symptoms of hallucinations; however, the Veteran in November 2016 reported they were rare occurrences when he was stressed; and from June 2017 to the present the Veteran reported his hallucinations had resolved and were no longer present. The November 2013 private DBQ indicated the Veteran’s symptoms to include persistent hallucination, near-continuous panic or depression, memory impairment, neglect of hygiene resulted in occupational and social impairment in most areas; however, the treating provider does not reconcile or address the Veteran’s medical treatment records showing at all the Veteran’s mental health visits the Veteran to consistently demonstrate adequate grooming and hygiene, no findings or reports of near continuous panic, no memory deficits or impairments, and deny hallucinations. As such, the Board affords the November 2013 DBQ less probative weight. Regarding the Veteran’s suicidal ideation, the Board notes the Veteran has reported that during depressive episodes the Veteran would experience suicidal ideation and has described sleeping with a gun or pills. However, the Veteran at all of his visits has consistently denied suicidal ideation; the Veteran admitted sleeping with pills but adamantly denied suicidal ideation when reporting; and the examinations of record show the examiners did not find the Veteran with symptoms arising to a finding of suicidal ideation. The Veteran in August 2019 and December 2019 reported obsessional or preoccupation with reorganization, however the Veteran denied the behavior resulted in functional impairment nor did the examiners find the behavior rise to the level of obsessional rituals. Review of the record does not contain evidence of symptoms of increased severity or additional impairment, such as intermittently illogical, obscure, or irrelevant speech; impaired impulse control; or spatial disorientation. The frequency, severity, and duration of psychiatric symptoms described by the Veteran does not approximate those listed as warranting a 70 percent evaluation. The Board has considered the Veteran’s statements regarding the severity of the Veteran’s bipolar disorder. However, as lay persons, they do not have the training or expertise to render a competent opinion which is more probative than the evidence of record as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Thus, the lay opinions are outweighed by the evidence of record. See id. ; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court’s conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert’s opinion more probative on the issue of medical causation). Therefore, based on the totality of the disability picture, the Board finds an evaluation in excess of 50 percent for the Veteran’s bipolar disorder, is not warranted. As the preponderance of the evidence is against a finding of an increased evaluation, there is no doubt to be resolved; and an increased rating is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Yang, Attorney-Advisor 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.