Citation Nr: 21026420 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 18-14 225 DATE: May 3, 2021 ORDER Entitlement to service connection for sleep apnea (OSA) to include as secondary to PTSD is granted. During the entire period on appeal, a 60 percent rating for Crohn's disease is granted. Before April 01, 2020, entitlement to a rating greater than 30 percent for posttraumatic stress disorder (PTSD) is denied. Beginning April 01, 2020, 70 percent for PTSD is granted. FINDINGS OF FACT 1. The preponderance of the evidence of record shows that the Veteran's currently diagnosed OSA is caused by his service-connected PTSD. 2. During the appeal period, the Veteran's Crohn's disease has not been manifested by pronounced symptoms resulting in marked malnutrition, anemia, and general debility, or with serious complications, such as a liver abscess. 3. Before April 01, 2020, the probative evidence of record shows that during the period on appeal, the Veteran's PTSD symptoms did not approximate occupational and social impairment with reduced reliability and productivity. 4. Beginning April 01, 2020, the probative evidence of record shows that during the period on appeal, the Veteran's PTSD symptoms did not approximate occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. The criteria for service connection for OSA have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. During the appeal period, the criteria for 100 percent for Crohn's disease have not been approximated. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.20, 4.27, 4.112, 4.114, Diagnostic Code 7399-7323. 3. Before April 01, 2020, the criteria for a 50 percent disability rating for PTSD have not been approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411. 4. Beginning April 01, 2020, the criteria for a 70 percent disability rating for PTSD have been approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1998 to March 1999 and September 2000 to September 2004. These matters come before the Board of Veterans' Appeals (Board) on appeal from August 2017 and December 2014 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). The rating decision in December 2014 continued the 30 percent ratings for the Veteran's PTSD and Crohn's disease. (A rating decision of February 2018 increased the disability rating for Crohn's disease to 60 percent, effective January 05, 2018. As a claimant will generally be presumed to be seeking the maximum benefit allowed by law or regulations, the claim remains in controversy where less than the maximum benefit available is awarded. AB v. Brown, 6 Vet. App. 35, 38 (1993).) The rating decision of August 2017 denied service connection for OSA. In August 2018, the Veteran's attorney presented testimony at an Informal Decision Review Officer (DRO) hearing regarding the warranting of a VA examination for OSA. A copy of the DRO Conference Report is of record. In April 2020, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ). A copy of the hearing transcript is also of record. The VLJ agreed to hold open the record for an additional 60 days to allow the Veteran an opportunity to supplement the record with further evidence. I. Entitlement to service connection for OSA is granted. The Veteran contends that service connection is warranted for his OSA. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1131 (2012); 38 C.F.R. § 3.303. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity for certain diseases. 38 C.F.R. §§ 3.303 (a), (b), 3.309(a) (2018); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). To establish service connection for the claimed disorder, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303; Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Secondary service connection may also be established for a nonservice-connected disability aggravated by a service-connected disability. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing before the aggravation. 38 C.F.R. § 3.310 (b); Allen v. Brown, 7 Vet. App. 439 (1995). To establish entitlement to service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509 (1998). The standard of proof to be applied in decisions on claims for veterans' benefits is outlined in 38 U.S.C. § 5107 (2012). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. Alemany v. Brown, 9 Vet. App. 518 (1996). The Veteran has been diagnosed with OSA. He is service connected for PTSD. Thus, the first and second Wallin elements are met. Regarding the third element for a secondary service connection claim, the Veteran in May 2020 provided a positive nexus opinion from J. D., MD, who found a secondary relationship between the Veteran's OSA and his service-connected PTSD. Per Dr. J. D., "his sleep apnea is more likely related to PTSD than it is to" his service-connected digestive disorder. Dr. J. D., in arriving at his conclusion, acknowledged a review of the Veteran's claims file and the medical literature provided by the Veteran and his attorney. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (noting that the probative value of a medical opinion comes from its being factually accurate, fully articulated, and having a sound reasoning for the conclusion.). Further, there is no competent medical evidence of record that contradicts the findings of Dr. J. D. Based on the said opinion, the Board finds that the nexus element of a secondary service connection claim is satisfied. Wallin, 11 Vet. App. at 512. Affording the Veteran the benefit of the doubt, service connection for OSA, to include as secondary to the service-connected PTSD, is, thus, granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102, 4.3; Gilbert, 1 Vet. App. at 55. II. Increased Disability Ratings Disability ratings are determined by applying the criteria established in VA's Schedule for Rating Disabilities, based on the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.20. Where there is a question as to which of two evaluations shall be applied under a particular Diagnostic Code, the higher evaluation is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the claimant. 38 C.F.R. § 4.3. Staged ratings are appropriate for an increased rating claim when the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007) (citing Fenderson v. West, 12 Vet. App. 119, 126 (1999)). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a competent source. Second, the Board must determine if the evidence is credible. Barr v. Nicholson, 21 Vet. App. 303 (2007). Third, the Board must weigh the probative value of the evidence considering the entirety of the record. 1. Entitlement to a 60 percent rating for Crohn's disease is granted, effective May 23, 2014. The Veteran contends that a 60 percent is warranted during the entire appeal period for his service-connected Crohn's disease. The Veteran's Crohn's disease is rated by analogy under Diagnostic Code 7399-7323 (ulcerative colitis). 38 C.F.R. § 4.114. A hyphenated diagnostic code is used when a rating under one code requires the use of an additional Diagnostic Code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. An unlisted disease, injury, or residual condition is rated by analogy with the first two digits selected from that part of the schedule most closely identifying the part or system of the body involved; the last two digits will be "99" for all unlisted conditions. Id. Diagnostic Code 7323 for ulcerative colitis directs the rater to rate the veteran's disability according to the limitation of motion of the affected parts, as one would rate degenerative arthritis. Specific provisions apply to rating disabilities of the digestive system. For purposes of rating conditions in § 4.114, the term "substantial weight loss" means a loss of greater than 20 percent of the individual's baseline weight, sustained for three months or longer. The term "minor weight loss" means a weight loss of 10 to 20 percent of the individual's baseline weight, sustained for three months or longer. The term "inability to gain weight" means that there has been substantial weight loss with the inability to regain it despite appropriate therapy. "Baseline weight" means the average weight for the two-year period preceding the onset of the disease. 38 C.F.R. § 4.112. There are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia, and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title "Diseases of the Digestive System," do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in 38 C.F.R. § 4.14. 38 C.F.R. § 4.113. The rating of the same disability or the same manifestations of a disability under multiple diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. For certain diseases of the digestive system, ratings under Diagnostic Codes 7301 to 7329, 7331, 7342, and 7345 to 7348 will not be combined with each other. A single rating is assigned under the diagnostic code that indicates the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability so warrants. 38 C.F.R. § 4.114. Under Diagnostic Code 7323 for ulcerative colitis, a 30 percent rating is warranted for moderately severe symptoms with frequent exacerbations. A 60 percent rating is warranted for severe symptoms with numerous attacks a year and malnutrition, with health only fair during remissions. A 100 percent rating is warranted for pronounced symptoms resulting in marked malnutrition, anemia, and general debility, or with serious complications, such as a liver abscess. 38 C.F.R. § 4.114. The words slight, moderate, and severe as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence that its decisions are equitable and just. 38 C.F.R. § 4.6. It should also be noted that the use of terminologies such as severe by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The Veteran was afforded an Intestinal Conditions (Other Than Surgical or Infectious), Including Irritable Bowel Syndrome, Crohn's Disease, Ulcerative Colitis and Diverticulitis examination, in December 2014. The Veteran reported having had a colonoscopy earlier in the year with a finding of a small bowel fistula into the colon. Also, he lost twenty pounds in the past month and had stool incontinence and diarrhea 10 to 20 times per day. The examiner diagnosed Crohn's disease. Regarding signs and symptoms, the examiner noted diarrhea, 10 to 20 times per day, daily abdominal distension, nausea, and bloody mousy diarrhea. The examiner also noted that the Veteran had episodes of bowel disturbance with abdominal distress, occurring more or less constantly. Regarding episodes of exacerbations and/or attacks of the intestinal condition included abdominal distress with frequent bouts of diarrhea with seven or more exacerbations and/or attacks in the past 12 months. The Veteran had a 20-pound weight loss attributable to his Crohn's disease. His baseline weight was 240, and at the examination, his weight was 220. Malnutrition was not noted, nor was any other pertinent physical findings, complications, conditions, signs, and/or symptoms In January 2018, the Veteran was afforded a second Intestinal Conditions (other than surgical or infectious), including Irritable Bowel Syndrome, Crohn's Disease, Ulcerative Colitis, and Diverticulitis examination. The Veteran reported daily basis to have approximately five stools per day with occasional nocturnal stool. There was no perianal disease. He has episodes of abdominal pain that usually followed some dietary indiscretion, such as eating chicken wings, which usually made him ill enough to miss work for a day. There was one episode where he was sick for seven days. He also reported some lower abdominal pain, periodically. He ran out of vitamin D about two months ago. There was no hematochezia. The Veteran also reported a long history of intermittent solid dysphagia referable to the subxiphoid area. However, in the last six months, it had become somewhat more prominent. He reported no odynophagia and denied liquid dysphagia. He also reported a long history of occasional pyrosis, and he had gained some weight. He took Tums for the pyrosis now and then. Regarding signs and symptoms, the examiner noted diarrhea, 5 to 10 stools daily, Abdominal bloating daily and worse during flare-ups, and nausea and vomiting with the flare-ups that occurred every two months. The Veteran also had episodes of bowel disturbance with abdominal distress, or exacerbations or attacks of the intestinal condition more or less constant abdominal distress. Regarding episodes of exacerbations and/or attacks of the intestinal condition included abdominal distress with frequent bouts of diarrhea with seven or more exacerbations and/or attacks in the past 12 months. The examiner noted that the Veteran had no weight loss. Malnutrition, however, was noted. No other pertinent physical findings, complications, conditions, signs, and/or symptoms were noted. The examiner noted Crohn's disease impacted his ability to work because his frequent diarrhea interfered with his sleep. He woke up during the night to use the restroom, and he missed work or arrived late due to frequent diarrhea. The examiner remarked that a colonoscopy revealed that the Veteran has Crohn's disease with fistula. The Veteran reported an increased frequency of diarrhea, abdominal pain, bloating, malabsorption, and missing work due to his symptoms. Of record also is a June 2017 clinical entry noting the Veteran's complaint of episodic pain due to Crohn's ileitis with ileorectal fistula. He reported right lower quadrant pain and some nausea without visible abdominal distention. The episode terminated with diarrhea. He also had a hard feeling or tightness in the right lower quadrant. The Veteran credibly testified to having had flare-ups every three months, lasting at least three days, which took him out of work for at least three to four days. During those days, he was "bedridden, to try to recover enough to participate in life again." He further testified that he had pain undulating throughout his entire digestive track with flare-ups, which typically lasted about three months. "Basically, [he had] numerous attacks per year, plus the malnutrition, and then, health only fair during remissions." He also had been Vitamin D and Vitamin B12 deficient, and been anemic, with continuous diarrhea that never went away. The Veteran's attorney during the hearing argued that although a 60 percent was awarded by the RO in February 2018, based on a finding of malnutrition in the January 2018 examination, the examination in 2014 demonstrated that he symptoms therein, were of malnutrition and were there "all along," as evidence by complaints of flare-ups, Vitamin D deficiency, and weight loss. Based on the evidence presented above, the Veteran's Crohn's disease is manifested by symptoms of diarrhea, worse with flare-ups, malnutrition, abdominal distension, nausea, and vomiting. The episodes of bowel disturbance manifested with abdominal distress/exacerbations/attacks more or less constant abdominal distress; and episodes of exacerbations and/or attacks of the intestinal condition, with seven or more exacerbations and/or attacks in the past 12 months. Thus, the Veteran's overall symptoms are more closely approximated by numerous attacks per year and malnutrition, with health only fair during remissions, contemplated by the 60 percent criteria. During the period on appeal, the lay and medical fails to show marked malnutrition, anemia, and general debility, or with serious complications, such as a liver abscess. Therefore, 100 percent is not approximated. In sum, the Board finds that, throughout the period of appeal, the Veteran's predominant symptomatology was of frequent abdominal pain, bowel disturbances with abdominal distress, and frequent exacerbations or attacks of the intestinal condition, causing Vitamin D deficiency and malnutrition. Therefore, the Board finds that the Veteran's Crohn's disease symptoms more closely approximate the criteria for a 60 percent rating under Diagnostic Code 7323. 38 C.F.R. § 4.114, Diagnostic Code 7399-7323. A 100 percent rating is not warranted. Although the January 2018 VA examiner found that the Veteran had marked malnutrition and anemia, his Crohn's disease does not result in "general debility." "General" means "involving, appliable to, or affecting the whole." Merriam-Webster's Collegiate Dictionary 520 (11th ed. 2012). "Debility" means "weakness, infirmity." Id. at 320. The record indicates that he has worked in the IT or communications field during the entire appeal period, and even though he misses work occasionally due to his symptoms he remains employed. Further, a July 2015 VA treatment record notes that he had back pain that got worse when he exercised. Being able to do physical exercise is not consistent with a finding of general debility. His VA treatment records note his appearance to be overweight or normal, as opposed to weak or frail. For example, in July 2014 and August 2015 he appeared overweight. In November 2017, a review of symptoms found that he did not have fatigue or weakness. There are not any other signs of general infirmity such as being unable to perform some of his activities of daily living. His medical records and lay testimony are not consistent with a finding that his overall state of being is weak or infirm due to his Crohn's disease. Additionally, he does not have a serious complication of his Crohn's disease. He does not have a benign or malignant neoplasm related to his Crohn's disease and he does not have a liver abscess. The VA examiner found that the Veteran had not had surgery for his conditions. He had daily diarrhea, daily bloating, and nausea and vomiting with flareups which happened every 2 months. He had 7 or more exacerbations and more or less constant abdominal distress. This corresponds to "numerous attacks a year." His anal fistula is already separately compensated under Diagnostic Code 7335-7332 (anal fistula and impairment of sphincter control). He asserts that his Crohn's disease interferes with his ability to sleep. The rating criteria for his already service-connected PTSD contemplate chronic sleep impairment. For these reasons, a 100 percent rating for Crohn's disease is not warranted. 2. Entitlement to a rating greater than 30 percent for PTSD is denied prior to April 01, 2020. 3. Beginning April 01, 2020, 70 percent for PTSD is granted. The Veteran contends that a higher rating is warranted for his PTSD. Currently, his PTSD is assigned a 30 percent disability rating under Diagnostic Code 9411. 38 C.F.R. § 4.130. PTSD is evaluated under the General Rating Formula for Mental Disorders. Under the General Rating Formula for Mental Disorders, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing effective work and social relationships. Id. A 70 percent 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 that 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 worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. Id. A 100 percent rating is assigned for total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability 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. Id. Symptoms listed in the General Rating Formula for Mental Disorders are not intended to constitute an exhaustive list but rather serve as examples of the type and degree of the symptoms or their effects that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). A veteran may only qualify for a given disability rating under § 4.130 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, 117 (Fed. Cir. 2013). Additionally, while symptomatology should be the primary focus when deciding entitlement to a given disability rating, § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused the requisite occupational and social impairment. Id. The Veteran's treatment records show that during a July 2014 PTSD assessment, he reported: "I don't really trust anybody. I'm suspicious of everyone." He characterized others as "selfish, self-serving. If I rely on someone else, I'll be let down." He reported that "anger" is the only genuine emotion he feels consistently. He indicated some "muted happiness" with his kids. He demonstrated insight about the problems associated with emotional numbing, "I tell myself I should care more, but I can't fake emotion." He reported that he felt the most normal when in a combat zone. The clinician noted that he endorsed the following trauma-related symptoms: avoidance; emotional numbing and feeling disconnected from loved ones; hopelessness; low distress tolerance; difficulty with concentration; intense psychological distress when reminded of traumatic events (e.g., crowds ); marked physiological reactions to internal and external cues that symbolize traumatic events; negative mood associated with traumatic events; irritable mood/angry outbursts; hypervigilance; and exaggerated startle response. She also noted that he demonstrated a pattern of interpersonal withdrawal and endorsed difficulty feeling connected to others. A mental status examination (MSE) conducted that same found the Veteran to be alert and oriented to person, place, time, and situation. His appearance was appropriate to the situation and season, and he was cooperative. His mood was dysphoric, and his affect was mood congruent. His speech rate, rhythm, and volume were within normal limits. His thought processes were linear and goal directed. There was no evidence of delusions, hallucinations, or disordered thinking. His judgment and insight appeared fair. He denied any suicidal or homicidal ideation, intent, or plan. During the appeal period, numerous MSEs consistently noted that the Veteran was grossly alert and oriented to person, place, time, and situation, with appropriate appearance appropriate, articulated speech, and calm psychomotor. His thought process was linear, logical, and organized. His thought content was absent active suicidal and homicidal ideation, intent, or plan. There was no evidence of delusional thoughts or perceptual disturbances. His insight and judgment were adequate, and cognition grossly intact. Regarding his mood, the MSEs noted his mood as depressed, flat, or fair. In a MSE of June 2014, however, his mood was noted as "angry," "irritable." As for his affect, it was mostly deemed appropriate. In MSEs of August 2015, it was deemed stoic, cordial, dry humor. In November 2015, it was guarded, stoic, some humor, while in March 2016, it was calm and stoic. In an August 2014 letter to the Veteran, the clinician informed the Veteran that he had been referred to and was invited to join the Cognitive Processing Therapy (CPT-C) Group Program for veterans who have been experiencing PTSD. The letter further explained that the psychotherapy group focused on the acquisition and/or refinement of skills for managing or resolving symptoms associated with PTSD, particularly in the cognitive area of beliefs and thoughts. The record also contains an August 2014 notation that a call was placed to the Veteran to discuss alternate treatment options since he was not available "due to work schedule demands to participate in the weekly CPT group." In December 2014, the Veteran was afforded a Review PTSD examination. He reported that he became divorced two years earlier ago. His then-wife stated that he did not "show emotion," although he never thought his marriage was on solid ground. He reported having three children, aged 6, 4, and one month. His newborn is from his current girlfriend, with whom he lived. The Veteran reported that he loved his children but did not feel connected or close with them. He had no friends outside of work because he has no interest in making friends. He had one military friend with whom he stayed in moderate contact. He belonged to no clubs or organizations. The Veteran earned his Bachelor's degree online in music production. He reported above-average grades. He currently worked full-time in IT for the government as a networking technician for video processes. The Veteran reported that he attended outpatient counseling (group session) for PTSD and that he was also on probation for a 2012 DUI. The examiner diagnosed chronic PTSD and Persistent Depressive Disorder. The examiner noted that the symptoms of hopelessness, diminished appetite, poor sleep, strained concentration, low energy were related to his diagnosed PTSD, while the depressive mood was incurred in childhood. Regarding the level of occupational and social impairment, the examiner determined that 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. He opined that both mental health conditions affect his social domain of functioning. His occupational and educational domains of functioning are not impaired by his mental health disorders. The symptoms of his disability included depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and impaired impulse control, such as unprovoked irritability with periods of violence. The examiner noted that the following other symptoms are also attributable to his PTSD: depressed mood, hopelessness, diminished appetite, poor sleep, strained concentration, low energy. The depressive symptoms were from his childhood. The examiner noted that the Veteran was not considered to be an imminent risk of harm to himself and that he was equipped with the VA crisis line information. The examiner's behavioral observations were that the Veteran was very pleasant and polite, with unremarkable behavior. The examiner noted that the Veteran could manage his financial affairs. The Veteran was afforded a second Review of PTSD examination in January 2018. The Veteran reported that he had been married to his current wife and the mother of his infant child for one year. He reported some conflict in the relationship, initially, but they were communicating better now and working out their differences. There has never been any problem with domestic violence in the relationship. His nine and 7-year-old children from his first marriage also live with them. The Veteran reported working as an IT engineer since 2011. He also reported completing an online having a Bachelor's degree in music production in November 2014. He reported having not been involved in any mental health counseling since 2010, when he attended an anger management group at the San Antonio VA. He also has not taken any prescribed psychotropic medication for two years. In the past, he had taken Prozac and several other psychotropic medications but discontinued them as they had not been beneficial. The examiner diagnosed PTSD. He determined that the Veteran's level of occupational and social impairment was best summarized by 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. The following symptoms applied to his PTSD: anxiety, suspiciousness, and chronic sleep impairment. The examiner noted behavioral observations of mood mildly anxious, affect appropriate to the content of the conversation, though the Veteran demonstrated little variation in affect. The Veteran was "somewhat quiet, though cooperative." The examiner found the Veteran capable of managing his financial affairs. In support of his claim for a higher rating, the Veteran has provided an April 2020 private PTSD Disability Benefits Questionnaire. Therein, the Veteran reported that he had been married to his current wife for four years and lived with her and his four children in a home they own. He reported that they probably would not stay for "I can't be in one spot" and plans to "move to Germany, probably." He reported that he had been with the same company since 2011 but had conflicts with colleagues, but nothing out of the ordinary. He reported working 60 hours of the week, which was somewhat helpful since it "keeps his mind off PTSD stuff." The examiner diagnosed PTSD and adjustment disorder with anxiety and depression secondary to the stress of having a service-connected medical condition. He determined that the Veteran's level of occupational and social impairment was best summarized by occupational and social impairment with deficiencies in most areas, such as work, school family relations, judgment, thinking, and/or mood. The following symptoms applied to his PTSD: depressed mood, anxiety, panic attacks that occur weekly less often, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, chronic sleep impairment, mild memory loss, 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 obsessional rituals which interfere with routine activities. The examiner noted behavioral observations denied feelings of harm toward others or planned to harm anyone. He denied any obsessions, paranoid ideas, hallucinations, and other symptoms of mental disorder. He, however, admitted compulsive behavior. The examiner found the Veteran capable of managing his financial affairs. During his April 01, 2020 hearing, he testified that he had many issues with anxiety, sleep, and suspiciousness. Throughout the whole appeal period, he's been having more difficulty than that exam really captured. He also testified to not finding joy in normal activities or his hobbies. Inter-personal relationships are "very difficult" for him, with me, his children, and his wife. He has trouble sleeping and sometimes woke up screaming. He has a hard time with crowds in public and always felt like he was on edge. He has somewhat of a temper and a hard time relaxing in his house. Everything has "to be a very certain way, for he is very strict about how things are and how clean it is, and everything's got to have its place, and I have to have that control over my domain. Otherwise, I'm very uncomfortable. It's very hard for me to interact with people if it's out of order." He also testified to feeling very isolated all the time. "I don't know if I ever really trust anybody anymore... I just don't feel connected to anyone. And that creates some issues with depression." He stopped taking his depression medication because it did not work and made him "feel worse, mentally unhinged. Things I wasn't comfortable with." The Veteran also testified to having considered group therapy for his PTSD, but there were no group sessions outside of business hours, and so his work would not give him time off every single week to attend a group session. After a review of the evidence presented above, the Board finds that the frequency, severity, and duration of the Veteran's PTSD symptoms reported or shown are suggestive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, the level of impairment contemplated by a 30 percent rating before April 01, 2020. Before April 01, 2020, the Veteran's symptoms from his PTSD included depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and impaired impulse control, such as unprovoked irritability with periods of violence, as reflected in the December 2014 VA examination. During the January 2018 VA examination, anxiety, suspiciousness, and chronic sleep impairment were identified. Nonetheless, these symptoms were not noted to affect his ability to function independently, appropriately, and effectively, including at work. His speech and attention were within normal limits, and he remained alert and oriented to person, place, time, and situation, with appropriate appearance, and fair insight and judgment, and denial of suicidal or homicidal ideation, intent, or plan. Although the Veteran was shown to have difficulty establishing and maintaining effective relationships, during this period, the Board notes that although he divorced his first wife, he soon had a girlfriend, whom he subsequently married and had a new baby. The Board acknowledges the Veteran's report of conflicts within the current marital relationship, but the Veteran reported that they were communicating better now and working out their differences. Further, the Board acknowledges his report that his previous wife noted that he did not "show emotion." Although he loves his children, he does not feel connected or close with them; he lacks friends "outside of work" and not belonging to any clubs or organizations. However, the severity of these symptoms is addressed in the 30 percent criteria he was awarded. Also, during this period, no VA examiner nor clinician found his overall symptoms affecting his ability to function independently, nor reached the level of 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 effective work and social relationships. The Board notes that the Veteran has consistently had symptoms of depression and anxiety. Depressed and anxious moods are contemplated by the 30, 50, and 70 percent rating criteria. However, simply because this Veteran has depressed and anxious moods, and because the 50 percent level contemplates "disturbances of motivation and mood," and the 70 percent level contemplates "deficiencies in most areas, such as mood[,]" does not mean his PTSD rises to the 50 or 70 percent level. The 30 percent criteria contemplate "occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to such symptoms as: depressed mood [and] anxiety[.]" The Board, instead, must look to the frequency, severity, and duration of the impairment. Vazquez Claudio, 713 F.3d at 117. Here, the Veteran's depressed mood is expressly contemplated by the 30 percent criteria. The Veteran is adequately compensated for his impairment. Additionally, his symptoms did not cause him to be less productive at work or at home, he was independent in his activities of daily living, competent to manage his finances, and did not require assistance for tasks. His symptoms did not impair his ability to be reliable at work, that is to be trusted or perform consistently well. The probative evidence of record does not show that the particular symptoms associated with the higher percentage or others of similar severity, frequency, and duration result in occupational and social impairment with reduced reliability and productivity. A higher rating of 50 percent rating is not warranted. Vazquez-Claudio, 713 F.3d at 114 (holding that a veteran "may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration"). Beginning April 01, 2020, a 70 percent is warranted. On April 01, 2020, during his Board hearing, the Veteran competently and credibly testified to having severe symptoms of his PTSD, which were not captured in the VA examinations. In the subsequently, May 2020 provided private DBQ, the clinician identified the Veteran's symptoms as: depressed mood, anxiety, panic attacks that occur weekly less often, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, chronic sleep impairment, mild memory loss, 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 obsessional rituals which interfere with routine activities. The 70 percent criteria contemplate "near-continuous" depression or panic that affects the ability to function independently, appropriately, and effectively. Further, the examiner determined that the Veteran's level of occupational and social impairment was best summarized by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. Therefore, a 70 percent is warranted beginning April 01, 2020. The evidence of record during this period shows that the Veteran's PTSD is not more closely described by both total occupational and total social impairment. The risk of self-harm is contemplated by the 100 percent criteria, which addresses whether one is a persistent danger to himself or others. Bankhead v. Shulkin, 29 Vet. App. 10 (2017). Here, the cumulative evidence of record does not show severity enough to cause both total occupational and total social impairment. Further, no VA clinician, examiner, nor private clinician has found the Veteran to be a persistent danger of hurting himself or others. The MSEs conducted during this period noted the Veteran's continuous denial of current suicidal/homicidal intent or plan. "Total" is defined as "whole, not divided; full; complete" and "utter, absolute." Black's Law Dictionary, 1498 (7th ed. 1999). As the most probative evidence of record does not show total social impairment, the 100 percent rating is not warranted. During this appeal period, the Veteran reported continued to be married to his wife for four years and living with his four children. He continued to work at the same job, where he has been for the last 11 years, and continues to count colleagues as friends, although admittedly, there have been some conflicts. This evidence supports a finding that he does not have total social and total occupational impairment. Given the frequency, nature, and duration of the Veteran's symptoms, the Board finds that they do not result in total occupational and total social impairment for the period on appeal. They do not more closely approximate the types of symptoms contemplated by the 100 percent rating, and therefore, a 100 percent rating is not warranted. Vazquez-Claudio, 713 F.3d at 114 (holding that a veteran "may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration"). In sum, the Board finds that the Veteran's symptoms from his PTSD are most closely described by the assigned 30 percent prior to April 01, 2020, and 70 percent, thereafter. Also, the probative evidence of record does not show that the particular symptoms associated with the higher percentage or others of similar severity, frequency, and duration result in total occupational and total social impairment. Thus, a 100 percent rating is not approximated, after April 01, 2020. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Stevens, 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.