Citation Nr: A24027167 Decision Date: 05/23/24 Archive Date: 05/23/24 DOCKET NO. 210120-136754 DATE: May 23, 2024 ORDER Entitlement to a total disability rating based on individual unemployability (TDIU) is dismissed. Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to post traumatic stress disorder (PTSD), is granted. The reduction in disability evaluation assigned for PTSD from 70 percent to 50 percent effective January 1, 2021, was proper; the appeal is denied. FINDINGS OF FACT 1. In May 2021, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran, through his representative, that a withdrawal of the issue of entitlement to TDIU is requested. 2. Resolving reasonable doubt in the Veteran's favor, his OSA is caused or aggravated by his PTSD. 3. The October 2020 rating decision reducing the Veteran's compensation for PTSD to 50 percent effective January 1, 2021, was based on an actual improvement in the Veteran's PTSD. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the issue of entitlement to TDIU have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.205. 2. The criteria for service connection for OSA have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. The reduction of the disability rating for PTSD from 70 to 50 percent, effective January 1, 2021, was proper. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.105, 3.344, 4.104, Diagnostic Code (DC) 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1969 to November 1970. The rating decisions on appeal were issued in August 2020 for entitlement to TDIU, September 2020 for entitlement to service connection for OSA, and October 2020 for the reduction in disability rating for PTSD. In January 2021, the Veteran opted into the Appeals Modernization Act (AMA) review system by filing VA Form 10182, Decision Review Request: Board Appeal. The Veteran selected the "Evidence Submission" lane. This allowed him 90 days to submit pertinent evidence. He acknowledged that his appeal would be based on all evidence submitted to VA as of 90 days after the date of that election. The Board cannot hold a hearing or accept into the record additional evidence in its review. As discussed below, based on the Veteran's May 2021 written statement withdrawing the issue of entitlement to TDIU, the Board is dismissing the issue from this docketed appeal. However, in August 2021, the Veteran submitted a separated timely VA Form 1082 disagreeing with the TDIU denial. As such, the issue of entitlement to TDIU is on appeal under a separate docket number and will be addressed in another Board decision. Dismissal The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.205. Withdrawal may be made by the appellant or by his or her authorized representative. Id. In a May 2021 written statement, the Veteran, through his representative, withdrew the claim for entitlement to TDIU from this docketed appeal. Hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, it is dismissed. As noted above, a separate appeal for TDIU arising from a different 10182 remains before the Board. 1. Entitlement to service connection for OSA, to include as secondary to PTSD A veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in the line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty in active service. 38 U.S.C. §§ 1110, 1131. Service connection may also be established for any disability which is proximately due to or the result of a service-connected disease or injury. See 38 C.F.R. § 3.310. In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Service connection may be granted for disability shown after service, when all the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § 4.3. A claim will be denied only if the evidence is persuasively against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Analysis The Veteran contends that his OSA is secondary to his service-connected PTSD. The Veteran has a current diagnosis of OSA. As such, element one under Wallin is met. The Veteran is service connected for PTSD. As such, element two under Wallin is met. As discussed below, the Board is granting service connection based on secondary service connection. Therefore, the Board finds it is unnecessary to discuss any other theory of entitlement. In September 2019, the Veteran was afforded a VA examination to determine the nature and etiology of his disability. The Veteran's condition began in March 2007. He stated that he fell asleep and began snoring at work. He was taken to the hospital and resigned because he could not stay up at work. The examiner confirmed the Veteran's OSA diagnosis. The examiner opined that the claimed condition is less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. After reviewing the medical records, the examiner opined that the claimed condition of sleep apnea is less likely as not proximately due to military service. The examiner stated that the medical records were silent for sleep apnea and no c/o respiratory condition or complications were noted during service. The examiner confirmed the Veteran's PTSD diagnosis. The examiner stated that there is no mention of c/o respiratory condition until many years after military service. In August 2020, VA obtained an addendum opinion to determine the nature and etiology of the Veteran's OSA. The examiner opined that the Veteran's OSA is less likely than not (less than 50 percent probability) proximately due to or the result of his service-connected condition. The examiner stated that research has shown that veterans with PTSD may be at risk for sleep apnea. There are factors that overlap in both disorders which affect and aggravate each other. Some of these factors are issues that veterans may have experienced in active duty, such as disturbed sleep in combat, excessive sleep deprivation, fragmented sleep, hyperarousal, and chronic stress. Although all of these symptoms contribute to the interaction between sleep apnea and PTSD, the main culprits seem to be sleep deprivation and chronic stress. Studies have shown that patients exhibiting these symptoms tend to have increased frequency and length of apneic events. Research has also shown that as the severity of PTSD increases in a person, the chances of developing sleep apnea increase as well because of the interplay between the shared factors of the two disorders. Sleep apnea and other mental illness are also associated with each other. The examiner stated that sleep apnea and PTSD are associated but there is no definitive evidence that PTSD is a nexus for sleep apnea. As such, it is less likely than not that the Veteran's sleep apnea is proximately due to his PTSD. In March 2021, the Veteran submitted a statement from M.L.C., MD. The examiner stated that there is a distinct clinical correlation between PTSD and OSA, especially in veterans with PTSD. The medical literature has a plethora of articles regarding the clinical correlation between PTSD and OSA. A perusal of this research reveals that the probability of having a high risk for OSA increases with the severity of PTSD symptoms. This clinical scenario is specifically representative of the Veteran's clinical condition. One study relevant to the Veteran's clinical condition involved 195 veterans who visited a VA outpatient PTSD clinic for evaluation. Of the veterans, such as this Veteran, who were seen for PTSD in outpatient clinics, 69.2 percent had a high risk of sleep apnea, which increased with PTSD symptom severity. Therefore, the Veteran's progressively more severe symptoms of PTSD are more likely than not to have increased his risk for OSA. Based on the evidence of record, the Board finds that the evidence is at least evenly balanced as to whether the Veteran's OSA was caused by his service-connected PTSD. While the August 2020 examiner opined that the Veteran's OSA is less likely than not proximately due to or the result of his service-connected condition, the examiner also noted that research has shown that veterans with PTSD may be at risk for sleep apnea. The examiner stated that although all of the symptoms that were listed contribute to the interaction between sleep apnea and PTSD, the main culprits seem to be sleep deprivation and chronic stress which veteran's experience in service. Studies have shown that patients exhibiting these symptoms tend to have increased frequency and length of apneic events. The examiner added that there are factors that overlap in both disorders which affect and aggravate each other. The examiner also noted that research has shown that as the severity of PTSD increases in a person, the chances of developing sleep apnea increase as well because of the interplay between the shared factors of the two disorders. The Board also notes that the private physician cited medical literature which reflected a strong correlation between OSA and PTSD. The private examiner provided a thorough rationale to support his opinion based on an accurate characterization of the evidence of record, thus his opinion is afforded significant probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Therefore, the evidence is at least evenly balanced as to whether the Veteran's OSA was caused by his service connected PTSD. As reasonable doubt must be resolved in the Veteran's favor, entitlement to service connection for OSA, to include as secondary to service-connected PTSD is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Propriety of the reduction In general, prior to reducing a veteran's disability rating, VA is required to comply with pertinent VA regulations applicable to all rating reduction cases, regardless of the rating level or the length of time that the rating has been in effect. When reduction in the rating of a service-connected disability is contemplated and the lower evaluation would result in a reduction or discontinuance of compensation payments, a rating decision proposing the reduction or discontinuance will be prepared setting forth all material facts and reasons. The beneficiary must be notified at his or her latest address of record of the contemplated action and furnished detailed reasons thereof. The beneficiary must be given 60 days for the presentation of additional evidence to show that compensation payments should be continued at the present level. 38 C.F.R. § 3.105(e). In the advance written notice, the beneficiary will be informed of his or her right for a pre-determination hearing, and if a timely request for such a hearing is received (i.e., within 30 days), benefit payments shall be continued at the previously established level pending a final determination. 38 C.F.R. § 3.105(i)(1). Under the additional rating reduction rules of 38 C.F.R. § 3.344, sections (a) and (b) apply to cases in which an evaluation has continued at the same level for five years or more; section (c) applies when an evaluation has been in effect for less than five years. For ratings that have been in effect for less than 5 years, as is the case here, reexaminations disclosing improvement in the disability will warrant reduction in rating. See 38 C.F.R. § 3.344(c). Nevertheless, general substantive requirements that apply to all rating reductions, notwithstanding how many years the rating has been in effect. In any rating reduction case, not only must it be determined that an improvement in a disability has actually occurred, but also that the improvement actually reflects an improvement in the Veteran's ability to function under the ordinary conditions of life and work. Brown v. Brown, 5 Vet. App. 413, 421 (1993). Also, a reduction must be based on the review of the entire history of the Veteran's disability. Id. When a reduction is effectuated without following the applicable regulations, to include procedural and substantive provisions, the reduction is void ab initio. See Greyzck v. West, 12 Vet. App. 288, 292 (1999). Analysis By way of history, in an August 2019 rating decision, the agency of original jurisdiction (AOJ) granted service connection for PTSD and assigned a 70 percent rating. In March 2020, the Veteran filed a claim for TDIU. While the Veteran did not specifically claim entitlement to an increased rating for his PTSD, due to the claim for a TDIU, he was scheduled for an examination. In an August 4, 2020, rating decision, the AOJ noted that the Veteran's disability had improved. The AOJ proposed to reduce the rating assigned from 70 percent to 30 percent disabling. The letter informed the Veteran that he could submit evidence that showed worsening of the disability. The letter explained that this evidence could be a statement from a physician with detailed findings about his condition. He was also notified that he could request a personal hearing so that he could provide testimony on this matter. He was further informed that, if he did not request a hearing or submit additional evidence within 60 days, the AOJ would decide the claim based on the evidence of record. In a letter dated October 6, 2020, the Veteran stated that his PTSD symptoms had not improved, but had in fact, worsened. He stated that he had both suicidal and homicidal ideation that had become so intense and frequent, his family members were staying with him around the clock to ensure his safety. He also stated that his nightmares had increased to at least three nights per week. Additionally, while sleeping, he had become so violent that he grabbed his girlfriend by her neck and began screaming about killing someone. He stated with the increased stress of today's societal climate, he experienced panic attacks multiple times per day and flashbacks approximately three to four times per week. He added that his depression had spiraled out of control, he was in a constant state of hopelessness, and it was hard for him to force himself out of bed. It had gotten to a point where he was unable to motivate himself to get the newspaper, and his girlfriend had to take it to his bed. He reported feeling persistent anxiety at the idea of facing the world and was unable to motivate himself to perform basic tasks such as showering. His girlfriend had to intervene. He also noticed his hypervigilance had increased, and he could hardly stand being around other people. He reported having a difficult time in public spaces and became too anxious and had to exit social settings. He spent more time in isolation than ever before, even with family around. He felt safest alone. The Veteran also became extremely irritable around people. He stated that he got into an argument with his sister, and he slapped her. One day, while at the grocery store, he was hit with a grocery cart, and he felt like it was done on purpose. He got into an altercation, and the store security had to intervene as the argument escalated. He stated that he was just unable to keep his cool when the situation arises. In an October 9, 2020, rating decision, the AOJ reduced the disability rating from 70 percent to 50 percent disabling, effective January 1, 2021. The AOJ stated that the overall evidentiary record showed that the severity of the Veteran's disability most closely approximates the criteria for a 10 percent disability evaluation. However, the AOJ reduced the evaluation to 50 percent to conform to the general policy of gradual reduction to afford the Veteran all possible opportunities for adjustment. On his January 2021 VA Form 10182, Notice of Disagreement, the Veteran disagreed with the reduction of his PTSD rating from 70 to 50 percent. The reduction of the rating for the Veteran's PTSD decreased his overall rating from 80 to 60 percent. As noted above, when reduction in the rating of a service-connected disability is contemplated and the lower evaluation would result in a reduction or discontinuance of compensation payments, a rating decision proposing the reduction or discontinuance will be prepared setting forth all material facts and reasons. In this case, in August 2020, the AOJ properly issued a rating decision proposing to reduce the rating from 70 to 30 percent. 38 C.F.R. § 3.105(e). The Veteran was notified of the proposed reduction. The notification letter advised the Veteran that he had 60 days from the date of the letter to submit additional evidence and the right to obtain a predetermination hearing by request submitted within 30 days of the letter. The Veteran did not request a predetermination hearing, and 60 days elapsed between the August 2020 notification of proposed reduction and October 2020 reduction. Therefore, the procedural requirements for reduction of the rating for the Veteran's PTSD have been met. 38 C.F.R. § 3.105(i)(1). The Board notes that the 70 percent rating for the Veteran's PTSD was in effect from June 28, 2018, to October 9, 2020. Because the rating was in effect for less than 5 years, the provisions of 38 C.F.R. § 3.344(c) apply. Under that provision, reexaminations disclosing improvement, physical or mental, in the disability will warrant reduction in rating. At the time of the reduction, the Veteran's disability was rated under DC 9411. Diagnostic Codes 9411 is subject to the criteria listed under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. Under the General Formula, a 50 percent is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and/or difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family 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 work-like setting); inability to establish and maintain effective relationships. A 100 percent evaluation is warranted for total occupational and social impairment, due to symptoms such as the following: 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. 38 C.F.R. § 4.130. In August 2019, and February, March, and June 2020, the Veteran was seen at the S. Prince George City VAMC for his PTSD and persistent depressive disorder, moderate. In August, his targeted symptoms included irritability, anxiety, and insomnia. He stated that things were going well, he felt pretty good, his mood was stable, he volunteered with VA a few hours a week, and he started up the MOVE program. He stated that his sleep had improved. He denied auditory and visual hallucinations, suicidal and homicidal thought, intent, and plan. The Veteran's grooming and hygiene were appropriate. He was calm and cooperative. His eye contact was fair. He was alert and oriented times three. His attention and concentration were fair. His fund of knowledge was appropriate. The examiner noted no psychomotor agitation or retardation, tremor, or abnormal movements. The Veteran's affect was euthymic, reactive. His speech was of regular rate and rhythm, his volume was normal, tone was euthymic, and relevant. His language was of good vocabulary, syntax, and grammar. His thought processes were organized, linear, and goal directed. The examiner noted no flight of ideas (FOI) or looseness of association (LOA). The Veteran reported no delusions, and none were elicited. No overvalued ideas/obsessions/ compulsions were evidenced. He also had no negative thinking. The Veteran denied auditory, visual, gustatory, olfactory, or tactile (AVTOG) hallucinations, and he did not seem to respond to internal stimuli during the interview. His insight and judgment were fair. In February 2020, the Veteran complained of poor sleep. His attire was appropriate. His cognitive functioning was intact. He made good eye contact. The Veteran had no tics or tremors. His mood was euthymic, and his affect was mood congruent. His speech was normal in rate, tone, and volume. His thought processes were linear and goal directed. The Veteran's insight and judgment were fair. He denied suicidal and homicidal ideation, intent or plan, and auditory or visual hallucinations/TH. Also in February, the Veteran was seen for a physician therapy consult complaining of left groin pain. The Veteran reported, prior to the accident, he was independent in activities of daily living (ADLS), mobility, driving and working. In March 2020, the Veteran's mood was stable, and he had no suicidal ideation. He denied auditory and visual hallucinations and delusions. He was calm and cooperative, alert, and oriented times three. His speech was coherent, the rate and volume were normal, and tone was euthymic. His thought processes were organized, linear, and goal directed. There was no evidence of delusions, obsessions, or suspicious thought. He denied auditory/visual hallucinations. He denied suicidal and homicidal thought, intent, or plan. His insight and judgment were fair and intact. In June 2020, the Veteran stated that for the most part, things had been stable; he reported some increase in nightmares and trouble sleeping, but otherwise, he was doing well. The Veteran's mood was stable, and he rated it at 6/10. He was calm and cooperative, alert, and oriented times three. His speech was coherent, the rate and volume were normal, and the tone was euthymic. The Veteran's thought processes were organized, linear, and goal directed. There was no evidence of delusions, obsessions, or suspicious thought. He denied AVGOT hallucinations, and suicidal and homicidal thought, intent, or plan. His insight and judgment were fair and intact. The Veteran stated that the half-way house he was working at part-time closed; however, he reported doing some telehealth peer-therapy sessions with some clients. He stated that he hoped a half-way house opened up in fall 2020, but he may just remain doing telehealth sessions with clients. In July 2020, the Veteran was afforded a VA examination to determine the severity of his disability. At the time of the exam, the Veteran lived with his 28 year old son. He was married two times; however, both wives passed away. He did have a fiancée of 11 years. The Veteran had two master's degrees and worked as a therapist for 30 years. The examiner confirmed the Veteran's PTSD diagnosis. He did not have more than one mental disorder diagnosed. At the time of the exam, the Veteran was alert and fully oriented and cooperative. He was dressed appropriately for the weather and sat without pain or discomfort. He was well groomed and well nourished. The Veteran's mood was not depressed or anxious, and his affect was of full range. His speech was coherent, relevant, and without thought disorder. His thought processes were logical and goal directed. There was no evidence or report of delusions or hallucinations. The Veteran was alert and oriented to time, place, and person. His memory for recent/remote events and attention were intact. His insight and judgment were fair. The Veteran denied current suicidal or homicidal ideation. His symptom included chronic sleep impairment. He did not have any other symptoms attributable to his PTSD. He was capable of managing his financial affairs. His symptom resulted in occupational and social impairment due to mild or transient symptom which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. In September 2020, the Veteran was seen at a VAMC Mental health department for PTSD and persistent depression disorder. His mood was more depressed, and his affect was depressed. The Veteran was calm and cooperative. He was alert and oriented times three. His speech was coherent, and the rate and volume were normal, his tone was euthymic. His thought processes were organized, linear, and goal directed. There was no evidence of delusions, obsessions, or suspicious thought. He denied auditory, visual, and tactile hallucinations. At the time of the exam, he had no suicide ideation. His insight and judgment were fair/intact. He denied alcohol or substance abuse. During the exam, the Veteran reported an increased in his stress levels which was related to his financial situation which triggered an increase in depression and suicidality. He reported having "really thought about [ending his life] a few weeks ago" but denied taking any steps to act on these thoughts in recent weeks or at other points in his life and denied any prior suicide attempts. In March 2021, the Veteran submitted a statement from M.L.C., MD. The examiner reviewed the Veteran's medical and service records, VA examination, lay statements, and conducted a clinical interview. The examiner confirmed the Veteran's PTSD diagnosis with dissociative symptoms, with delayed expression. The examiner stated that the Veteran would also meet the criteria for a substance use disorder, including alcohol, cocaine, and cannabis, all of which were in remission. The examiner stated that the Veteran had remarkably severe psychiatric illness associated with being physically and sexually assaulted while on active duty. During the exam, the Veteran made fair eye contact and impulse control. His appearance was somewhat disheveled, hair uncombed, unshaven, and he indicated that he forgot to insert his dentures. His speech was normal in rate, tone, and volume. His mood was "depressed," and his affect was consistent with his mood. The Veteran endorsed passive suicidal ideation. During the interview, the Veteran stated that he was extraordinarily close, on several occasions, to ending his life due to the constant shame, guilt, hopelessness, despair, and anger that he lived with for decades. He did not articulate any homicidal ideation and expressed no delusions or illusions. His thought processes were linear and logical. There was no evidence of looseness of associations or flight of ideas. He denied perceptual alterations, such as auditory, visual, or tactile hallucinations. The Veteran was cognitively intact. The examiner noted that the Veteran had recurrent distressing dreams in which the content and/or affect of the dream were related to the traumatic event; dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event were recurring; and intrusive distressing memories of the traumatic event. The Veteran became an extraordinarily avoidant individual regarding anything associated with intimate interpersonal interactions, militaristic activity, media accounts of physical or sexual assault, and similar subjects. He presented as extraordinarily negativistic, lived in a negative emotional state, and did not participate in pleasurable activities. During the interview, he did not display anything suggestive of a positive emotional response. Since being assaulted, the Veteran had been irritable, hypervigilant, had difficulty with focus and concentration, and manifested an escalated startle response. He manifested this constellation of symptoms for decades, and the symptoms were not associated with any other disease process. The examiner stated that there is no question that since 2018, the Veteran has manifested the full constellation of PTSD symptomatology as noted above, without evidence of remission in fifty years. The Veteran's symptoms of PTSD progressed unfettered, leading to severe neurovegetative symptoms of depression, active suicidal ideation, failed intimacy, poor occupational performance, social isolation, reclusiveness, and extensive despair. The Veteran, by his own words, "never returned from being assaulted "and lived a "shadow life" that was marked by severe social isolation, fear, hopelessness, despair, and the inability to find his place in society. The Veteran was unable to adapt to civilian life and attempted to create a facsimile of a normal existence but could not do so because of his complete incapacity to participate in interpersonal relationships and engagement in society. The Veteran struggled with any type of focus and concentration and was now enveloped by PTSD and the onslaught of symptoms associated with being physically assaulted and raped. The Veteran is trapped in a vicious cycle of intrusive memories, dissociative episodes, and nightmares affecting every sphere of his life. The Veteran struggled to complete his instrumental activities of daily living and other basic and prosocial activities. From 2018 through the current day, the Veteran continues to struggle even in a protected occupational setting, having difficulty managing appropriate, reasonable, consistent and focused interpersonal interactions in conjunction with task completion. The VA examiner who suggested the Veteran's severity of disease had diminished from June 2018 to January 2021 is incorrect, and the interview with the Veteran indicates no remission in his symptomatology. During the interview, simply going through the criteria for PTSD revealed the continued presence of intense symptomatology. At times, the Veteran used denial and avoidance as a mechanism to minimize his symptoms, but they are, nevertheless, present at a continuing level of high intensity. Based on the evidence of record, the Board finds that the decision to reduce the Veteran's evaluation for PTSD from 70 percent to 50 percent was proper. Here, the Veteran endorsed passive suicidal ideation, which correlates to a 70 percent rating. However, the overall nature, frequency, and severity of his symptoms have not risen to the level of a 70 or even a 50 percent rating. During his March 2021 interview, the examiner stated that the Veteran was disheveled, hair uncombed, unshaven, and indicated forgetting to insert his dentures; but, prior to that evaluation, it was consistently noted that the Veteran was appropriately groomed, and his hygiene was also appropriate. All examiners, including the March 2021 examiner, noted that the Veteran's speech was of regular rate and rhythm, and his volume was normal. The Veteran's VA examiners noted that he was calm and cooperative, alert, oriented times three or four, and he was capable of managing his financial affairs. All examiners, including the 2021 examiner, noted that the Veteran's thought processes were organized, linear, and/or goal directed with no evidence of delusions, obsessions, and/or hallucinations, and he denied homicidal thoughts, intent, or plan. The VA examiners noted that the Veteran's cognitive functioning was intact, and his insight and judgment were fair and intact. Additionally, throughout the period on appeal, the Veteran's symptoms included anxiety, chronic sleep impairment, depressed mood, and suspiciousness, which all correlate to a 30 percent rating. During his 2021 interview, the examiner stated that the Veteran had been irritable, hypervigilant, had difficulty with focus and concentration, manifested an escalated startle response, had struggled with focus and concentration, and was unable to adapt to civilian life and attempted to create a facsimile of a normal existence but could not do so because of his complete incapacity to participate in interpersonal relationships and engage in society. The 2021 examiner added that the Veteran struggled with any type of focus and concentration and was now enveloped by PTSD and the onslaught of symptoms. However, during the period on appeal, the Veteran's son resided with the Veteran in the Veteran's home, the Veteran was able to maintain an 11 year relationship with his girlfriend, and he was able to volunteer and later obtained a position at VA counseling clients. Additionally, the Veteran was independent in ADLS, mobility, driving, and working. In other words, the description/symptoms listed above by the March 2021 examiner did not prevent the Veteran's ability to function under the ordinary conditions of life and work. Therefore, the Board finds the evidence persuasively weighs against restoration of the 70 percent rating. Here, the evidence, to include records spanning many years, indicates the Veteran's PTSD has demonstrated sustained improvement, not simply periods of short-lived improvement. Thus, the Board finds the reduction to be proper, and the appeal is denied. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Moore, T. 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.