Citation Nr: 21027849 Decision Date: 05/07/21 Archive Date: 05/07/21 DOCKET NO. 17-04 847 DATE: May 7, 2021 ORDER Entitlement to a rating in excess of 30 percent prior to April 13, 2017, for posttraumatic stress disorder (PTSD) is denied Entitlement to a rating of 70 percent beginning April 13, 2017 for PTSD, is granted. Entitlement to a rating of 100 percent is denied for the entire appeal period. FINDINGS OF FACT 1. For the appeal period prior to April 13, 2017, the Veteran's PTSD was manifested by symptomatology resulting in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation, without more severe manifestations that more nearly approximate occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. 2. For the appeal period since April 13, 2017 the Veteran's PTSD has been manifested by symptomatology resulting in occupational and social impairment with deficiencies in most areas but not total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent prior to April 13, 2017 for PTSD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411. The criteria for a rating of 70 percent from April 13, 2017 for PTSD are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, DC 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1966 to May 1970. This issue comes before the Board of Veterans' Appeals (Board) on appeal from a November 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2019, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. The transcript is of record. Increased Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155, 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. When there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. Under DC 9411, a 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted 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; impairments of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. As the United States Court of Appeals for the Federal Circuit explained, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. VazquezClaudio v. Shinseki, 713 F.3d 112, 11617 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e., "the regulation... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-18 ; 38 C.F.R. § 4.130, DC 9411. Additionally, when evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination." 38 C.F.R. § 4.126 (a). Furthermore, when evaluating the level of disability arising from a mental disorder, 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 (b). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. In Bankhead v. Shulkin, 29 Vet. App. 10 (2017), the United States Court of Appeals for Veterans Claims (Court) held that the language of the General Rating Formula "indicates that the presence of suicidal ideation alone may cause occupational and social impairment with deficiencies in most areas." However, as recognized by the Court, VA must engage in a holistic analysis in assessing the severity, frequency, and duration of the signs and symptoms of a veteran's service-connected psychiatric disability, and their resulting social and occupational impairment. The Board notes that the revised DSM-5, which, among other things, eliminates Global Assessment of Functioning (GAF) scores, applies to appeals certified to the Board after August 4, 2014, as is the case here. See 79 Fed. Reg. 45, 093 (August 4, 2014). Consequently, the Board will not consider the previously assigned GAF scores in determining the outcome of this case. See Golden v. Shulkin, 29 Vet. App. 221 (2018). 1. Entitlement to a rating in excess of 30 percent prior to April 13, 2017, and in excess of 50 percent from that date forward for posttraumatic stress disorder (PTSD), is denied. A March 2015 rating decision granted service connection for PTSD and assigned a 30 rating. In September 2015, the Veteran submitted a claim for an increased rating. This claim was denied in November 2015. The Veteran has disagreed with the disability rating assigned and perfected an appeal with this rating decision. In May 2017, the RO granted an increased rating to 50 percent, effective from April 13, 2017. The Veteran has not indicated that he is satisfied with the disability evaluations assigned and the issue remains on appeal. The clinical records during the appeal period dated September 2014 through October 2014 document that the Veteran underwent individual psychological sessions. Mental status examinations showed that the Veteran was well dressed. He did not display psychomotor agitation nor retardation and he maintained good eye contact. His attitude was cooperative and friendly. His speech had a regular rate, tone, and volume. His thought was sequential, goal oriented, and had no flight of ideas. His mood was irritable. His affect was full range. He was oriented. The Veteran had no auditory or visual hallucinations and did not appear to be responding to internal stimuli. He denied current suicidal intent, plan or desire and no ideas of reference. He also expressed no homicidal ideation. There was no evidence of delusionality. His insight was ok but he had variable judgement. The Veteran was diagnosed with unspecified depressive disorder. The clinical records during the appeal period dated November 2014 through January 2015 document that the Veteran underwent individual psychological sessions. The Veteran reported triggers of hyperarousal including interpersonal stressors and incidents he perceives represent injustice. He was not sleeping well at night. He had decreased his medication and it has helped him to become calm. He reported interpersonal stress related to family stressors and his role as VP of a community organization. Mental status examinations consistently shows the Veteran's behavior was mildly agitated and psychomotor activity. His attitude was cooperative. His was grossly oriented to person, place, time, and purpose. His speech had a regular rate and rhythm. His thought form was linear. His mood was dysphoric. His affect was congruent. His cognition was grossly intact although no formal tests of cognitive function were performed. The Veteran had no auditory or visual hallucinations and did not appear to be responding to internal stimuli. He denied current suicidal intent, plan or desire. He also expressed no homicidal ideation. There was no evidence of delusionality. His insight was ok but he had variable judgement. The Veteran had diagnostic impressions of depressive disorder with anxious distress, mild and moderate history of positive screen for PTSD. In February 2015, the Veteran underwent a VA compensation and pension examination for PTSD. The diagnosis was PTSD which the examiner reported was moderate, chronic, with daily symptoms and daily use of medication. To best summarize the Veteran's level of occupational and social impairment with regard to the mental diagnosis, the examiner opined it was productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Veteran has been married for 48 years and has no biological children. He lives with his wife. He attends church and is active in youth programs and has some friends and community involvement. Occupationally, the Veteran is retired. The Veteran's mental health history is he had no psychiatric care prior to military service. There was no history of serious legal difficulties but a reported history of chronic irritability which has led to confrontational behaviour with a variety of people over the years. The past couple of years he's been attending the psychiatric clinic where he's treated for PTSD. He has an individual psychotherapist who prescribes him medicine. The Veteran has no history psychiatric hospitalizations, no history of suicidal behavior, and no psychosis. The examiner found that the symptoms which actively apply to the Veteran's diagnosis were anxiety and difficulty in adapting to stressful circumstances, including work or a worklike setting. The examiner noted that he was cooperative, pleasant, talkative and capable of managing his financial affairs. The examiner opined that the meets the DSM-5 stressor and clinical criteria for PTSD. It was determined that the symptoms were moderate as he is overall a functional person for years, but his irritability has been a problem in his life and marriage. His symptoms are overall moderate severity. With regards to routine activities of daily living he has some functional limitations in routine driving and shopping due to anxiety, but he is socially active and functional. The clinical records during the appeal period dated August 2015 through October 2015 document the Veteran undergoing individual psychological sessions. The Veteran discussed his increasing rumination, hyperarousal, and how this relates to current complaints such as more irritable mood at home and being distracted and forgetting things. His wife has expressed concern he is so stressed it is impacting the quality of their relationship. Mental status examination consistently showed the Veteran was agitated. His attitude was cooperative. His was grossly oriented to person, place, time, and purpose. His speech had a regular rate and rhythm. His thought form was generally linear however somewhat easily distracted. His mood was dysphoric and his was congruent. His cognition was grossly intact although no formal tests of cognitive function were performed. The Veteran had no auditory or visual hallucinations and did not appear to be responding to internal stimuli. He denied current suicidal intent, plan or desire. He also expressed no homicidal ideation. There was no evidence of delusionality. His insight was ok but he had variable judgement. In November 2015, the Veteran was afforded another VA compensation and pension examination for his PTSD. The Veteran was diagnosed with PTSD. The examiner noted the Veteran had chronic symptoms and some treatment. The PTSD was somewhat subjectively worse over the past year with increased irritability and somewhat due to alcohol consumption which does not rise to the level of abuse. To best summarize the Veteran's level of occupational and social impairment with regard to the mental disorder, the examiner opined that it was productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. Socially, the Veteran has no change to living situation. He was still married, attends church and is very active in his community. He is fearful that his chronic irritability has escalated in recent years and is causing more problems for him interpersonally and socially. He occasionally has a verbal outburst with friends or those he has known for a long time. He drives, maintains hygiene and contributes to maintenance of home. His anxiety and irritability are present and sometimes limit driving or shopping activities. Occupationally, the Veteran remains retired. As relevant mental history, the Veteran has no hospitalizations and no suicide attempts. In his last appointment, he was prescribed sertraline as it helps with anxiety and his irritability. There was no formal legal problems but irritability caused occasional non-physical confrontations. He continues individual psychotherapy at the VA. He tried one session of group therapy but did not continue. The examiner found the symptoms attributable to the PTSD were anxiety and difficulty in adapting to stressful circumstances, including work or a worklike setting. The examiner noted that the Veteran was well groomed with good hygiene, he was calm with an okay mood. He had full affect and was quite pleasant and conversational with the examiner. The Veteran's cognition was intact and there was no suicidal or homicidal ideation. The Veteran was capable of managing his financial affairs. The clinical records during the appeal period dated January 2017 through March 2017 document the Veteran undergoing individual psychological sessions. The Veteran's discussed how things are not going well between he and his wife and how he stopped drinking in March 2017. The Veteran reports his wife says he is less agitated/less restless at night and he also feels better. This makes him less irritable. He discussed that keeping his marriage intact seems to be an important motivator for behavior change at this time. Mental status examination consistently showed the Veteran's behavior was agitated and psychomotor activity. His attitude was cooperative. His was grossly oriented to person, place, time, and purpose. His speech had a regular rate and rhythm. His thought form was generally linear however somewhat easily distracted by circumstantial details. He had a mood was anxious, depressed without evidence of self-harm ideation. His affect was congruent. His cognition seems grossly intact although no formal tests of cognitive function were performed. The Veteran had no auditory or visual hallucinations. He does not appear to be responding to internal stimuli. He denied current suicidal intent, plan or desire. He also expressed no homicidal ideation. There was no evidence of delusionality. His insight was ok but had variable judgement. In January 2017, the Veteran reported his major difficulties were managing anxiety and cognitive rumination about stressors and angry reactivity with little or no provocation; it was noted the Veteran had impaired social functioning and conflict with others when participating in community settings. The Veteran underwent a VA examination for compensation and pension purposes in April 2017. The diagnosis was PTSD and unspecified alcohol abuse. The examiner noted that the two diagnoses are different. The examiner found that recurrent distressing memories, avoidance of external reminders associated with trauma in Vietnam, and hypervigilance appeared unique to PTSD. Other symptoms such as anxiety appear to overlap with both conditions. To best summarize the Veteran's level of occupational and social impairment due to all mental disorders, the examiner opined that they were productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The examiner found that the majority of the Veteran's current impairment appears to be secondary to PTSD. Socially, the Veteran has been married for approximately 50 years although the couple had frequent arguments. The Veteran has been retired since 2014. As relevant mental health history, the Veteran has been receiving treatment since 2015. He is involved with the Optimist club but is not called as much lately as the Veteran reported he had upset some people. He reported the frequency of his yelling as his wife had increased as had his distrust in others. He recently took a trip to Las Vegas with his wife. He denies a history of suicidal attempts, or inpatient mental health treatment. He discontinued utilization of previously prescribed unspecified medications. The Veteran's symptoms linked to the mental health diagnoses were depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, difficulty in understanding complex commands, impaired judgment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. As behavior observations, the examiner noted that the Veteran presented with very poor concentration. He rambled extensively and required virtually constant redirection. His voice tone was loud, and mood was irritable. He reports his wife drove today because he takes too many chances (appears to be reckless driving/judgment issues). Other symptoms attributable to the PTSD include irritability with verbal outbursts and frequent arguments with his wife. The Veteran reported that no one called him anymore and his old friends no longer want anything to do with him as he's easily irritated. He reported he had recently chased someone in his vehicle after the individual cut the Veteran off on the road. The examiner found the Veteran was able to manage his own financial affairs. The examiner found the Veteran does not appear to pose any threat of danger or injury to self or others. The clinical records during the appeal period dated May 2017 through August 2018 document the Veteran undergoing individual psychological sessions. Mental status examinations consistently showed the Veteran's behavior was agitated. His attitude was cooperative. His was grossly oriented to person, place, time, and purpose. His speech had a regular rate and rhythm. His thought form was generally linear however he was somewhat easily distracted by circumstantial details. His mood was anxious, depressed without evidence of self-harm ideation. His affect was congruent. The Veteran's cognition seemed to be grossly intact although no formal tests of cognitive function was performed. The Veteran had no auditory or visual hallucinations and did not appear to be responding to internal stimuli. He denied current suicidal intent, plan or desire. He also expressed no homicidal ideation. There was no evidence of delusionality. His insight was ok but had variable judgement. In November 2018, the Veteran went to a general psychiatry clinic. The Veteran was very talkative, detailing all the things going on around him psychosocially. He appears to have lost significant amount of weight. He expressed that he has difficulty in expressing his problems. He admits that he yells at his wife. He sleeps fine. Upon mental status examination, the Veteran's appearance was noted as casually dressed with good grooming and hygiene. His attitude was talkative, cooperative and engaged in evaluation. His was oriented, alert and attentive. His speech was loud volume, and significant word finding problem and anomia. His thought process tends to be overly inclusive as he likes to talk, circumstantial, and needs repeated prompting to stay focused. His mood is not too good. His affect was less dysphoria. He denied current suicidal intent, plan or desire. He also expressed no homicidal ideation. The Veteran has a negative thought content about his self. He has no sign of active delusions or paranoia. No obsession and denies having auditory or visual hallucinations. His insight was moderate, and his judgement was moderate, tending to try to fix too many things. The clinical records during the appeal period dated January 2019 through November 2019 document the Veteran undergoing individual psychological sessions. Upon mental status examination, it consistently shows the Veteran's appearance was noted as casually dressed with good grooming and hygiene. His attitude was talkative, cooperative and engaged in evaluation. He was oriented, alert and attentive. His speech was loud volume, and significant word finding problem and anomia. His thought process tends to be overly inclusive as he likes to talk, circumstantial, and needs repeated prompting to stay focused. His mood is "ok". His affect was less dysphoria. He denied current suicidal intent, plan or desire. He also expressed no homicidal ideation. The Veteran has a negative thought content about his self. He has no sign of active delusions or paranoia. No obsession and denies having auditory or visual hallucinations. His insight was moderate, and his judgement was moderate, tending to try to fix too many things. In September 2019, the Veteran testified before the undersigned. The Veteran's wife testified that the Veteran had dementia. The Veteran testified he had trouble with relationships and working with people. The Veteran's spouse testified that the Veteran has changed and is getting angry without patience. They did not isolate but tried to attend family events. The Veteran testified that, since 2013 he had depressed mood, anxious and suspicious, problems sleeping, memory problems, difficulty understanding complex commands. Risky driving began in 2017. He had difficulty making friends. The Veteran had memory problems but thought his symptoms were the same in 2013 as they were at the time of the hearing. The Veteran's spouse testified that she had seen a decline in the Veteran's functioning since prior to 2013. The testimony was found truthful and credible. In January 2020, the Veteran attending another VA examination for his PTSD. The Veteran was diagnosed with major neurocognitive disorder. The examiner noted that this diagnosis is based upon the Veteran's diagnosis by history. Currently the Veteran suffers from dementia and could not participate in the examination in a meaningful way. For example, he was unable to recall any stressful events that occurred while he was in Vietnam, other than to state that he had served on guard duty. He forgot details of his service and couldn't remember anything else about Vietnam. To best summarize the Veteran's level of occupational and social impairment, the examiner states that he has total occupational and social impairment. Socially, the Veteran has been married for almost 53 years. He likes to go places, belong to groups, attends church, and goes out to eat. He has close friends and has a good relationship with them. Occupationally, the Veteran is retired. For mental health history, the Veteran has been receiving treatment for his mental condition on medication. The Veteran has memory loss. As symptoms, the examiner noted the Veteran having anxiety, chronic sleep impairment, memory loss for names of close relatives, own occupation, or own name, impaired judgment, impaired abstract thinking, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including work or a work like setting, inability to establish and maintain effective relationships, intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene, disorientation to time or place. As behavior observations, the examiner noted that the Veteran suffers from serious memory problems with recall of 0/3 words after three minutes. He was also disoriented to time. He had no idea of the year or day of the week. He could not recall who was the President. He correctly recalled the year of his birth but did not know his age or the month in which he was born. The Veteran's wife was in attendance of the examination and stated that he is often frustrated and says he says he's not okay. The Veteran's wife states he is pretty much quiet during the day and at night, he gets up to go to the bathroom like a hundred times. He is very different from the way he used to be. The Veteran's wife also states that she doesn't know if his PTSD symptoms have worsened but stated that when his dad died in 2016, it took a toll on him. As other symptoms, the Veteran has serious memory loss and disorientation to time and sometimes person. The Veteran is not capable of managing their financial affairs because he suffers from serious memory loss and is disoriented. As remarks, the examiner stated she unable to confirm or deny the VA established diagnosis of PTSD since the claimant was disoriented with serious memory loss. For the VA established diagnosis of PTSD, the diagnosis is changed, and it is given a new and separate diagnosis of major neurocognitive disorder. In February 2020, the Veteran underwent a mental status exam. Upon mental status examination, the Veteran's appearance was noted as clean shaven and nicely dressed. His attitude was apprehensive and unable to engage in discussion. The examiner noted that the Veteran did not know his age. His speech was loud volume, and significant word finding problem and anomia. His thought process was unable to express significant anomia and word finding problem. The Veteran stated that he gets anxious. His affect was apprehensive and mainly looking for his wife. He denied current suicidal intent, plan or desire. He also expressed no homicidal ideation. The Veteran has a negative thought content about his self. He has no sign of active delusions or paranoia. There was no obsessional thoughts and he denied having auditory or visual hallucinations. His insight was moderate, and his judgement was moderate, tending to try to fix too many things. Based on the foregoing, for the appeal period prior to April 13, 2017, the Board finds that a rating in excess of 30 percent for the Veteran's PTSD is not warranted. In this regard, the record, to include VA treatment records and VA examination reports reflect that such disability was manifested by anxiety, difficulty in adapting to stressful circumstances, including work or a work like setting, depressive disorder, nightmares, and irritable mood, all of which are contemplated in the currently assigned 30 percent rating. In this regard, the Board observes that the Veteran has denied any suicidal or homicidal intent throughout the duration of the appeal period prior to April 13, 2017. Socially, the Veteran has been married throughout the entire appeal period. The Veteran did not report issues in the marriage, besides minor arguments. He attends church and is active in youth programs and has some friends and a lot of community involvement. The Veteran also reported to be involved with volunteer groups and enjoys going out to eat. Occupationally, the Veteran has been retired throughout the entire appeal period. His ability to function as an officer in his volunteer organization indicates that the Veteran has industrial capacity. The Veteran does experience memory loss but this has been determined to be mild. The record documents consistent reports of irritability during this time period. The Board notes that impaired impulse control which can consist of unprovoked irritability with periods of violence is one of the criteria for a 70 percent rating. While the record consistently documents irritability during the time period, there is no evidence that is was accompanied by periods of violence. There is no indication in the record the Veteran was ever violent. In consideration of the totality of the Veteran's symptomatology, the February 2015 and November 2015 VA examiners provided the Veteran's PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. Furthermore, the Veteran does not demonstrate any symptoms of flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; impaired judgment; impaired abstract thinking; and difficulty in understanding complex commands. Consequently, the Board finds that, prior to April 13, 2017, a rating in excess of 30 percent for the Veteran's PTSD is not warranted. For the appeal period beginning April 13, 2017, the Board finds that a rating of 70 percent for the Veteran's PTSD is warranted. The records show that the Veteran has consistently reported irritability. Furthermore, in 2017, there are reports that the Veteran is beginning to act on the irritability such as following cars which had cut him off. The Veteran's spouse testified that she had to drive now to avoid these instances. The Board finds this symptomology equates to impaired impulse control consisting of unprovoked irritability and periods of violence. While violence is not demonstrated, it is implied if a Veteran is willing to chase down another car due to anger. Furthermore, the evidence of this time period tends to show that the Veteran's relationships with his friends was deteriorating due to the Veteran's irritability which indicates an inability to maintain effective relationships. The Board finds that a rating in excess of 70 percent is not warranted at any time. There is no evidence demonstrating that the service connected PTSD was productive of gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The most recent VA examination documented the presence of some of this symptomology but attributed it all to major neurocognitive disorder. The symptomology was not attributed to the PTSD. There is no indication in the claims file that the neurocognitive disorder is linked, in any way, to the service connected PTSD. Service connection is not in effect for major neurocognitive disorder. In sum, the Board finds that the preponderance of the evidence is against a rating in excess of 30 percent prior to April 13, 2017, and in excess of 70 percent from that date forward. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Hughes 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.