Citation Nr: 21031225 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 13-22 433 DATE: May 20, 2021 ORDER Entitlement to service connection for a lumbar disorder is granted. Evaluation of 50 percent for PTSD prior to March 17, 2018 and a rating of 70 percent thereafter, but no higher, is granted, subject to the laws and regulations governing the award of monetary benefits is granted. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACTS 1. The evidence is at least in relative equipoise as to whether the Veteran's back disability had onset in service and that it continued since service. 2. From April 23, 2009 to March 16, 2018, the Veteran's service-connected PTSD is productive of occupational and social impairment with reduced reliability and productivity. It was not productive of occupational and social impairment with deficiencies in most areas. 3. From March 17, 2018, the Veteran's service-connected PTSD is productive of occupational and social impairment with deficiencies in most areas. It did not manifest with manifested by total occupational and social impairment. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for a back disability have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for a rating of 50 percent, but no higher, for PTSD is warranted prior to March 17, 2018. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code 9411. 3. The criteria for a rating of 70 percent, but no higher, for PTSD is warranted since March 17, 2018. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1988 to April 1992. This matter is on appeal before the Board of Veterans' Appeals (Board) from a September 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office. In February 2019, the Board denied the claims, and the Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). A Joint Motion for Partial Remand was then issued which vacated the denials of service connection for a back disability and for higher ratings for PTSD. Service Connection for a Lumbar Disorder Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). For chronic disabilities, VA may presume a nexus between an in-service incurrence or event and a current disability provided there is a showing of continuity of symptomatology. 38 C.F.R. §§ 3.303 (b), 3.309(a). VA must consider all lay and medical evidence of record. 38 U.S.C. § 1154 (a); 38 U.S.C. § 5107; 38 C.F.R. § 3.303. Laypeople are competent to report symptoms and experiences observable by their senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). It is the Veteran's contention that his current low back disability had onset in service and that he has been experiencing pain ever since his separation from active duty. Service treatment records are silent for any complaints or treatment for a low back disability prior to his March 1992 separation examination. On his report of medical history at separation, he reported experiencing recurrent low back pain. Clinical evaluation of his back was normal, but the physician noted that the Veteran experienced chronic back pain, especially after physical training. The Veteran was afforded a VA examination in May 1992 to evaluate his low back disability. He reported that he began experiencing back pain during field exercises and would sometimes get a "twinge" in his low back when exercising. Physical examination of his spine was normal, and X-rays were negative for any abnormalities. He was however, diagnosed with a low back strain. The Veteran's VA treatment records do show reports of chronic back pain. In May 2009, the Veteran reported chronic back pain, in which he denied experiencing a precipitating injury. In December 2011, the Veteran sought medical attention for constant lower back pain, specifically to the upper lumbar segment. In April 2015, it was noted that the Veteran was involved in a motor vehicle accident in either 1990 or 1992, and he reported that the pain slowly developed overtime. The Veteran's private physician, Dr. W.R., who had been treating the Veteran's back pain for approximately a year, submitted a February 2010 letter indicating that it was his medical opinion that the Veteran's condition is caused by his military service. Dr. W.R., however, did not provide any supporting rationale for such conclusion. Private treatment record from Dr. W.R. in May 2010 reported that the Veteran had frequent lower back pain with sharp pain particularly on the left side. By October 2010, his clinical assessment was chronic lumbago with trigger point tenderness and acute muscular spasms. The Board notes that although the Veteran consistently reported a right finger and respiratory disability since his active duty service and service in Saudi Arabia, there was no documentation of low back pain or injury during such time. However, in another letter dating July 2013, Dr. W.R. opined that it is at least as likely as not that the Veteran's low back condition (lumbago) is related to his active duty service. The physician explained that it was likely that the Veteran's lumbago was a continuation of the problems that began while on active duty, because repeated or extreme trauma, strains, excessive use, age, and normal wear and tear are normal factors in developing lumbago. He also opined that the Veteran's degenerative joint disease was a residual associated with his back injury sustained during basic training in 1988. More recent private treatment records in from Dr. W.R. between 2019 and 2020 showed the Veteran continued to show that he sought treatment for his back. He consistently demonstrated tenderness with guarding and restricted motion. In a June 2019 note, Dr. W.R. again reiterated that the Veteran's chronic severe low back pain as well as documented lumbar disc disease is caused by his military service, shortly after back training. Since then, his back pain has progressively worsened over time. The Veteran was afforded a VA examination in February 2015 to determine the etiology of his low back disability. He reported that he experienced back pain since service. The examiner noted he had a diagnosis of lumbar strain and degenerative disc disease. After reviewing the entire claims file, to include the reported chronic back pain in March 1992, the examiner opined it was less likely than not that the Veteran's low back disability was etiologically related to his active duty service. The examiner explained that despite the isolated incident in service, the May 1992 post-service examination was completely normal, and his medical records were silent for many years post service. Moreover, the Veteran worked driving a truck for a beer company for seven years and worked in the railroad industry for 10 years. In support of the Veteran's assertion that he was involved in a motor vehicle accident, his fellow serviceman submitted a statement describing the accident. He explained that during Desert Shield, he responded to a motor vehicle accident where he assisted the Veteran out of the wreckage. He recalled that when he pulled the Veteran out of the car, he complained immediately of back pain. The Veteran's sister also submitted a statement describing the Veteran's back pain when he returned from service. The Veteran had complained to her about his low back pain but had refused to seek medical attention at the VA medical centers. A new VA medical opinion was obtained in March 2018 to determine the etiology of his low back disability. The examiner noted the Veteran had complaints of back pain at separation, but the clinical evaluation was normal. He also noted the Veteran's initial VA examination in May 1992 was normal. The Veteran's post-service treatment records were silent for complaints of back pain until 2009, and his employment as a beer distributor and with the railroad required heavy lifting. Review of the pertinent medical literature reflected the vast majority of low back strains resolved completely. However, the examiner could not opine as to the etiology of the low back disability because the Veteran's periodic physicals from his places of employment were not contained in the claims file. In reviewing the record, the Board finds that the evidence is at least in equipoise that a back disability began in service, and service connection for a low back disability is granted. The Veteran's lengthy medical treatment records show that he suffered from a chronic back condition which developed into a degenerative disability. His service treatment records revealed a complaint of back pain in service. While treatment records immediately after service do not reflect a clear diagnosis of a degenerative back disability, the Veteran has consistently reported chronic pain in which he traced back to his time in basic training. To address his condition, he sought long-term medical treatment with a private physician, Dr. W.R. In treating the Veteran for his back disability, Dr. W.R. opined that it was at least as likely as not that the Veteran's current condition had onset in service and has continued ever since. In his July 2013 private treatment note, the physician explained that the repeated trauma and excessive use of his back, combined with age and wear and tear, were factors in the development of his lumbago, and his degenerative joint disease was a residual associated with back injury during basic training. The Board finds that this medical opinion does provide persuasive evidence in favor of the claim, and it is at least evenly balanced with the negative VA medical opinion from February 2015 and the March 2018 VA opinion that was inconclusive. The Board finds persuasive the Veteran's consistent detailed report of onset of his back condition and finds that the nature of this injury is likely to persist and develop into a chronic degenerative condition. The Board interprets the Veteran's lay assertions broadly and finds that the statements imply that the Veteran has continued to suffer back pain and related back issues since the documented in-service back complaint. Thus, the Board finds the Veteran's account of experiencing in-service back trauma and symptomatology to be credible and consistent with the current disability, which has also been supported by his private treatment reports. The claims file contains both negative and positive medical opinion, but the evidence need only be in equipoise to grant the benefit sought. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Here, there is competent medical evidence on the nexus question in favor of the claim and against the claim. Accordingly, the Board finds that there is an approximate balance of positive and negative evidence, and the Veteran's service connection claim is granted. Increased Rating for PTSD The Veteran is currently seeking a rating higher than 30 percent prior to March 17, 2018, and a rating higher than 50 percent thereafter, for his service-connected PTSD. Under the Diagnostic Code 9411, a 30 percent disability rating is assigned where a psychiatric disability causes 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 disability rating is assigned where a psychiatric disability causes occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating is assigned where a psychiatric disability causes 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); and inability to establish and maintain effective relationships. The maximum schedular disability rating of 100 percent is assigned where a psychiatric disability causes 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; and memory loss for names of close relatives, own occupation, or own name. When determining the appropriate disability evaluation to assign, the Board's primary consideration is the Veteran's symptoms, but it must also make findings as to how those symptoms impact the Veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442. Nevertheless, as all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the Veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. Entitlement to a rating higher than 30 percent prior to March 17, 2018 From April 23, 2009 to March 17, 2018, the Veteran has been assigned a rating of 30 percent for his service-connected PTSD. VA treatment records in May 2009 noted that the Veteran complained of flashbacks, nightmares, avoidant behavior, and was 'always on guard.' He also reported previously having chronic suicidal ideations (in service) but not at the time of the evaluation. He indicated that he was easily startled by loud noises due to his combat experience. He often became emotional when talking about his military experiences. He became tearful, numb, and reported feeling the loss of interest in things that he once enjoyed. At the time of the evaluation, the Veteran was living with his wife of three years and his stepson. He indicated that his children lived nearby and saw them often. The physician noted that the Veteran was able to work and take care of his own needs. He preferred to keep to himself as a way of coping with his PTSD, but still has a few friends. The Veteran was afforded a VA examination to evaluate the severity of his PTSD in July 2009. He reported experiencing nightmares and flashbacks once or twice a week. He made efforts to avoid thinking about his time in Saudi Arabia. His nightmares caused him to wake in a cold sweat, preventing him from sleeping through the night. He managed to go out to eat once or twice a year, but sat with his back to the wall, and would prefer to wait for his wife in the car while she shopped. He reported getting along with his wife, visiting with an uncle, and enjoying riding around in his car alone. He maintained employment as a train conductor but added that he had been written up a couple of times for minor rule violations. The examination report reflected that the Veteran was appropriately groomed, cooperative, and truthful. He displayed some anxiety and dysphoria, with affect appropriate to content. His speech was within normal limits in rate and rhythm. His thought processes were logical and tight, with no loosening of associations noted. He was oriented in all spheres, and his memory was grossly intact. He did not report or any hallucinations or delusions. His insight and judgment were adequate, and he denied any suicidal or homicidal ideations. In his final remarks, the VA examiner noted that the Veteran's symptoms occurred many days of the week and that they have reached mild to moderate levels, which have persisted for several years. Vet Center treatment records reported that the Veteran consistently struggled with sleep disturbances due to combat related nightmares. He engaged in group counseling approximately twice per month. In November 2009, the Veteran reported little progress with his problems. His mood and affect were within normal limits and he did not voice any suicidal or homicidal thoughts. A mental status evaluation reported that the Veteran's appearance was neat, and his speech and affect were appropriate. His manner was friendly but appeared tense. He was well oriented to time, place, and person. His intelligence was noted as average, his memory function was normal, and his judgment was good. The Veteran reported some delusions as he is paranoid about loud noises and fireworks. He also complained of disorganized thinking with some memory lapses. He reported experiencing suicidal thoughts back in the 1990s immediately following service. However, there was no report of any current ideations. The Veteran was examined again at a September 2012 VA examination. He reported maintaining his employment as a railroad engineer, and that he lived with his wife, had friends, and enjoyed time with his daughter. He also reported improved functioning over the past couple of years. The examiner noted that the Veteran's PTSD manifested as occupational and social impairment due to mild or transient symptoms, with decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. His symptoms were depressed mood, anxiety, hypervigilance, difficulty falling and staying asleep, exaggerated startled response. VA treatment records dating November 2014 showed that the Veteran underwent a mental status evaluation. There, he did not demonstrate any acute physical distress. He was awake, alert, neatly groomed, with fair eye contact. He was tearful and anxious but was cooperative. His speech was coherent and was normal in rate and volume. His thought process was organized and was goal directed. There was no indication of suicidal or homicidal ideations, auditory or visual hallucinations. The Veteran's spouse indicated that he was more relaxed, but he still needed to drink to calm down. He reported getting roughly 4 to 5 hours per night with persistent nightmares. He reported irritability, anger outbursts, hypervigilance, and sadness. He also complained of chest pains and anxiety attacks triggered by stress. He tried using the hotline but did not speak to them. He added that he had been feeling sadder but is still able to complete tasks around the house. While he does not enjoy family gatherings, he will spend time with his daughter. The Board notes that in November and December 2015, the Veteran was presented with thoughts of being better off dead or thoughts of hurting himself in some way. By January 2015, the Veteran did not demonstrate any notable improvements in his mental status. He appeared well groomed and was cooperative during the interview. He maintained proper eye contact throughout the session. However, he appeared depressed, serious, anxious, and guarded. His speech was normal in rate, tone, and volume. His thought process was linear, and goal directed. He was well oriented and alert. His long term and short-term memory appeared intact. While he denied suicidal and homicidal thoughts, he was presented with paranoid thoughts. In February 2015, the Veteran reported some improvement in mood and sleep. While he still experienced nightmares, he indicated that he is less panicky and could return to sleep. His relationship with his wife also improved with him promising to consume less alcohol. In March 2015, the Veteran expressed some thoughts of being better off dead or hurting himself in some way. However, his overall assessment did not find any risk of suicidal intent. The Veteran did not demonstrate any changes in his condition throughout 2015 and 2016. In September 2015, VA treatment records reported that he was well groomed at his mental status evaluation. He was cooperative and maintained good eye contact. His speech was normal in rate, tone, and volume. He denied suicidal and homicidal thoughts. Despite paranoid ideations, he demonstrated no cognitive deficits. He indicated that his nightmares continued to persist with bad memories. Unfortunately, he and his wife divorced, causing feelings of increased loneliness. In a suicidal risk assessment, the Veteran reported that he has thoughts of not wanting to live but denied having any suicidal thoughts. His children were identified as protective factors. In another September 2015 psychiatric status follow up note, it showed that the Veteran reported some improvements as he was able to go out in public more. He complained of depression and loneliness. He also expressed anger toward management at his job due to cutbacks and conflicts about his absences to attend PTSD therapy. He reported no issues with coworkers and that he was doing a good job. In July 2017, the Veteran was afforded a third VA examination to evaluate the severity of his PTSD symptoms. He reported having relationships with his children, but that he and his wife had been separated for over a year. He reported that he took his daughter out to eat, washed her car, and took her school shopping. He also reported that she played in a band, and he would attend her concerts and other performances. The Veteran maintained a friendship with a coworker, with whom he enjoyed cleaning cars and having a drink with. He continued to maintain his employment with the railroad, but stated he was experiencing difficulties due to missing work because of the number of VA appointments he had. He also reported being in a physical altercation in late 2016 with a neighbor, but no charges were pressed. The examiner noted that the Veteran's PTSD manifested as occupational and social impairment due to mild or transient symptoms, which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. He demonstrated symptoms of anxiety, suspiciousness, and chronic sleep impairment. Examination notes reflected that he was appropriately groomed and dressed and was cooperative throughout the interview. His speech was within normal limits in rate and rhythm. His mood was mildly anxious, with affect appropriate to content. His thought processes were logical and tight, with no confusion. He was oriented in all spheres, with no evidence of delusions or hallucinations. He denied any suicidal or homicidal ideation. At his January 2018 mental status examination, the Veteran was well-groomed, clean shaven and appropriately dressed. He was pleasant and cooperative, with good eye contact. He appeared somewhat anxious but more euthymic than his last visit. His speech was normal in rate, volume, and tone. His thought process was logical and goal oriented. He denied suicidal and homicidal ideations. There was no indication of auditory or visual hallucinations. His memory was grossly in-tact and his concentration were normal. The Veteran continued to report irritability, hypervigilance, and nightmares but some improvement in his sleep, getting approximately 5 to 6 hours. After more PTSD therapy classes, he indicated that he was able to engage in more things he enjoys such as going shopping with his daughter. In support of his claim, the Veteran also submitted a private medical opinion dating December 2020. The physician noted that the Veteran reported nightmares, causing violent behavior, panic attacks occurring 1 to 2 times per week, and flashbacks. In efforts to cope with his trauma, the Veteran would engage in avoidant behaviors and stay away from public places. He expressed feelings of detachment from others and has difficulty at work. The physician indicated that the Veteran's arousal and reactivity symptoms are adversely impact his sleep. The Veteran has complained of flaring tempers and physical altercation. It was noted that the Veteran's poor concentration has been impaired and had led him to stop working. Overall, the Veteran has become hypervigilant, easily startled, has thoughts about suicide and hurting others. He has also developed an alcohol habit as a form of self-medication, drinking three to six beers per day to help him cope and relax. In a statement dating March 2021, the Veteran summarized his PTSD symptoms from April 2009, describing his hypervigilance both when he is out in public and at home. He was always alert to movements and sounds, checking his locks 2 to 3 times before going to bed. If he woke up in the middle of the night, he would check his doors. He experienced panic attacks 3 to 4 times per week and is uncomfortable around people he did not know. Because he was often distracted by his surroundings, he had difficulty concentrating. This has caused problems in his work performances. His irritability made it difficult to engage in conversations with others. He was easily provoked by people in public and at work. He was even written up by his supervisor for his behavior towards his coworkers. When he is angered and anxious, he often harbored bad thoughts towards people and engage in obsessive rituals. He experienced flashbacks at least once a day and suffered from nightmares every night. Unlike what was reported in his medical treatment records, he now stated that he experienced suicidal ideations at least once a week due to the severity of his symptoms and his inability to maintain relationships with others. His nightmares and flashbacks were increasing and developed into hallucinations. He described seeing shadows or a person popping up and disappearing. These sightings often provoked him into a fight or die mode. The Veteran specifically noted that between 2015 and 2016, he experienced an increase in mood swings and irritability, often engaging in altercations with both strangers and coworkers. His increased irritability also caused tension between him and his neighbor, even leading to a physical fight. He had feelings of hopelessness because of his inability to maintain his relationships. He even had thoughts of being better off dead. Upon reviewing the record, the Board finds that a rating of 50 percent is warranted for the period prior to March 17, 2018. Taken in totality, the Veteran's overall symptoms most closely approximate a 50 percent rating. His lengthy medical treatment records show that he sought intermittent treatment for his PTSD between 2009 and 2018. Over the course of the years, the Veteran exhibited waxing and waning symptoms with brief periods of deterioration and improvements. He consistently reported experiencing flashbacks, anxiousness, hypervigilance, and sleep impairment due to chronic nightmares. The Veteran has also reported one or two instances of conflicts between him and others. Most, alarming, despite the Veteran's several denials on having suicidal thoughts or intent, the Board has noted the Veteran's occasional complaints of thoughts of being better off dead or hurting himself in some way, specifically in November 2014, December 2014, and March 2015. The Board has considered whether a rating of 70 percent is warranted for this time period but finds that it does not as the Veteran's symptoms do not result in occupational and social impairment, with deficiencies in most areas. Mental status evaluations consistently noted he was appropriately groomed, his speech was normal, and his thought processes were logical, and goal directed, without any evidence of looseness of associations or flight of ideas. He was always noted to be alert and oriented, without hallucinations or delusions. Treatment records did not reflect the majority of the symptoms recognized under a 70 percent rating such as obsessional rituals which interfere with routine activities, illogical or obscure speech, spatial disorientation, neglect of personal appearance, or near to continuous panic affecting his ability to function independently. The Board acknowledges the Veteran's March 2021 statement and December 2020 private opinion by Dr. K.B., in which she argues that the Veteran is entitled to a 70 percent rating as his symptoms result in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgement and/or mood. However, the Board finds that the symptoms reported by the December 2020 report and the March 2021 statement were not reflected by the Veteran's lengthy treatment records for the period between 2009 and 2018. Dr. K.B. cited to the Veteran's treatment notes dating May 2009, November 2014, May 2016, and the Veteran's August 2020 affidavit to illustrate the Veteran's chronic suicidal ideations. However, the totality of his records reported fleeting thoughts of being better off dead, with no plan or action. The Veteran also denied suicidal ideation during most of his VA treatment encounters, indicating that the frequency and duration of these thoughts was low, and the Board does not find that they manifested with the severity, frequency, and duration that would warrant a higher 70 percent rating. See Vazquez-Claudio, 713 F.3d at 118. For example, screenings in April 2013, November 2014, May 2015, September 2015, December 2015, October 2016, December 2016, March 2017, June 2017, and October 2017 all noted that the Veteran specifically denied having suicidal thoughts. His VA treatment records noted that the Veteran indicated that he never endorsed suicidal or homicidal thoughts. In fact, in an October 2016 mental health evaluation, the Veteran was adamant that after his one attempt in 1991 during his deployment to Saudi Arabia, he has "never had suicidal thoughts or attempted suicide since 1991." Nevertheless, the Board has considered the Veteran's occasional thoughts of being better off dead and finds that the limited severity and frequency of this symptom likely result in occupational and social impairment with reduced reliability and productivity, but no greater. The Board also notes that the Veteran's March 2021 statement indicated that he suffered from visual hallucinations in the form of shadows and people that would pop up and disappear. These reported hallucinations were not previously mentioned in his VA treatment records. His medical records between 2009 and 2018 did not reflect any complaints of delusions or hallucinations. In fact, the Veteran has consistently denied such symptoms at various VA examinations and mental status evaluations. The JMR also highlighted the Veteran's argument that he has impaired impulse control and difficulties adapting to stressful environment, which had led to altercations at work and even a physical confrontation with his neighbor in 2016. The Veteran has also asserted that his negative feelings have made him easily provoked by his coworkers, even causing altercations at work. He has even been disciplined by his supervisor for his inappropriate behavior at work. However, the majority of symptoms identified by his treatment reports during this period do not illustrate problems with impulse control and adaptation to stressful environment. His treatment records during this time period only showed that the Veteran was written up in July 2009 for a minor rule violation. Then in September 2015, he complained about upper management regarding his absences and cutbacks, but otherwise reported getting along with his coworkers. Despite his symptoms, he has been able to maintain important relationships with his children, who have provided significant emotional support. But even taking into consideration the Veteran's exaggerated startled responses and his altercation with his neighbor, the September 2012 and July 2017 VA examinations both found that the Veteran's PTSD symptoms result in occupational and social impairment due to mild or transient symptoms with decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, which corresponds only to a 10 percent disability rating. The Board has not found, nor has the Veteran argued, that the pertinent VA examination reports were inadequate. Nevertheless, the Board finds that the Veteran's stresses at work and self-reported isolated incident with his neighbor contribute to occupational and social impairment with reduced reliability and productivity mostly due to the difficulty in establishing and maintaining effective work and social relationships, which equates to a 50 percent rating. While the Veteran has claimed severe symptoms such as hallucinations, poor impulse control, and an inability to adapt to stressful circumstances, these symptoms do not represent his overall condition during the period between April 2009 and March 2018. Not only that his more recently reported symptoms are contradicted by his own previous statements to several VA physicians, they are not shown to occur to a level of frequency, severity, and duration, for the next higher rating of 70 percent. Vazquez-Claudio, 713 F.3d at 118. The Board has also considered whether a rating of 100 percent is warranted during this time period but finds that it does not. The Veteran has shown that he maintains a strong relationship with his daughter, who provides him with emotional support. As previously discussed, while the Veteran has reported having visual hallucinations, this report is unsupported by his own statements to his medical care providers. Additionally, the Veteran has not exhibited other symptoms such as a persistent danger to himself or others, severe memory loss, disorientation to time and place, and an intermittent inability to perform activities of daily living. His medical records have shown that the Veteran maintained employment and even have a small number of friends whom he socializes with. Accordingly, the Board finds that the Veteran's symptoms between April 2009 and March 2018 more closely approximate a 50 percent rating during this time period, but the preponderance of the evidence is against any higher rating. Entitlement to a rating in excess of 50 percent from March 17, 2018 From March 17, 2018, the Veteran was assigned a 50 percent rating for PTSD. He argues that he is entitled to at least a 70 percent rating for this time period. In a March 2018 mental health note, the Veteran reported having thoughts of being better off dead or of hurting himself in some way. The Veteran was afforded a VA examination in March 2018. There, he reported that he maintained good relationships with his children and a few friends, but has difficulty getting along with others. He experienced nightmares, cold sweats, sleep disturbance, intrusive memories, increased irritability. He believed his PTSD symptoms contributed to his marital strife and his subsequent divorce. He also reported getting into frequent arguments and occasional physical altercations, even admitted to getting in a fight with his neighbor in 2017. At work, he reported difficulty getting along with coworkers and that he had been the subject of investigations concerning attendance and verbal altercations with coworkers. The examiner noted that his PTSD manifested as occupational and social impairment with reduced reliability and productivity due to symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a work like setting. His mental status evaluation reflected appropriate grooming. His affect had wide range, which was congruent with the topic of conversation. He was cooperative and oriented in all spheres. He made appropriate eye contact and demonstrated average intelligence. His speech was fluent, and his thought processes were logical. The examiner noted no obvious genitive problems. VA treatment records dating June 2018 reflected that he struggled with loneliness after his daughter graduated from high school and moved out. It also showed that he was experiencing difficulty at work with a supervisor, expressing concern that he would "lose it" on his supervisor. He continued to experience sleep disturbance and nightmares. He maintained a close relationship with his uncle. His hygiene and appearance were noted to be appropriate, and his behavior was pleasant and cooperative, despite being tearful and anxious. He maintained good eye contact, and although he demonstrated agitation, he had no tics or tremors. His mood was emotional with a tearful, dysthymic, and anxious affect. His thought process was logical and goal oriented, and his speech was normal in rate and rhythm. He denied any suicidal or homicidal ideation, hallucinations, or delusions. His memory was grossly intact, and he demonstrated no deficits in attention or concentration. By November 2018, at his medication management session, the Veteran reported some improvement with citalopram. He denied having crying spells and that his nightmares have been "okay," more recently, and now he is sleeping around 6 hours per might. He continued to cope with his divorce and has been able to spend time with his daughter, which is very positive for him. He denied irritability and denied getting into altercations with people. He also engaged in a couple of hobbies at home. However, he still struggled with crowds of people and had started drinking more. He continued to maintain his full-time employment. The Board notes however, that in November 2018, the Veteran also indicated that he had thoughts of being better off dead or hurting himself in some way. In support of his claim, the Veteran submitted a December 2020 report from his private physician in which she highlighted the Veteran's problems at work and his supervisor due to psychiatric condition. His continued lack of sleep, panic attacks, depressed mood, irritability, and avoidant behavior have worsened his overall condition. His panic attacks have been so severe that he feels it equivalent to a heart attack. Additionally, due to his nightly paranoia, the Veteran would check the locks in his house two to three times per night. He developed negative thoughts and feelings, which has affected the way he interacts with people. This has caused significant problems at work as his relationship with his supervisor had deteriorated. He is unable to trust and often feels that he is being taken advantage. He has also continued to express suicidal thoughts and even homicidal thoughts if anyone harmed him or his family. In an August 2020 statement, the Veteran indicated that his symptoms have continued to progress. He has panic attacks at least 2 to 3 times per week. Because of his divorce, he only had a few people he talks to. His increased irritability was easily provoked in the workplace, and he continued to have frequent mood swings. He had tried to control his anger outburst and anxiousness, which caused further panic and worry. He noticed his depression over the things that he has lost in his life. VA mental health treatment notes reflected that in June 2020, the Veteran endorsed instances of depression. His sleep had been poor due to persistent nightmares. He reported becoming more isolating than usual. His irritability increased to high levels, even resulting in him leaving work abruptly after an altercation with his supervisor. September 2020 treatment records showed that the Veteran endorsed increased anxiety and irritability. He reported struggling with fluctuating mood and poor sleep due to physical pain and nightmares. He complained of depressed mood, fatigue, decreased motivation, persistent flashbacks, anxiety, emotional numbness, and hypervigilance. In a January 2021 declaration of statement, the Veteran indicated that his PTSD has led to changes in his activities and food habits as he used food to cope with his symptoms. His nightmares have persisted throughout the years and he often wake up every two to three hours because of them. He had a hard time controlling his appetite whenever he has a bad day with severe symptoms. Additionally, he struggled with motivation and energy. He spent most of his free time on the couch and engaged in light walks around his neighborhood. VA mental health treatment records in January 2021 noted that the Veteran had been unable to work, partly due to COVID and his surgery. He has been feeling more tired and a more depressed. Reports of his overall condition showed no improvement. In fact, with his poor physical condition, the Veteran's reported increased difficulty with depression. He continues to struggle with isolation, poor sleep, emotional numbing, exaggerated startled response, irritability, hypervigilance, and decreased motivation. He specifically denied suicidal and homicidal ideations at his evaluation. In reviewing the record, the Board finds that a rating of 70 percent rating is warranted for the period beginning March 17, 2018. The Veteran has clearly demonstrated a worsening of his psychiatric condition due to symptoms such as increased isolative behavior, irritability, panic attacks, and inappropriate behavior. He continued to report nightmares and flashbacks that affect his sleep, resulting in increased paranoia. While he may be able to maintain relationships with a selected few, his work relationships have deteriorated. The Veteran reported having altercation with his coworkers, even his supervisor. In June 2020, the conflict with his supervisor became so severe, he reported leaving his job on the same day. The Board also notes that during this time period, the Veteran has expressed negative thoughts about his wellbeing. While he has reported that he would not attempt suicide, it has not prevented him from thinking that he would be better off dead or hurting himself. The Board has also considered whether a higher rating of 100 percent is warranted but finds that it does not. While the Veteran voluntarily quit his job, the overall evidence does not show total occupational and social impairment, evidence by his existing relationships with a selected few, especially with his daughter. He also has been able to maintain some friendships and a close relationship with his uncle. He is able to present normally, without any gross behavioral impairment, delusions, or hallucinations present. The Veteran has not demonstrated a persistent danger of hurting himself or others, an intermittent inability to perform activities of daily living, disorientation of time or place, or demonstrates severe memory loss, such as forgetting his own name. The Board therefore finds that the Veteran's symptoms, while generally severe, are not of such frequency, duration, and severity that they cause total occupational and social impairment. In summation, the Board recognizes the Veteran's PTSD symptoms, the difficulties it causes him on a daily basis and finds that the evidence supports a rating of 70 percent, and no higher, from March 17, 2018. The Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against any ratings higher than those now assigned, that doctrine is not applicable. 38 U.S.C. § 5107(b). REASONS FOR REMAND TDIU The Board finds that TDIU has been raised by the record and will determine whether the Veteran is entitled to TDIU as a result of his service-connected disabilities. Rice v. Shinseki, 22 Vet. App. 447 (2009). Based on his VA treatment records, the Veteran had been employed as a locomotive engineer at Union Pacific, as a full-time employee, with varying shifts. In June 2020, the Veteran confided in his VA physician that he got into an argument with his supervisor, causing him to walk off the work site earlier that month. By January 2021, he indicated that he had not been able to return to work due to both his back condition and the COVID-19 restrictions. In support of his claim, the Veteran's private physician submitted a March 2021 report on the Veteran's Residual Functional Capacity. The physician found that the Veteran would miss 3 or more days of work per month due to his psychiatric symptoms and would have to leave work early at least 3 times per month. His attention and concentration have been impaired due to his mental condition. Additionally, the Veteran has reportedly reacted violently when subjected to the normal pressures and constructive criticisms of his job. While the record suggests that the Veteran has difficulties obtaining or maintaining substantial gainful employment, the Board finds that more development is required prior to the adjudication of TDIU. Thus, the matter is remanded. The matters are REMANDED for the following action: Contact the Veteran to provide him with an opportunity to submit a formal TDIU application form (VA Form 21-8940). Ask the Veteran to provide his full history of employment and periods of when he was not employed, and the reasons why he was not employed. Then, adjudicate the issue of entitlement to a TDIU. Mary E. Rude Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Yeh, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.