Citation Nr: A24029723 Decision Date: 06/06/24 Archive Date: 06/06/24 DOCKET NO. 191224-103033 DATE: June 6, 2024 ORDER Entitlement to a 70 percent rating, but no higher, for post-traumatic stress disorder (PTSD) during the period prior to June 29, 2018, and to a 50 percent rating, but no higher, thereafter is granted. FINDINGS OF FACT 1. During the period prior to June 29, 2018, the severity, frequency, and duration of the Veteran's PTSD symptoms were characterized by occupational and social impairment with deficiencies in most areas but did not more closely approximate total occupational and social impairment. 2. During the period from June 29, 2018, the severity, frequency, and duration of the Veteran's PTSD symptoms were characterized by occupational and social impairment with reduced reliability and productivity but did not more closely approximate occupational and social impairment with deficiencies in most areas. CONCLUSION OF LAW The criteria for a 70 percent rating, but no higher, for PTSD during the period prior to June 29, 2018, and to a 50 percent rating, but no higher, thereafter have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty in the United States Air Force from May 2004 to July 2006 and in the United States Army from July 2006 to October 2010. The rating decision on appeal was issued in April 2019 and constitutes an initial decision; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies. In the December 2019 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held in January 2024. Therefore, the Board may only consider the evidence of record at the time of the April 2019 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or his representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801. If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. The Veteran testified at a hearing held in January 2024 before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims file. Entitlement to a 70 percent rating for PTSD during the period prior to June 29, 2018, and to a 50 percent rating thereafter. The Veteran is currently assigned a 30 percent rating for PTSD during the entire period on appeal. He contends, as stated by his attorney during the January 2024 hearing, that he is entitled to at least a 50 percent rating for PTSD due to the severity of his symptoms. The Board finds that an increased, staged rating is warranted in this case. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where, as in this Veteran's case, the question for consideration is the propriety of the initial rating assigned, evaluation of the evidence since the effective date of the grant of service connection is required. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Where VA's adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or "staged" ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson, 12 Vet. App. at 126-27. Ratings are assigned according to the manifestation of symptoms, but the use of the term "such as" in the General Rating Formula demonstrates that the symptoms after the phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Neither the number of symptoms nor the type of symptoms controls in determining whether the criteria for the next higher rating have been met. It is the effect of the symptoms, rather than the presence of symptoms, pertaining to the criteria for the next higher rating, that is determinative, and the Board must draw fact-based conclusions as to whether those symptoms, and their severity, frequency, and duration, have caused the level of occupational and social impairment associated with a rating. Bankhead v. Shulkin, 29 Vet. App. 10 (2017). The presence of suicidal ideation alone conceivably might cause occupational and social impairment with deficiencies in most areas, consistent with a 70 percent rating. Bankhead, 29 Vet. App. at 19. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case, and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (benefit-of-the-doubt rule not for application when evidence persuasively favors one side or the other). In this case, during the entire period from the March 1, 2013, effective date of the grant of service connection for PTSD to the April 2019 rating decision on appeal, the Veteran's PTSD has been rated at 30 percent disabling under DC 9411, which rates PTSD under the General Formula for Mental Disorders. Under DC 9411, a 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause 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 normal conversation). A 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such 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 worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for 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; or memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.310, DC 9411. The Veteran reached out to the VA Crisis Center in April 2013 and exchanged text messages with a counselor. He stated that, when he was in the Army, he had been part of a high tempo unit that completed more than 300 combat missions during a 15-month deployment. Now he felt numb, like he was on auto-pilot and his switch for emotions had been turned off. Even though he had just learned that his fiancé was pregnant, he was unable to feel any "genuine" emotions about learning he was having a son. The Veteran told the crisis counselor that he was not considering suicide that night but that he wanted to feel normal and have genuine feelings instead of feeling numb. He relayed that he was struggling with sleep deprivation and that he was using alcohol on a daily basis to cope. He also stated he was withdrawn and unable to make new friends. He did not like public places or crowds and avoided interacting or connecting with others, including his family and his fiancé. The conversation ended with the counselor referring the Veteran to a call center where the Veteran could speak with someone over the phone. The following month in May 2013, the Veteran contacted the VA Crisis Center again by text. During that text exchange with a different counselor, the Veteran expressed anger at his former Army unit that had warned him not to answer the post-deployment debriefing health questions "wrong" if he wanted to avoid being flagged for the alcohol and mental health issues that he was told would have a negative impact on his Army career and his future ability to own guns. The Veteran stated that he could have gotten the help he needed way before it got to the current point where he was self-medicating with alcohol. The Veteran said he was not currently thinking about suicide but had been suicidal for a period of time while he was in Iraq. The text conversation ended with the counselor stating he would put in a request for a combat veteran to contact the Veteran the following day about VA resources for PTSD. The Veteran attended 5 sessions with a non-VA counseling service in July and August 2013. His treatment records showed that he wanted help reintegrating into society and the workforce after service and noted that he had just had to resign from a job with the fire department after 18 months. The Veteran told his counselor that he had a difficult time every year on the anniversary of the death of 3 friends killed in Iraq and that lately things were getting worse. Whereas once he had liked to fish, hunt, hike, joke, and be around people, he now had sleep problems and isolated himself at home. He stated that he avoided crowds and felt anxious, joyless, and like he did not have normal feelings. The counselor noted that the Veteran had a flat affect. The Veteran later noted in a January 2014 VA treatment record that these non-VA counseling sessions had not been helpful and had not addressed his military experiences. In an October 2013 statement, the Veteran asked VA to evaluate him for PTSD. He stated that his symptoms had affected his school performance and social life as well as his work, and he explained that he had recently had to resign from a job with the fire department. The Veteran stated that he had trouble going to sleep, felt anxious around crowds, didn't like doing the things that he used to enjoy doing, felt like he did not fit in and like he was on emotional auto-pilot, was always tired, saw rings around bright lights, and heard buzzing and noises that no one else heard. The Veteran attended a VA examination in October 2013. The examiner stated that the claims folder was not reviewed and concluded that the Veteran's symptoms were due to alcohol use rather than PTSD. During the examination, the Veteran expressed concern that he felt nothing emotionally toward his two children, had trouble displaying affection, and did not enjoy doing activities he had once enjoyed. He stated his relationship with his fiancé was "rocky" and that, since he got out of the military, he feels detached and just feels like he is killing time until he dies. The Veteran also stated that he was unemployed because in June 2013, after a night of drinking on the anniversary of losing 3 friends in Iraq, he overslept and was late turning in an assignment required for his EMS program. As a result, he was asked to resign from the fire department. The AOJ's April 2019 rating decision noted that, at the time of this October 2013 examination, the Veteran's military personnel records, including his service in Iraq, were not available to the examiner. The Veteran screened positive for PTSD during a November 2013 VA Vet Center appointment. The Veteran stated that he was not doing well and was detached from work and relationships; he had recently had to resign from the fire department and learned his fiancé was pregnant. He was suffering from emotional detachment and was having trouble sleeping. The Veteran also reported drinking alcohol on a daily basis. The Veteran received alcohol treatment through VA, and, in February 2014, the Veteran began weekly individual counseling sessions at a VA Vet Center. The Veteran's psychologist noted in a February 2014 treatment record that the Veteran appeared to have been wanting to avoid a PTSD diagnosis due to the misapprehension that he would lose employment opportunities and his right to own firearms. After being advised that those consequences were inaccurate, the Veteran agreed to undergo psychological testing for PTSD in April 2014 and was assessed to have PTSD, major depressive disorder, anxiety disorder with panic, and alcohol dependence. The Veteran's symptoms included nightmares, irritability, emotional numbness, hypervigilance, startling at loud sounds, insomnia, concentration problems, and depression. He avoided crowds, stayed home most of the time, and avoided any stimuli that reminded him of deployment in Iraq. His emotional numbness made his relationships very difficult with his fiancé and children. His hypervigilance, startling, insomnia, and concentration problems were noted to have significantly affected his interpersonal relationships and his ability to work. In his VA counseling records in May 2014 and August 2014, the Veteran was consistently noted to have a depressed mood and flat affect. He was started on medications to help with his sleep and mood. His memory and concentration were noted to appear fine during treatment sessions, and yet he continued to be highly emotionally avoidant. In an April 2015 treatment record, the Veteran stated that he and his wife were close to divorce, and he was continuing to isolate himself and withdraw, although he was feeling slightly less anxiety in crowds and was working again full time as a fireman. In a July 2015 treatment record, the Veteran continued to express feeling completely emotionally numb toward his family and was continuing to have marital problems. In an August 2015 treatment record, the Veteran told his psychologist that he had had an intense panic attack the week before. The Veteran also reported that he had noticed an increase in his PTSD symptoms since he had started attending counseling sessions every 3 weeks instead of every week. Despite being on antidepressants and attending frequent counseling sessions, the Veteran continued to experience depression and lack of motivation, with symptoms reported to his therapist in September 2015 including poor energy and appetite, trouble concentrating, and even thoughts that he would be better off dead. The Veteran stated that these problems had made it extremely difficult for him to take care of things at home and to get along with other people. In a January 2016 treatment record, the Veteran stated that he was working but that otherwise he stayed home. He stated his concentration was chronically poor, and he continued to report conflicts with his partner, as well as continued feelings of apathy, anxiety, and panic. He denied suicidal ideation during the appointment but was noted to have a restricted affect. In a February 2016 treatment record, the Veteran was noted to have reported experiencing suicidal ideation, and in a treatment record the following month, the Veteran also admitted to having thoughts that he would be better off dead. The Veteran underwent psychological testing in April 2016. In the assessment results, the Veteran's clinical psychologist noted that the Veteran's "schizoid" and "avoidant" personality pattern results indicated the presence of severe relationship deficits, consistent with his complaints of feeling emotionally numb and his reluctance and difficulties forming close relationships with others. The psychologist noted that the Veteran's alcohol dependence was in remission and noted that his elevated "negativistic" personality pattern result indicated, consistent with his previous diagnoses of PTSD and alcohol dependence, that he was likely to experience moodiness, irritability, and pessimism and to have problems with coworkers, friends, and family. Under assessment for clinical syndromes, the Veteran had elevated anxiety disorder results that the psychologist stated were consistent with his noted difficulties related to panic attacks, physical tension, and restlessness. The Veteran had additional elevated scores for dysthymic disorder consistent with his ongoing feelings of guilt, anhedonia, and detachment, and he also had elevated scores for PTSD, consistent with his difficulties related to past combat trauma, including the presence of intrusive thoughts, emotional numbing, and psychological distress when reminded of past traumatic events that made it difficult for him to manage anger and maintain concentration. In a May 2016 treatment record the Veteran reported having trouble concentrating, feeling depressed, and continuing to wonder if life was worth living. A June 2016 treatment record stated that the Veteran indicated he was making efforts to decrease the amount of time spent hiding in the closet and instead had tried to spend time with his children and had gone to church, although he also reported having a panic attack since his last therapy session. In September 2016, the Veteran attended another VA examination for PTSD. The examiner diagnosed the Veteran with major depressive disorder but stated that he did not meet the criteria for PTSD due to the stressors he relayed. The Veteran's therapist discussed these findings with the Veteran in an October 2016 session and stated that she was not necessarily surprised by the examiner's apparent misunderstanding of the Veteran's PTSD because the Veteran's cognitive rigidity resulted in him having a difficult time identifying responses that were most representative of his current experiences and feelings. Additionally, the AOJ noted in the April 2019 rating decision that, like the October 2013 examiner, the September 2016 examiner did not have access to the Veteran's military personnel records discussing his service in Iraq. The AOJ also noted that the September 2016 examiner incorrectly stated the Veteran had not had any mental health treatment or concerns until 3 years after separation from service when, in fact, the Veteran had reported to VA as early as November 2010 (within a month after separation) that he felt numb and detached from others, activities, and surroundings and was constantly on guard and easily startled. Based on the Veteran's January 2024 testimony and a November 2016 treatment record, when the Veteran first experienced the sensation of missing his kids while he was at work, it meant the world to him after having been so numb for so long, even with respect to having feelings for his children. The Veteran's progress in therapy continued, with his symptoms waxing and waning, but with no further recorded reports of suicidal ideation after the May 2016 treatment record. A November 2016 treatment record noted that the Veteran had been experiencing an increase in nightmares and waking up in a cold sweat and that he was continuing to engage in avoidance behaviors like watering the lawn for hours until it became dark. In January 2017, the Veteran discussed with his psychologist that he had recently gotten into an argument with his wife while driving with their children, and the Veteran had jumped out of the car and walked home without returning calls or letting anyone know where he was. A March 2017 treatment record stated that the Veteran reported his co-workers at the fire station had been telling him he was screaming in his sleep. In November 2017, the Veteran began to have therapy sessions every three months, and in June 2018, the Veteran and his psychologist agreed that, since the Veteran was demonstrating the ability to use skills more independently that he had learned in therapy, they would end individual therapy. The Veteran attended another VA examination for PTSD in March 2019, and the Veteran was noted to have a diagnosis of PTSD. The examiner opined that the Veteran had occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. The examiner noted that the Veteran was working as a firefighter and that he was married and occasionally socialized with coworkers locally. The examiner further noted that the Veteran's PTSD symptoms included anxiety, suspiciousness, chronic sleep impairment, and difficulty in establishing and maintaining effective work and social relationships, but the examination did not go into any detail regarding the Veteran's past and present manifestations of PTSD symptoms, especially as documented over the course of his VA therapy sessions. The AOJ relied on the March 2019 examination to grant entitlement to service connection for PTSD with a rating of 30 percent disabling effective from the Veteran's March 1, 2013, claim. During the January 2024 hearing, the Veteran testified about his PTSD. The Veteran testified that, before starting medication and therapy with VA, he had nightmares and would wake up crying and screaming in a cold sweat and would have to change his sheets every day. The Veteran testified that currently he does not experience nightmares anymore since he is strict about taking his medication before going to bed. The Veteran testified that his wife moved out for a period of time in 2013, and that was around the time he sought treatment with VA. His PTSD symptoms caused him to be distant, like an empty shell, and that negatively affected his relationship with his wife, especially when she told him she was pregnant, and he reacted in a very flat, robotic, and emotionless way. His PTSD symptoms also impacted his relationship with his oldest daughter from a prior relationship. He gave up his parental rights to her in the fall of 2017 because he was convinced that he was a bad person for what he had done in his past and while on deployment and was convinced that he was not a good father. He testified that he now 100 percent regrets that decision after going through therapy and understanding that he is not a bad person and can have feelings for his children. The Veteran testified that his therapist first had him use an egg timer to spend time trying to develop emotions for his children. The Veteran testified that he had suicidal ideations for many years that ended around 2015 or so but that he does not have those dark feelings anymore. He had had the plan to use a gun to kill himself. The Veteran testified that, currently, if there is a birthday party at his house with a big group of people, he removes himself from it and goes into another room or outside, even if the people are just his family and close relatives. The Veteran testified that, socially, he does not go out or do anything; he just stays home. He does not invite friends over to his house. The Veteran testified that he works a lot as a firefighter. The Veteran testified that he will only go to a movie if it is a matinee of a movie that has been showing for awhile already, and he avoids grocery shopping at times when the store may be crowded. If the Veteran does not get seated in a certain seat at a restaurant or if there are too many people in the restaurant, even when he is there with his wife and children, he will just get up and leave even after having ordered water and sodas. The Veteran further testified about working for the fire department in 2013 when he was still self-medicating with alcohol. He could not cope with being jarred awake at night by very loud alarms and then having to go and respond to a call using loud lights and sirens. The Veteran testified that there were occasions when he had frozen up and not been able to perform his job to his best ability due to PTSD symptoms. The Veteran testified that, currently, he feels his memory and concentration are getting worse. He will lose all train of thought while talking with his wife and has trouble maintaining attention and focusing on the task of driving. The Veteran testified he continues to meet with his VA medication management doctor on a regular basis and would not be able to function without his medication, especially the medication he takes to go to sleep and control his nightmares. The Veteran testified that, including his nightmares when he used to have them, he probably had panic attacks about three times a week. Now he is able to sense when he is about to be triggered and engages in an avoidance behavior to try to anticipate and avoid a panic attack. The Veteran's wife also testified during the January 2024 hearing. She testified about the Veteran having nightmares and cold sweats every night that required changing the sheets. She testified that the Veteran's PTSD symptoms impacted their relationship to the point that she left him for a period of time and considered leaving with the children at other points after that as well. She further testified that the Veteran currently has a lot of trouble remembering things that they previously discussed, including childcare planning, and that the Veteran has difficulties maintaining attention on any overlapping tasks. The Board finds that, while the October 2013 and September 2016 VA examinations were flawed in lacking access to the Veteran's military personnel records and in failing to diagnose the Veteran with PTSD, the March 2019 VA examination is adequate for appellate review. The examiner's report was based on the Veteran's statements, in-person examination, and the examiner's observations, and the Board assigns it significant probative value, at least in conjunction with the Veteran's VA treatment records and the other evidence of record. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-05 (2008). At the January 2024 hearing, the Veteran reported past and current PTSD symptoms such as attempts to avoid having panic attacks, memory impairment, and difficulty in establishing and maintaining effective work and social relationships. The Veteran's wife also testified regarding observing the Veteran's nightmares and the impact that his PTSD symptoms had on their relationship. The Veteran and his wife are competent to report lay observable symptoms, and the Board finds their statements credible and assigns them significant probative weight. Period prior to June 29, 2018 While the Veteran's PTSD is rated at 30 percent for the entire period on appeal from March 1, 2013, to April 2019, the Board finds that increased, staged ratings are more appropriate in this case. Giving the Veteran the benefit of the doubt, the Board is identifying the June 29, 2018, date that the Veteran's clinical psychologist ended his individual therapy sessions as the date that delineates between when the Veteran's symptoms warranted a 70 percent rating and when they warranted a 50 percent rating. Upon review of the evidence, during the period from March 1, 2013, to June 29, 2018, the Board concludes that a 70 percent rating, but no higher, is warranted. During this period, the evidence as discussed above shows the Veteran's PTSD symptoms of suicidal ideation, near-continuous depression affecting his ability to function appropriately, impaired impulse control, difficulty adapting to stressful circumstances (including work), and inability to establish and maintain effective relationships, resulted in occupational and social impairment with deficiencies in most areas, including work, school, family relations, judgment, thinking, or mood. The Veteran had multiple instances of suicidal ideation during this period, as documented in his VA treatment records and in his testimony to the Board. The Veteran's suicidal ideations were documented in April 2014, September 2015, February 2016, March 2016, and May 2016 VA treatment records, and he testified that he had thought about using a gun if he committed suicide. Suicidal ideation is contemplated under the 70 percent rating criteria. The Court of Appeals for Veterans Claims (Court) has held that suicidal ideation generally rises to the level contemplated in a 70 percent evaluation. See Bankhead v. Shulkin, 29 Vet. App. 10 (2017). The Court specified that VA must not require more than thought to establish the symptom of suicidal ideation and may not require that the Veteran have been hospitalized or treated on an impatient basis to establish suicidal ideation because that imposes a higher standard than the criteria in the General Formula. Id. Moreover, the Court cautioned VA not to conflate the risk of suicidal ideation, which VA generally considers indicative of a 70 percent evaluation, and the risk of self-harm, the persistent danger of which VA generally considers indicative of a 100 percent evaluation. Id. As applied, the passive suicidal ideation that VA treatment providers documented and that the Veteran testified to having is sufficient to establish the suicidal ideation symptom consistent with a 70 percent rating in the General Formula for Mental Disorders. 38 C.F.R. § 4.130. Additionally, during the period prior to the end of his VA individual therapy sessions on June 29, 2018, the Veteran's treatment records and lay statements showed he had near-continuous depression with ongoing nightmares, a flat affect, and emotional numbness, which negatively impacted his ability to function appropriately and effectively as a firefighter, husband, and father. He self-medicated with alcohol, had to resign from his first professional firefighting job, and suffered from an inability to establish a relationship with his children and to maintain a relationship with his wife. He suffered from impaired impulse control, including going out drinking on the anniversary of the death of 3 friends in Iraq rather than finishing a paper required for work, getting out of the car in the middle of the street during an argument with his wife, and deciding to relinquish his parental rights to his daughter because of his impaired judgment that he was a bad person and father. While the Veteran did eventually return to working as a firefighter, he continued to socially isolate himself at home and continued to struggle with establishing and maintaining relationships with his wife and young children. He did not go out or socialize and did not engage in any activities that he once enjoyed like hiking and hunting. He also experienced ongoing panic attacks and nightmares during this period. Given these symptoms of suicidal ideation, near-continuous depression, impaired impulse control, difficulty adapting to stressful circumstances, and inability to establish and maintain effective relationships, the Board finds that the criteria for a 70 percent rating have been met for the period from March 1, 2013, to June 29, 2018. 38 C.F.R. § 4.130, DC 9411. A rating higher than 70 percent is not warranted during the period prior to June 29, 2018. To grant the higher rating of 100 percent, the evidence must establish that the Veteran is totally occupationally and socially impaired. Throughout the period on review, although he struggled with his marriage and with working as a firefighter at times, the Veteran was able to maintain his marriage and his employment once rehired. Such evidence persuasively weighs against a finding that the Veteran's symptoms rendered him totally occupationally and socially impaired. 38 C.F.R. § 4.130, DC 9411. The Veteran's multiple reports of suicidal ideation were certainly functionally impairing and supported the finding that the Veteran's PTSD impaired him in most areas of his life. On the other hand, the evidence reflected denials of any specific plans or intent, and treatment providers never found the Veteran to be a persistent danger to himself. Accordingly, the Board finds this symptom did not approach a severity, frequency, or duration such that it totally impaired him. Therefore, the Board finds that the Veteran's PTSD symptoms, either individually or combined, did not approach a severity, frequency, or duration such that the Veteran's disability picture was one of total occupational and social impairment prior to June 29, 2018. 38 C.F.R. §§ 4.126, 4.130. Without such evidence, a rating higher than 70 percent may not be granted. Id. Period from June 29, 2018 Around the June 29, 2018, date that the Veteran and his VA clinical psychologist agreed that he was ready to end individual counseling sessions, the Veteran's PTSD symptoms had improved such that a 50 percent rating, but no higher, is warranted for the period from June 29, 2018, to the April 2019 rating decision on appeal. The Veteran's last documented report of suicidal ideation was in May 2016. During the April 2019 VA examination, the examiner noted that, although the Veteran was married and working as a firefighter, the Veteran had symptoms including anxiety, suspiciousness, chronic sleep impairment, and difficulty establishing and maintaining effective work and social relationships. The Veteran's symptoms during this period are contemplated by the 50 percent rating criteria, which includes occupational and social impairment with reduced reliability and productivity due to symptoms such as difficulty in understanding complex commands, impairment of memory, disturbances of mood and motivation, and difficulty in establishing and maintaining effective work and social relationships. Even around the time after stopping individual counseling, the Veteran continued to see a VA medication management doctor every 3 months. Socially, he testified that he did not go out or do anything; he mostly just stayed home when he was not working, which shows an impairment in motivation and mood. The Veteran testified that he continued to feel anxious and avoided being in the same room with other people at family gatherings, even in his own home and even with close relatives. Although the Veteran's depression and nightmares appeared to be well-managed with medication during this period, he continued to report the routine need to engage in avoidance behavior when he recognized a trigger, in order to avoid having a panic attack. He testified that he would often get up and leave a restaurant with his wife and children even after ordering drinks if the restaurant was too crowded or he did not feel comfortable where he was seated. He limited his activities and avoided going to movie theaters or the grocery store at times when those places might be crowded. The Veteran testified that his memory and concentration were getting worse, and he could not multitask or complete overlapping tasks like carrying on a conversation while driving. The Veteran's wife testified that the Veteran would forget about tasks like childcare responsibilities that had been previously discussed and noted on the calendar. These examples show that the Veteran had reduced reliability and productivity as a husband, father, and firefighter. Given these symptoms of difficulty in understanding complex commands, impairment of memory, disturbances of mood and motivation, and difficulty in establishing and maintaining effective work and social relationships, the Board finds that the criteria for a 50 percent rating have been met for the period from June 29, 2018. 38 C.F.R. § 4.130, DC 9411. A rating higher than 50 percent is not warranted during the period from June 29, 2018. To grant the higher rating of 70 percent, the evidence must establish that the Veteran has occupational and social impairment with deficiencies in most areas. From June 29, 2018, although the Veteran continued to struggle with anxiety and engaged in avoidance behaviors, his relationship with his wife and children had improved, he did not have suicidal ideation, near-continuous depression, impaired impulse control, or an inability to establish and maintain effective relationships. Such evidence persuasively weighs against a finding that the Veteran's symptoms rendered him occupationally and socially impaired with deficiencies in most areas. 38 C.F.R. § 4.130, DC 9411. (Continued on the next page) ? In sum, giving the benefit of the doubt to the Veteran, the evidence of record persuasively supports a rating of 70 percent, but no higher, during the period prior to June 29, 2018, and a rating of 50 percent, but no higher, thereafter. The appeal for a higher rating for the Veteran's PTSD is granted. K. Parakkal Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Eisenstatt 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.