Citation Nr: 21023881 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 17-05 160 DATE: April 21, 2021 ORDER Entitlement to service connection for fungal infection of the left foot is granted. Entitlement to service connection for fungal infection of the right foot is granted. Entitlement to a disability rating in excess of 10 percent prior to May 4, 2015, in excess of 30 percent from May 4, 2015 to January 12, 2020, and in excess of 50 percent from January 13, 2020 for posttraumatic stress disorder (PTSD) is denied. FINDINGS OF FACT 1. Resolving all doubt in his favor, the Veteran’s fungal infection of the left foot is etiologically related to active service. 2. Resolving all doubt in his favor, the Veteran’s fungal infection of the right foot is etiologically related to active service. 3. Prior to May 4, 2015, the evidence shows that the symptomatology of the Veteran’s PTSD more nearly approximates 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. 4. From May 4, 2015 to January 12, 2020, the evidence shows that the symptomatology of the Veteran’s PTSD more nearly approximates 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. 5. From January 13, 2020, the evidence shows that the symptomatology of the Veteran’s PTSD more nearly approximates occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. The criteria for service connection for fungal infection of the left foot have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for fungal infection of the right foot have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. Prior to May 4, 2015, the criteria for a disability rating in excess of 10 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. 4. From May 4, 2015 to January 12, 2020, the criteria for a disability rating in excess of 30 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. 5. From January 13, 2020, the criteria for a disability rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1966 to April 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from February 2013 and March 2015 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). In October 2017, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that proceeding has been associated with the record. The Board previously remanded the case in January 2019 for further development. The requested development has been completed to the extent possible, and no further action is necessary to comply with the Board’s remand directives. Stegall v. West, 11 Vet. App. 268 (1998). The Veteran’s initial 10 percent disability rating for service-connected PTSD was increased to 30 percent, effective May 4, 2015, by way of a September 2015 rating decision and later increased to 50 percent, effective January 13, 2020, by way of a June 2020 rating decision. As these grants of increased disability ratings do not constitute a full grant of the benefits sought, the issue remains on appeal. AB v. Brown, 6 Vet. App. 35, 39 (1993). 1. Entitlement to service connection for fungal infection of the left foot is granted. 2. Entitlement to service connection for fungal infection of the right foot is granted. The Veteran is seeking to establish service connection for fungal infections of the left and right foot. He contends his fungal infections are etiologically related to service. A veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in the line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty in active service. 38 U.S.C. § 1110. Generally, to establish a right to compensation for a present disability, a veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection means the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). Service connection may be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). After a review of the entire evidentiary record and in light of the applicable legal criteria, the Board affords the Veteran reasonable doubt and grants service connection for fungal infections of the feet. With regard to a present disability, a December 2019 VA examination reflects a diagnosis of onychomycosis. As the Veteran has a current diagnosis, the first element of service connection is met. With regard to an in-service injury, the Veteran’s military occupational specialty (MOS) was that of an amphibian vehicle operator. In the December 2019 VA examination, the Veteran reported that his toenail fungus started in 1967 while he served in Vietnam. His boots were always wet because he was constantly going in and out of the water due to his MOS. He noted that, back then, medical treatment was only sought in the dire situations. The Veteran indicated he had sought treatment for his nails in 1968/1969 and was given an antifungal tincture that did not help. In 1972, he was given Lamisil pills but had to stop due to side effects. In the October 2017 Board hearing, the Veteran testified that he stood in the jungle wearing wet boots every day during his service in Vietnam. He stated that he had problems with his feet since service and was ashamed to take his shoes off. The Board finds that the Veteran’s reports of the constant wearing of wet boots are consistent with his MOS as an amphibian vehicle operator and his service in Vietnam. Thus, the second element of service connection is met. As for the third element of service connection, evidence of a nexus between the Veteran’s fungal infections of the feet and service, the Board notes the evidence of record consists of credible statements from the Veteran and a negative medical opinion regarding the etiology of the Veteran’s fungal infections. The Board notes that the December 2019 VA examiner opined that the Veteran’s fungal infections of the feet were less likely than not related to service and supported the opinion by noting the absence of treatment records related to the Veteran’s condition prior to 1995. However, the examiner indicated that risk factors for the Veteran’s diagnosis of onychomycosis, a fungal infection of the nails, included extended exposure to water, repeated trauma to the nails, shoes that constrict the feet, sweating feet, and shoes that damage the toenail. The Board places greater probative weight on the Veteran’s competent and credible statements and testimony regarding the onset and continuity of his fungal infections of the feet. The Board notes that the Veteran is competent to report observable symptoms, such as infections in the toenails. See Layno v. Brown, 6 Vet. App. 465 (1994). Further, the Board finds that the Veteran was exposed to the increased risk factors for nail fungus that were noted by the December 2019 VA examiner. Therefore, despite a negative nexus opinion of record, the Board places greater value on the Veteran’s competent and credible statements regarding the continuity of symptoms he experienced since service. Service connection may be granted upon a finding of continuity of symptomatology, not necessarily continuity of treatment, between a current disorder and service. 38 C.F.R. § 3.303(b). Thus, resolving all reasonable doubt in favor of the Veteran, the Board finds that the Veteran’s fungal infections of the feet are related to service. Accordingly, service connection for a fungal infection of the left foot and a fungal infection of the right foot are granted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 3. Entitlement to a disability rating in excess of 10 percent prior to May 4, 2015, in excess of 30 percent from May 4, 2015 to January 12, 2020, and in excess of 50 percent from January 13, 2020 for PTSD is denied. The Veteran is seeking increased disability ratings for his service-connected PTSD. Specifically, the Veteran contends that his PTSD is more severe than reflected by his assigned disability ratings. 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. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings,” whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The regulations for mental disorders are found in 38 C.F.R. §§ 4.125-4.130. The Board notes that the Veteran’s diagnosis of PTSD is evaluated under Diagnostic Code 9411 and is rated according to the General Rating Formula for Mental Disorders. Pursuant to the rating formula, a 30 percent disability 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; and mild memory loss (such as forgetting names, directions, recent events). A 50 percent disability 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; and difficulty in establishing and maintaining effective work and social relationships. 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); and inability to establish and maintain effective relationships. A 100 percent disability rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is the veteran’s symptoms, but it must also make findings as to how those symptoms impact the veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term “such as” in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran’s impairment must be “due to” those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. Turning to the evidence of record, the Veteran was afforded a VA examination in February 2015. He reported having a good childhood and was in constant contact with his siblings. The Veteran reported he was married to his fourth wife, but the VA examiner noted he was rather vague about his wives, stating he was Muslim. He had seven children ranging from 22 to 48 years old. He stated he had a good relationship with his children; however, the examiner noted that CPRS reflected that he had not seen some of his children since 1994. The Veteran noted he had only lived in the area since 2012 and did not have many friends. His leisure activities included reading, listening to music, horseback riding, going to the park, and watching sports. The Veteran reported that he reexperienced symptoms related to being on bridge guard and receiving fire. He stated he would wake up screaming up to three times a week. He also noted he physically reacted to dreams by tossing and turning, and recently nearly stuck his wife. The Veteran reported intrusive memories of military experiences nearly every day. He expressed his inability to trust others including the government. During the interview, the Veteran began to cry and expressed concern about feeling as if no one cared about him. He wondered aloud if negative things had happened to him because he was Muslim. However, the Veteran also expressed that his religious beliefs offered him strength and support. On examination, the examiner noted that the Veteran presented casually dressed. He was calm and had full range of affect. The Veteran denied hopelessness, helplessness, irritability, or agitation. He denied suicidal and homicidal ideation. The examiner confirmed a diagnosis of PTSD and noted that the Veteran was not on psychiatric medication. The examiner noted that suspiciousness and chronic sleep impairment were symptoms related to the Veteran’s PTSD. The examiner determined that although a mental condition had been formally diagnosed, symptoms were not severe enough either to interfere with occupational and social functioning or to require continuous medication. The Veteran was afforded another VA examination in August 2015. The Veteran reported he had been married to his wife for 31 years. He indicated it was good sometimes and bad sometimes. The Veteran noted he woke up screaming as often as once a week and his wife thought he was crazy because of Vietnam. He stated he had been violent with her when acting out his dreams and had woken up choking her one year ago. The Veteran reported he had seven children and noted he had a very good relationship with all of them except his eldest twins, with whom he had no contact. He added that he had a positive relationship with his siblings and spoke to them often. The Veteran stated he had some close friends and had recently joined a veterans’ organization; however, he noted that his religion had ostracized him from some of the other veterans. The Veteran indicated he was active within his faith and participated in religious ceremonies weekly. He noted that his faith prevented him from being violent or self-destructive. The Veteran noted current symptoms of nightmares, intrusive thoughts of traumatic military and psychological distress, avoidance of thoughts and feelings associated with traumatic military experiences, poor concentration, anxiety/avoidance of war related movies, mild anhedonia, difficulty trusting others, insomnia, daytime fatigue, irritability, hypervigilance, anger towards the government based on his difficulty obtaining benefits, and decline in short-term memory. On examination, the VA examiner noted that the Veteran presented neatly dressed and groomed and polite and cooperative. He was mildly dysthymic and agitated. The Veteran was fully oriented. He had some difficulty remaining focused and on topic. The Veteran’s judgement and insight were adequate. He denied hallucinations/delusions, suicidal ideation, and homicidal ideation. The examiner confirmed a diagnosis of PTSD and noted associated symptoms of suspiciousness, chronic sleep impairment, disturbances of motivation and mood, and mild memory loss. The examiner determined that the Veteran’s PTSD caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. A March 2016 treatment record indicated that the Veteran expressed belief that he should be evaluated at 100 percent for his service-connected PTSD. The clinician noted that the Veteran focused on being drafted at age 19 and expressed confusion as to why he was not rated at 100 percent. The Veteran had been dropped from a past PTSD program for being a no-show and when mentioned by the clinician, the Veteran became livid. He asserted that he was told at the time that medication would be prescribed, and he did not want to take “psychotic medications” that caused hallucinations. He had chosen not to continue with the program. The Veteran noted he frequently got angry with his wife and almost choked her but did not. The clinician noted that throughout the session, the Veteran was focused on not being treated fairly, deserving a 100 percent evaluation for his PTSD, and his confusion as to why everyone was against Muslims. On examination, the Veteran was noted as appropriately dressed, irritable, and in moderate distress. His speech was rapid, and his language was fair. His cognitive function appeared intact and he was fully oriented. The Veteran’s affect was irritable, and his mood was agitated. The Veteran was alert with good attention. His concentration and fund of knowledge could not be fully assessed. Thought process was goal directed and no psychosis was detected. Poor to fair judgement and insight were noted. There were no perceptual disturbances. In March 2017, the Veteran presented for an initial psychiatric assessment, noting that he had been diagnosed with PTSD in the past and needed help to increase his service-connected compensation. The Veteran had been last seen in 2014 and expressed his disappointment that VA had not evaluated his PTSD as 100 percent disabling. He believed his compensation was not increased because of his experience in the PCT clinic. On examination, the Veteran presented with adequate grooming and hygiene and was calm and cooperative. His speech was appropriate. He was alert, fully oriented, and engaged well. The Veteran’s affect was congruent with full range and his mood was anxious and frustrated. His cognitive function was grossly intact. The Veteran displayed adequate concentration and fund of knowledge. Thought processes were linear and goal directed and thought content was logical with no delusions or obsessions. Insight and judgement were fair. Audio and visual disturbances were denied. The Veteran denied suicidal and homicidal ideation. He denied feeling hopeless and helpless. The Veteran denied feeling depressed and it was noted that the Veteran had good energy, good concentration, and appetite. He denied symptoms of mania in the present and past. The Veteran reported having memory decline and had forgotten a lot of things he had been doing recently. He reported feeling anxious most of the day due to finances. The Veteran reported he could not live with 30 percent for a service-connected disability. In addition to financial stressors, he also noted medical, housing, and marital stressors. In the October 2017 Board hearing, the Veteran testified that he had tried to choke his wife on one occasion. He stated he was not a nice person sometimes. He stated that he had tried therapy for his PTSD, but it did not work out because he refused to take prescribed drugs and he would only accept medical marijuana for treatment. The Veteran testified that he was confused as to why others who had taken prescribed psychotic medication were able to receive a 100 percent disability rating and he was denied a higher rating when he had refused treatment and had experienced the same thing as other veteran’s receiving a 100 percent disability rating. In July 2018, the Veteran was referred to PC-Behavioral Health by his primary care physician. The Veteran reported he was moody and had a short wire. The clinician noted that other than irritability, no other symptoms of PTSD were reported, and the Veteran seemed to be a high functioning individual. The Veteran presented well-groomed and casually dressed. His speech was normal, affect congruent and appropriate, and mood euthymic. The Veteran was alert and oriented with linear, logical, and goal directed stream of thought. There were no signs of delusions or hallucinations and no gross impairments in concentration and memory were noted. The Veteran denied suicidal and homicidal ideation. In an October 2018 consultation note, the Veteran presented casually dressed with adequate grooming and hygiene. He was pleasant and cooperative with adequate concentration. His affect was appropriate, and his mood was euthymic. The Veteran was fully oriented with a cooperative attitude, and coherent speech. His thought processes were logical, linear, and goal directed. The Veteran displayed adequate insight and judgement. Delusions and hallucinations were not present. The Veteran denied suicidal and homicidal ideations. For leisure and recreation, the Veteran liked rhythm and blues, art, reading, horticulture, and disc jockeying. When asked about his goals in therapy, the Veteran responded that he did not have any specific goals to work on. In response to his assertion that he was seeking an increase in compensation for his PTSD, the clinician explained that the focus of therapy was on treatment and recovery, not compensation. Pursuant to the Board’s January 2019 remand, the Veteran was afforded a VA examination in January 2020. The Veteran reported that he had been married for 35 years and described his relationship as perfect, loving, and long-lasting. He lived with his wife and granddaughter. The Veteran had seven children and had a “fine” relationship with all of them. He noted that he had reconnected with his 49-year old twins and their relationship had improved. The Veteran had a positive relationship with his siblings and spoke to them often. He had seven grandchildren who thought he was the “greatest grandpa in the world.” The Veteran reported he was a lifelong member of a veterans’ organization and was a Muslim that attended services every Friday. He was active with his faith and participated in religious ceremonies regularly. The Veteran noted he volunteered with homeless veterans. He stated that he had some friends and remained in contact via text message and email. The Veteran reported that he enjoyed art, music, horticulture/gardening, reading, calligraphy, walking, and the stationary bike. He and his wife enjoyed going to the museum and parks. The Veteran reported nightmares, sleep disturbance, anxiety, intrusive thoughts of traumatic military with psychological distress, irritability, avoidance of trauma cues, attempts to avoid thoughts/feelings associated with traumatic military experiences, feelings of detachment from others but did have some friends, anxiety with loud crowds/venues, hypervigilance, and feelings of anger and resentment toward the government. The Veteran denied panic attacks, feelings of hopelessness, helplessness, or worthlessness, sporadic exaggerated startle response, and chronic worry/ruminations. He noted his memory was “more than ok” and that he had always been able to concentrate. The Veteran reported he slept six to seven hours, uninterrupted but with frequent nightmares. On examination, the VA examiner noted that the Veteran presented appropriately groomed and attired. He was alert, appropriate, pleasant, polite, and respectful. The Veteran’s speech was within normal limits and his thought process was goal-directed and linear. His mood was euthymic and self-described as “perfect.” The Veteran’s affect was congruent with ideation and appropriate to the situation. Insight and judgement were adequate, and memory was grossly intact. No delusions were noted. Suicidal and homicidal ideation were not reported or evidenced at the time. The examiner confirmed a diagnosis of PTSD and noted associated symptoms of anxiety, chronic sleep impairment, disturbances of motivation and mood, mild memory loss, and difficulty in establishing and maintaining effective work and social relationships. The examiner determined that the Veteran’s PTSD caused occupational and social impairment with reduced reliability and productivity. For the period prior to May 4, 2015, the evidence of record does not support a finding that the Veteran’s PTSD resulted in 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. In this regard, the Veteran’s disability during this period on appeal was predominately manifested by symptoms such as chronic sleep impairment, nightmares, intrusive memories, suspiciousness and trust issues. The Veteran did not exhibit depressed mood, anxiety, panic attacks that occurred weekly or less often, or mild memory loss, such as forgetting names, directions, recent events. In fact, the Veteran reported he was married and had good relationships with his siblings and most of his children. He enjoyed many leisurely activities and found strength and support in his faith. The Board notes that while the Veteran’s symptoms included chronic sleep impairment and suspiciousness, the February 2015 VA examiner specifically indicated that the Veteran’s symptoms were not severe enough either to interfere with occupational and social functioning or to require continuous medication. Further, the evidence of record does not reflect that these symptoms were of such a frequency or severity to warrant a higher rating. This level of PTSD manifestation warrants a 10 percent disability rating. For the period from May 5, 2015 to January 12, 2020, the evidence for record does not support a finding that the Veteran’s PTSD resulted in occupational and social impairment with reduced reliability and productivity. In this regard, the Veteran’s disability during this period on appeal was predominately manifested by symptoms such as suspiciousness, chronic sleep impairment, disturbances of motivation and mood, and mild memory loss, as was noted by the August 2015 VA examiner. The Veteran self-reported additional symptoms of violent nightmares, intrusive thoughts, avoidance of thoughts and feelings associated with traumatic military experiences, poor concentration, anxiety/avoidance of war related movies, mild anhedonia, daytime fatigue, irritability, and hypervigilance. From May 5, 2015 to January 12, 2020, the Veteran did not exhibit 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 abstract thinking, or difficulty in establishing and maintaining effective work and social relationships. In fact, in the August 2015 VA examination, the Veteran reported 31 years of marriage with ups and downs, very good relationships with most of his children, positive relationships with his siblings, with whom he spoke with often, and close friends. He noted he was a part of a veterans’ organization and was an active participant in his faith and religious ceremonies. The August 2015 VA examiner indicated that the Veteran was polite, cooperative, mildly dysthymic, and agitated. His judgement and insight were adequate. The March 2016 treatment record noted that the Veteran’s speech and language were rapid and fair. Cognitive function appeared intact and he was fully oriented. The Veteran was alert and displayed good attention. His thought processes were goal directed and no psychosis was detected. The March 2017 treatment record indicated that the Veteran was calm and cooperative with appropriate speech. He was fully oriented and engaged with congruent and full range of affect. The Veteran displayed adequate concentration and fund of knowledge. Thought processes were linear and goal directed and thought content was logical with no delusions or obsessions. Insight and judgement were found to be fair. Similarly, June 2018 and October 2018 treatment records noted that the Veteran presented with normal speech, congruent and appropriate affect, and logical, linear, and goal directed thought processes. The July 2018 treatment record noted there were no gross impairments of concentration or memory found and the October 2018 treatment record noted that the Veteran displayed adequate insight and judgement. The Board notes that while the Veteran was noted to have exhibited poor to fair judgement in the March 2016 treatment record, the frequency and severity of this symptom during this period on appeal did not result in reduced reliability or productivity. While the Board recognizes that the existence of impaired judgement is suggestive of a 50 percent disability rating under Diagnostic Code 9411, it finds that, given the totality of the evidence showing a high degree of functioning, a 30 percent disability rating is more reflective of the Veteran’s overall degree of impairment from May 5, 2015 to January 12, 2020. From January 13, 2020, the evidence of record does not support a finding that the Veteran’s PTSD results in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. In this regard, the Veteran’s disability during this period on appeal is predominately manifested by symptoms such as anxiety, chronic sleep impairment, disturbances of motivation and mood, mild memory loss, and difficulty in establishing and maintaining effective work and social relationships. The Veteran self-reported additional symptoms of nightmares, intrusive thoughts of traumatic military with psychological distress, irritability, avoidance of trauma cues, attempts to avoid thoughts/feelings associated with traumatic military experiences, feelings of detachment, anxiety with loud crowds/venues, and hypervigilance. For the period from January 13, 2020, the Veteran did not exhibit suicidal ideation, obsessional rituals that interfered with routine activities, speech intermittently illogical, obscure, or irrelevant, near-continuous panic or depression affecting his 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), or an inability to establish and maintain effective relationships. In fact, on the January 2020 VA examination, the Veteran positively described his relationships with his wife, siblings, children, and grandchild, even noting a reconciliation with his eldest children. He reported membership in a veterans’ organization and active participation in his religion. Further, the Veteran indicated he volunteered with homeless veterans and maintained contact with friends. The January 2020 VA examiner noted that the Veteran was appropriately groomed with normal speech and the Veteran self-described his mood as perfect. His thoughts were goal oriented and linear and his insight and judgement were adequate. His memory was found to be grossly intact and there was no indication of delusions. The Veteran denied suicidal and homicidal ideation, as he had done for the entirety of the appeal period. Further, the Veteran denied panic attacks, ruminations, and reported that his memory was “more than ok” and that he had always been able to concentrate. This level of PTSD manifestation warrants a 50 percent disability rating. The Board notes that the Veteran has expressed frustration and confusion with the disability ratings assigned to his PTSD and his belief that his refusal of medication has impacted his evaluation. Additionally, the Veteran has expressed his belief that due to similar in-service stressors and experiences, he is entitled to the same 100 percent disability rating that other veterans have received. The Board would like to assure the Veteran that his refusal of psychiatric medications has not been a factor in the assessment of the severity of his PTSD symptoms. Additionally, the Board would like to clarify for the Veteran that a traumatic event in service is a necessary element in supporting a claim of entitlement to service connection for PTSD. However, once service connection for PTSD is established, the rating assigned to the disability reflects the severity of the symptoms related to PTSD. Veterans diagnosed with psychiatric disorders related to similar in-service traumatic events may manifest different symptoms to varying degrees of severity. Therefore, each veteran is evaluated according to the individual presentation of their diagnosis. VA evaluates the severity of a veteran’s service-connected PTSD not based on the stressor event, but on the symptoms related to the service-connected diagnosis. In sum, the Board finds that the Veteran’s service-connected PTSD is best reflected by the criteria for a 10 percent disability prior to May 4, 2015, a 30 percent disability rating from May 4, 2015 to January 12, 2020, and a 50 percent disability rating from January 13, 2020. Accordingly, because the preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt doctrine is not for application and his claim for increased disability ratings for PTSD must be denied. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Silverblatt, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.