Citation Nr: 22011645 Decision Date: 03/01/22 Archive Date: 03/01/22 DOCKET NO. 17-04 831A DATE: March 1, 2022 ORDER Entitlement to an initial rating of 70 percent, but not higher, for posttraumatic stress disorder (PTSD) is granted. REMANDED Entitlement to a total rating based on individual unemployability due to service connected disability (TDIU) is remanded. FINDING OF FACT Throughout the period on appeal, the Veteran's PTSD manifested with occupational and social impairment with deficiencies in most areas. CONCLUSION OF LAW The criteria for a rating of an initial 70 percent for PTSD have been met. 38 U.S.C. § 1155, 5107; 8 C.F.R. §§ 3.102, 4.14.14, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1967 to December 1969, to include combat service in the Republic of Vietnam. These matters come to the Board of Veterans' Appeals (Board) on appeal from April 2012 and January 2018 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) St. Petersburg, Florida. The Veteran testified at a hearing before the undersigned Veterans Law Judge of the Board in August 2021. A transcript of the hearing has been associated with the claims file. In an October 2017 rating decision, the agency of original jurisdiction (AOJ) granted a 50 percent rating, effective November 20, 2012 and a 70 percent rating, effective May 30, 2017 for the Veteran's PTSD. However, a higher rating is available for bilateral hearing loss. The Veteran is presumed to seek the maximum available benefit for a disability. As such, this claim is still considered to be on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Increased Rating PTSD The Veteran asserts that he is entitled to a higher initial rating for his PTSD as his symptoms are worse than those contemplated by his assigned ratings. Specifically, the Veteran testified at his Board hearing that his psychiatric symptoms manifested in self-medication with alcohol, relaxing with friends that understand what he experienced; estranged relationship with his siblings and an inability to work. See Board hearing transcript, August 9, 2021. Additionally, the Veteran testified that he would have arguments with his roommate and responded with angry outbursts and suicidal ideation. Id. Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Board must also consider staged ratings. Hart v. Mansfield, 21 Vet. App. 505, 50910 (2007). The veteran's entire history is considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A review of the recorded history of a disability is necessary to make an accurate rating. 38 C.F.R. §§ 4.2, 4.41. The regulations do not give past medical reports precedence over current findings where such current findings are adequate and relevant to the rating issue. Francisco v. Brown, 7 Vet. App. 55 (1994); Powell v. West, 13 Vet. App. 31 (1999). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The assignment of a particular diagnostic code is dependent on the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. In reviewing the claim for a higher rating, the Board must consider which diagnostic code or codes are most appropriate for application in the veteran's case and provide an explanation for the conclusion. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. When there is an approximate balance of positive and negative evidence as to any issue material to the determination of a matter, VA will resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran's claims. The Veteran's PTSD is rated under the General Rating Formula for Psychiatric Disabilities (General Formula). 38 C.F.R. § 4.130. Psychiatric disabilities are rated based on the General Rating Formula codified in 38 C.F.R. § 4.130, which provides disability ratings are based on a spectrum of symptoms. "A Veteran may qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of a similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) and (5th ed. 2013) (DSM-5). See Mauerhan v. Principi, 16 Vet. App. 436, 44243 (2002). VA is to engage in a holistic analysis in which it assesses the severity, frequency, and duration of the signs and symptoms of the veteran's service-connected mental disorder; quantifies the level of occupational and social impairment caused by those signs and symptoms; and assigns an evaluation that most nearly approximates that level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). Under the General Rating Formula for Mental Disorders per 38 C.F.R. § 4.130, 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). 38 C.F.R. § 4.130, Diagnostic Code 9411. 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 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. Id. A 70 percent rating is warranted if the disability is productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. A schedular maximum 100 percent rating is warranted if the disability is productive of 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. In addition, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the lengths of remissions, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation on the basis of social impairment. The Board notes that with regard to the use of the phrase "such as" in 38 C.F.R. § 4.130 (General Rating Formula for Mental Disorders), ratings are assigned according to the manifestations of particular symptoms. However, the use of the phrase "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve only as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment. The Board acknowledges that psychiatric examinations frequently include assignment of a global assessment of functioning (GAF) score. The American Psychiatric Association has released the Diagnostic and Statistical Manual of Mental Disorders (5th Ed.) (DSM-5), and 38 C.F.R. § 4.130 has been revised to refer to the DSM-5. The DSM-5 does not contain information regarding GAF scores. Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders to remove outdated references to the DSM-IV and replace them with references to the DSM-5. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). VA adopted as final, without change, the interim final rule and clarified that the provisions of the final rule did not apply to claims that were pending before the Board, this Court, or the U.S. Court of Appeals for the Federal Circuit on August 4, 2014, even if such claims were subsequently remanded to the agency of original jurisdiction. See 80 Fed. Reg. 14,308 (Mar. 19, 2015). In Golden v. Shulkin, 29 Vet. App. 221 (2018), the Court held that given that the DSM-5 abandoned the GAF scale and that VA has formally adopted the DSM-5, the Board errs when it uses GAF scores to assign a psychiatric rating in cases where the DSM-5 applies. This appeal was certified to the Board in July 2019. As such, the DSM-5 applies, and the GAF scores will not be considered. Turning to the evidence, the Veteran was afforded a VA examination in January 2012. At that time, the examiner opined the Veteran's PTSD manifested in occupational and social impairment with reduced reliability and productivity. The Veteran reported that he lived alone, was divorced, and did not have any children. Most of his jobs had been in the maintenance field, but that now he had not worked and was collecting social security benefits. He had a history of drug use and was currently drinking two to three times a week in excess. The Veteran reported sleep disturbances that included interruptions to sleep, sweating at night, waking up startled, nightmares, and not feeling rested. Symptoms attributable to the Veteran's PTSD in January 2012 included depressed mood, panic attacks that occur weekly or less often, chronic sleep impairment and mild memory loss, such as forgetting names, directions, or recent events. A flattened affect, disturbances of motivation and mood, difficulty in adapting to stressful circumstances, including work or a worklike setting, an inability to establish and maintain effective relationships and frequent repetitive thoughts about finance and being alone were also noted. Other symptoms were noted to include excessive tiredness, feeling empty, numb, and non-compassionate, remembering important parts of a stressful military experience, a loss of interest in activities that he once enjoyed, feeling distant or disconnected, feeling emotionally numb and feelings of a foreshortened future. Additional symptoms were noted to include having trouble falling asleep and staying asleep, feeling irritable, having angry outbursts, having difficulty concentrating, repeated disturbing memories, thought or images of a stressful military experience from the past and repeated disturbing dreams of a stressful military experience from the past. The Veteran was afforded a VA examination in December 2012. At that time, the examiner opined the Veteran's PTSD manifested in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran reported that he did not speak to his sister and one brother following financial disputes after his mother's death, but that he spoke on the phone with one brother and that they stayed in touch via phone and the Veteran had visited him previously. The Veteran reported he loved his brother and his nieces and nephews. The Veteran reported he had some friends who lived locally and he enjoyed their company; he would see them weekly, and they enjoyed fishing and golfing. He would golf about once a month and go fishing twice a month. The Veteran described mental health problems that included nightmares occurring three to four times a month, anger, guilt, memories from Vietnam, waking up sweaty, anxious, and upset and averaging about six hour of sleep per night with interruptions and some medication. He reported feeling very alert and looking out of the window when watching TV but not knowing why, getting short with his friends, avoiding thinking about Vietnam by watching TV, playing golf, and going fishing, enjoyed being with his friends and that avoided talking about Vietnam. Other symptoms were reported to include problems with concentration on activities such as reading and watching movies, enjoyed reading the newspaper every day, talking to his brother, who was a positive influence and trying to push the negative aside. He reported he would drink alcohol with his friends on the weekend, hang out and talk with them, but that his alcohol intake was no longer a problem. He lived alone. Symptoms attributable to the Veteran's PTSD in December 2012 included a depressed mood, anxiety and chronic sleep impairment. December 2012 VA treatment records that indicate the Veteran was seen for regular mental health treatment. The Veteran discussed sadness associated with being alone, and that he may go to a local veteran services organization on Christmas for dinner. Behavioral observations showed the Veteran presented as well-groomed, casually dressed, fully oriented in all spheres, alert, pleasant and cooperative. The Veterans attention, concentration, memory, speech, and thought process and content were all found to be within normal limits with no evidence of psychosis, delusions or hallucinations. Mood was found to be euthymic, affect was found to be congruent with mood and full range of expression and appropriate to the conversation. The Veteran endorsed he would continue to socialize and walk on the beach for exercise. He indicated that he had a few friends that he would see on occasion, did not attend church but would pray every day. He endorsed suicidal ideation that was intermittent, without intent nor prior attempts. An October 2013 private psychiatric evaluation completed by Dr. J.A. was submitted. At that time, Dr. J.A. opined the Veteran's PTSD manifested in occupational and social impairment with reduced reliability and productivity. Dr. J.A. noted a complete review of the claims file was conducted. Symptoms attributable to PTSD at the October 2013 private psychiatric evaluation included a depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks and a flattened affect. Other symptoms were reported to include difficulty in understanding complex commands, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, an inability to establish and maintain effective relationships, obsession rituals which interfere with routine activities, impaired impulse control, such as unprovoked irritability with periods of violence, neglect of personal appearance and hygiene and an intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. A June 2014 VA medical opinion that indicates the October 2013 private evaluation by Dr. J.A. should be considered invalid. In this regard, the VA examiner noted that a VA examination was conducted 1.5 years prior to the October 2013 private psychiatric evaluation, that the VA examination noted the Veteran had 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 and that the evaluation by Dr. J.A. noted the Veteran demonstrated occupational and social impairment with reduced reliability and productivity. However, the June 2014 VA examiner noted that, due to the lapse in time between both evaluations and contradictory information regarding symptomatology and impairment in functioning, the two conclusions regarding occupational and social impairment could not be resolved without resorting to mere speculation and recommended the Veteran undergo another VA examination. Of record are VA treatment records from June 2014 to December 2014. During those times, the Veteran endorsed some suicidal ideations, inability to "love anymore," lived with a roommate, worked intermittently as a painter, had some friends that he socialized with on occasion, and endorsed symptoms of depression, nightmares, isolation, and sleep disturbances. Throughout this time period, the Veteran generally presented as well groomed, casually dressed, fully oriented to all spheres, alert, and with attention, concentration, memory, speech, and thought process and content within normal limits. Mood was found to be depressed and congruent affect with full range of expression, insight was found to be good, and judgment was found to be fair and somewhat motivated when participating in treatment. The Veteran was afforded a VA examination in January 2017. At that time, the examiner opined the Veteran's PTSD manifested with occupational and social impairment with deficiencies in most areas. The Veteran reported he had been separated from his wife, lived with a roommate with whom he got along "fine," was close with one brother, and had a few friends he saw socially. He reported he enjoyed playing golf and drinking with his friends. He spent time at home watching television. He would avoid social activities on occasion and engaged in religious prayer. He had been retired since 2013 and was a self-employed painter; he would still occasionally take on some jobs part time. The Veteran reported having a good reputation as a painter, but that on occasion he would have issues with customers. Symptoms attributable to his PTSD in January 2017 included a depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, such as forgetting names, direction or recent events, disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships. Behavioral observations showed the Veteran was oriented to all spheres, affect was congruent with stated mood and symptoms and he was relatively calm and responsive. Speech was normal and he maintained focus and responded appropriately to questions. There was no evidence of a formal thought disorder and judgment and insight were found to be grossly intact. Suicidal ideation was denied. The VA examiner noted that the above assessment of conflicting data was most likely largely moot at this point as three years had passed, and that psychological conditions often change in severity over time. The VA examiner noted that the above data in the January 2017 VA examination report represented the current evaluation and documentation of symptoms. A May 2017 private psychiatric evaluation conducted by Dr. J.A. was submitted. At that time, Dr. J.A. noted the Veteran was humorless, distant, terse, reticent, and would talk over him in an impatient and stubborn manner on occasion. The Veteran reported various attempts at psychiatric treatment that did not work for him, and that he was not currently treated at the present time. The Veteran described PTSD symptoms that included severe continuing unwanted memories of the event, occurring at a 7 out of 10 severity, that caused distress, and occurred about 15 times in the past month, severe recurrent distressing dreams that occurred 10 times in the past month and mild dissociative flashbacks that occurred twice in the past month. Other symptoms were reported to include moderate physical reactions to triggers that caused emotional upset, racing heart, sweating, feeling tense and shaking, that occurred four to five times in the past month, and the avoidance of people, places, events, and activities that would remind him of Vietnam. The Veteran reported difficulty remembering some parts of the event, exaggerated negative beliefs, severe suspicion, moderate distorted cognitions about cause, consequence, or blame, and severe feelings of anger, guilt, and shame, severe diminished interests or pleasure in usual activities but did report he would get together with friends and play golf, fish, or walk on the beach alone. He reported severe feelings of being distant from others, severe inability to experience positive emotions including happiness, satisfaction, love, and empathy, moderate feelings of irritability, but denied violent or destructive outbursts and severe hypervigilance. Other symptoms were reported to include severe exaggerated startle response, severe problems with concentration and focus, severe sleep disturbances, chronic onset of symptoms, severe subjective distress with significant impact in social functioning with marked impairment and few aspects of social functioning remaining and marked impairment with working. The Veteran reported PTSD symptoms severely impacted other important parts of his life, like marriage, family, interests, activities, and friendships. The Veteran denied dissociative or depersonalization symptoms but admitted to instances of derealization where reality seemed distant or distorted, that these episodes would last for about an hour, occur once or twice a month, and were described as mild. Mental status examination in May 2017 showed the Veteran presented as somewhat tentative with fair concentration, average attention span and psychomotor activity increased. Speech patterns was found to be coherent and appropriate and the ability to abstract and calculate was unimpaired and within normal limits. Affect was found to be normal. Other symptoms were reported to include emotional lability with temper problems and crying spells, chronic historic thoughts of suicide with plan but without intent, diminished energy, fatigue, anxiety, phobia of going to sleep and irritability a history of assault on others without any plans to harm others at the present time. The Veteran denied obsessions or compulsion and paranoia but reported of some auditory hallucinations, feelings that people are trying to read his mind and attempts to avert or masks his thoughts. The Veteran denied any other disturbing strange or frightening thoughts or impulses or odd things going on around him or feelings of supernatural forces or impulses. The Veteran was found to have a fair general fund of information with fair judgment and limited insight. He was found to be fairly oriented to time, place, and person with memory broadly intact, relevant associations, normal stream of thought, incessant initial insomnia with intermediate awakening, stable weight, good appetite and nightmares. In sum, Dr. J.A concluded in May 2017 that the Veteran had occupational and social impairment with deficiencies in most areas including work, family relations, judgment, thinking and mood with suicidal plans, continuous major depressive disorder with psychotic features, provoked irritability, and inability to establish and maintain effective relationships consistent with a 70 percent disability rating, that verged toward a total 100 percent disability rating. A May 2017 VA treatment record that indicates the Veteran was seen for ongoing PTSD symptoms of suicidal ideation, depression, self-medication with alcohol use, stress, and nightmares. The Veteran reported he would golf and fish to take his mind off of the PTSD symptoms and did not drink every day. He endorsed suicidal ideation on occasion, but indicated they were infrequent. He denied plans or intent. The Veteran was afforded a VA examination in August 2017. At that time, the Veteran reported that when he went somewhere he would have his back to a wall, did not like people until they gave him a reason to like him, got angry with others, and demonstrated impatience. The VA examiner opined the Veteran's PTSD manifested in occupational and social impairment with reduced reliability. The Veteran reported he was working on occasion, spent his days watching TV, tried to sleep, exercised and walking up and down ladders. The Veteran reported that his PTSD interfered with work because he would have nightmares and flashbacks that interfered with his sleep and would be too afraid to go back to sleep. He had recently lost a friend to suicide, felt judged and angry, and left his group therapy. The Veteran thought of harming himself three to four times a week and had plans for suicide without imminent intent. The Veteran reported anxiety, felt anxious on the way to his examination, experienced panic attacks with nervous and sweating, that would occur three to four times a week. Symptoms attributable to his PTSD in August 2017 included a depressed mood, chronic sleep impairment, a flattened affect, disturbances of motivation and mood, an inability to establish and maintain effective relationships and suicidal ideation. Other symptoms were reported to include impaired impulse control, suspiciousness, panic attacks that occur weekly or less often, anxiety and some slight irritability that lessened throughout the examination. The Veteran indicated he had thoughts of killing himself but would not carry out the thoughts, he was not deemed an imminent harm to himself but did not have intermittent active thoughts of self-harm. The examiner noted the Veteran had a history of past attempts at self-harm. The August 2017 VA examiner noted the Veteran's PTSD would impact his ability to work due to intrusive thoughts which interfere with the ability to stay focused on the task at hand, a significant difficulty accepting supervision or receiving instructions without becoming angry (authority conflict), a significant difficulty functioning around other people, difficulty functioning as a team member, and feeling uncomfortable around others. The examiner noted that the Veteran's sleep so disrupted that he would usually be fatigued at work, making concentration and focus on work assignments difficult and other mental health problems or symptoms, e.g. panic attacks, irritability, suspiciousness, that would interfere significantly with the ability to work, described as angry and easily irritable with others. An October 2017 private psychiatric evaluation completed by Dr. Z.G. was submitted. At that time, Dr. Z.G. opined the Veteran's PTSD manifested in occupational and social impairment with deficiencies in most areas. Dr. Z.G. noted the Veteran dropped out of high school and did not complete college or technical school of any kind. He trained in helicopter maintenance in the military. At his October 2017 private psychiatric evaluation, the Veteran reported his roommate began as a live-in girlfriend but that they are no longer intimate because he did not want a relationship and did not want to hurt someone. His reported work history included "bouncing from job to job," as an electrician, and explained that he had a lot of difficulty working for different people. Eventually, the Veteran started his own painting company and still did odd jobs on occasion when he felt well enough to do so. He reported he had previously taken medication to treat his nightmares, depression, and sleep disturbances, but was not currently taking medication. He avoided crowds because they triggered bad memories, had frequent nightmares related to his combat experiences, emotional numbness, and difficulty being around other people. He endorsed difficulty responding with appropriate emotions, crying spells for no reason, and would see silhouettes out of the corner of his eyes on occasion. Mental status examination in October 2017 showed that the Veteran presented as oriented to all spheres, calm and cooperative with clear and concise speech. Affect was found to be congruent with mood, calm and appropriate, thought process was found to be intact, thought content was found to be logical, and perception was found to be normal. Judgment was found to be intact, insight was found to be good and appetite was found to be decreased. The examiner noted that there was a heightened risk of suicide, suicidality, with a lot of suicidal ideation and plan, but unsure about his intent, homicidally only when provoked and "ok" ability to care of himself. Symptoms associated with his PTSD in October 2017 included a depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, and mild memory loss, such as forgetting names, directions or recent events. Affect was found to be flattened with speech intermittently illogical, obscure, or irrelevant. The provider noted that the Veteran had difficulty in understanding complex commands, impaired judgment, disturbances of motivation and mood, 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 maintaining effective work and social relationships and difficulty adapting to stressful circumstances, including work or a worklike setting. The provider noted that there was an inability to establish and maintain effective relationships, suicidal ideation, impaired impulse control, such as unprovoked irritability with periods of violence, spatial disorientation, an intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene and mild visual hallucinations. Dr. Z.G. concluded that the Veteran's PTSD impaired his functioning across all environments, and most closely approximated a 70 percent rating. Dr. Z.G. opined that it was not recommended for the Veteran to attempt to work a regular work position due to suicidality, mild visual hallucinations, and flashbacks that made him a liability in a work environment. Dr. Z.G. opined the Veteran had occupational and social impairment with deficiencies in most areas and had difficulties with family relationships, judgment, thinking, mood, with suicidal ideation, anxiety, paranoia, and hypervigilance. Dr. Z.G. further noted the Veteran had difficulty functioning at work and getting along with others, and had difficulty adapting to stressful situations. An October 2021 private psychiatric evaluation completed by Dr. D.D. was submitted. At that time, Dr. D.D. noted the Veteran's PTSD symptoms included guilt, nightmares, impaired sleep, fear, depression, substance abuse, paranoia and an altered view of the world as extremely dangerous. Dr. D.D. noted the symptoms persisted and resulted in one attempted suicide. The Veteran reported he continued to experience nightly nightmares, continued to abuse alcohol, slept poorly, checked his windows and doors throughout the night, had anger, suspicious of others and had few friends. He was divorced and believed his divorce was as a result of his psychological difficulties. The Veteran was unable to hold down regular employment following separation from active service due to anger and avoidance of others, and he eventually settled on work as a painter that he could perform in a solitary manner for 25 years. He reported he last worked five years prior until he was physically unable to perform his work. The Veteran spent his days alone at home watching TV and lived in a "psychologically dark and lonely space." Dr. D.D. noted the Veteran graduated high school. Behavioral observations in October 2021 showed the Veteran presented as spontaneous in verbalizations, oriented, coherent in thoughts and verbalizations, memory for recent events was poor while long-term memory was intact, poor concentration, premorbid intelligence judged to be average, overall compromised mental status and denied psychotic thinking by way of delusions or hallucinations. His mood was significantly depressed. The Veteran reported poor sleep, low productivity, and social isolation. His insight was impaired, judgment was poor, and social skills were poor. Dr. D.D. found that the Veteran's PTSD symptoms severely affected his ability to function, and that he experienced significant occupational and social impairment as the Veteran could not socially interact effectively. His mental status was compromised and his fear and anxiety were palpable. His psychiatric symptoms were responsible for his inability to perform occupational duties on a full-time basis. Dr. D.D. concluded that the Veteran's PTSD experienced occupational and social impairment due to symptoms such as nightmares, fear, anxiety, suicidal ideation and depression. Dr. D.D. noted that his symptoms and poor functioning had remained stable since 2012 and noted that the Veteran was precluded from full-time employment due to unlikely ability to maintain concentration for more than 20 percent of an eight hour workday, and difficulty relating to others and maintaining a schedule. Dr. D.D. opined that the Veteran would be unable to return to competitive employment. The Board notes that a review of the record shows that the Veteran has received treatment for his PTSD from both VA Medical Centers and private providers. However, there is no indication from the record that the Veteran's symptoms are worse than those reported in the various records discussed above. Based on the foregoing, and resolving all doubt in favor of the Veteran, the Board finds that the Veteran is entitled to an initial rating of 70 percent, but not higher, for his PTSD throughout the period on appeal. In this regard, the Board notes that the Veteran had occupational and social impairment with deficiencies in most areas, but not total occupational and social impairment. Impairment to mood was demonstrated as the Veteran consistently reported anxiety and depression. Impairment to thinking was demonstrated as the Veteran endorsed some auditory and visual hallucinations on occasion and admitted to instances of derealization where reality seemed distant or distorted. Some impairment to family relations was demonstrated as the Veteran endorsed having only a few friends whom he saw on occasion, being close with only one brother, and not having stable romantic relationships. Significantly, his female roommate was a former live-in girlfriend, but he could not maintain that relationship due to symptoms of emotional numbing and feelings of an inability to love others, the Veteran reported he would have angry outbursts with his roommate on occasion. In addition, the Veteran endorsed suicidal ideation, that consistently worsened in frequency and manifested with one suicide attempt with concrete plans. At his August 2017 VA examination, the Veteran indicted suicidal ideation, with intermittent active thoughts of self-harm, with a history of past self-harm. Therefore, occupational and social impairment with deficiencies in most areas was demonstrated. However, throughout the period on appeal, the Board also finds that the Veteran is not entitled to a rating in excess of 70 percent for PTSD. In this regard, the Board notes that the Veteran does not have total occupational and social impairment as a result of his PTSD. Total social impairment was not demonstrated as the Veteran maintained a relationship with his brother, his roommate and a few friends. The record does not reflect, and the Veteran has not alleged, gross impairment in thought processes or communication, grossly inappropriate behavior and an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene. Although the Veteran endorsed suicidal ideation, with passive thoughts of dying, there is no evidence of record that the Veteran was found to be a persistent danger to herself or others. Further, there is no indication from the record that the Veteran experienced significant delusions or hallucinations that interfered with orientation to person, time, or place. Rather, the Veteran consistently presented as oriented to all spheres. There was some indication from the record that the Veteran was unable to maintain his personal hygiene as a result of his PTSD. However, on examination and at his mental health treatment appointments, the Veteran consistently presented with adequate hygiene. Therefore, a rating in excess of 70 percent is not warranted at any time. 38 C.F.R. § 4.130, Diagnostic Code 9411. While the Board recognizes that the Veteran is competent to provide statements regarding his observable symptomatology, he is not competent to provide an opinion regarding the severity of her symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Rather, the Board finds the medical evidence in which professionals with medical expertise examined the Veteran, acknowledged his reported symptoms, and described the manifestations of such disability considering the rating criteria to be more persuasive than the Veteran's reports regarding the severity of his condition. Despite the foregoing, the Board acknowledges the Veteran's assertions that his various symptoms and functional impairments warrant a higher rating. However, even after considering such contentions as to the effects of the disability on his daily life, the Board finds that the criteria for a higher rating are not met. The Rating Schedule contemplates such impairment under the ordinary conditions of daily life. 38 C.F.R. § 4.10; see also Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). The Board has considered whether staged rating under Fenderson v. West, supra is appropriate; however, the Board finds that his symptomatology was been stable throughout each period on appeal. Therefore, assigning staged ratings is not warranted. The Veteran nor his representative have not raised any other issues, nor have any other issues been reasonably raised by the record in regard to the increased rating claim adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Accordingly, the Board finds the evidence supports the assignment of an initial 70 percent rating, but not higher throughout the period on appeal. To that extent, the appeal is granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND Entitlement to a TDIU The Veteran asserts that he is entitled to a TDIU. Specifically, he contends that he is unemployable as a result of his service-connected PTSD. See Board hearing transcript, August 9, 2021. In the instant case, as of the date of this decision, service connection is currently in effect for PTSD rated as 70 percent disabling from November 16, 2011; status post gunshot wound, right foot with degenerative joint disease involving the metatarsophalangeal joint of the right second toe, rated as 10 percent disabling from September 27, 1972; tinnitus, rated as 10 percent disabling from November 20, 2012; and bilateral hearing loss rated as noncompensable from November 20, 2012. Thus, the schedular criteria for a TDIU have been met throughout the period on appeal. In support of his claim, the Veteran submitted a Veterans Application for increased Compensation Based on Unemployability (VA Form 21-8940) in July 2017. At that time, the Veteran indicated his PTSD prevented him from securing of following substantially gainful occupation. However, at that time, he indicated he was still currently self-employed and did not have a high school diploma. Having carefully reviewed the evidence, the Board finds that remand is necessary to attempt to obtain outstanding VA and private treatment records as well as employment records. 38 C.F.R. § 3.159(c). The record is unclear as to when the Veteran became too disabled to maintain substantially gainful employment and the record is unclear as to his employment history and educational history. Significantly, the above clinical evidence on occasion indicates the Veteran either last worked in 2016 or 2017, is unclear as to the nature and duration of the work, and whether such employment is substantial for VA purposes. The Veteran reported he worked part-time but the record is unclear as to when he was no longer gainfully employed. Additionally, the Veteran indicated on occasion that he graduated from high school and at other times he dropped out. As noted above, the record is unclear regarding the Veteran's employment and education history. This information is relevant to the issue of entitlement to a TDIU and accordingly is necessary for the Board to render a decision on the Veteran's claim. On remand, the RO is directed to obtain any employment records available and to obtain an updated VA Form 21-8940. The matters are REMANDED for the following action: 1. Contact the Veteran to obtain information regarding his employment history and the dates of such employment. Ask him to provide a complete and accurate listing of his employers and dates of employment during the period on appeal, to complete an updated VA Form 21-8940 and to complete a VA Form 21-4192 (Request for Employment Information in Connection with Claim for Disability Benefits) as relevant. (Continued on the next page) 2. After completing the above, to include any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs (to include consideration of whether additional examination is required), the Veteran's claim should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mariah N. Sim, 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.