Citation Nr: 21025780 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 16-53 079 DATE: April 29, 2021 ORDER For the period prior to February 4, 2019, entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is denied. For the period from February 4, 2019, to December 30, 2019, entitlement to a 50 percent rating, for PTSD is granted. For the period from February 4, 2019, a rating in excess of 50 percent for PTSD is denied. FINDINGS OF FACT 1. For the period prior to February 4, 2019, the Veteran’s PTSD did not more nearly approximate occupational and social impairment with reduced reliability and productivity. 2. For the period from February 4, 2019 to December 30, 2019, the Veteran’s PTSD more nearly approximated occupational and social impairment with reduced reliability and productivity. 3. For the period from February 4, 2019, the Veteran’s PTSD did not more nearly approximate occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. For the period prior to February 4, 2019, the criteria for a 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 (DC) 9411. 2. For the period from February 4, 2019, to December 30, 2019, the criteria for a 50 percent rating, for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.130, DC 9411. 3. For the period from February 4, 2019 the criteria for a 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, DC 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1966 to December 1969. He served honorably in the U.S. Navy, including sea service in Asia. The Board thanks the Veteran for his service to our country. The Veteran testified before the undersigned at a Board hearing in February 2019. A transcript of the hearing is of record. The Board previously remanded this case in June 2019 for additional development. Upon consideration of additional evidence obtained pursuant to the June 2019 Board remand, an interim July 2020 rating decision assigned a 50 percent rating from December 31, 2019. The case has now returned to the Board for further appellate review. Increased Rating 1. For the period prior to February 4, 2019, entitlement to a rating in excess of 30 percent for PTSD is denied. 2. For the period from February 4, 2019, to December 30, 2019, entitlement to a 50 percent rating, for PTSD is granted. 3. For the period from February 4, 2019, entitlement to a rating in excess of 50 percent for PTSD is denied. The Veteran contends that higher ratings for PTSD are warranted. The Board finds that ratings in excess of 30 percent prior to February 4, 2019 and 50 percent thereafter are not warranted, but that an increased rating to 50 percent is warranted for the period from February 4, 2019 to December 30, 2019. Disability evaluations are determined by comparing a veteran’s present symptomatology with criteria set forth in VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more nearly approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. PTSD is rated under DC 9411, which is rated using the General Rating Formula for Mental Disorders (Rating Formula). The Rating Formula reads in pertinent part as follows: 100 percent rating (the maximum scheduler rating) - 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. 70 percent - 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). 50 percent - 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. 30 percent - 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). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the veteran’s capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). 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. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126(b). When determining the appropriate disability rating to assign, the Board’s primary consideration is a veteran’s symptoms, but it must also make findings as to how those symptoms impact a veteran’s occupational and social impairment. Mauerhan v. Principi, 16 Vet. App. 436, 441 (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. Id. at 442. 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 rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). The veteran’s entire history is reviewed when making disability ratings. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where, as here, the question for consideration is the propriety of the initial disability rating assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of “staged rating” is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board has reviewed all of the evidence in the Veteran’s record. Although the Board is required to provide reasons and bases supporting its decision, there is no need to discuss each item of evidence in the record. The Board will summarize the pertinent evidence as deemed appropriate, and the Board’s analysis will focus specifically on what the evidence of record shows, or does not show, with respect to the claim. See Gonzalez v. West, 218 F.3d 1278, 1380-81 (Fed. Cir. 2000).   Factual Background In this case, in a July 2014 mental health note, the Veteran reported nightmares and depression symptoms. He denied thoughts of harming himself or others and denied a history of suicidal or violent behavior. Later that month, in a primary care note, the Veteran reported that he was not currently depressed but that it had been a problem in the past. His spouse, who accompanied him for the appointment, corroborated his report. He reported that he did not feel rested in the morning and felt lethargic. He reported diminished concentration and motivation, as well as occasional hopelessness about his nightmares going away. The provider noted that his mood was worried and his affect was mildly dysthymic and anxious. In a September 2014 note, the provider also noted that his affect was mildly dysthymic to full range. In a December 2014 VA examination report, the Veteran reported a wonderful, loving relationship with his spouse and denied any marital problems due to his disability except when she had to wake him up from his nightmares. He reported socializing well with his spouse without noting difficulties, but that he was irritable with his spouse and children at times and that they argued 3 to 5 times each week. He reported having 12 or more friends, mostly from church, with whom he played games and watched football. The examiner noted a diagnosis of PTSD and noted nightmares, flashbacks, irritability and anger, low concentration, avoidance of trauma triggers and activity triggers, and hypervigilance. The examiner noted symptoms of the disability: anxiety, suspiciousness, chronic sleep impairment, and difficulty adapting to stressful circumstances. The examiner noted that he was fully oriented with normal thought process, average concentration and memory, and no suicidal ideation. The examiner concluded that the Veteran’s disability manifested in 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, or symptoms controlled by medication. In a February 2015 statement, the Veteran relayed having nightmares and frequent memories of his in-service experiences. He stated that loud noises or sounds of any kind made him jumpy or nervous and could cause him to relive his traumatic experiences. In an April 2015 statement, he relayed being progressively haunted by nightmares and fears of loud sounds since his discharge, and that he had even hidden under the bed out of fear. He stated that he was startled and panic-stricken and that he felt controlled by his fear and limited from his true enjoyment of life. In a May 2015 primary care note, the Veteran reported an episode of “not being with it” which lasted for hours; there is no evidence linking this to his psychiatric disability. He also reported having dreams and becoming nervous when talking about his in service experiences. In a June 2015 VA examination report, the Veteran reported making efforts to avoid talking about incidents and efforts to avoid reminders, described himself as mildly distant and mistrustful of others, and reported sleep disruption and hypervigilance; the examiner characterized these as “mild symptoms” of PTSD. He reported a close and loving relationship with his spouse and that they regularly go out together. He reported a close relationship with his children. He reported being involved in his church, with most of his social contacts there, and assisting with services as a deacon. He reported that he attended a social group at the church once each week. The examiner noted anxiety and chronic sleep impairment as symptoms of the disability. The examiner noted that he was fully oriented and well groomed, spoke freely during the examination, that his thought process was logical and goal-directed and his thought content unremarkable, that his affect was within normal limits, and that his attention and memory were grossly intact. The examiner concluded that the Veteran’s disability manifested in 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, or symptoms controlled by medication and remarked that he reported very little, if any, functional impairment related to PTSD. In an October 2015 statement, the Veteran stated that his PTSD was worse than had been diagnosed. He stated that he was suicidal, had nightmares almost every night, and had no social life other than church. In a June 2016 note, the Veteran endorsed feeling hopeless about the present or future and denied having recent thoughts of taking his own life. In a September 2016 statement, the Veteran relayed problems socializing due to apathy towards others whom he feels do not understand his withdrawing from conversations. He stated that he sometimes had flashbacks during the day and long and enduring nightmares at night. He stated that other than church he had no social life at all and that he felt sad most of the time and closed in. In a June 2017 mental health consultation, the Veteran reported low mood, loss of sleep, and nightmares. The provider noted slightly dysthymic mood with congruent affect. In another screening from the same day, he denied feeling hopeless about the present or the future or having thoughts about taking his own life. In a primary care note his provider noted that he was negative for suicidality but had some hopelessness. In a February 2018 screen, the Veteran denied feeling hopeless about the present or the future or thoughts about taking his life. In a review of symptoms, he reported no depression or anxiety and no suicidal ideation. In a July 2018 note, the Veteran endorsed feeling hopeless about the present or future and denied thoughts about taking his life. The provider noted that his depression tended to have a sine wave. He endorsed little interest or pleasure in doing things nearly every day and feeling down, depressed, and hopeless nearly every day. In a September 2018 psychosocial pain evaluation, the Veteran reported spending time with his religious community. He reported a good social support network of his spouse, family, and church community and that his daily activities, hobbies, and values were based on his spouse, family, and church. He reported 8 to 10 hours of sleep which was poor in quality and interrupted by nightmares, pain, and the need to urinate. He reported a low to moderate energy level. He reported chronic depressive symptoms with low mood; reexperiencing during the day and nightmares at night; disruptions to sleep, eating, attention, and self-esteem; avoidance and being reclusive. He reported strong faith and engagement with his church community. The provider noted dysthymic mood with consistent affect and insight and judgment limited into a biopsychosocial model of pain. At the February 4, 2019 hearing, the Veteran testified that his anxiety kept him from being a part of his family, stating that he had 3 sisters in town whom he had not seen in 3 years. He testified that he and his spouse eat together and that, apart from attending church services and VA appointments, he might go through the drive-through for dinner but otherwise stayed home. He testified that his in-town daughter visited frequently and that he saw her daughter, his granddaughter, frequently. He testified that he did not feel safe going out and could not be in crowds because of his anxiety. He and his spouse testified that on several occasions he called her because he did not know where he was and could not focus to get back to where he should be. He testified that during periods of high anxiety, approximately monthly or more frequently, he was unable to focus to the point where he needed assistance with personal hygiene such as reminders to get a haircut or bathe. He testified that he did not sleep well and that he became very irritated. He testified that he still had thoughts of self-harm and feelings that “it is not worth it” but that he tried to keep them at bay and had never gotten to the point of planning or attempting self-harm. His spouse testified that she worried about this. In a March 2019 behavioral team member note, the Veteran reported no changes to his PTSD symptoms since the September 2018 meeting. The provider noted dysthymic mood with consistent affect and insight and judgment limited into a biopsychosocial model of pain. Days later, in a GI endoscopy nursing note, the provider noted normal affect and interaction with his environment and no evidence of depression or anxiety. Days later, in another behavioral team member note, the provider again noted dysthymic mood with consistent affect and insight and judgment limited into a biopsychosocial model of pain. In a June 2019 note, the Veteran’s spouse reported changes in his behavior such as grabbing her arm and looking afraid in public, fear of being in public or around others, and increasing reclusiveness. In a June 2019 statement, the Veteran’s representative relayed that since his travel board hearing he was having daily sleep disturbances and nightmares. In an October 2019 mental health consultation, the Veteran presented with complaints of nightmares. He reported that he and his spouse were very close and were often in the role of the other’s caregiver. He reported that his spouse and church were supportive. He endorsed anhedonia and feeling down, depressed, or hopeless more than half the days but denied thoughts that he was better off dead or of self-harm. The provider noted that his mood was “struggling” and that his affect was mildly restricted in range. Days later, in a behavioral health introduction consultation, the Veteran endorsed anhedonia more than half the days; feeling down, depressed, or hopeless more than half the days; trouble sleeping nearly every day; tired or low energy nearly every day; trouble concentrating more than half the days; and motor retardation, agitation nearly every day. He denied thoughts of being better off dead or of hurting himself. In a November 2019 behavioral health initial assessment, the Veteran reported sleeping 6 hours each night and waking due to nightmares. He endorsed anhedonia for several days; feeling down, depressed, or hopeless for several days; trouble sleeping nearly every day; tired or low energy more than half the days; trouble concentrating nearly every day; and motor retardation and agitation for several days. He endorsed feeling nervous, anxious, or on edge more than half the days; unable to stop or control worrying more than half the days; worrying too much about different things more than half the days; and becoming easily annoyed or irritable nearly every day. In a PTSD checklist, he endorsed moderate trouble with recall; feeling distant from others quite a bit; feeling irritable a little bit; extreme difficulty concentrating; and quite a bit of trouble sleeping. He reported a strong social support system of family, friends, and his church group. He denied suicidal and homicidal ideation and reported that his only history of suicidal ideation was a side effect to Halcion, stating that he discontinued use of the medication afterward and things kind of went back to normal. In a December 2019 mental health initial evaluation note, the Veteran reported a strong support network of family and friends. He reported that he and his spouse provide loving support to each other and that, while he did not keep close contact with his son, his relationship with his daughter was very good. He endorsed feeling down almost every day; anhedonia; difficulty with concentration; low energy; insomnia; and feelings of worthlessness, particularly related to letting his family down. He denied recurrent thoughts of death and, in the past month, wishing he was dead or could go to sleep and not wake up and thoughts of suicide. The provider noted that he had excellent hygiene; normal speech; somewhat restricted affect; and, though he reported impaired concentration and not keeping on track, sustained focus during the session. The Veteran strongly denied suicidal ideation except for in 1988, when he was prescribed Halcion for sleep problems and entertained thoughts of jumping out the door of a moving van; he firmly denied any other suicidal thoughts or intentions since then. In a January 2020 VA examination report, the Veteran reported that his relationship with his spouse was “very good” and that he had a “very close” relationship with his daughter, who had moved back into the house due to his spouse’s health, and a distant relationship with his son. He reported that he spent the majority of his time at home reading, and that he attended church occasionally and left as soon as service was over to avoid talking to people. He reported hypervigilance and feeling unsafe in crowds. He reported that his symptoms had intensified over the last few years with intense intrusive memories and nightmares most nights, which interrupted his sleep. He reported feeling emotionally detached and mistrustful of others and that he preferred to stay home due to anxiety around others and in unknown situations. He reported that he had lost touch with friends and extended family. He reported difficulty falling and staying asleep and having low energy. He reported struggling with concentration due to intrusive memories and feeling down most of the time and stated that fishing with his daughter was the only activity he enjoyed. He reported frequent feelings of worthlessness but denied suicidal ideation since around 1990; acknowledging that he sometimes wondered if people would be better off without him, he again denied suicidal ideation. He acknowledged that he had gotten lost while driving in unfamiliar areas and had called his wife for help but denied getting lost in familiar settings and stated that he drove regularly without concerns. He acknowledged that he was sometimes distracted by intrusive thoughts, leading to difficulty with concentration. He reported having decent hygiene but that he had struggled with hygiene in the past due to his chronic back pain and procedures. He reported that he sometimes forgot to take his medication without reminders. The examiner noted diagnoses of PTSD and major depressive disorder and stated that major depressive disorder was a progression of the Veteran’s service-connected PTSD. The examiner noted symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, impairment of short- and long-term memory, and difficulty establishing and maintaining effective work and social relationships. The examiner noted that he was well-groomed, alert, and fully oriented, with dysthymic mood with flattened affect and normal speech. The examiner noted that his thought process was clear, goal-directed, and logical and that he denied current suicidal or homicidal ideation. The examiner stated that no other symptoms were attributable to the psychiatric disability. The examiner concluded that the disability manifested 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 normal routine behavior, self-care, and conversation. In a January 2020 mental health consultation, the Veteran reported distressing dreams and nightmares 2 to 3 times each week and feeling anxious and on edge all day after a nightmare. He reported feeling detached from others and feeling a distance between himself and others. He stated that he attended church but sat in the back and did not engage actively. He reported difficulty sleeping, feeling angry and irritable often, and having difficulty concentrating, requiring him to read and reread something before comprehending it. He reported difficulty getting motivated to engage in activities he previously enjoyed such as fishing, family reunions, and cooking. He reported strong suicidal ideation years ago due to medication and that he had not had any recent suicidal ideation or impulse towards suicide. The provider noted that he was appropriately dressed and groomed, that his behavior was appropriate for the setting, that he was fully oriented, that his mood was mildly anxious and down and his affect was consistent with mood, that he had linear, goal-directed thought process and content, and that he did not report suicidal or homicidal ideation. In a March 2020 note, the Veteran reported increased anxiety and trauma from his treatment for PTSD. He reported that he was estranged from his son and his son’s daughter. The provider noted that his grooming and hygiene were excellent and that his affect was constricted. Later that month, he reported struggling with poor sleep quality which he believed had worsened since starting treatment. The provider noted that his speech was normal and he did not report suicidal or homicidal ideation. In an April 2020 note, the Veteran reported that his nightmares had turned to night terrors, leaving him lethargic the next morning with increased agitation. Later that month, he reported feeling more agitated since discontinuing his medication for about a week. He was noted to be more energetic but also distressed, tense, and edgy around others. In a late April note, he reported that his main concern was with poor sleep as it had worsened over the past 3 or so years. He reported nightmares 2 to 3 times a week which woke him up and that he was unable to fall back asleep. He reported, on the other nights, sleeping 3 to 4 hours with difficulty falling and staying asleep. He endorsed sleep avoidance due to nightmares. The provider noted that his speech was slowed. In a May 2020 note the Veteran reported continuing to experience increased anger related to increased anxiety. He relayed having a strong family support network and displayed a clear future focus. In a June 2020 note, the Veteran stated that he was stepping back from mental health treatment as he found himself more irritable the more he focused on mental health issues. The provider noted no indication of suicidal ideation and that he had a strong support system. During the period on appeal the Veteran was consistently noted to be fully oriented, with unremarkable thought process and no reported or apparent delusions or audial or visual hallucinations. His speech was consistently noted to be normal. He consistently denied suicidal and homicidal ideation during treatment, although he reported feeling suicidal during the appeal period in a written statement. With the exception of some notations of limited insight into a biopsychosocial model of pain, insight and judgment were consistently noted to be intact or good. His dress and hygiene were consistently noted to be fair or excellent, he was consistently noted to be capable of managing his financial affairs, and there are no notations of inappropriate behavior. Analysis: period prior to February 4, 2019 For the period prior to February 4, 2019, the preponderance of evidence is against finding that the Veteran’s PTSD symptomatology warranted a 50 percent, or higher, disability rating. On multiple occasions the Veteran reported dysthymia, feeling sad, having diminished motivation, and being in a low mood, indicating that there may be some disturbance of motivation and mood. There are multiple notations of anxiety and in February 2015 the Veteran relayed having several panic attacks each week. However, there is no competent evidence that he experienced panic attacks rather than increased anxiety: there are no notations of panic attacks in his treatment records or diagnoses of panic disorder and both the December 2014 and the June 2015 examiners, noting anxiety as a symptom of his disability, indicated by omission that he did not have panic attacks. The Board finds these findings highly probative and persuasive as they are based on interviews with the Veteran and a review of his history. There is evidence of the listed 50 percent criteria of disturbances of motivation and mood; however, that criteria alone, even when considered with other symptomatology does not result in impairment more nearly approximating the 50 percent rating before February 4, 2019. With respect to the 50 percent criteria of difficulty in establishing and maintaining effective work and social relationships, while the Veteran expressed apathy towards others, being mildly distant toward and mistrusting of others, and anger and irritability due to nightmares and chronic sleep impairment resulting in arguments, he consistently reported a very close and supportive relationship with his spouse, a close relationship with his daughter and granddaughter, and socializing and engaging with his church community. He consistently characterized his spouse and daughter and church community as providing a strong support system. These manifestations are not so severe as to more nearly approximate difficulty in establishing and maintaining effective work and social relationships. Further, during the period on appeal there is no evidence of his anger and irritability manifesting in impaired impulse control or a persistent danger of hurting others; indeed, his judgment was consistently noted as intact or good. Likewise, though the Veteran reported having diminished concentration and a short memory for tasks, on examination and in behavioral observations during treatment his memory and attention were consistently noted to be average or grossly intact, indicating that the manifestations were not so severe as to constitute impaired short- and long-term memory. Impairment of short- and long-term memory is a listed criteria for a 50 percent rating. However, the Board does not find that the report and observations with respect to memory equated to the frequency and severity memory problems like retention of only highly learned material and forgetting to complete tasks, such that a 50 percent rating was more nearly approximated prior to February 4, 2019. The December 2014 examiner noted symptoms of anxiety, suspiciousness, chronic sleep impairment, and difficulty adapting to stressful circumstances but nevertheless concluded that the Veteran’s PTSD manifested in impairment due to mild or transient symptoms. The June 2015 examiner noted symptoms of anxiety and chronic sleep impairment and also concluded that the disability manifested in impairment due to mild or transient symptoms. Based on the foregoing, the Board finds, for the period prior to February 4, 2019, that the level of impairment caused by the severity, frequency, and duration of the Veteran’s symptoms more closely approximates the level associated with a 30 percent rating. Accordingly, a rating in excess of 30 percent is not warranted. Analysis: period from February 4, 2019, onward The Board finds that for the period from February 4, 2019, to December 30, 2019, a 50 percent rating is warranted. However, from February 4, 2019, onward, the preponderance of evidence is against finding that the Veteran’s PTSD symptomatology warranted a 70 percent, or higher, disability rating. In the February 2019 hearing, the Veteran testified that he did not socialize at church but only attended services and later reported leaving church as soon as service ended to avoid talking to people. He also reported that he and his spouse were estranged from their son and the son’s granddaughter. However, the evidence is against finding that the disability manifested in an inability to establish and maintain effective relationships. During the period on appeal he maintained a strong support system of his family and church community. He consistently reported a supportive and loving relationship with his spouse of 47 years and reported a close relationship with his daughter and granddaughter. As noted above, there are multiple notations and reports of anxiety during the period on appeal. Further, the Veteran testified that he experienced periods of high anxiety affecting his concentration such that he would require reminders to get a haircut or bathe and reported anxiety around crowds which discouraged him from leaving the house. He also reported anhedonia, depression, and low mood and was eventually diagnosed with major depressive disorder. However, his “sine wave” depression and periods of high anxiety affecting concentration are not of a frequency, severity and duration approximating near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively. During the period on appeal, on multiple occasions, the Veteran endorsed flashbacks and diminished concentration. However, there is no evidence that these manifested in gross impairment in thought processes or communication or constituted persistent delusions or hallucinations. Mental status examinations and behavioral observations consistently showed his thought processes to be logical and goal-oriented and his thought content to be unremarkable. Further, all three examiners indicated by omission that his disability did not manifest in gross impairment in thought processes or delusions or hallucinations. The January 2020 examiner noted impairment of short- and long-term memory but there is no evidence that his memory loss was so severe that he forgot names of close relatives or his own name. Neglect of personal appearance and hygiene is a listed criteria for the 70 percent rating; however, the Board does not find that hygiene issues alone or with consideration of other symptoms warrant a higher rating. The need for hygiene reminders noted rarely in the record does not rise to the level of frequency and severity so as to equate to neglect of personal appearance and hygiene. The Board acknowledges the Veteran’s testimony with respect to hygiene but further observes that in the January 2020 examination he clarified that past struggles with hygiene were due to his back pain and procedures. The Board additionally acknowledges the Veteran’s October 2015 statement that he was suicidal. However, he clarified in his testimony that he had thoughts of self harm and feeling like “it is not worth it” but did not endorse thoughts of suicide. Further, during the period on appeal he consistently denied thoughts of suicide when questioned by treatment providers; significantly, on multiple occasions he denied suicidal ideation since the late-1980s or 1990. To the extent that the October 2015 statement might convey suicidal ideation during the period on appeal, it does not rise to the level of frequency, severity, and duration so as to warrant a higher rating. Further, the report in 2015 is less than credible as it is inconsistent with his other statements of record, including his reports for the purpose of receiving medical treatment, that he has not had suicidal thoughts since the late 1980s or early 1990s in connection with medication. See White v. Illinois, 502 U.S. 346, 356 (1992) (a statement made in the course of procuring medical services, where the declarant knows that a false statement may cause misdiagnosis or mistreatment, carries special guarantees of credibility). Based on the foregoing, the Board finds that, for the period from February 4, 2019 to December 30, 2019, the level of impairment caused by the severity, frequency, and duration of the Veteran’s symptoms more closely approximates the level associated with a 50 percent rating. Hence, after reviewing all the evidence of record, the Board finds that the preponderance of the evidence is against finding that ratings in excess of 30 percent prior to February 4, 2019 and in excess of 50 percent after that date are warranted. The Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. Accordingly, an earlier staged rating date of February 4, 2019 for a 50 percent rating is granted; the claim for increased ratings is otherwise denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.   Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Vashaw, Associate 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.