Citation Nr: 21027540
Decision Date: 05/06/21	Archive Date: 05/06/21

DOCKET NO. 14-02 803
DATE: May 6, 2021

ORDER

Entitlement to an increased rating in excess of 10 percent from April 21, 2010 to May 26, 2011 for diabetes mellitus with left eye retinopathy, cataracts and erectile dysfunction is denied.

Entitlement to an increased rating in excess of 20 percent from May 26, 2011 for diabetes mellitus with left eye retinopathy, cataracts and erectile dysfunction is denied.

Entitlement to a separate compensable rating for left eye retinopathy as secondary to diabetes mellitus is denied.

Entitlement to a separate compensable rating for erectile dysfunction as secondary to diabetes mellitus is denied.

Entitlement to a separate compensable rating for cataracts as secondary to diabetes mellitus is denied.

Entitlement to an increased rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is denied.

Entitlement to a total disability rating based on individual unemployability (TDIU) based on service-connected disabilities is denied.

FINDINGS OF FACT

1. From April 21, 2010 to May 26, 2011; the evidence of record indicates the Veteran's diabetes mellitus with left eye retinopathy, cataracts and erectile dysfunction was medically managed by restricted diet and did not require insulin or oral hypoglycemic agent.

2. From May 26, 2011, the evidence of record indicates that the Veteran's diabetes mellitus with left eye retinopathy, cataracts and erectile dysfunction treatment does not require regulation of activities.

3. The Veteran does not have a current diagnosis for left eye retinopathy.

4. The Veteran's erectile dysfunction has been manifested by loss of erectile power, but not deformity of the penis.

5. The Veteran's cataracts have not resulted in compensable visual impairment.

6. The Veteran's symptoms of PTSD was manifested by depression, anxiety, chronic sleep impairment, problems with relationships, and disturbance of motivation and mood, resulting in a disability picture that more nearly approximates that of occupational and social impairment with reduced reliability and productivity.

7. The preponderance of the evidence is against finding that the Veteran was unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities.

CONCLUSIONS OF LAW

1. The criteria for an increased rating in excess of 10 percent from April 21, 2010 to May 26, 2011 for diabetes mellitus with left eye retinopathy, cataracts and erectile dysfunction have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.119, Code 7913.

2. The criteria for an increased rating in excess of 20 percent since May 26, 2011 for diabetes mellitus with left eye retinopathy, cataracts and erectile dysfunction have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.119, Code 7913.

3. The criteria for a separate compensable rating for service-connected diabetic retinopathy have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.119, Diagnostic Code 6006.

4. The criteria for a separate compensable rating for erectile dysfunction are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.7, 4.115(b), 4.119, DC 7522.

5. The criteria for a separate compensable rating for cataracts have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.84a, Diagnostic Code 6027.

6. 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. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.130, Code 9411.

7. The criteria for entitlement to a TDIU rating have not been met. 38 U.S.C. §§ 1155, 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.18, 4.19.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served in active duty service from June 1968 to September 1971.

This matter is on appeal from a December 2010, October 2011, and November 2011 rating decisions. The Veteran was afforded a February 2017 hearing before the undersigned Judge. A transcript of the hearing has been associated with the claims record.

The Board remanded this appeal in December 2017 for additional development.

Increased Rating

Disability ratings are based upon VA's Schedule for Rating Disabilities as set forth in 38 C.F.R. Part 4. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity in civil occupations. 38 U.S.C. § 1155. The disability must be viewed in relation to its history. 38 C.F.R. § 4.1. A higher evaluation shall be assigned where the disability picture more nearly approximates the criteria for the next higher evaluation. 38 C.F.R. § 4.7. 

The Board must consider entitlement to "staged" ratings to compensate for times since filing a claim when the disability may have been more severe than at other times during the course of the appeal. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Where, as here, entitlement to compensation has already been established and an increase in disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). 

Thus, although the Board has thoroughly reviewed all evidence of record, the more critical evidence consists of the evidence generated during the appeal period. Further, the Board must evaluate the medical evidence of record since the filing of the claim for increased rating and consider the appropriateness of a "staged" rating (i.e., the assignment of different ratings for distinct periods of time, based on the facts). See Hart v. Mansfield, 21 Vet. App. 505 (2007).

Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3.

Diabetes mellitus with left eye retinopathy, cataracts and erectile dysfunction

The Veteran is service connected for diabetes mellitus with left eye retinopathy and erectile dysfunction evaluated at 10 percent from April 21, 2010 to May 26, 2011; and then at 20 percent from May 26, 2011.

The Board notes that an October 2011, January 2014 and February 2019 rating decisions granted entitlement to service connection for left eye retinopathy, cataracts, and erectile dysfunction as noncompensable complications related to the Veteran's diabetes mellitus. As noncompensable conditions, they were included within the existing disability rating for his diabetes, pursuant to the rating criteria.  See 38 C.F.R. § 4.119, Diagnostic Code 7913, Note 1.  Once compensable, the complications of diabetes are separately rated.

Under 38 C.F.R. § 4.119, Code 7913, a 20 percent rating is assigned when diabetes mellitus requires insulin and a restricted diet, or oral hypoglycemic agent and a restricted diet. A 40 percent rating is warranted for diabetes mellitus that requires insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities). A 60 percent rating is warranted for diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is warranted for diabetes mellitus requiring more than one daily injection of insulin, a restricted diet, and regulation of activities and involving episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. 

"Regulation of activities" under Code 7913 has been defined as a situation in which the veteran has been prescribed or advised to avoid strenuous occupational and recreational activities. 61 Fed. Reg. 20,440, 20,446 (May 7, 1996).

The notes to the Code provide, in part, that compensable complications of diabetes are evaluated separately unless they are part of the criteria used to support a 100 percent evaluation, and that noncompensable complications are considered part of the diabetic process under the Code 7913.

Diagnostic Code 7522 awards a 20 percent rating for deformity of the penis with loss of erectile power. This is the only schedular rating provided under this diagnostic code. In every instance where the schedule does not provide a zero percent rating for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31.

Concerning cataracts, during the pendency of the appeal, VA issued a final rule revising the portion of the VA Schedule for Rating Disabilities that addresses the organs of special sense and schedule of ratings-eye. 89 Fed. Reg. 15316 (Apr. 10, 2018). The final rule went into effect May 13, 2018. Where there is a change in the rating criteria during the appeal period, the Board will consider the claim in light of both the former and revised schedular rating criteria, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments.

Cataracts is rated under DC 6027. 38 C.F.R. § 4.79. Both the former and revised criteria distinguish preoperative and postoperative cataracts.

For preoperative cataracts, the former criteria instructed to evaluate based on visual impairment. The revised criteria instruct to evaluate under the General Rating Formula for Diseases of the Eye, which instructs to evaluate a condition based on visual impairment or its rating criteria for incapacitating episodes. Thus, the primary difference between the former and revised criteria is consideration of incapacitating episodes. With regard to visual impairment, the amendments made no substantive changes to how visual acuity is rated. With regard to visual field and muscle function examinations, the use of a Goldmann chart is no longer required. There are otherwise no substantive changes to how those types of visual impairment are rated.

The evaluation of visual impairment is based on impairment of visual acuity (excluding developmental errors of refraction), visual field, and muscle function. 38 C.F.R. § 4.75 (a).

The General Rating Formal for Diseases of the Eye indicates that, for the purposes of ratings under 38 C.F.R. § 4.79, an incapacitating episode is an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes.

Eye disabilities with visual impairment are rated based on impairment in visual acuity with correction. See 38 C.F.R. §§ 4.75, 4.76.

Under Diagnostic Code 6066, where visual acuity is 20/40 or better in both eyes, a noncompensable rating is warranted. Where visual acuity is 20/50 in both eyes, a 10 percent rating is warranted. See 38 C.F.R. § 4.79.

Review of the medical treatment record shows in April 2010 the Veteran complained of blurry vision at near and at distance. An OS blot hemorrhage in the retina was assed but no cataracts were found.

In a June 2010 nutrition note, the Veteran reported that he just found out from his physician that he has diabetes mellitus. After discussion of the Veteran's diet, the treating provider recommended the Veteran to alter his diet to help prevent the Veteran from "full blown DM."

The Veteran was afforded a September 2010 VA examination. The Veteran was diagnosed with diabetes based on a 2010 screening that found elevated blood sugar levels. The examiner noted the Veteran was not yet receiving medication for treatment and found the Veteran's diabetes to be stable and currently treated only by diet alone.

The examiner noted there was cataracts in both eyes. No complaint or finding of erectile dysfunction was made at the examination. The examiner concluded that the evidence did not show any visual impairment; cardiovascular disease; kidney disease; neurologic disease; or other diabetic conditions.

In a January 2011 VA examination for the eye, the examiner noted an August examination found a single blot hemorrhage in the left eye and nasal pterygium in each eye. The examiner found no history of hospitalization, surgery, or incapacitating periods due to eye disease.

Upon physical examination, the examiner found the Veteran's near and distance acuity of both eyes to be 20/30 or better when corrected.

The examiner found trace nuclear sclerosis cataracts in both eyes but did not find any visual field defect. The examiner diagnosed trace early cataracts that did not cause impairment at this time. The examiner noted that trace early cataracts were "well-known to be a normal aging process. Early cataracts can be associated with diabetes mellitus, but these are not considerably early...[and] less likely than not to be caused by or a result of the diabetes mellitus."

In May 2011 the treating provider noted the Veteran with presurgical cataracts. In a separate May 2011 primary care note, the Veteran reported that he has been trying to take care of his diet in order to lose weight.

The provider noted the Veteran's diagnosis for diabetes for a year and a half as reported by the Veteran. The provider also noted the Veteran's reports on trying to diet, eat healthier and trying to lose weight. The provider stated that they would start the Veteran on metformin medication.

In July 2011 the Veteran reported having diabetes that was treated with oral medication with good control; the Veteran also reported an eye "growth" from diabetes. In August 2011 the Veteran was reported to be complaint with diet and medication treatment for diabetes; however, the treating provider noted the Veteran would have better results if "he were taking medication as prescribed (took 30 days and did not call for refill.)"

In November 2011 Agent Orange attending note, the Veteran reported "long-term trouble" with his vision "ranging from cataracts to bilateral pterygia and bilateral epiretinal macular membrane." The Veteran stated that last year he began to experience diplopia, sometimes when driving to the extent that he would need to pull over to the side of the road. The Veteran noted that his vision would return to normal within 15 to 30 minutes; the Veteran admitted to blurry vision and poor night vision. The treating provider diagnosed the Veteran with blurred vision but did not indicate any evaluation was done for the Veteran's eyes.

The Veteran was afforded a November 2011 VA examination. The examiner found the Veteran's diagnosed diabetes to be treated with restricted diet and prescribed oral hypoglycemic agent. The examiner found the Veteran did not require regulation of activities to manage diabetes. The examiner did not find the Veteran with erectile dysfunction or eye conditions as a complication from diabetes and found the Veteran's diabetes did not permanently aggravate any other medical conditions.

The Veteran reported a new visual problem to include decreased vision at night. The examiner noted that they "reassured [the Veteran] that he does not have any changes in his eyes that are related to diabetes." The examiner did not find diabetic retinopathy.

In December 2012, review of the Veteran's systems showed the Veteran reported erectile dysfunction. In a separate December 2012 annual diabetic eye examination, the Veteran reported near blurriness with current SV distance glasses; the provider explained that the glasses were only meant to be used for distant vision.

The Veteran reported that vertical diplopia still occurred, last occurring 1 month ago lasting for 30 minutes. The provider noted the Veteran was unable to elicit diplopia at the current visit. The provider assessed the Veteran with intermittent vertical monocular diplopia with mild cataracts in both eyes. The provider indicated the Veteran had presurgical cataracts. The provider did not find diabetic retinopathy.

In a February 2013 VA examination for male reproductive systems, the examiner diagnosed the Veteran with erectile dysfunction, noted that it was reported in 2012, and found it to be related to his diabetes. The examiner found that the Veteran was unable to achieve an erection sufficient for penetration and ejaculation with or without medication treatment. Physical examination of the Veteran's penis found normal findings.

In a January 2014 optometry visit the Veteran complained of blurry vision and dry eye. Physical examination found the Veteran's vision at distance corrected to be at 20/40 or better in both eyes. The Veteran was assessed only with glaucoma.

In March 2014, it was noted that the provider did not find cataract treatment was required at this time. In an April 2014 primary care note for a 6-month followup, the Veteran reported bilateral cataracts that needed to be removed. The Veteran stated that the cataracts were affecting his vision and made it difficult to see in low light. The treating provider referred the Veteran to the eye clinic for consultation for removal.

In an October 2014 primary care note the Veteran again reported bilateral cataracts that were making things more blurry; the Veteran stated that he wants to have them removed and that he could not see too well out of his current prescribed glasses.

In a January 2015 optometry consultation, the Veteran reported that his vision was mildly decreasing, "symptomatic of glare (night worse than day)"; the Veteran stated that he had not had episodes of diplopia "for a long time" and wanted to know if he needed cataract surgery.

Upon physical examination, the Veteran's acuity at distance after correction was 20/25 or better in both eyes.

The treating provider assessed the Veteran with a history of intermittent vertical monocular diplopia that was currently asymptomatic with no reported episodes in a long time. The provider found no evidence of diabetic retinopathy. The provider noted the Veteran with mild presurgical cataracts in both eyes that resulted in minimal impact on vision but symptomatic with decreased vision and difficulty with glare.

The provider found that surgery for cataracts was not required at this point and new glasses were ordered.

In a June 2016 record noting completion of Non-VA consultation, an impression of age-related nuclear cataracts was given and found to be stable that affected or impaired the Veteran's vision. No diabetic retinopathy was found.

At the Veteran's May 2017 hearing, the Veteran's wife testified that the Veteran was unable to drive at night because he could not see down the road while driving at night.

The Veteran's son testified the Veteran would need to hold a letter close and move it back and forth to adjust and read it. The Veteran's son noted that while driving the Veteran around the Veteran would sometimes say that no one was passing them on the road, but when the son checked, the son would notice a vehicle coming. The Veteran's son indicated that the vision problems have become more of a problem in the past two to three years. The Veteran's other son noted that in general the Veteran has been driven around because his difficulties driving at night and now during the day.

In August 2017 the treating provider found eye examination found cataracts, but surgery was currently not needed. In January 2018 the Veteran mentioned that he had cataracts but that he was "not quite at the point to need surgery yet."

The Veteran was afforded a March 2018 VA examination for the Veteran's diabetes. The examiner found the Veteran's diabetes to be managed by restricted diet and prescribed oral hypoglycemic agent. The examiner did not find the Veteran's diabetes required regulation of activities. The examiner noted the Veteran with complications of diabetic retinopathy and erectile dysfunction.

The examiner noted that the Veteran at the examination reported that he was sexually active and able to perform and ejaculate 2 times a week. Physical examination of the penis showed normal findings with no penile deformity.

In a March 2018 VA examination for the eye, the examiner diagnosed the Veteran with cataracts, pterygium OU, and epiretinal membrane. The Veteran reported that currently it was harder to see, especially in his left eye.

Upon physical examination, the Veteran's vision corrected was 20/40 or better for both eyes for distance and near. The Veteran did not have a difference equal to two or more lines on the Snellen test type chart or its equivalent between distance and near corrected vision, with the near vision being worse. The Veteran did not have diplopia or visual field defect.

The Veteran was noted with preoperative cataracts in both eyes but with no aphakia or dislocation of the crystalline lens. The examiner did note the Veteran's cataracts contributed to mild decrease in vision. No incapacitating episodes were found.

The examiner noted the Veteran's pterygium was unrelated to diabetes and did not impact the Veteran's vision. The examiner also noted the Veteran's epiretinal membrane equally contributed to an impact on the Veteran's vision but was not related to the Veteran's diabetes.

After review of the record, the Board finds that an increased evaluation in excess of 10 percent for the period from April 21, 2010 to May 26, 2011 and an increased evaluation of 20 percent for the period from May 26, 2011, for diabetes is not warranted.

As noted above, a 20 percent rating requires the Veteran's diabetes to be treated with the utilization of insulin and restricted diet; or, oral hypoglycemic agent and restricted diet. For a 40 percent rating, utilization of insulin, restricted diet, and the regulation of activities is required.

For the period from April 21, 2010 to May 26, 2011, the medical treatment record does not show the Veteran was receiving insulin or an oral hypoglycemic agent to treat his diabetes. The records show the Veteran was initially trying to reduce weight and control blood sugar via diet and exercise before in May 2011 the treating provider decided to start the Veteran on metformin.

The Board notes that regulation of activities is defined as "avoidance of strenuous occupational and recreational activities". 38 C.F.R. § 4.119, Diagnostic Code 7913; see also Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007). For the period from May 26, 2011, the objective medical evidence does not show that the Veteran's diabetes mellitus results in any regulation of activities. The Veteran has not provided any specific detail or explanation on how his diabetes has manifested by regulation of activities as part of medical management of his disability, nor is it demonstrated by the medical evidence of record. The VA examinations of record did not find the Veteran's diabetes mellitus to require regulation of activity. For these reasons, the Board finds the conclusion of the VA examiners to be the most probative evidence of record as to whether or not regulation of activities is required.

The Board also finds that separate compensable ratings for left eye retinopathy, cataracts, and erectile dysfunction are not warranted. 

Regarding left eye retinopathy, review of the medical treatment record only shows that the January 2011 VA examination found "trace early diabetic retinopathy" in the left eye; following medical treatment records to include VA examinations in November 2011 and most recently in March 2018 did not find evidence of diabetic retinopathy affecting the Veteran's visuals.

Regarding erectile dysfunction, the Board notes that a separate compensable rating is available for erectile dysfunction under Diagnostic Code 7522, which provides for a single 20 percent disability rating where the evidence shows deformity of the penis with loss of erectile power. 38 C.F.R. § 4.115(b). There is no schedular rating for loss of erectile power alone.

Review of the medical treatment record does not show any findings or documentation of penile deformity or abnormality. VA examinations in December 2012 and February 2013 showed the Veteran reported erectile dysfunction but no findings of penile deformity or abnormality. Notably in a March 2018 VA examination for diabetes, the Veteran reported that he was sexually active and able to perform and ejaculate twice a week with no findings of penile deformity or abnormality.

Regarding cataracts, the Veteran's cataracts are noted to be presurgical. Review of the medical treatment record to include VA examinations show although remarks were made that the Veteran's cataracts resulted in mild impairment to the Veteran's vision; the Veteran's visual acuity in both eyes was found to be 20/40 or better after correction. 

As such, the medical evidence of record does not warrant a separate compensable evaluation of the Veteran's left eye retinopathy, erectile dysfunction, or cataracts.

Accordingly, the Board finds that the preponderance of the evidence is against the assignment of an initial rating in excess of 10 percent from April 21, 2010 to May 26, 2011, and in excess of 20 percent from May 26, 2011 for diabetes mellitus with left eye retinopathy, cataracts and erectile dysfunction as well as separate compensable evaluations for left eye retinopathy, erectile dysfunction, or cataracts. Thus, the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 4.3.

Posttraumatic stress disorder (PTSD)

The Veteran is service connected for PTSD evaluated at 50 percent under Diagnostic Code 9411.

When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustments during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on the social and occupational impairment, rather than solely on the examiner's assessment of the level of disability at the time of examination. The rating agency will consider the extent of social impairment but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126.

A 50 percent rating is assigned when 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 (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships.

A 70 percent evaluation is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships.

Lastly, a 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: 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 closes relatives, own occupation, or own name. See 38 C.F.R. § 4.130.

The "such symptoms as" language means "for example," and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The list of examples provides guidance as to the severity of symptoms contemplated for each rating. Id. However, this fact does not make the provided list of symptoms irrelevant. See Vasquez-Claudio v. Shinseki, 713 F.3d 112, 11617 (Fed. Cir. 2013). The Veteran must still demonstrate either the particular symptoms associated with the rating sought, or other symptoms of similar severity, frequency, and duration. Id. at 117.

The Board notes that one factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). According to the DSM-IV, GAF scores ranging between 61 to 70 reflect some mild symptoms [e.g., depressed mood and mild insomnia] or some difficulty in social, occupational, or school functioning [e.g., occasional truancy, or theft within the household], but generally functioning pretty well, and has some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect more moderate symptoms [e.g., flat affect and circumstantial speech, occasional panic attacks] or moderate difficulty in social, occupational, or school functioning [e.g., few friends, conflicts with peers or co- workers]. Scores ranging from 41 to 50 reflect 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]. Scores ranging from 31 to 40 reflect 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 man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school]. 

VA has changed its regulations, and now requires use of DSM-5 effective August 4, 2014. Among the changes, DSM-5 eliminates the use of the GAF score in evaluation of psychiatric disorders. The change was made applicable to cases certified to the Board on or after August 4, 2014; and is not applicable to cases certified to the Board prior to that date. 79 Fed. Reg. 45093 (Aug. 4, 2014). 

As the Veteran's case was certified to the Board after August 4, 2014, DSM-5 applies, and GAF scores are no longer used in evaluation of psychiatric disorder. Id. However, the examiner's discussion of symptoms associated with any assigned score would still be useful in evaluation of psychiatric disabilities.

In an April 2010 VA medical center (VAMC) record, the Veteran presented "for the first time with VA to establish care." The Veteran indicated that he previously was treated with the Indian Health Service (IHS) but "only when I get sick"; the Veteran stated that he has not been seen for any other chronic medical condition.

The Veteran reported problems with depression; getting easily irritated at home; occasionally not feeling eating or doing much; and a history of weekly nightmares or flashbacks. The Veteran denied suicidal ideation or attempts. The Veteran was observed to be alert and oriented; and demonstrated good insight and judgement.

In a separate April 2010 social work note, the Veteran was observed to be alert and oriented; appropriately dressed; and displayed euthymic mood with incongruent affect.

In an April 2010 mental health assessment, the Veteran reported that he was raised by his grandparents as his mother died early. The Veteran stated that he had a good relationship with his brother whom with he keeps contact but does not keep contact with his half-siblings. The Veteran reported that he currently works in maintenance with Parks and Recreation.

The Veteran stated that he was married with 4 children. The Veteran noted tension with his wife and that she says that the Veteran gets angry easily and "not enough loving feelings." The Veteran also stated that he gets along with his children but with tension as "they think he is too strict or mean." 

The Veteran reported symptoms of hypervigilance; exaggerated startle; anger management; depression; insomnia; emotional distance and tension with his immediate family as "they think he is mean at times" and almost daily panic attacks.

The Veteran stated that he has not received any inpatient care and received some outpatient counselling where he received a diagnosis of depression. The Veteran stated that he does not use medication but uses his own tribal healing ceremonies. 

The Veteran did report suicidal ideation but denied plans as well as homicidal ideation. The Veteran clarified that he only felt hopelessness and sometimes had a passive wish to die. The Veteran identified strong protective factors to include his family, community, and faith. The treating provider did not find the Veteran to be a suicide risk.

The Veteran was observed to be groomed and appropriately dressed. The Veteran was cooperative but was noted to break down ater discuss the effect on his family. The Veteran's mood was mixed with flat affect, and the Veteran demonstrated appropriate thought and fair insight and judgement.

In a May 2010 psychiatry note, the Veteran reported his current worst problem was insomnia and nightmares which cause him to awake sweating with shortness of breath. The Veteran stated that his mood was depressed and irritable where "I lose my temper right away."

The Veteran stated that he retired in October 2003 after working for the Indian Health Service for 35 years; however, he became restless at home and has returned to working for the Parks and Recreation department.

The Veteran was observed to be cooperative, well-groomed and neatly dressed. The Veteran's mood and affect was described to be depressed, irritable, and with a quick temper. The Veteran's insomnia was noted with awakenings from nightmares with panic symptoms. The Veteran demonstrated logical thought with good insight and judgement. The Veteran denied suicidal and homicidal ideation.

In a May 2010 outreach note, the Veteran identified as a traditional Navajo Native American. The Veteran claimed that he never sought treatment for PTSD and just suffered with it without awareness of symptoms.

In a separate May 2010 statement from the Veteran, the Veteran reported that he was depressed, irritable and angry. The Veteran stated that he continued to have nightmares with panic attacks and memory lapses. The Veteran noted that he prefers to utilize traditional healing and ceremonies for wholistic health care but will use "Western medicine" on occasion; the Veteran stated that he has kept silent all these years regarding his health problems and now deals with all these ailments.

In a June 2010 psychiatry note, the Veteran reported that he was retiring from the Parks and Recreation department after 7 years; the Veteran stated that he looks forward to retirement and that there was "lots of work at home". The Veteran stated that he enjoys being with his children and grandchildren.

The Veteran stated that the prescribed medication has not changed his mood or issues with broken sleep and nightmares but did note a slight decrease in the intensity of his nightmares.

The Veteran was observed to be well groomed and neatly dressed. The Veteran reported his mood as "I'm hanging in there" and described as somewhat depressed with continued trouble with anger and irritability.  The treating provider noted the Veteran continued to have panic attacks, broken sleep, and nightmares.

The Veteran demonstrated logical thought and good insight and judgement. The Veteran reported no issues with memory and concentration and denied suicidal and homicidal ideation.

In an August 2010 psychiatry note, the Veteran stated that his wife continues to complain that the Veteran gets angry quickly; the Veteran stated that his anger issues feel a little better with medication as well as better sleep.

The Veteran was observed to be well groomed and neatly dressed. The Veteran's mood was noted to continue to be mild to moderately depressed and still irritable. The treating provider noted the Veteran was sleeping better with current medication but still had nightmares.

The Veteran demonstrated logical thought and good insight and judgement. The Veteran reported no issues with memory and concentration and denied suicidal and homicidal ideation.

In a separate August 2010 social work note, the Veteran reported that he was doing better with improved mood but still had symptoms of nightmare, hypervigilance, startled response and anger management; the Veteran did indicate that such symptoms were not as frequent.

The Veteran was observed to be neatly dressed and oriented with euthymic mood and affect.

The Veteran was afforded a September 2010 VA examination. The Veteran stated that he was raised by his grandparents because his mother died early, and his father moved back with his family shortly after her death. The Veteran noted that discipline "consisted of being hit with a whip" but it was "just one time" and denied any abuse. The Veteran states he has one surviving brother that he gets along with well.

The Veteran reported he was married twice; the first was from 1972 for 10 years with two daughters and ended because "we were not getting along", and then he remarried in 1985 with two sons. The Veteran stated that he has a good relationship with his wife and sons, but he does "get angry, frustrated because of nightmares and flashbacks." 

The Veteran stated that he has a few relatives and friends that he sees "once in a while." The Veteran indicated limited social interaction, stating that he "used to have a lot of friends but now I just really want to be alone, I stay away from others."

The Veteran reported that he first retired in October 2003 and then again in June 2010. The Veteran indicated the reasons that he retired both times was because he was eligible by age or because of duration of work.

The Veteran was observed to be clean, neatly groomed, and appropriately dressed. The Veteran demonstrated unremarkable speech and thought process and was oriented with intact attention. The Veteran demonstrated average attention, agitated mood and appropriate affect. The Veteran denied hallucination, inappropriate behavior and homicidal ideation.

The Veteran reported sleep impairment where he only gets 3 to 4 hours of sleep and wakes up several times during the night.

The Veteran described having an obsessive or ritualistic behavior; reporting "when we go into town, I always wonder if the heater or the stove or the hair curler is on, or the door is locked. Sometimes we have to come back to check."

The Veteran reported the presence of suicidal thoughts. The Veteran stated that "sometimes when I get anxious, depressed, I think 'what's the use of living'; but then I think about my wife and kids and grandkids."

The Veteran noted that when he used to work, he would try to improve the facility he worked in; however, "there's always somebody that doesn't want to do it. That really got me frustrated, angry." The Veteran also described outbursts of anger where "when I talk to my wife, my kids, and they don't meet my requirements, I snap at them, I really get angry at them."

The Veteran reported difficulty concentrating, describing that "I forget real easy, sometimes I'm talking about something and I forget, and ask what I was talking about, I get off course, I just go blank." The examiner found the Veteran's remote and recent memory to be severely impaired and immediate memory to be mildly impaired.

The Veteran stated that his symptoms affected his family and others where "I get really angry, frustrated. I didn't used to be that way before I went to Nam...some words will really tick me off. I worry that I'll hurt the people. That's why I always want to be by myself, I don't want to join the crowd. It interfered with my job, with my family, like I really forget when I'm trying to do something, when somebody tells me something or to do this. When I'm told something I forget, I really forget."

The examiner found diagnostic testing showed the Veteran's PTSD symptoms to be of moderate severity. The examiner remarked that the Veteran's PTSD symptoms caused significant distress to interpersonal and occupational function to include suicidal thinking. The examiner did not find the symptoms resulted in total occupational and social impairment.

 In an October 2010 psychiatric note, the Veteran reported that the prescribed medications were "helping me a lot"; however, the Veteran also indicated that he was only using the medication on "an as needed basis" against the provider's instructions and recommendations that the medication had to be taken daily in order to be effective.

The Veteran reported nightmares twice a week and had some "bad nights" but indicated that he was taking medication for treatment and to prevent additional nightmares after they occur.

The Veteran was observed to be well groomed and neatly dressed. The Veteran's mood was "pretty good" with some irritability. The Veteran demonstrated logical thought with no psychotic symptoms; good insight and judgement; and had no complaints with memory and concentration. The Veteran did not report suicidal or homicidal ideation and indicated future plans.

In a November 2010 social work note, the Veteran reported doing well and that his anger management problem was no longer a problem; however, the Veteran indicated that he continued to have sleep problems. The Veteran was observed to neatly dressed, oriented, and demonstrated a positive mood and congruent affect.

In a December 2010 psychiatry note, the Veteran reported "I'm doing pretty good." The Veteran indicated that he continues to take his psychiatric medication  on an as-needed basis.

The Veteran reported and off and on low mood as well as passive suicidal ideation; the Veteran noted "I think about it, but my family..."

The Veteran was observed to be well groomed and neatly dressed. The Veteran's mood was noted to be off and on depressed with sleep that was "sometimes good, not good." The Veteran demonstrated logical thought with psychotic symptoms, good insight and judgement and no memory complaints. The Veteran reported off and on suicidal ideation with no plans or intent.

The treating provider noted the Veteran did not take much medication and again strongly urged the Veteran to take his medication daily for his depression and thoughts of suicide.

In a separate December 2010 social work note, the Veteran reported doing good. The Veteran was observed to be oriented with elevated mood and full affect.

In a January 2011 social work note, the Veteran reported that he was enjoying his retirement but disagreed with his current PTSD rating; the Veteran felt that it should be higher because of ongoing effects. The Veteran was observed to be neatly dressed and in a euthymic mood with flat affect.

In a February 2011 social work note the Veteran reported that he was moderately depressed and noted to "continue to hold back issues related to combat trauma"; the Veteran was observed to be oriented; neatly dressed; and demonstrate euthymic mood and affect.

In a February 2011 psychiatric note, the Veteran reported using psychotropic medication with success and prevented nightmares. The Veteran was observed to be clean; neatly dressed; and cooperative. The Veteran's mood was mildly depressed with improved sleep and suppressed nightmares due to prescribed medication.

The Veteran demonstrated logical thought with no psychotic symptoms; good insight and judgement; no complaints with memory and concentration; and denied suicidal and homicidal ideation.

In an April 2011 social work note, the Veteran reported he only had symptoms of insomnia and denied other symptoms of depression. The provider noted the Veteran was compliant with medication and it was effective in treating his PTSD.

The Veteran was observed to be oriented; neatly dressed; and demonstrated elevated mood and affect.

In a May 2011 psychiatric note the Veteran reported poor sleep quality despite prescribed medication; the Veteran did note that his nightmares were prevented by medication. The Veteran was observed to be clean; neatly dressed; and cooperative. The Veteran's mood was neutral with anxiety well controlled by medication. The Veteran's sleep continued to be poor quality, but medication suppressed his nightmares.

The Veteran demonstrated logical thought with no psychotic symptoms; good insight and judgement; no complaints with memory and concentration; and denied suicidal and homicidal ideation.

In a July 2011 social work note, the Veteran appeared stressed and stated, "everything is alright." The Veteran stated that irritability was still a problem, but he is managing it. The Veteran was observed to be oriented; neatly dressed; and demonstrated stressed mood and affect.

In an August 2011 psychiatric note, the Veteran reported that he ran out of medication and still has very poor sleep. The provider noted that although the Veteran has nearly run out of his prescribed medication, the Veteran has not yet reordered a refill himself.

The Veteran was observed to be clean and neatly dressed; the treating provider noted the Veteran was yawning and "scarcely able to stay awake during out appointment." The Veteran's mood was depressed. The Veteran demonstrated logical thought with no psychotic symptoms; good insight and judgement; no complaints with memory and concentration; and denied suicidal and homicidal ideation.

In a separate August 2011 social work note, the Veteran initially reported that he was doing okay but later admitted to having continued sleep problems where he thinks "his heart stops and he has difficulty waking up...scares him."

The Veteran stated that his wife complains to him about his attitude and anger issues, but he is not aware as to what upsets his spouse. The Veteran admits that he has difficulty tolerating his grandchildren and their active nature; the Veteran stated that sometimes he goes after the grandchildren and "perhaps for that reason they think he is mean", otherwise the Veteran stated that he gets along with them.

The Veteran was observed to be oriented; neatly dressed; and demonstrated anxious mood with congruent affect.

In an October 2011 social work note, the Veteran reported that he continues to have hyperarousal symptoms managed by medication. The Veteran stated that he is beginning to have suicidal ideation but with no plans; the Veteran also indicated feelings of impending doom, hypervigilance, depression, and dreams that scare him.

The Veteran denied that he was presently suicidal and that he "just thinks about it but never plans to do it." The Veteran was observed to be oriented; neatly dressed; and demonstrated alert and euthymic mood and affect.

The Veteran was afforded a November 2011 VA examination.

The Veteran reported that he lives with his wife, two sons, and grandchild. The Veteran reported that he gets along with his wife and children and his relationships were stable and satisfying.

The Veteran stated that he has many friends and participates in Native American traditional ceremonies at least once a week as well as horseback riding with relatives once a month. The Veteran noted that he enjoys driving, traveling, rodeos and attending Native American gatherings with his wife.

The Veteran reported stable and satisfying occupational history for decades, noting that he worked 35 years as an ambulance driver until his first retirement in 2003 due age and duration of service, and then working 2003 to 2010 because "I couldn't stand being bored at home." The Veteran stated that at both jobs he had good attendance; good performance evaluations; and good relationships with his co-workers and supervisors. The Veteran stated he considered himself retired and not looking for further work.

The Veteran reported panic attacks occurring weekly or less; transient sadness and crying spells occurring twice a month; and occasional palpitations and heart pounding due to nightmares occurring three times a week. The Veteran noted sleep impairment that leaves him only getting three to four hours of sleep.

The examiner found the Veteran with symptoms of panic attacks occurring weekly or less and chronic sleep impairment. The examiner remarked that the Veteran's PTSD symptoms were in the mild range as compared to the September 2010 VA examination. 

In a following November 2011 social work note, the Veteran reported that he was doing good but still had symptoms of PTSD to include irritability, insomnia and anger.

The Veteran noted that most of the time he reports that everything is going ok and that "he wanted to report the positive during the [VA examination] and did not want to bring out the suffering."

 The Veteran also indicated that he is requesting appeals because "of time served in Vietnam and he feels some entitlement."

The Veteran was observed to be oriented; neatly dressed; and demonstrated mixed mood with congruent affect.

In a separate November 2011 psychiatric visit, the Veteran reported that he was tired from very poor sleep; the Veteran stated that his wife has observed the Veteran as restless and talking in his sleep.

The treating provider noted the Veteran has not yet requested medication refills as instructed in his previous visit but noted that he increased medication to treat nightmares. The Veteran reported that he has not had panic attacks recently but did have "that problem about six months ago with such intensity that he was having suicidal ideation."

The Veteran was observed to be clean; neatly dressed; and cooperative. The Veteran demonstrated logical thought with no psychotic symptoms; fair insight and judgement; and no complaints with memory and concentration. The Veteran was noted to report suicidal ideation six months ago in the context of panic attacks but has had no problems since.

In a December 2011 social work note, the Veteran reported being stressed all the time and angry at his family for "no other reason other than feeling irritable". The Veteran discussed his denial for an increased evaluation; the treating provider noted that previously they had recommended the Veteran document all his problems and to report them at these sessions but the Veteran "did not bring anything to report other than general information."

The Veteran was observed to be oriented; neatly dressed; and demonstrated negative mood with congruent affect.

In a January 2012 psychiatric note, the Veteran reported that his restless sleep was the same and his nightmares worse than ever. The treating provider observed the Veteran to be "blinking, sometimes yawning" and the Veteran was unclear whether his blinking was associated with sleepiness; the Veteran also noted that he would get up three to four times a night to urinate. The provider noted the Veteran has missed taking his medication and has not ordered refills.

The Veteran was observed to be clean and neatly dressed; the treating provider noted the Veteran was blinking and noted this to be "either very sleep or possible tic." The Veteran's mood was depressed. The Veteran demonstrated logical thought with no psychotic symptoms; fair insight and judgement; no complaints with memory and concentration; and denied suicidal and homicidal ideation.

In a separate January 2012 social work note, the Veteran reported continuing to have irritability; the Veteran recounted an incident where "an elderly talked to them and appeared to take advantage of them...[the Veteran] generally does not address the issues and keeps quiet." The Veteran noted that he "has encounters with his wife from time to time" and manages to avoid these by avoiding the issue and taking a drive.

The Veteran was observed to be oriented; neatly dressed; and demonstrated mixed mood with flat affect.

In a March 2012 psychiatric note, the Veteran reported no changes in poor sleep but had some help with medication. The Veteran stated having the same depressed mood exacerbated with poor sleep.

The Veteran was observed to be clean and neatly dressed; the treating provider noted the Veteran was yawning and blinking to which the treating provider "believes represents tics." The Veteran's mood was low. The Veteran had very poor sleep broken by restless leg syndrome and frequent urination resulting in intense daytime sleepiness. The Veteran demonstrated logical thought with no psychotic symptoms; good insight and judgement; no complaints with memory and concentration; and denied suicidal and homicidal ideation.

In a June 2012 psychiatric note, the Veteran reported his sleep remained poor with no improvement with medication. The Veteran was observed with red eyes; less yawning; low mood; and poor sleep broken by restless leg syndrome and frequent urination. The Veteran denied suicidal ideation.

In a separate June 2012 social work note, the Veteran was observed to be alert and oriented; demonstrated speech, behavior and thought within normal limits; and demonstrated mood congruent with content.

In a July 2012 social work note, the Veteran reported his family has its ups and downs but confirms a "happy and joyful life most of the time." The Veteran then stated that he had anxiety and depression and recounted how a neighbor for the past 20 years made threats to kill him for "living on the land"; the Veteran noted that he did not wish to hurt the neighbor but "will protect himself in the event the neighbor attempts physical harm."

The Veteran was observed to be alert and oriented; demonstrated speech, behavior and thought within normal limits; and demonstrated mood and affect congruent with content.

In a separate July 2012 psychiatric note, the Veteran reported his sleep was just as bad but medication helps him "going in the right direction" regarding his irritability with his family but still depressed. The Veteran stated that he enjoys his retirement; works on home improvements; and goes to places with his wife to include attending traditional ceremonies. The provider noted the Veteran was reluctant to increase his medication to an effective level.

The Veteran was observed to be clean and neatly dressed; the treating provider noted the Veteran appeared tired but "tic-like movements less prominent." The Veteran's mood was depressed but irritability improved. The Veteran demonstrated logical thought with no psychotic symptoms; fair insight and judgement; no complaints with memory and concentration; and denied suicidal and homicidal ideation.

In an August 2012 social work note the Veteran discussed keeping busy taking care of his yard in order to avoid arguments with his wife and PTSD. The Veteran was observed to be alert and oriented; demonstrated speech, behavior and thought within normal limits; demonstrated mood and affect congruent with content; and did not indicate suicidal and homicidal ideation.

In an October 2012 psychiatric note, the Veteran reported and up and down mood and continued poor sleep. The provider noted the Veteran was inconsistent with his use of medication for treatment.

The Veteran was observed to be clean and neatly dressed; the treating provider noted the Veteran appeared very tired. The Veteran's mood was "up and down" but mostly down. The Veteran demonstrated logical thought with no psychotic symptoms; fair insight and judgement; no complaints with memory and concentration; and denied suicidal and homicidal ideation.

In a February 2013 psychiatric note, the Veteran reported that medication was not effective for depression or anxiety but also stated that has not been using them consistently. The Veteran stated that "I'm doing pretty good with the wife, kids, grandkids" as well as doing well at work.

The Veteran was observed to be well groomed and cooperative; eyes "less red than they have been in the past, and not as overtly tired as sometimes in the past"; and demonstrated low mood with poor sleep. The treating provider found no evidence of hallucinations, thought disorder, or cognitive problems. The Veteran's insight and judgment were found to be intact and the Veteran denied suicidal ideation.

In an April 2013 social work note, the Veteran reported difficulty sleeping with little effect from prescribed medication.

In a June 2013 psychiatric note, the Veteran reported being married for many years and retired since 2010. The Veteran stated that he gets along well with his wife as well as having good friends and enjoyment. 

The Veteran reported chronic up and down moods but described these as the usual and did not have any specific complaints or concerns. The Veteran stated his response to prescribed medication was partial, with better mood and sleep but with multiple awakenings and not restful sleep.

The Veteran was observed with appropriate dress and good hygiene. The Veteran's demonstrated polite behavior with good eye contact and attitude, and the treating provider noted the "excess blinking was not observed." The Veteran's affect was calm, stable, and appropriate with full range. The Veteran demonstrated organized thought; alertness; and good memory within interview context. The Veteran did indicate suicidal and homicidal ideation or preoccupation.

In a September 2013 psychiatry note, the Veteran stated that he was not currently depressed as he was on maintenance anti-depressants. The Veteran noted several nocturnal awakenings during sleep with disturbing dreams.

The Veteran reported that he was involved with traditional Navajo ceremonies as well as helping friends and neighbors.

The Veteran was observed to be oriented' appropriately dressed and hygienic; demonstrated appropriate behavior; displayed euthymic mood; and demonstrated linear thought with unremarkable sleep.

The Veteran admitted to passive suicidal ideation but denied active ideation, plan or intent.

In an October 2013 psychotherapy note, the Veteran stated that his nightmares were worse last week, "possibly related to sinus symptoms and headaches" that affect sleep. The Veteran stated that otherwise he was doing well to include his mood and other PTSD symptoms.

The Veteran was observed with appropriate clothing, grooming and hygiene; demonstrated appropriate and good range of affect; demonstrated good organization of thought, alertness and memory; and did not indicate any current or recent suicidal and homicidal ideation. The treating provider found the Veteran's progress to be stable.

In a separate October 2013 social work note the Veteran reported bad dreams that wake him up sweating and needing to go outside for air. The Veteran enjoys watching basketball but tries to stay away from crowds as much as he can. The provider noted they discussed with the Veteran about his future as the Veteran "thinks his life may get short." The Veteran discussed his anger when "he gets blamed" and the belief "that others are not to be trusted...easily gets angry when others blame him for the good thing he has in life."

The Veteran was observed to be alert and oriented; demonstrated speech, behavior and thought content within normal limits; and showed mood and affect congruent with content. The treating provider found no indication of suicidal or homicidal behavior.

In a December 2013 social work note, the Veteran reported continued issues with sleeping where he wakes up unable to breath, rating heart, and sweating. The Veteran stated his belief that "he dies if he allows himself to give the intensity of his memories over to the Creator." The treating provider noted that the Veteran spends his life helping others but knows to take for himself as well; the provider also found the Veteran not to be suicidal.

In a separate December 2013 psychiatric note, the Veteran reported that he was doing about the same. The Veteran stated that his current medication was ineffective in preventing nightmares. The Veteran stated that he takes walks daily; does some household chores; helps friends and neighbors; and is involved in some traditional Navajo ceremonies.

The Veteran was observed to be oriented; demonstrated appropriate dress, behavior and hygiene; displayed euthymic mood; and demonstrated linear thought with unremarkable speech. The Veteran admitted to passive suicidal ideation but denied active ideation, plan or intent.

In a January 2014 social work note the Veteran "wondered what PTSD is" and the treating provider provided education. The Veteran and provider discussed the Veteran "being a loner and at times his family bug him into going to visit other relations, then he goes and stays outside." The Veteran stated that he did not like to fight and stays to himself; the Veteran noted his awareness that many Veterans fight because of their PTSD and that he would fight if someone bothered a family member.

In a February 2014 social work note, the Veteran reported he still struggles with waking up at night three to four times to use the restroom. The Veteran discussed his PTSD and his ability to "keep himself from having angry outbursts"; the Veteran also noted "memories but not all the time" and his worries about how long he will live and thoughts about the end of his life. The treating provider noted the Veteran was not thinking of taking his own life.

In a March 2014 psychiatry note, the Veteran was noted to tolerate a decrease in medication and reports feeling that he may "pass out" if he stands too 	quickly; the Veteran stated that he continued to have several nocturnal awakenings with regular disturbing dreams.

The Veteran continued to report helping his friends and neighbors and involvement with traditional Navajo ceremonies. The Veteran was observed to be oriented; demonstrated appropriate dress, behavior and hygiene; displayed euthymic mood; and demonstrated linear thought with unremarkable speech. The Veteran admitted to passive suicidal ideation but denied active ideation, plan or intent.

In an April 2014 social work note, the Veteran reported that he was doing well and tries to avoid getting upset which causes him to experience PTSD. The Veteran stated that he tries to keep his mind off by watching sports and staying busy with chores. The Veteran stated that he has new sleeping pills and thinks that they will help with the nightmares. The Veteran was noted to not want to do advanced directives as it "does not fit with his Navajo beliefs." The Veteran was noted to show no indication of suicidal or homicidal behavior.

In a July 2014 social work note, the Veteran reported that his PTSD was still acting up. The Veteran stated that he has a hard time "making himself understood in English...thinks that he [carries] a heavy burden." The provider noted the Veteran's PTSD worsened when he retired but noted the Veteran was not suicidal. The treating provider instructed the Veteran to continue therapy to in order to be able to "put into words his concerns."

In a September 2014 social work note, the Veteran stated that he was "working on getting unemployability to get increased to 100 percent" and requested a letter of support from the treating provider.

The Veteran reported "as usual that his PTSD comes and goes, and he gets easily agitated." The Veteran stated that he tries to avoid getting agitated by being very pleasant "but then gives up." The provider found no indication of suicidal or homicidal behavior. The Veteran was observed to be alert and oriented; demonstrated speech, behavior, and thought within normal limits; and displayed mood and affect congruent with content.

In September 2014 the Veteran was provided a psychiatry initial evaluation. The treating provider noted the Veteran reported the provider who had previously treated the Veteran had passed away earlier in the year and the Veteran was looking to get reestablished. 

The Veteran reported that he had a first marriage for 10 years from 1972 and then has been married since 1985. The Veteran stated that he worked 35 years with the IHS before retiring in 2003; then worked another 7 years because he was restless at home.

When asked about depression, the Veteran reported getting hopeless at times with low mood. The Veteran stated that he sleeps poorly which is interrupted by nightmares. The Veteran also indicates he has short-term memory problems where he forgets things easily such as getting lost driving or forgotten family member names.

When asked about anxiety, the Veteran stated that he would get nightmares two to three times a week, waking up several times in the night scared and sweating. The Veteran stated he had hyper startle with loud noises, irritable, and angered easily without physical aggression.

The Veteran denied mania, psychosis or hallucinations.

The Veteran stated that he had passive suicidal ideation with no attempts. The treating provider found no new onset, increased frequency or intensity of suicidal thoughts. The Veteran reported protective factors in family and community support and a need to stay alive for a loved one.

The Veteran was observed to be well groomed and dressed, with no tics or tremors. The Veteran's mood was "sometimes good and sometimes bad" with affect congruent, euthymic, reactive and with good range. The Veteran demonstrated logical and appropriate thought content as well as fair insight and intact judgement. The Veteran denied hallucinations, suicidal and homicidal ideation.

The provider noted the Veteran's cognition appeared impaired as the Veteran upon testing was unable to repeat sentences and missed dates or letters on spelling.

The provider's summary noted the Veteran reported a lifelong struggle with PTSD symptoms. The Veteran indicated a past benefit from prescribed medication; but it was noted that the Veteran has not taken any medication since this past April "for unclear reasons (stated he 'misplaced' his medication but has refills available)". The provider noted the Veteran with some mild memory or cognition impairment based upon today's testing results.

In an October 2014 psychiatry note, the Veteran stated that "I'm alright...hanging in there." The treating provider noted the Veteran had not yet started prescribed medication as instructed in the previous visit; as such, the provider found the Veteran's status to be unchanged.

The Veteran continued to report nightly nightmares, sometimes occurring multiple times a night, that disrupted sleep. The Veteran stated that he has "some good days, some bad days, but the bad days are draining." The Veteran stated that he feels at times irritable to his family and then has to apologize for his demeanor. The Veteran denied suicidal and homicidal ideation.

The Veteran was observed to be well dressed and groomed with no tics or tremors. The Veteran's mood was "hanging in there" with affect congruent, euthymic and reactive with good range. The Veteran demonstrated logical and appropriate thought content as well as fair insight and intact judgement. The Veteran denied hallucinations, suicidal and homicidal ideation. The provider noted the mild memory or cognition impairment results from the previous visit and the Veteran agreed to be referred for neuropsychiatric testing for further evaluation.

In a separate October 2014 social work note, the Veteran reported his PTSD "is not bad but not beautiful either." The Veteran continued to keep himself busy with chores to avoid thinking about PTSD. The treating provider observed the Veteran to be very pleasant and engaging; alert and oriented; demonstrated speech, behavior and thought content within normal limits; and displayed mood and affect congruent with content. The provider found the Veteran to be safe and not suicidal.

In a November 2014 psychiatry note, the Veteran reported "I'm hanging in there." The Veteran stated that he was tolerative medication but not seeing any benefit or change in PTSD symptoms. The Veteran discussed "invisible wounds" from war and combat and worries about his family and their health.

The Veteran was observed to be well dressed and groomed with no tics or tremors. The Veteran's mood was "about the same" with affect congruent, euthymic and reactive with good range. The Veteran demonstrated logical and appropriate thought content as well as fair insight and intact judgement. The Veteran denied hallucinations, suicidal and homicidal ideation. The provider noted the mild memory or cognition impairment results from the September 2014 visit.

In December 2014 the Veteran was afforded a neuropsychology evaluation. The treating provider initially noted the Veteran's concerns that his English language would not be good enough to do well in the evaluation; the provider noted that they would do their based to "take on [the Veteran's] unique language and cultural heritage into consideration."

When asked about memory problems, the Veteran reported that he has noticed problems with his memories in the past several years; the Veteran stated that he has forgotten things that have been told to him. The Veteran stated that he worried that "somedays he's just not going to wake up" and that sometimes he feels like his heart races, sweats, and then worries about his health.

The Veteran indicated that he began mental health treatment in 2010. The Veteran denied any overt history of suicidal and homicidal ideation and denied present intent or ideation.

The Veteran reported currently living with his wife and two sons. The Veteran stated that his wife is doing well who does a lot to take care of him and that they have been together since 1985.

The Veteran stated that after his separation from the military, he worked overseeing some land for 6 years; worked as a custodian for 5 years for boarding schools; and then from 1990 to 2003 worked for an IHS hospital.

The Veteran was observed to be alert, cooperative, and oriented. The treating provider found the Veteran with no abnormalities in gait, movement or speech. The Veteran demonstrated logical and coherent speech, unremarkable mood, and constricted but stable and full affect.

Upon testing, the provider found the results "clearly show [the Veteran] performs within expectation (normal range) on sensitive measures of memory and executive problem solving."

The provider noted that while the Veteran's attention and concentration showed distractibility common among Veterans with chronic PTSD, the provider stated that the "key finding is that [the Veteran] is able to recall as much -or more- new information after the standard 20 minute interval for both word list learning task and a visual memory task."

The provider found the Veteran performed within expectations on diagnostic tests evaluating executive functioning and memory. As such, the provider did not find the results to raise any concerns of Alzheimer's or vascular dementia.

The provider did note that the Veteran's behavioral presentation of slow verbal response or "somewhat round-about...even tangential response to questions", some of which showed up during the easier tests in attention and concentration. However, the provider noted the Veteran "really rallied in the more demanding testing procedures and he performed quite well."

In a February 2015 psychiatry note, the Veteran reported "there is something going on with my mind." The Veteran further stated, "I'm not good at education and it is hard to explain my situation and how I am and I don't know how to say it...being a psychiatrist on your side and being the psychiatrist I need your help..." The provider noted the Veteran to be a difficult historian.

The Veteran was observed to be slightly unkempt. The Veteran's mood was described as "mood, argh...it is all mixed, I really can't say that I am getting better or that I am perfect" with affect that was congruent, reactive and with good range. The Veteran demonstrated logical and appropriate thought with no delusional content. The Veteran denied hallucinations, suicidal and homicidal ideation. The Veteran demonstrated fair insight and intact judgement. The provider noted the Veteran's cognition to be chronically impaired.

The provider noted the Veteran presentation was overall unchanged despite starting prescribed medication.

In a March 2015 social work note, the Veteran reported that he still gets short with his wife and takes medication to help his mood and reduce nightmares. The Veteran was observed to be alert and oriented; demonstrated speech, behavior and thought content within normal limits; and displayed mood and affect congruent with content. The provider found the Veteran to be safe and not suicidal.

In a separate March 2015 psychiatric note, the Veteran reported, "I guess that I am doing OK." The treating provider noted the Veteran tended to give a rambling history. The Veteran reported that he tried to work but that he is forgetful and that he rarely sleeps because of nightmares most evenings that awaken him.

The Veteran was observed to be casually groomed, alert and oriented. When asked about mood and affect, the Veteran responded: "What did I say? I am a little mixed up and sometimes I am all right. My wife treats me well."

The Veteran demonstrated somewhat circumstantial thought process and somewhat loose association. The provider found the Veteran's cognition, attention and concentration adequate for the purposes of this visit. The Veteran denied suicidal and homicidal ideation.

In an April 2015 social work note, the Veteran was noted to be in a good mood. The Veteran was observed to be alert and oriented; demonstrated speech, behavior and thought content within normal limits; and displayed mood and affect congruent with content. The provider found the Veteran to be safe and not suicidal.

In a May 2015 social work note, the Veteran was noted to be more talkative and able to ask more about ways to change. The Veteran was observed to be alert and oriented; demonstrated speech, behavior and thought content within normal limits; and displayed mood and affect congruent with content. The provider found the Veteran to be safe and not suicidal.

In a June 2015 psychiatric note, the Veteran reported "I don't know if I can be alright not, it comes and goes." The Veteran stated that he keeps busy working around the property and reports that he thinks that the prescribed medication is working. The treating provider reviewed neuropsychiatric testing that indicated PTSD concentration difficulty but no dementia.

The Veteran was observed to be casually groomed, alert and oriented. When asked about mood and affect, the Veteran responded: "I am not really in a good mood right now my head is about to explode and my eyes...." The Veteran demonstrated slightly restricted affect.

The Veteran demonstrated somewhat circumstantial thought process and somewhat loose but directable association. The Veteran demonstrated fair insight and intact judgement. The provider found the Veteran's cognition, attention and concentration adequate for the purposes of this visit. The Veteran denied suicidal and homicidal ideation.

In a separate June 2015 social work note, the Veteran was noted to be in an anxious but good mood. The Veteran was observed to be alert and oriented; demonstrated speech, behavior and thought content within normal limits; and displayed mood and affect congruent with content. The provider found the Veteran to be safe and not suicidal.

In a July 2015 social work note, the Veteran was noted to be in a tense mood but relaxed after doing provided exercises. The Veteran reported that he was working on unemployability and stated that he was aware that his PTSD will be with him the rest of his life. The Veteran also expressed that he was aware about "how much he thinks emotionally and over generalizes current happenings to his experiences in the Vietnam War."

The Veteran was observed to be alert and oriented; demonstrated speech, behavior and thought content within normal limits; and displayed mood and affect congruent with content. The provider found the Veteran to be safe and not suicidal.

In an August 2015 social work note, the Veteran was noted to be in an anxious mood. The Veteran reported that he was working on obtaining "100 percent service connection" and discussed topics to include health concerns, working with an attorney to establish unemployability and difficulty following a diet.

The Veteran was observed to be alert and oriented; demonstrated speech, behavior and thought content within normal limits; and displayed mood and affect congruent with content. The provider found the Veteran to be safe and not suicidal.

In a September 2015 psychiatric note, the Veteran reported that the social worker who was following him had left the clinic and agreed to see a therapist until a replacement social worker could be found. The Veteran reported that his nightmares had improved with medication but stated still having some flashbacks.

The Veteran was observed to be casually groomed, alert and oriented. When asked about mood and affect, the Veteran responded: "Like I said, I am not really in a good mood, sometimes I wake up like that." The Veteran demonstrated restricted affect.

The Veteran demonstrated somewhat circumstantial thought process and somewhat loose but directable association. The Veteran demonstrated fair insight and intact judgement. The provider found the Veteran's cognition, attention and concentration adequate for the purposes of this visit. The Veteran denied suicidal and homicidal ideation.

In an October 2015 mental health consultation, the Veteran was seen for a first session for supportive therapy as the Veteran was awaiting a new social worker.

The Veteran stated that he lives with his wife of more than 25 years and two sons. The Veteran describes a strong relationship with his wife and occasional frustration with his sons.

The Veteran reported PTSD-related nightmares almost every night, waking up three to four times and getting at most 4 hours of sleep. The Veteran stated that he stays home often to avoid triggering anxiety as well as having a strong hypervigilance and hyper startle response.

The Veteran reported occasional bouts with depressed mood with some suicidal ideation but denied any history of suicide attempts.

The Veteran was observed to be courteous and pleasant, mostly euthymic with adequate range of affect. The treating provider found no obvious deficit in concentration and memory. The Veteran denied suicidal and homicidal ideation.

In a December 2015 psychiatric note the Veteran reported stressors from Agent Orange and diabetes. The Veteran stated that he wishes that "he could speak to me in Navajo so that he could explain his PTSD symptoms better to me." The Veteran further stated: "If you could understand Navajo, I could tell you all about me insight and out, it is hard to say in English." The Veteran reported nightmares most nights and agreed to increase prescribed medication.

The Veteran was observed to be casually groomed, alert and oriented. When asked about mood and affect, the Veteran responded: "Like I said, I have not been in a good mood the last few days." The Veteran demonstrated restricted affect.

The Veteran demonstrated somewhat circumstantial thought process and somewhat loose but directable association. The Veteran demonstrated fair insight and intact judgement. The provider found the Veteran's cognition, attention and concentration adequate for the purposes of this visit. The Veteran denied suicidal and homicidal ideation.

In January and February 2016 psychotherapy notes, the Veteran was observed to be courteous and pleasant, mostly euthymic with adequate range of affect. The treating provider found no obvious deficit in concentration and memory. The Veteran denied suicidal and homicidal ideation.

The treating provider noted that the Veteran appeared to understand the provider adequately and has not asked for translation.

In a March 2016 psychiatry note, the Veteran indicated that recent therapy sessions were helpful. The Veteran stated that he still has some anxiety but less depression and intrusive thoughts. The Veteran reported nightmares on most nights.

The Veteran was observed to be casually groomed, alert and oriented. When asked about mood and affect, the Veteran responded: "Up and down, I think that it's going to be like that forever, medicine helps me a little bit." The Veteran demonstrated restricted affect.

The Veteran demonstrated somewhat circumstantial thought process and somewhat loose but directable association. The Veteran demonstrated fair insight and intact judgement. The provider found the Veteran's cognition, attention and concentration adequate for the purposes of this visit. The Veteran denied suicidal and homicidal ideation.

In psychotherapy notes from March 2016 through July 2016, the Veteran was observed to be courteous and pleasant, mostly euthymic with adequate range of affect. The treating provider found no obvious deficit in concentration and memory. The Veteran denied suicidal and homicidal ideation.

In an August 2016 mental health note, the Veteran reported that he was "doing ok" and doing fine on current medication. 

The Veteran stated that "now an again I think about 'what would happen if I killed myself, but then remember I have a wife and kids, so I would never do it.'" The Veteran denied feelings of helplessness or hopelessness. The Veteran denied any urgent needs.

The Veteran was observed to be well groomed with appropriate hygiene. The Veteran's affect was documented as angry or hostile. The Veteran demonstrated intact memory and normal speech with organized thought. The Veteran denied hallucinations, suicidal and homicidal ideation.

In a September 2016 psychiatry note, the Veteran reported "things are up and down" but the same as before. The treating provider noted the Veteran's previous reported language barrier and concerns of difficulty expressing himself in English.

The Veteran stated that he was somewhat physically sick and typically feels  a little down when feeling on the depressed side; however, the Veteran noted that the day before he felt more down and ended up laying as he was not feeling well physically.

The Veteran reports no issues falling asleep but wakes up several times during the night to use the restroom and has nightmares about service-related trauma. The treating provider noted the Veteran was no longer taking medication to treat these symptoms and "unsure why note."

The Veteran reported other ongoing PTSD symptoms to include intrusive thoughts, hypervigilance, increased startle response, avoidance and isolation at times, and some emotional numbing.

The Veteran stated that he has some feelings of hopelessness and passive suicidal ideation; however, the Veteran stated that he lives for his family, wife, sons and grandkids and adamantly denied any active suicidal ideation, plan or intent. The Veteran further denied hallucinations, paranoia, and homicidal ideation.

The Veteran was observed to demonstrate adequate grooming and hygiene with no observed tics or tremors. The Veteran was alert and oriented. The Veteran's mood was "up and down" with somewhat restricted affect that brightened appropriately at times. The Veteran demonstrated slightly tangential or circumstantial thought but was redirectable. The Veteran's memory was noted to have some difficulty recalling the names of previous medication but otherwise was found to be grossly intact; the Veteran's concentration was found to be adequate without significant redirection. The Veteran demonstrated partial insight and fair to good judgement. The Veteran was noted with passive suicidal ideation but adamantly denied active suicidal ideation, plan or intent as well as denied hallucinations and homicidal ideation.

The provider noted the Veteran was open and forthcoming during the interview but noted the Veteran's concerns of difficulty with interview due to the language barrier.

In a separate September 2016 psychotherapy note, the Veteran discussed difficulty sleeping and awaking several times a night. The Veteran was observed to be courteous and pleasant, mostly euthymic with adequate range of affect. The treating provider found no obvious deficit in concentration and memory. The Veteran denied suicidal and homicidal ideation.

In a November 2016 psychiatry note, the Veteran reported "I'm hanging in there." The Veteran reported that he was going well overall but stated having some mild symptoms of depression and PTSD. The provider noted the Veteran appeared to be in good spirits, smiling and interactive during the visit; the Veteran noted that he was feeling "a little better" than the last visit but was also sometimes slightly down. The Veteran stated that he would feel down for a day or so and then come back up again to do something outside.

The Veteran continued to report not sleeping well and getting only three to fours of sleep on average. The Veteran stated his PTSD symptoms remained about the same with some recurrent thoughts and some avoidance. The Veteran stated that he has learned skills from previous therapy sessions to deal with panic symptoms but continues to have panic symptoms, especially in the afternoons. 

The Veteran also stated that he continues to have passive suicidal ideation but is able to "push these out of his mind." The Veteran reported things were going okay with his family and denied hallucinations and homicidal ideation.

The Veteran was observed to demonstrate adequate grooming and hygiene with no observed tics or tremors. The Veteran was alert and oriented. The Veteran's mood was "a little better" with somewhat restricted affect that brightened appropriately at times. The Veteran demonstrated slightly tangential or circumstantial thought but was redirectable. The Veteran's memory was noted to have some difficulty recalling the names of previous medication but otherwise was found to be grossly intact; the Veteran's concentration was found to be adequate without significant redirection. The Veteran demonstrated partial insight and fair to good judgement.

The Veteran was noted with passive suicidal ideation but adamantly denied active suicidal ideation, plan or intent as well as denied hallucinations and homicidal ideation.

In a December 2016 and January 2017 psychotherapy note, the Veteran noted an upcoming hearing and expressed anxiety. The Veteran was observed to be courteous and pleasant, mostly euthymic with adequate range of affect. The treating provider found no obvious deficit in concentration and memory. The Veteran denied suicidal and homicidal ideation.

In a February 2017 psychiatry note, the Veteran reported that he was "hanging in there" and continuing to work with therapy on anxiety and depression. The Veteran stated that he was sleeping better with medication with no side effects but still gets up 2 to 4 times to use the restroom. The Veteran also noted some ongoing nightmares. The Veteran reported being pretty complaint with medication and states they are helpful.

The Veteran admitted to some ongoing, fleeting hopelessness and passive suicidal ideation; however, the Veteran thinks about positive things or spends time with his family. The Veteran denied active suicidal ideation, suicidal plan and intent, hallucination and homicidal ideation.

The Veteran was observed to demonstrate adequate grooming and hygiene with no observed tics or tremors. The Veteran was alert and oriented. The Veteran's mood was "hanging in there" with overall euthymic affect with appropriate reactive smiles. The Veteran demonstrated linear and logical thought. The Veteran's memory was found to be grossly intact; the Veteran's concentration was found to be adequate without significant redirection. 

The Veteran demonstrated partial insight and fair to good judgement. The Veteran was noted with passive suicidal ideation but adamantly denied active suicidal ideation, plan or intent as well as denied hallucinations and homicidal ideation.

At the Veteran's February 2017 hearing, the Veteran's representative testified to the Veteran's low GAF scores as an indication of the severity of the Veteran's PTSD. As addressed above, the Board notes that GAF scores are no longer used to evaluate the Veteran's PTSD.

The Veteran testified that he had trouble with nightmares where he wakes up sweating and difficulty with breathing; the Veteran stated that he goes out for fresh air but then finds it hard to fall back asleep. The Veteran noted that he also gets up three to four times to use the restroom because of his prostate.

The Veteran next stated that he has issues with his memory where he would be "doing something over there, and then I forget about what I was doing there....saying something to my kids...I forgot what I was saying to them."

The Veteran's wife testified that if you asked the Veteran something, he would forget. The Veteran's son testified that when he stays up late, he will sometimes see the Veteran up due to trouble sleeping or for nightmares. The Veteran's son stated the Veteran had trouble with concentration; concerning anger, the Veteran's son stated  "sometimes [the Veteran] wakes up angry....or sometimes it's like, when he gets up like that, just the little, slightest thing can trigger that anger."

The Veteran's other son testified the Veteran's concentration issues  would be described as where the Veteran would be "talking to you about one thing, and then it will change to the next, or sometimes he'll forget what he's doing. Then he'll do something else." The Veteran's other son noted the Veteran had a very short temper if the family tried to say something to him, it would "backlash and lead to a short temper." The Veteran's son described the Veteran's anger as yelling and then the family will try to not make it bigger.

In a March 2017 psychotherapy note, the Veteran reported that his family sometimes "feels chaotic and he gets frustrated"; however, the Veteran noted that he was happy to report that he will soon be a great-grandfather. The Veteran was observed to be courteous and pleasant, mostly euthymic with adequate range of affect. The treating provider found no obvious deficit in concentration and memory. The Veteran denied suicidal and homicidal ideation.

In an April 2017 psychiatry note, the Veteran reported things were "up and down". The Veteran acknowledged that when he is physically better, he feels emotionally better as well. The Veteran stated that his family is doing well and sleeps okay other than getting up to use the restroom multiple times and getting about 4 to 5 hours of sleep on average. The Veteran did note that he still has some nightmares on a nightly basis.

The Veteran noted that he has some fleeting suicidal ideation whenever he becomes frustrated, but he was able to redirect his mind to include thinking about his family.

The Veteran was observed to demonstrate adequate grooming and hygiene with no observed tics or tremors. The Veteran was alert and oriented. The Veteran's mood was "up and down" with fairly euthymic and full affect. The Veteran demonstrated linear and logical thought. The Veteran's memory was found to be grossly intact but with some difficulty naming medication and dosage; the Veteran's concentration was found to be adequate. 

The Veteran demonstrated partial insight and fair to good judgement. The Veteran was noted with passive suicidal ideation but adamantly denied active suicidal ideation, plan or intent as well as denied hallucinations and homicidal ideation.

In a May 2017 primary care note, the Veteran was documented to be noncompliant with medication. The Veteran stated that "some medications are too much" and therefore takes his medications "as he sees reasonable"; the Veteran did not understand the provider's explanation to the Veteran that the medication required to be taken as directed and not to underdose or overdose. The Veteran was noted to disagree and was unhappy with the provider's recommendations.

In a separate May 2017 psychotherapy note, the Veteran was observed to be courteous and pleasant, mostly euthymic with adequate range of affect. The treating provider found no obvious deficit in concentration and memory. The Veteran denied suicidal and homicidal ideation.

In a June 2017 psychiatry note, the Veteran reported "I am feeling better." The Veteran stated that he was doing okay and when he wakes up "he thinks about it being another day and looks forward to walking."

The Veteran stated that he was feeling physically better, doing "alright" and not feeling as depressed and in better spirits. The Veteran stated he was feeling that he was sleeping pretty well and tolerating current medication. The Veteran stated that his family felt that he was doing pretty good and he denied active suicidal ideation and homicidal ideation.

The Veteran was observed to demonstrate adequate grooming and hygiene with no observed tics or tremors. The Veteran was alert and oriented. The Veteran's mood was "alright" with overall euthymic and full affect. The Veteran demonstrated linear and logical thought. The Veteran's memory was found to be grossly intact with ongoing difficulty recalling medication and dosage; the Veteran's concentration was found to be adequate without significant redirection. 

The Veteran demonstrated partial insight and fair to good judgement. The Veteran was noted with passive suicidal ideation but adamantly denied active suicidal ideation, plan or intent as well as denied hallucinations and homicidal ideation.

The treating provider summarized the Veteran reported doing better since the last visit and is physically feeling better. The Veteran stated that he has been more consistent with medication and that the current prescribed medication was helping.

In a July 2017 psychotherapy note, the Veteran was observed to be courteous and pleasant, mostly euthymic with adequate range of affect. The treating provider found no obvious deficit in concentration and memory. The Veteran denied suicidal and homicidal ideation.

In a September 2017 psychiatry note, the Veteran reported pain in his left shoulder that bothered him, so he was unable to do as much as before as well as not sleeping well. The Veteran stated that he had some depression due to limitation from pain but denied any significant periods of depression. 

The Veteran reported his mood was "pretty good" and denied any problems with anxiety. The Veteran stated that he still enjoys spending time with his family and they are doing well. The Veteran denied hallucinations, suicidal and homicidal ideation.

The Veteran was observed to demonstrate adequate grooming and hygiene with no observed tics or tremors. The Veteran was alert and oriented. The Veteran's mood was "pretty good except the pain" with overall euthymic and full affect. The Veteran demonstrated linear and logical thought. The Veteran's memory was found to be grossly intact with ongoing difficulty recalling medication and dosage; the Veteran's concentration was found to be fair and somewhat distracted due to pain. 

The Veteran demonstrated partial insight and fair to good judgement. The Veteran was noted with passive suicidal ideation but adamantly denied active suicidal ideation, plan or intent as well as denied hallucinations and homicidal ideation.

In a November 2017 psychotherapy note, the Veteran discussed short-term memory loss which the treating provider found "appears to be age-related." The provider found the Veteran to be fairly stable at this visit. The Veteran was observed to be courteous and pleasant, mostly euthymic with adequate range of affect. The treating provider found no obvious deficit in concentration and memory. The Veteran denied suicidal and homicidal ideation.

In a January 2018 psychiatry note, the Veteran reported "I am not at 100 percent." The Veteran clarified that this was due to physical problems to include headaches, sore throat, ongoing eye and ear issues, fatigue, and chronic pain that impacted his mood.

The treating provider noted the Veteran in generally "remained rather somatically preoccupied" and described his mood was down in the context of physical issues. The Veteran reported compliance with medication but was noted to not yet refilled certain medication; the Veteran stated that he still has a supply at home and that the medications were working well. The Veteran noted that the meds "keep me going."

The Veteran stated that he enjoys spending time with the grandchildren. The Veteran stated that he has some fleeting suicidal ideation at times but denied active suicidal ideation, plant or intent, citing his family as a protective factor.

The Veteran was observed to demonstrate adequate grooming and hygiene with no observed tics or tremors. The Veteran was alert and oriented. The Veteran's mood was "down right now" with somewhat restricted affect that brightened appropriately. The Veteran demonstrated linear and logical thought. The Veteran's memory was found to be grossly intact with ongoing difficulty recalling medication and dosage; the Veteran's concentration was found to be fair and somewhat distracted due to pain. 

The Veteran demonstrated partial insight and fair to good judgement. The Veteran was noted with fleeting passive suicidal ideation but adamantly denied active suicidal ideation, plan or intent as well as denied hallucinations and homicidal ideation

In a February 2018 psychotherapy note, the Veteran reported celebrating a recent birthday and discussed finding meaning in life. The provider found the Veteran have a good sense of belonging to his family. The Veteran was observed to be courteous and pleasant, mostly euthymic with adequate range of affect. The treating provider found no obvious deficit in concentration and memory. The Veteran denied suicidal and homicidal ideation.

The Veteran was afforded a March 2018 VA examination.

The examiner diagnosed the Veteran with unspecified trauma and stressor related disorder and adjustment disorder with depressed mood.

The Veteran reported that he was married for a "quite a while"; the examiner noted that the Veteran initially claimed that he was married for more than 60 years but when pointed out that he was 70 years old at the time of the exam, "stated that maybe he has been married for 44 years."

The Veteran stated his marriage has ups and downs because of PTSD and Agent Orange exposure; the Veteran reported a good relationship with his children.

The Veteran stated that he had many friends while growing and has contact with these friends "once in a while." The Veteran stated that he spends most of his time with his family and participates in tribal culture, ceremonies on weekends, and sweat lodges twice a month.

The Veteran reported working for the federal government after service until his retirement in 2003. The Veteran stated that he spends his time taking care of his home, the church, and shopping.

The Veteran stated that he initially went to IHS for medical issues and did not think to apply for C&P benefits until after his retirement in 2003. The Veteran noted that "he had heard that as a Vietnam Veteran he could apply to get some 'money back', up to 100 percent."

The Veteran reported symptoms of nightmares and startle response occurring two to three times a month. The Veteran stated that he had avoided crowds but was unable to explain to the examiner the relationship to his experiences in Vietnam; the Veteran could only explain "that's the way I am...in crowds there can be some people that talk about something else in a 'bad way'."

The Veteran next stated that he sometimes feels distant and cut off from family and friends but was unable to provide specific examples when asked, stating that it was "hard to explain." The Veteran later described an example of not asking his children on how they are doing and being distant from his grandchildren by not playing with them or taking them places. The Veteran stated that he prefers to stay home with his wife and stated that this was "just the way I am."

The Veteran blamed his anger on PTSD. The Veteran stated that when he "tells his wife or sons to do something and they don't do it right away he gets frustrated or angry." The Veteran stated that he does not want to repeat himself and "wants them to obey him" and then later yells.

When asked about problems with concentration, the Veteran reported "problems with concentration because of poor focus, which he described as problems with his vision." The Veteran reported problems with sleep due to frequent nighttime urination and nightmares that occur three to four times a night.

The examiner found the Veteran with symptoms of chronic sleep impairment; disturbance of motivation and mood; and difficulty establishing and maintaining relationships.

The Veteran was observed to be alert and oriented. The Veteran was noted to be "not clear about the purpose of the evaluation and appeared to have difficulty separating physical concerns that he relates to Agent Orange exposure to mental health concerns."

The examiner noted the Veteran stated that he was doing this examination "because he wants to get 100 percent service connection because he thinks he deserves it because he served the country."

The examiner did note the Veteran demonstrated difficulty understanding the questionnaires and diagnostic tests, requiring extensive explanation before starting tasks. 

The Veteran displayed bright and responsive affect; the examiner noted this was "in contrast to his stated mood of depressed and 'not all here'". The examiner noted that when the Veteran was asked to explain what he meant by depressed, the Veteran "asked what the difference between depression and anxiety." The Veteran stated his worry over whether he was going to wake up tomorrow due to health concerns and expressed frustration with his health. The Veteran further described getting angry with himself but could not elaborate.

The Veteran reported suicidal ideation approximately once a week without plan or intent and identified his family as a protective factor. The Veteran did not endorse homicidal ideation or hallucination.

The examiner found the Veteran's symptoms to result in formally diagnosed mental condition with symptoms not severe enough to either interfere with occupational and social functioning or require continuous medication.

The examiner remarked on the diagnosed adjustment disorder and defined the nature of an adjustment disorder as occurring in response to an identifiable stressor with symptoms that resolved as soon as the stressor resolved. The examiner stated "it is clear from the Veteran's clinical presentation that he is experiencing increasing distress as the result of loss of physical function due to his physical conditions; however there is no documentation to support that this is the direct pathophysiological consequence of the medical condition." The examiner further found the Veteran's mood symptoms intertwined with the other diagnosed condition.

The examiner also noted in July 2013 the Veteran's medication for depression was increased and in September 2013 the Veteran reported passive suicidal ideation. The examiner noted that prior medical treatment records showed the Veteran was inconsistent in his use of medication and refills; the examiner stated that such "inconsistent use of medication makes interpretation of any dosage increase or fluctuation in symptoms impossible to interpret without resort to speculation and conjecture."

The examiner noted the Veteran was advised on taking medication consistently but "was unable to provide an explanation for his deviation from the prescription."  The Veteran stated that he takes medication when "not in a good mood" and that some medication he would take once a week and others everynight.

The examiner noted there was inconsistency in the Veteran's report of symptoms to providers over time as well as inconsistency between the Veteran's written and verbal description of symptoms during the examination. 

The examiner first noted the Veteran's inconsistency in his "ability to communicate in English throughout the examination." The examiner noted that when discussing personal history the Veteran did not have difficulty with communication;  however when asked to discuss or describe PTSD symptoms, the Veteran complained of "not being able to speak language of 'white man'" which contrasted with the Veteran's use of "very specific English language at other times." The examiner did note language difficulty could impact the Veteran's answers on diagnostic testing but noted that review of the treatment record shows treating providers did not find noticeable barriers in communication.

The examiner noted that the Veteran demonstrated a tendency to answer "yes" to questions but later change his answer when he was unable to provide examples or rationale for his response.

The examiner next noted that after diagnostic testing, the Veteran obtained a score that exceeded the cut-off score to indicate a "very high statistical probability of symptom exaggeration." The examiner noted the Veteran endorsed symptoms "that have atypical severity and pervasiveness; that are rarely seen in combinations; that are extremely rare in genuine psychiatric patients; and/or are inconsistent with recognized psychiatric disorders."

The examiner found the findings suggested the Veteran "readily endorsed unusual symptoms in the context of this [VA examination] to a degree that exceeds the customary range of endorsement and therefore does not provide empirical support for the Veteran's self-report of symptoms."

In an August 2018 psychiatric note, the Veteran reported that he wanted to continue individual therapy. The Veteran noted in a previous visit he admitted to taking medication only on an as needed basis; the treating provider educated the Veteran the need to take medication on a daily basis. The provider noted the previous provider whom which the Veteran had therapy sessions had recently left the VA system; the provider determined the Veteran had received the maximum possible benefit from therapy and as such individual therapy was terminated.

The Veteran expressed his desire to see an individual therapist; the Veteran "asks this provider what a psychologist does...says there are  'lots of things wrong with me'  and wants to see someone for his 'stress and anxiety'."

The Veteran stated that he feels that his not doing "very well", his mood was "mixed" and sometimes not in a good mood and worries about his family and the future. The provider noted that the Veteran spoke about somatic complaints throughout his body and his feelings that "medications aren't going to cure me... [and the providers] always wants to talk about medication."

The Veteran noted that he has more good days than bad and explained that he wants to get 100 percent for PTSD. The Veteran admitted to fleeting suicidal ideation where he thinks "what can I do...why go on?"; however, the Veteran denied active suicidal ideation, plan or intent and that his family keeps him going.

The Veteran was observed to demonstrate adequate grooming and hygiene with no observed tics or tremors. The Veteran was alert and oriented. The Veteran's mood was "mixed" with somewhat more restricted affect and mildly irritable. The Veteran demonstrated linear and logical thought. The Veteran's memory was found to be grossly intact with ongoing difficulty recalling medication and dosage; the Veteran's concentration was found to be fair and somewhat distracted. 

The Veteran demonstrated partial insight and fair to good judgement. The Veteran was noted with ongoing fleeting passive suicidal ideation but adamantly denied active suicidal ideation, plan or intent as well as denied hallucinations and homicidal ideation.

In a November 2018 psychiatry note, the Veteran reported that he "doesn't know about my mood and PTSD" but was "still there"; the Veteran stated his wish that he was "a white man" and that he cannot explain things as well in Navajo as he can in English. The Veteran stated that doctors think he is doing a good job but "he feels that he is not doing so good and will forget things at times." The Veteran reported compliance with medication.

The Veteran stated that he would feel down at times up to a week at a time where he would have thoughts of "What's the point of living?" during times of stress; however, the Veteran thinks about his wife and kids and denied any suicidal plan or intent.

The Veteran was observed to demonstrate adequate grooming and hygiene with no observed tics or tremors. The Veteran was alert and oriented. The Veteran was noted to be cooperative but slightly frustrated and irritable about treatment goals and his expectations. The Veteran's mood was "I am still there" with somewhat restricted affect and frustrated at times. The Veteran demonstrated linear and logical thought. The Veteran's memory was found to be grossly intact with ongoing difficulty recalling medication and dosage; the Veteran's concentration was found to be adequate. 

The Veteran demonstrated partial insight and fair to good judgement. The Veteran was noted with fleeting passive suicidal ideation but adamantly denied active suicidal ideation, plan or intent as well as denied hallucinations and homicidal ideation.

In a February 2019 psychiatry note, the Veteran reported "I am hanging in there." The Veteran indicated the recent group therapy sessions as a waste of time because they do not talk about things that he wants to talk about. The Veteran remained complaint on medication and felt they were beneficial.

The Veteran stated is mood was okay and worked on trying to make himself feel happy and that he has to be "strong." The Veteran stated that his family was alright, and sleep was variable when he has to get up to use the restroom or wakes up sweaty from bad dreams.

The Veteran denied any recent suicidal ideation.

The Veteran was observed to demonstrate adequate grooming and hygiene with no observed tics or tremors. The Veteran was alert and oriented. The Veteran's mood was "Okay" with somewhat restricted affect that brightened more today. The Veteran demonstrated linear and logical thought. The Veteran's memory was found to be grossly intact; the Veteran's concentration was found to be adequate. 

The Veteran demonstrated partial insight and fair judgement. The Veteran denied hallucinations, suicidal and homicidal ideation and was noted to be less irritable and frustrated.

Upon review of the evidence of record above, the Board finds that the Veteran's posttraumatic stress disorder (PTSD) also claimed as anxiety and depression was manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as: anxiety, chronic sleep impairment, problems with relationships, and difficulty adapting to stressful circumstances, more nearly approximating a 50 percent rating under Diagnostic Code 9411. 38 C.F.R. § 4.130. However, the evidence does not show that the Veteran was experiencing panic attacks, suicidal ideation, impaired impulse control or near-continuous panic or depression affecting the ability to function independently, appropriately and effectively. 

Although the Veteran has reported or described isolative behavior such as a preference of staying home with his wife, the Veteran has reported involvement in his community to include attending tribal ceremonies as well as helping family and friends; the Veteran in March 2018 reported many friends whom he keeps in contact with once in a while. The Veteran has reported symptoms of irritability, aggression and anger; however, the examinations of record did not find the Veteran with symptoms of impaired impulse control nor did the Veteran state that such irritability resulted into physical outbursts or periods of violence.

The Veteran reported or described symptoms to include, memory impairment, or issues with concentration; however, the VA examiners did not find the Veteran's reports sufficient to make a finding of such symptom of memory impairment or interference in concentration.

Regarding the Veteran's suicidal ideation, the Board notes the Veteran has reported that the Veteran would experience passive suicidal ideation and has. However, the Veteran in his medical treatment record and examination has consistently denied active suicidal ideation and the examinations of record show the examiners did not find the Veteran with symptoms arising to a finding of suicidal ideation.

The Veteran has reported symptoms of panic attacks or symptoms as well as a September 2010 VA examination report describing obsessive or ritualistic behavior where he worries about leaving the stove on or door unlocked; however none of the VA examiners found such reports to rise to the level of finding a symptom of near continuous panic or obsessional ritual.

Review of the record does not contain evidence or findings of symptoms of increased severity or additional impairment, such as suicidal ideation; obsessional rituals; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression; impaired impulse control; spatial disorientation; or neglect of personal appearance and hygiene. The frequency, severity, and duration of psychiatric symptoms described by the Veteran does not approximate those listed as warranting a 70 percent evaluation.

The Board has considered the Veteran's statements regarding the severity of the Veteran's bipolar disorder. However, as lay persons, they do not have the training or expertise to render a competent opinion which is more probative than the evidence of record as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Thus, the lay opinions are outweighed by the evidence of record. See id. ; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the issue of medical causation).

The Board notes that review of the record shows inconsistencies with the Veteran's statements in comparison with other credible evidence of record. Such inconsistencies include the Veteran's September 2010 VA examination report of having a lot of friend but "just really want to be alone...stay away from others" conflicting with his November 2011 and March 2018 VA examination report of having many friends and keeping in touch with them and reporting involvement with the Native American community to include reports of helping friends and family; the Veteran reporting in March 2018 that he sought benefits in 2003 conflicting with his initial claim filed in 2010; and the March 2018 VA examiner's findings of the Veteran's diagnostic scores showing exaggeration or misattribution of symptoms, changing answers when unable to provide rationale or explanations, or inconsistency in use of the English language in describing symptoms where he was able to use English without issue when reporting personal history but then complained of being unable to use English to describe his symptoms.

Given the inconsistencies of the statements made by the Veteran compared to the findings in the claims record, the Board affords the Veteran's statements less probative weight and outweighed by the examinations and determination of record performed by professionals.

Therefore, based on the totality of the disability picture, the Board finds an evaluation in excess of 50 percent for the Veteran's bipolar disorder, is not warranted. As the preponderance of the evidence is against a finding of an increased evaluation, there is no doubt to be resolved; and an increased rating is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3.

Total Disability Rating Based on Individual Unemployability (TDIU) 

VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the Veteran is precluded from obtaining or maintaining any substantially gainful employment consistent with his education and occupational experience, by reason of his service-connected disabilities. 38 C.F.R. § § 3.340, 3.341, 4.16.

Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that the Veteran meets the schedular requirements. 38 C.F.R. § 3.340. 

Specifically, if there is only one such disability, this disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability that is ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § § 3.340, 3.341, 4.16(a). 

For the above purpose of one 60 percent disability, or one 40 percent disability in combination, the following disabilities will be considered as one disability: (1) Disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor, if applicable, (2) disabilities resulting from common etiology or a single accident, (3) disabilities affecting a single body system, e.g. orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric, (4) multiple injuries incurred in action, or (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16 (a).

The central inquiry is, "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993).

In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but not to his age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. § § 3.341, 4.16, 4.19. 

"Substantially gainful employment" is that employment "which is ordinarily followed by the nondisabled to earn their livelihood with earnings common to the particular occupation in the community where the veteran resides." Moore v. Derwinski, 1 Vet. App. 356, 358 (1991). "Marginal employment shall not be considered substantially gainful employment." 38 C.F.R. § 4.16 (a).

The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough; the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993).

Alternatively, if a veteran is found to be unemployable because of service-connected disabilities but does not meet the percentage standards set forth in 38 C.F.R. § 4.16 (a), the rating authority should refer the matter to the Director of the Compensation and Pension Service for extraschedular TDIU consideration. 38 C.F.R. § 4.16 (b) (2018). The veteran is not required to show 100 percent unemployability; the question is whether he or she is unable to pursue a substantially gainful occupation. Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). 

Whether the veteran can actually find employment is not determinative, as the focus of the inquiry is on "whether the veteran is capable of performing the physical and mental acts required by employment." Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (emphasis in original). The Board cannot consider entitlement to TDIU on an extraschedular basis in the first instance, but it is required to ensure that all cases where there is evidence of unemployability due to service-connected conditions are referred to the Director for initial consideration under 38 C.F.R. § 4.16 (b). See Bowling v. Principi, 15 Vet. App. 1 (2001).

The ultimate responsibility for a TDIU determination is a factual rather than a medical question and is an adjudicative determination made by the Board or the AOJ. Geib, 733 F.3d at 1354 (citing 38 C.F.R. § 4.16 (a)).

The Veteran is currently service connected for PTSD evaluated at 50 percent; diabetes mellitus with left eye retinopathy, cataracts and erectile dysfunction evaluated at 20 percent; and benign prostate hypertrophy (BPH) evaluated at 20 percent. The Veteran's combined evaluation was 70 percent. As such, the Board finds the Veteran has met the schedular requirements for TDIU.

Review of the medical treatment record shows in October 2003 the Veteran reported he was an ambulance drive for 32 years.

In April 2010 the Veteran reported working in maintenance with Parks and Recreations. In May 2010 the Veteran reported that he initial retired in 2003 after 35 years working with IHS but became restless at home and now works with Parks and Recreations.

In June 2010 the Veteran reported that he was retiring from Parks and Recreations after seven years of service; the Veteran indicated that he was looking forward to retirement. In August 2010 the Veteran reported that he was completely retired.

In a September 2010 VA examination for PTSD, the Veteran reported that he retired in October 2003 and then again in June 2010. The Veteran indicated the reasons for retirement was by eligibility age or duration of work.

The examiner remarked the Veteran's symptoms of PTSD caused significant distress in interpersonal and occupational function but did not result in total social and work impairment.

In a separate September 2010 VA examination for diabetes, the examiner did not find the Veteran's diabetes to result in occupational impact. The Veteran was noted to report working as a federal worker with IHS as an ambulance driver and housekeeper. The Veteran indicated that he retired in June 2010 and the reasons for retirement was eligibility by age or duration of work; the Veteran also stated there was a medical reason, stating that it was a psychiatric problem and that he was "forgetful."

In November 2010 the Veteran stated that he was retired and enjoying retirement. In a January 2011 VA examination for eye, the examiner did not find the Veteran's claimed eye issues to result in physical impairment. The examiner noted the Veteran reported his retirement in 2003 and stated the reasons for retirement was eligibility by age or duration of work.

In a January 2011 application for TDIU, the Veteran indicated his disabilities of PTSD, depression and diabetes rendered him unable to work. The Veteran stated that he last worked in June 2010 and reported a past history as a maintenance worker with the Navajo Nation from January 2003 to June 2010. The Veteran indicated his education as completing high school.

In a July 2011 employer information request, it was reported that the Veteran worked as a Parks maintenance worker from November 2004 to June 2010. The employer stated the reason for termination of employment as retired and the Veteran was currently receiving retirement benefits.

In a November 2011 VA examination for diabetes, the Veteran claimed visual impairment in decreased vision and that it "could affect" his ability to hold a job. The examiner did not find the Veteran's diabetes to result in any functional impact. In a separate opinion, the examiner did not find any genitourinary or medical condition that prevented the Veteran from working in an occupation that did not require heavy physical labor.

In a November 2011 VA examination for PTSD the Veteran reported working 35 years as an ambulance driver before retiring in 2003 because of age and duration of service. The Veteran stated that he returned to work from 2003 to 2010 wit Parks and Recreation because "I couldn't stand being bored at home." The Veteran stated that his second retirement was due to his health as "my eyes, I was seeing double." 

The Veteran stated that at both jobs he had good attendance, performance evaluations, and relationships with his co-workers and supervisors. The Veteran considered himself self-retired and not looking for work. The examiner noted the Veteran reported decades of stable and satisfying occupational history.

In March 2012 the Veteran's representative asserted that VA had the Veteran's work history from 1988 to 1994. In a February 2013 VA examination for BPH, the examiner did not find the disability to result in functional impact.

In September 2014 the Veteran requested a letter in support of his claim for TDIU and asserted that "he also cannot work because of his knee."

In a September 2014 letter from the Veteran's treating social worker, the social worker stated the Veteran suffered from PTSD symptoms to include disturbing memories, nightmares, depression, insomnia, and "irritability which turns to rage." The social work stated the Veteran could no longer work, that his temper causes him to show both verbal and physical rage towards his supervisor that resulted in three suspensions. 

The social worker next stated  the Veteran's lack of sleep created undue stress when on rotating shifts which caused depression and lack of motivation and in turn "making it dangerous for him to work as ambulance driver or housekeeping where he handles toxic chemicals." The social worker stated the Veteran "suffered needless when directed to clean the morgue where he would have flashbacks and have panic anxiety attacks."

As such, the social worker asserted the trauma experienced by the Veteran while driving an ambulance rendered him unable to work.

In March 2015 the Veteran reported that he tried to work but he was forgetful and rarely slept because of nightmares most evenings. The Veteran did not specify in any detail what type of work this was or how long he had been trying this work.

In an April 2015 letter from the same social worker who provided the September 2014 letter, the social worker stated the Veteran suffered from PTSD in addition to "Agent Orange illnesses of diabetes and prostate cancer". The social worker asserted the Veteran was no longer able to work as he experienced flashbacks and left his employment with IHS when they worsened "because of the blood messes he encountered as a housekeeper and ambulance driver." 

The social worker also noted the Veteran's employment with Parks and Recreation but then experienced flashbacks from a fear of heights that reminded him of jumping out of choppers into fire fights.

The Board notes the April 2015 letter incorrectly found the Veteran suffering from prostate cancer whereas the record shows only a finding of BPH and no diagnosis or treatment for prostate cancer. Neither the September 2014 or April 2015 letter reconcile their findings of the Veteran leaving employment with the September 2010 report of retiring from employment due to age or duration of employment; the November 2011 Veteran's reports of a good relationship with co-workers and supervisors; and the July 2011 employer information indicating the Veteran terminated employment with Parks and Recreation due to retirement. The Board also notes while the September 2014 letter indicated the Veteran was involved in verbal or physical altercations at work resulting in three suspensions, review of the record does not show any record of such employer disciplinary action associated and therefore unclear as to how the September 2014 letter makes that assertion with no specific supporting evidence in the claims record. As such, the Board finds both the September 2014 and April 2015 letters inadequate and affords them less probative value.

At the Veteran's February 2017 hearing, the Veteran's representative remarked on the Veteran's "pretty good work history all these years...worked for many, many years with the [Bureau of Indian Affairs] as an ambulance driver and in different parts of the hospital."

In a March 2018 VA examination for the Veteran's diabetes, the examiner did not find the Veteran's disability to result in functional impact.

In a separate March 2018 VA examination for the Veteran's PTSD, the Veteran reported working for the federal government after his separation from service until 2003 in security, custodial, housekeeping, maintenance and the motor pool.

The examiner noted the Veteran had consistent and successful employment until his 2003 retirement. The examiner found the Veteran's cognitive symptoms resulted in mild functional impairment where significantly shortened sleep would impact the Veteran's processing and memory; the Veteran's disturbance of mood and motivation in irritability impacted interactions with others, job satisfaction and motivation to complete duties; and social impact where the Veteran reported enjoying time with family and grandchildren but difficulty trusting others. 

Based on the evidence of record, the Board finds that the Veteran's disabilities did not precluded him from all forms of employment. Specifically, the evidentiary record, which includes medical evidence, opinion evidence, and the Veteran's lay assertions, demonstrates the Veteran is not precluded from working due to his service-connected disabilities.

The Board acknowledges the Veteran's statements and contentions of his unemployability. However, the ultimate responsibility for a TDIU determination is a factual rather than a medical question and is an adjudicative determination made by the Board or the AOJ. Geib, 733 F.3d at 1354 (citing 38 C.F.R. § 4.16 (a)).

The Board notes that review of the record shows inconsistencies with the Veteran's statements in comparison with other credible evidence of record. 

The Board notes the Veteran in September 2010 reported that he retired due to age or duration of work as medical problems noted as "forgetful";  in January 2011 the Veteran reported retirement in 2003 due to age or duration of work; in July 2011 the Veteran's former employer noted the Veteran last worked in June 2010 and left because of retirement; in November 2011 the Veteran reported retiring from work because of his eyes; in September 2014 the Veteran asserted that he could not work because of his knees; and at the March 2018 VA examination the Veteran reported retiring in 2003 without discussing his employment from 2003 to 2010 with Parks and Recreation.

The reported inconsistencies further indicate that the histories and statements the Veteran has provided for VA disability compensation purposes are at odds with other histories that were previously given for other purposes, including for treatment purposes; therefore, the Board affords these statements less probative weight.

Nonetheless, the Board acknowledges that the focus of a TDIU rating should not be on the Veteran's unemployment and the reasons why he is unemployed; rather, the focus must be on whether his service-connected disabilities currently render him unable to secure or follow substantially gainful employment.

The Board notes in March 2012 the Veteran's representative indicated that VA had records of the Veteran's work history from 1988 to 1994; however review of the claims record does not show records of such work history and the Veteran has not identified or submitted such records to be associated with the claims record.

The Board also notes in March 2015 the Veteran reported trying to work but was forgetful, which indicates the Veteran had obtained work, even though it is not raised by the Veteran in later statements and assertions.

The Board notes that the other medical examinations and reports on record indicate the Veteran's disabilities caused some functional impairment but did not opine or find that the impairments prevented the Veteran from obtaining or maintaining substantially gainful employment.

Taken as a whole, the Veteran's symptoms do not suggest he has been unable to obtain and maintain employment. The Board acknowledges his physical limitations would make it difficult to work. As found in the most recent March 2018 VA examination, the examiner found the Veteran's symptoms of his disabilities caused impairment but did not did not find the severity of the Veteran's disabilities to preclude employment or leave him unable to secure or follow a substantially gainful occupation.

The Board observes that while the Veteran's past work experience is limited, he completed high school and as well as having many years of work experience. On the other hand, it is also clear that he has not sought employment in a number of years. The question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment. See Van Hoose v. Brown, 4 Vet. App. 361 (1993).  

Overall, when considering the Veteran's education, training and work history, while the Veteran may have been restricted from certain kinds of employment during the during the appeal period, the evidence did not indicate that his service-connected disabilities precluded him from doing other kinds of substantially gainful work. See Pederson v. McDonald, 27 Vet. App. 276 (2015).

In sum, the Board finds that the Veteran did not meet the schedular TDIU requirements and that he has not been unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 

As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable, and the claim is denied. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990).

 

 

MICHAEL LANE

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	J. Yang, Attorney-Advisor

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.