Citation Nr: 21024082 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 13-08 448 DATE: April 22, 2021 ORDER Entitlement to a 70 percent rating, but no higher, prior to September 27, 2012, for posttraumatic stress disorder (PTSD) is granted. Entitlement to a rating in excess of 70 percent from September 27, 2012, for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to an effective date prior to September 27, 2012, for a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Prior to September 27, 2012, the Veteran’s PTSD overall was manifest by 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); or an inability to establish and maintain effective relationships. 2. From September 27, 2012, the Veteran’s PTSD overall has not been manifest by 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. CONCLUSIONS OF LAW 1. The criteria for a 70 percent rating, but no higher, prior to September 27, 2012, for PTSD have been met. 38 U.S.C. §§ 1155, 5107 (b) (2012); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2020). 2. The criteria for a rating in excess of 70 percent from September 27, 2012, for PTSD have not been met. 38 U.S.C. §§ 1155, 5107 (b); 38 C.F.R. § 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty for training from May to September 2002, and served on active duty from January 2003 to January 2004, October 2005 to March 2007, and from August 2008 to November 2009. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from September 2010 and September 2015 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded this matter in May 2018. The Board finds there has been substantial compliance with its May 2018 remand directives. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268 (1998)) violation when the examiner made the ultimate determination required by the Board’s remand.) Entitlement to a 70 percent rating, but no higher, prior to September 27, 2012, for posttraumatic stress disorder (PTSD) and entitlement to a rating in excess of 70 percent from September 27, 2012, for posttraumatic stress disorder (PTSD) Disability evaluations are determined by the application of the VA’s Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2020). 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. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2020). 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14 (2020). 38 C.F.R. § 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Veteran claims entitlement to an increased disability rating for his service-connected PTSD, which he asserts is more severe than the 50 percent rating assigned prior to September 27, 2012, and more severe than the 70 percent rating assigned from September 27, 2012. A 50 percent rating is warranted for PTSD where 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 such as, 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. Id. A 70 percent rating for PTSD contemplates occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; 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. Id. Finally, a 100 percent disability rating is warranted for PTSD resulting in 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. Id. The evidence considered in determining the level of impairment under the Rating Schedule for PTSD is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant’s condition that affect the level of occupational and social impairment. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In evaluating the evidence, the Board has considered the various Global Assessment of Functioning (GAF) scores that clinicians have assigned. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV); Carpenter v. Brown, 8 Vet. App. 240 (1995). The Board also notes, however, that the GAF scale was removed from the more recent DSM-V for several reasons, including its conceptual lack of clarity, and questionable psychometrics in routine practice. See DSM-V, Introduction, The Multiaxial System (2013). A GAF score of 61-70 reflects some mild symptoms, such as depressed mood and mild insomnia, or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, and has some meaningful interpersonal relationships. A GAF score of 51-60 indicates moderate symptoms or moderate difficulty in social, occupational or school functioning. A GAF score of 41-50 is assigned where there are “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).” A GAF score of 31-40 contemplates 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 adult avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). Id. Current mental health evaluations no longer use the GAF as an assessment of functioning. Compare Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV) with Diagnostic and Statistical Manual of Mental Disorders (5th ed.) (DSM-5); see also 38 C.F.R. § 4.125 (2020). Prior to September 27, 2012 In a November 2009 private treatment record, the Veteran complained of anxiety and visual hallucinations. He recently had heavy alcohol consumption and his last drink was just prior to arrival; he was under the influence. He had not been eating or sleeping and had been depressed. There was no evidence of anger, unusual behavior, paranoia, suicidal thoughts, or self-injury inflicted. Symptoms were described as severe. Upon examination, the Veteran was alert and appearance was normal. He was in mild distress and anxious. Speech and cognition were normal. Thought process and content were normal. Insight and judgment were normal. The Veteran was oriented to all spheres. He gave appropriate answers and a rational explanation of refusal of care. There were no signs of psychosis, auditory hallucinations, delusional thinking, suicidal ideations, or slurred speech. There was no evidence of tangential thinking or homicidal ideations. Abstract thinking was intact. It was determined that the Veteran had the capacity to make decisions regarding the medical care offered. In a later November 2009 private treatment record, the Veteran was admitted to the behavioral unit from the emergency room. The Veteran presented to the emergency room with the complaint of having problems with alcohol abuse and needing to have a detox. The Veteran also complained of increasing depression. The Veteran was noted to have alcohol intoxication and major depression with some psychosis. Upon discharge from treatment, the Veteran was noted to be oriented in all spheres. He had come through his detoxification protocol without further incident and said that his hallucinations had markedly diminished. The Veteran was also sleeping better. The Veteran was still somewhat guarded, but was motivated to continue treatment. Insight and judgment remained tenuous. The Veteran’s PTSD and alcohol dependence was found to be moderate to severe and a GAF score of 45 was assigned. In a June 2010 statement, the Veteran had he had sleeping problems, going into crowds, and always looked over his shoulder. He described himself as irritable and short-tempered with his family. He attended rehab for 30 days to help cope with his tour of Iraq. The Veteran said he was on several medications to help deal with the effects of PTSD and social anxiety. In a July 2010 VA examination, the Veteran reported sleeping problems 3 to 4 times per week, social anxiety, irritability and anger; these symptoms were described as moderate to severe. The Veteran said his anxiety was ongoing and irritability was more controlled recently, but remained present. It was noted that the Veteran worked full time as an electrician working for a company. The Veteran said he lost 35 days of work during hospitalization for alcohol dependence and PTSD symptoms, plus 2 weeks for alcohol related problems. The examiner noted that the Veteran avoided others and did not go anywhere. The Veteran reported relationship problems with his fiancée. Symptoms of his PTSD also included re-experiencing, avoidance, difficulty falling asleep, irritability, difficulty concentrating, hypervigilance, and exaggerated startle response. Upon examination, there was no evidence of impairment of thought process and the Veteran did not have delusions. The Veteran had visual hallucinations of seeing shadows and thinking people were walking by window about 2 times per week alternating with periods of a week free from symptoms. There was no evidence of inappropriate behavior or suicidal thoughts. The Veteran reported homicidal thoughts. The Veteran was able to maintain minimal personal hygiene and other basic activities of daily living. The Veteran was oriented in all spheres. There was no evidence of memory loss or impairment. There was evidence of obsessive or ritualistic behavior, which the Veteran described as locking the door and setting the alarm multiple times at night. Speech was normal. The Veteran had panic attacks weekly. The Veteran did not have depression, but he did have anxiety. The Veteran was assigned a GAF score of 55. The examiner noted that there was discord in the Veteran’s relationship with his fiancée. He had problems relating socially to workers and was irritable in the workplace and at home. He avoided social situations and was socially isolated. He had a lack of friendships, fear of crowds, loss of trust in others, and was hyper-aware of surroundings. The examiner noted that social isolation was likely related at least partially to alcohol problems because the Veteran avoided long-time friends because they continued to use alcohol. He also missed many days of work related to substance use and resulting treatment. When the Veteran was asked what caused him to binge drink, he responded that he did so when he became “real pissed off,” suggesting a possible connection to PTSD irritability. Overall, the examiner determined that the Veteran’s PTSD signs and symptoms were transient or mild, which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. In an August 2010 statement, the Veteran’s wife, M.B., stated that when the Veteran returned from service he drank non-stop for weeks at a time. He also had “nothing to do” with his lifelong friends and other close friends. He was withdrawn from family functions. The Veteran constantly checked outside when he thought he heard noises. If her and the Veteran went somewhere, he would check the doors multiple times to make sure they were locked, and would repeat this process at bedtime. In any crowded areas, the Veteran checked over his shoulder, and when driving over bridges he drove cautiously as if “he were to be blown up.” The Veteran also slept very little at night and would sit up to check his surroundings; he paced to the window to look outside, and when he did sleep he experienced night sweats. M.B. stated that despite the Veteran being heavily medicated, he still was obsessive with checking locks, windows, over his shoulder in public, driving carefully over bridges, and had sleepless and “sweaty” nights. In a second August 2010 statement, the Veteran’s mother, D.B., stated that since the Veteran had returned home he had become a loner and had little to no contact with any of his friends. The Veteran used to enjoy going to the gym and to the movies, but now he would rather stay at home by himself or with his wife. He also did not like crowds or talking to people. After his tour in Iraq, his drinking also worsened. The Veteran also had trouble sleeping and had nightmares. In a third August 2010 statement, the Veteran’s friend said that since returning from Iraq, the Veteran was distant, unfriendly, and sometimes violent. His friend said that the Veteran’s girlfriend had called him on a number of occasions stating that the Veteran was “on a binge, eating raw meat, and being violent.” The Veteran hardly returned his calls and when they did talk, the Veteran was easily agitated. In an April 2011 statement, the Veteran’s fellow servicemember stated that the Veteran became extremely angry when he talked about Iraq, and seemed to be “stuck in Iraq.” He looked for IEDs while driving and would binge drink and become violent. The Veteran’s wife was scared of him at times. During the binges, the Veteran would forget the time and day and forget to go to work; the Veteran would also refuse to shower or use the bathroom and would use a bucket instead. The Veteran hardly left his house because he feared being around Muslims. In a July 2011 statement, the Veteran’s coworker, B.P., stated that he noticed the Veteran changed after his return from Iraq. The Veteran showed up late at least once a week to work and he did not talk to anyone. When he became angry it was like he was “a different person;” he would “cuss you out or go in a tantrum.” In an October 2011 statement, M.B. further described the Veteran’s symptoms. She noted that she had a bachelor’s degree in Sociology and Applied Behavior Analysis and that with the experience she had in studying PTSD, the Veteran had more than just a mild case of PTSD. The Veteran could not sleep without taking medication and had vivid nightmares. He avoided discussing his feelings and wanted to be left alone. M.B. said they had been married over a year and fought over small things. When the Veteran’s grandmother died, he was emotionally non-responsive despite being close up until he left for Iraq. He would stay with their baby 3 days per week and would call her “griping and yelling about the baby,” and would have to put the baby down in the crib and go outside for a break; he was easily overwhelmed. The Veteran’s relationship with his parents had “soured” and during family gatherings he did not socialize with anyone. In a February 2012 private treatment record, the Veteran presented with anxiety attack, nightmares, insomnia, hyper alertness, difficulty concentrating, and social avoidance. From September 27, 2012 In a September 2012 VA examination, PTSD was diagnosed with a GAF score of 51. The examiner determined that the Veteran had occupational and social impairment with reduced reliability and productivity. The Veteran had been married for two years and had one child. He fought with his wife all the time. He had family in the area, but did not see them; however, when he did see them they ended up fighting. The examiner noted the following symptoms: depressed mood; anxiety; panic attacks that occur weekly or less often; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances, including work or a worklike setting. In a November 2012 statement, the Veteran said that he was prescribed medication due to insomnia. He had extreme difficulty sleeping every day. He also had depression and anxiety. In a January 2013 private treatment record, it was noted that the Veteran was in school but having difficulty paying attention. He had moderate feelings of anxiety and frequent depression; he avoided crowds and had social anxiety. The Veteran had moderate short-term memory problems and moderate problems remembering names. He had moderate reading comprehension, concentration, changes in mood or personality, and increased irritability. The Veteran was not on speaking terms with his parents. The Veteran was able to go shopping, do handyman work, and care for himself. The Veteran reported the following symptoms: anxiety and depression; obsessive thought patterns leading to engagement in compulsive behaviors; and social avoidance. The Veteran was generally withdrawn and isolative when possible and had thought disruptions due to ruminative processes. Significant impaired functioning due to difficulties with anxiety and depression was likely. Memory impairment was more consistent with emotional interference. The Veteran was assigned a GAF score of 50. In a March 2013 statement, D.B. stated that the Veteran had only one or two friends with whom he did not keep in contact. The Veteran did not like leaving his house and only went to family gatherings if he felt like he had no choice. He had mood swings and D.B. worried about his sleep patterns. The Veteran attended college, but was having a hard time managing his time with the projects he was assigned. In the March 2013 VA Form 9, the Veteran said that he had ongoing deficiencies in school, family/marital relations, and work. He had no desire to work and only went to school and came home. He rarely went out in the community and would go long periods of time without visiting his family members. The Veteran said that sometimes he did not even want to be around his wife and child, which burdened the marriage and caused frequent arguments. He had panic attacks and did not speak to any of his friends. The Veteran said he had difficulty sleeping. In social situations or “situations with the slightest stress or anxiety” he became extremely irritable. The Veteran said he did not have much value or confidence in himself. Loud noises triggered flashbacks and he could not sit in a classroom with a classmate sitting behind him. In a March 2013 statement, M.B. said that the Veteran isolated himself from her and his family members. The Veteran cut off all communication with his friends. She said that they argued over finances, housework, childcare, and parenting. The Veteran could not handle completing household chores without “shutting down” and going into a room for isolation. M.B. said she paid the bills to ensure that they were paid on time. The Veteran had a flat affect and was withdrawn from intimacy. He had sleeping issues and obsessed about having assault rifles and magazines to protect the home. His attention to hygiene had decreased and only took a shower “once a week or so” and only shaved the morning of his drill weekend. The Veteran was also not concerned with his significant weight gain and had panic attacks. The Veteran went to school but went through periods of time where he had no interest in participating or completing required class work. He had difficulty concentrating on his schoolwork and successful reading comprehension. M.B. said that out of necessity, their two year old son did not spend any long periods of unsupervised time with the Veteran; loud noises such as a toddler screaming or crying could trigger flashbacks. M.B. said that she let like a caregiver and walked on eggshells to make sure the Veteran’s needs were met. In an August 2013 VA examination, the examiner stated that due to the overlapping signs and symptoms of PTSD, major depression, and alcohol abuse, it was not possible to differentiate what portion of the indicated level of occupational and social impairment was attributable to each diagnosis without resorting to mere speculation. A GAF score of 41 to 45 was assigned. The examiner determined that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran was married but the relationship was very conflicted and separation was being considered. The Veteran was not able to pass the courses he took in college and dropped out. The Veteran reported poor compliance taking his medication due to his alcohol use. The examiner noted the following symptoms: depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work like setting; suicidal ideation; and neglect of personal appearance and hygiene. The examiner noted that the Veteran met DSM-IV criteria for alcohol abuse and DSM-IV criteria for major depressive disorder. The Veteran was administered a BDI-II and obtained a score of 42, which was in the severe range of depression. The examiner opined that these disorders were the result of PTSD, which had worsened. In a November 2013 VA treatment record, the Veteran had low energy, slept three to four hours at night, and was restless in his sleep. The Veteran said he could not recall if he was having nightmares. He startled easily and continued to be hypervigilant. He denied psychotic symptoms and there was no suicidal ideation. Upon examination, the Veteran was well-groomed and his behavior was cooperative. Speech was fluent and there was no evidence of psychomotor abnormalities. Mood was “ok” and affect was congruent with mood, restricted. Thought process was linear. There was no homicidal ideation and the Veteran denied hallucinations. There was no evidence of delusions. Insight and judgment were fair. The Veteran was oriented in all spheres. In a January 2014 VA treatment record, the Veteran had improved attention since starting medication. There was no depressed mood and anxiety was well-controlled. The Veteran slept six hours per night and had good appetite. There was poor motivation, and the Veteran had no thoughts of suicide since last visit. In an August 2014 VA treatment record, the Veteran and his wife reported improved agitation and stable mood on current regimen. The Veteran appeared confused and hesitant to answer questions, but when pressed denied depressive symptoms. The Veteran admitted he had ongoing struggles with low frustration tolerance and verbal altercations, but denied escalation into physical threats. The Veteran denied suicidal and homicidal ideation. The Veteran’s wife did not see any change in cognition. Upon examination, the Veteran was noted to have fair grooming and behavior was cooperative and forthcoming. Eye contact was appropriate. There was evidence of psychomotor retardation. Speech was slow, mostly fluent but delayed responses with content poverty. Mood was “I don’t know, she (wife) made the appointment.” Affect was flat. The Veteran was alert and grossly oriented in all spheres. Memory, concentration, and attention were slightly impaired. The Veteran was able to perform serial 7’s and had very concrete thinking with minimal ability to interpret abstractions. Thought processes were slow, organized, and goal directed. The Veteran denied suicidal ideation, homicidal ideation, and audiovisual hallucination. There was no evidence of delusions or response to internal stimuli. Insight/judgment was limited/fair. In a January 2016 VA treatment record, the Veteran said he was doing well and not working. He stayed home and was busy with raising two children. The Veteran dressed casually and speech was coherent but low tone. Mood was good and affect was somewhat flat. The Veteran denied suicidal or homicidal ideations. There were no delusions or hallucinations. His insight and judgment were good. In a July 2017 VA treatment record, it was noted that the Veteran was divorced. He stayed at home most days and liked to exercise. He denied significant depressed mood or anxiety and said he was managing well for the most part; he believed his current medication helped. Upon examination, the Veteran was casually dressed and cooperative. Affect was mildly anxious, and mood, insight, judgment, and cognition were fair. Speech was normal and thought process was logical, coherent and goal-directed. The Veteran denied suicidal and homicidal ideation. The Veteran also denied audiovisual hallucinations, paranoid delusions, and racing thoughts. He was alert and oriented in all spheres. Recent memory was fair and remote memory was intact. Concentration was fair. In a November 2017 VA examination, the Veteran reported the following symptoms: irritability and anger outbursts; sleep disturbance with nightmares and related fatigue; flashbacks and troubling recall of combat events; hypervigilant thoughts and behaviors; exaggerated startle response; marital and family distress; and avoidance of stimuli associated with his combat experiences. The examiner determined that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. It was noted that the Veteran was divorced after six years of marriage with two children. He had regular weekend visits with his children. He maintained regular contact with his parents and sister. He denied participating in social activities and added that he kept to himself. He did enjoy woodworking. The Veteran completed his undergraduate degree in 2014, and had been unemployed for years but recently started working. The examiner noted the following symptoms: depressed mood; anxiety; chronic sleep impairment; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; and impaired impulse control, such as unprovoked irritability with periods of violence. The Veteran’s thought process and communication skills appeared to be within normal limits. He denied having any symptoms of delusions or hallucinations and none were apparent. The Veteran was cooperative, maintained good eye contact, and exhibited no inappropriate behavior. The Veteran denied having any current suicidal or homicidal ideation. He appeared able to maintain personal hygiene and basic activities of daily living. The Veteran was well-oriented to all three spheres. His short and long-term memory appeared to be without gross deficits. In a January 2018 VA treatment record, the Veteran reported having a stable mood since his last visit and he did not feel depressed. His anxiety was well-controlled. He slept five to six hours per night and had good level of attention and concentration with his medication. There were no thoughts of suicide since last visit. Upon examination, the Veteran was well-groomed and behavior was cooperative and pleasant. Psychomotor activity was neither increased nor decreased. Speech was spontaneous, clear, with appropriate volume and rate. Mood was euthymic and affect was restricted. The Veteran was oriented in all spheres and there was an appropriate level of concentration. Recent and remote memory were intact. Thought content was coherent, logical, and goal-oriented. There were no delusional or paranoid thoughts. There was no suicidal or homicidal ideation. There was no evidence of any auditory or visual hallucinations. Thought process was linear and insight and judgment were fair. In an October 2018 VA treatment record, the Veteran reported having a stable mood and that he had been feeling “mellow.” He did not feel depressed. Anxiety was well-controlled and he slept 5 hours per night. The Veteran had good appetite, energy level, and concentration. There were no thoughts of suicide and he was tolerating his medications well. Upon examination, the Veteran was neatly dressed and well groomed. Behavior was cooperative and pleasant. Psychomotor activity was neither increased nor decreased and speech was spontaneous, clear, with appropriate volume and rate. Mood was euthymic. Affect was restricted. The Veteran was alert and oriented in all spheres. He had an appropriate level of concentration and memory was intact. Thought content was coherent, logical, and goal oriented. There were no delusional or paranoid thoughts. There was no suicidal or homicidal ideation. There was no evidence of any auditory or visual hallucinations. Thought process was linear and insight and judgment were fair. Overall, after reviewing the evidence and giving the Veteran the benefit of the doubt, the Board finds that a 70 percent rating, but no higher, is warranted for the Veteran’s PTSD prior to September 27, 2012. However, from September 27, 2012, the records do not show that a higher 100 percent rating is warranted for the Veteran’s PTSD. Prior to September 27, 2012, the Veteran exhibited the following symptoms: hallucinations, homicidal thoughts, ritualistic and obsessive behavior, panic attacks and near-continuous panic, homicidal thoughts, major depression with some psychosis, sleeping problems with nightmares, irritability and impulse control, isolative behavior, missing work, and relationship problems with his fiancée. Statements from the Veteran’s wife, mother, friend, coworker, and fellow servicemember corroborated the Veteran’s reported symptoms. The Board notes that the Veteran is an alcoholic and that some behaviors could be attributed to alcoholism; however, the July 2010 VA examiner determined that the Veteran’s alcoholism was partially related to his PTSD. He said that when the Veteran was asked what caused him to binge drink, he responded that he did so when he became “real pissed off,” suggesting a possible connection to PTSD irritability. Therefore, the Board finds that, if not for his PTSD, the Veteran’s alcohol use would not be as severe, which then manifest into severe PTSD symptoms. The Board acknowledges that the Veteran’s fellow servicemember noted that the Veteran would also refuse to shower or use the bathroom and would use a bucket instead. Intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene) is a symptom associated with a 100 percent disability rating. However, there are no other symptoms that would rise to this severe of a rating. Specifically, the Veteran was not found to have gross impairment of thought processes or communication and his hallucinations were not found to be persistent. There was no evidence of delusions or grossly inappropriate behavior and the Veteran was not a persistent danger of hurting himself or others. Therefore, overall, the Board finds that a 70 percent rating, but no higher, is warranted for the Veteran’s PTSD prior to September 27, 2012. From September 27, 2012, the overall evidence does not warrant a rating in excess of 70 percent. The Board acknowledges that there is evidence of intermittent inability to maintain minimum personal hygiene. However, there is no overall evidence of total occupational and social impairment. The evidence shows that the Veteran divorced his wife and dropped out of college for a short time. Yet, in spite of this, the evidence also shows that the Veteran returned to college and finished his undergraduate degree, was employed, saw his two kids every weekend, and had a good relationship with his family members. He enjoyed woodworking as a hobby. There was no evidence of gross impairment of thought process; in fact, thought process was normal. Despite the August 2014 VA physician noting speech as slow, mostly fluent but delayed responses with content poverty, overall, the Veteran did not have any problems with his speech that would suggest gross impairment. The Board notes that it was determined by the August 2013 VA examiner that the Veteran at the time had poor compliance with his medications due to his alcohol use. Ultimately, even with findings of mild impairment with memory, it does not rise to the 100 percent disability rating symptom of memory loss for names of close relatives, own occupation, or own name. Finally, the November 2017 VA examiner determined that the Veteran had occupational and social impairment with deficiencies in most areas. The Board has considered the lay statements of record; however, these statements also do not suggest that a higher disability rating is warranted. Thus, the evidence indicates that although the Veteran’s PTSD is severe, it is not severe enough to warrant a 100 percent disability rating as the evidence does not suggest total occupational and social impairment. Accordingly, the Board finds that a 70 percent rating, but no higher, is warranted prior to September 27, 2012, for PTSD. Also, a rating in excess of 70 percent from September 27, 2012, for PTSD is not warranted. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence during the appeal period is against the Veteran’s claim for a disability rating in excess of 70 percent from September 27, 2012, for his service-connected PTSD, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND Entitlement to an effective date prior to September 27, 2012, for a total disability rating based on individual unemployability (TDIU) is remanded. Based on the increased rating for PTSD prior to September 27, 2012, and the RO’s finding that TDIU was not warranted prior to September 27, 2012 based in part on the fact that the Veteran’s service-connected disabilities did not meet the schedular criteria for TDIU, the Board finds that the issue of an effective date prior to September 27, 2012, should be remanded and readjudicated by the RO after implementing the grant of increased rating for PTSD. (Continued on the next page)   The matter is REMANDED for the following action: Readjudicate the issue of an effective date prior to September 27, 2012, for TDIU after implementing the grant of a 70 percent disability rating for the service-connected PTSD prior to September 27, 2012. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Saudiee Brown 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.