Citation Nr: 21023766 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 15-46 133 DATE: April 21, 2021 ORDER Entitlement to an initial disability rating of 100 percent for posttraumatic stress disorder (PTSD) is granted. FINDING OF FACT Throughout the appellate period, the Veteran’s PTSD is manifested by psychiatric symptomatology which most nearly approximates total occupational and social impairment. CONCLUSION OF LAW The criteria for an initial disability rating to 100 percent for PTSD are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 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 October 1969 to May 1971 and he is the recipient of the Bronze Star Medal. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a July 2013 decision by the for the Department of Veterans Affairs (VA) Regional Office (RO) which is the agency of original jurisdiction (AOJ). Although the Veteran filed a VA Form 9 in August 2019 in response to a Statement of the Case for service connection for hypertension, he limited his appeal to the issue listed above. Here, the Board finds he did not perfect an appeal as to the issue of service connection for hypertension. See August 2019 VA Form 9. Entitlement to an initial disability rating of 100 percent for posttraumatic stress disorder (PTSD) is granted. The Veteran seeks an increased rating for his PTSD conditions, currently rated at a 50 percent disability compensation level. The Veteran has asserted that he should be evaluated at 70 percent or 100 percent for PTSD. Based on severe symptoms throughout the appellate period which approximate total occupational and social impairment, the Board finds an initial evaluation of 100 percent is warranted. The Veteran’s service-connected PTSD is currently evaluated as 50 percent disabling under the criteria of DC 9411, which provides that such disability is evaluated pursuant to the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 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. The benefit of reasonable doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in the condition, it is necessary to consider the complete medical history of the Veteran’s condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). A 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, 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 work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent evaluation is assignable where there is 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); and disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The evaluation under 38 C.F.R. § 4.130 is “symptom-driven,” meaning that “symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating” under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather “serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating.” Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering “not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas” - i.e., “the regulation... requires an ultimate factual conclusion as to the Veteran’s level of impairment in ‘most areas.’“ Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, Diagnostic Code 9411. Additionally, consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran’s capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). Furthermore, when evaluating the level of disability arising from a mental disorder, 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(b). In evaluating the level of disability, it is also necessary to evaluate such from the point of view of a Veteran working or seeking work. 38 C.F.R. § 4.2. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed or experienced, and which are within the realm of his or her personal knowledge. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159 (a). However, a lay witness is not competent to establish facts or opinions which require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 470 (1994). Analysis The Veteran was examined for PTSD initially in June 2013. See June 2013 Examination. The Veteran reported he lived alone, had few close friends, and that he performed odd jobs. The Veteran reported a chronic sleep impairment, longstanding irritability, and having no long-term relationship with a partner. The Veteran reported that he was never fired but had difficulty with coworkers. The Veteran was noted to have depressed mood, disturbances in mood and motivation, and difficulty in adapting to stressful circumstances. The June 2013 examiner found the Veteran’s PTSD was manifested by mild or transient symptoms which result in occupational and social impairment with decreases work efficiency only during periods of significant stress; or symptoms controlled by medication. The examiner noted the Veteran reported enjoying camping and fishing with friends. The Veteran reported he lived in his deceased mother’s house since her death 2013. Following the VA examination, the Veteran asserted in his July 2013 Notice of Disagreement (NOD) that he reported to the VA examiner symptoms of impaired impulse control, unprovoked irritability with periods of violence, difficulty adapting to stressful circumstances, inability to establish and maintain relationships, mental confusion, and spatial disorientation. See July 2013 NOD. The Veteran reported in a December 2015 VA Form 9 that he experiences unprovoked irritability and periods of violence which has resulted in extreme social isolation. See December 2015 VA Form 9. The Veteran also reported that he collects Social Security Administration (SSA) benefits, a request for these records shows SSA does not possess any records for the Veteran. The Veteran submitted a July 2019 VA Form 9 stating that he has never been married, has lived alone his adult life, has no children, that he has few friends, and an inability to establish or maintain new friendships. See July 2019 VA Form 9. The Veteran was most recently provided a VA psychological evaluation in August 2019. The examiner noted the Veteran had deficiencies in most areas due to symptoms of PTSD, such as work, school, family relations, judgment, thinking and/or mood. The examiner noted severe symptoms of grossly inappropriate behavior, near continuous panic, impaired impulse control, such as unprovoked irritability with periods of violence, inability to establish and maintain effective relationships, and intermittent inability to perform activities of daily living, such as hygiene and neglect of personal appearance and hygiene. See August 2019 VA Examination. The Veteran reported he continued to live alone in his deceased mother’s house, had not had a relationship since his last partner died in 2013, and that he had not worked since 2012. The Veteran did not receive any therapeutic services, very seldom drives outside of close proximity to his home, experienced road rage, and primarily remained alone in his home. After review of the entire record, the Board finds the Veteran to be both competent and credible in his reports of extreme isolation, and impaired impulse control, such as unprovoked irritability with periods of violence. The August 2019 examiner’s assessment is consistent with the Veteran’s statements in July 2013 and the Board attributes more probative value to this assessment than to the June 2013 VA examination. Given the Veteran’s July 2013 reports and the August 2019 VA examination assessment are consistent with one another, the Board finds the Veteran’s statements highly probative concerning his PTSD symptoms and their impact on his abilities and difficulties in dealing with others in both his social and occupational functions. See Jandreau, 492 F.3d at 1377; 38 C.F.R. § 3.159(a). Additionally, the Board finds the Veteran’s statements to be consistent with the rest of the evidence of record. Based on the foregoing, the Board finds that the frequency, severity, and duration of the Veteran’s PTSD symptomatology more nearly approximate total occupational and social impairment. The Board finds that the criteria for a 100 percent rating under the General Rating Formula have been met. See 38 C.F.R. § 4.130. Here, the Veteran’s PTSD symptoms and their impact are taken in consideration with his disability picture as a whole. First, the symptoms and history set forth by the Veteran in his July 2013 NOD are confirmed in the August 2019 VA examination report and show a level of severity and frequency which was severe over the entire period of the appeal, resulting in near total social isolation and no indication of employment during the period except odd jobs. Further, the Veteran reported ceasing all work shortly after the June 2013 examination and contends he cannot interact with other in or out of a worklike setting due to symptoms of PTSD. The symptoms listed above have clearly had significant adverse impact on his ability to maintain relationships with existing friends and have rendered him almost incapable of developing supportive relationships, including any potential partner which could provide him support. Given the Veteran’s competent and credible reports of little to no occupational or social functioning and the August 2019 VA examination showing assessments of grossly inappropriate behavior and intermittent inability to perform maintenance of minimal personal hygiene, the Board finds the Veteran’s PTSD symptoms approximate a total occupational and social impairment. Accordingly, an initial evaluation of 100 percent is assigned. 38 U.S.C. § 1114; 38 C.F.R. § 4.3. J. B. FREEMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Trickey 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.