Citation Nr: 21023484 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 15-04 218A DATE: April 20, 2021 ORDER Entitlement to an initial evaluation in excess of 30 percent for post-traumatic stress disorder (PTSD) is denied. FINDING OF FACT The severity, frequency, and duration of the Veteran’s symptoms did not more closely approximate occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW The criteria for an increased initial evaluation in excess of 30 percent for PTSD are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1980 to July 1981. In November 2020, the Board remanded this issue for additional development. The Board finds that there was substantial compliance with the November 2020 remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Increased Rating 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. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Evidence to be considered in an appeal from an initial disability rating is not limited to current severity, but will include the entire period of the disorder. Additionally, it is possible for a Veteran to be awarded separate percentage evaluations for separate periods (staged ratings), based on the facts. See Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Most psychiatric disorders, including PTSD, depression, and anxiety disorder, although assigned separate diagnostic codes, are evaluated under the General Rating Formula for Mental Disorders (General Rating Formula). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 100 percent disability rating will be 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; memory loss for names of close relatives, own occupation, or own name. A 70 percent disability rating is warranted 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 work-like setting); inability to establish and maintain effective relationships. A 50 percent rating is warranted for 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 30 percent rating is warranted for 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). Code 9411. Entitlement to an increased initial evaluation in excess of 30 percent for PTSD The Veteran contends that she is entitled to an initial evaluation in excess of 30 percent for PTSD. Evidence of the record indicates that the Veteran regularly underwent mental health treatment at the VA during the period on appeal. During a July 2012 VA mental health note, the Veteran reported that she is planning to return to work and was presently seeking employment. The examiner noted that the Veteran presented alert, cooperative, and displayed normal speech. In a September 2013 VA PTSD examination, the examiner diagnosed the Veteran with PTSD and dysthymic disorder and assigned a GAF score of 70. The examiner noted that the Veteran has symptoms of persistent depressed mood most days, but not over two years. The examiner also noted that the Veteran has not experienced any major depressive episodes in the past two years which is likely due to her prescribed antidepressants. Concerning functional and occupational limitations, the Veteran reported full-time employment as a special education teacher for the past six years. The Veteran also reported volunteer activity as a co-pastor at her local church where she preaches bi-weekly. Examiner findings included a depressed mood, suspiciousness, chronic sleep impairment, and mild memory loss as a result of an in-service sexual trauma. The examiner determined that the Veteran is capable of managing her financial affairs. In a February 2019 VA PTSD examination, the examiner diagnosed the Veteran with major depressive disorder in remission. The Veteran reported experiencing insomnia and only sleeping two to three hours a night. She also reported experiencing nightmares related to her in-service mental trauma. The Veteran presented with normal speech, appearance, thought process, and behavior. The Veteran was diagnosed as negative for any delusions, obsessions, or suicidal ideation. The examiner also noted that the Veteran was oriented to time and place and her immediate and remote memory was fair. The Veteran’s judgment was noted as good. Concerning functional and occupational limitations, the examiner noted that the Veteran does not experience any clinically significant impairment that impacts the Veteran’s ability to maintain gainful employment. During the examination, the Veteran reported having graduated from college with a doctorate degree. The Veteran also reported that she is currently employed as a special education teacher. In a February 2021 VA PTSD examination, the examiner did not diagnose the Veteran with any mental disorders, nor were any functional or occupational limitations noted. The examiner noted that the Veteran’s service connected PTSD diagnosis has resolved itself. He explained that the Veteran presents no indicators to suggest impairment in occupational, educational, or social functioning. The examiner noted that the Veteran is successfully employed as a teacher specializing in special education and has successfully completed a doctoral program. She also reports that her family relations are intact. Based on a review of the record, the Board finds, the initial evaluation of 30 percent was consistent with the severity of the Veteran’s PTSD. The examiners findings in a September 2013 VA psychiatric examination above reflect occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks This diagnosis closer reflects the criteria for a 30 percent evaluation. As noted by the September 2013 examiner, the Veteran has not experienced any major depressive episodes in the past two years which is likely due to her prescribed antidepressants. Furthermore, the Veteran reported full-time employment and volunteering as a co-pastor at her local church where she preaches bi-weekly. Moreover, during the February 2019 examination, the examiner noted that the Veteran does not experience any clinically significant impairment that impacts the Veteran’s ability to maintain gainful employment. Lastly, the examiners findings in the February 2021 examination above also reflects that the Veteran experiences no social or occupational impairment. Moreover, the examiner diagnosed the Veteran’s service connected PTSD as having resolved itself altogether. As indicated in the Veteran’s most recent PTSD examination, she does not experience any clinically significant impairment that impacts her ability to maintain gainful employment. Furthermore, the Veteran reported limited social or occupational impairments. In fact, the Veteran reported graduating from college with a doctorate degree, volunteering as a co-pastor at her local church and being currently employed as a special education teacher. The Board considered a 50 percent evaluation and found that it was not warranted as the Veteran’s symptoms did not reflect, occupational and social impairment with reduced reliability and productivity. Based on a review of the evidence of record, the Board finds, that the Veteran’s current evaluation for PTSD symptomatology more nearly approximates the 30 percent criteria. The Board finds that based on the evidence of the claims file, the current 30 percent evaluation currently assigned better approximates the trajectory of the Veteran’s PTSD. As the Board reviewed the Veteran’s records and determined that they do not support an increased disability rating in excess of 30 percent for this disorder, the evidence for this period preponderates against an increase so reasonable doubt provisions are inapplicable. 38 C.F.R. § 3.102. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Harris, Michael E. 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.