Citation Nr: 18139654
Decision Date: 09/28/18	Archive Date: 09/28/18

DOCKET NO. 16-16 084
DATE:	September 28, 2018
ORDER
Entitlement to service connection for a hip condition secondary to patellofemoral pain syndrome, right knee, is denied.
Entitlement to a disability rating of 70 percent, but no higher, prior to April 13, 2016, for posttraumatic stress disorder (PTSD) is granted, subject to the regulations governing the payment of monetary awards.
Entitlement to a disability rating in excess of 70 percent for the period beginning April 13, 2016 for PTSD, is denied.
FINDINGS OF FACT
1. The record does not show that the Veteran has had a disability of the right hip or pain that causes any functional impairment at any point during the appeal period.
2. Throughout the appeal period, the Veteran’s PTSD has manifested as occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood.
CONCLUSIONS OF LAW
1. The criteria for service connection for a right hip disability have not been met.  38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309.  
2. The criteria for entitlement to a disability rating of 70 percent, but no higher, prior to April 13, 2016, have been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411.
3. The criteria for entitlement to a disability rating in excess of 70 percent for the period beginning April 13, 2016, have not been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411.
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran served on active duty in the Army from November 2001 to March 2009.
These matters are before the Board of Veterans’ Appeals (Board) on appeal from a December 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO).

1. Entitlement to service connection for hip condition secondary to patellofemoral pain syndrome, right knee
The Veteran seeks service connection for a right hip disability which he contends has been caused or aggravated by his service-connected right knee disability.
Establishing entitlement to direct service connection generally requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - which is the so-called “nexus” requirement.  Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).  
Turning to the evidence, the Veteran has complained of pain in his right hip at least since October 2008.  A February 2009 VA examination noted that the Veteran had back pain extending into his right hip.  He reported right hip pain in a February 2010 VA treatment record.  A November 2010 VA treatment record reflects full range of motion in the hip with no discomfort.  An October 2014 VA treatment record shows the right hip was not tender and there was no pain with flexion or external or internal rotation.
The Veteran underwent a VA examination of the right hip in November 2014.  He reported experiencing pain in the hip in the past year when ascending stairs or when on his feet for an extended time.  The Veteran’s range of motion was normal with no objective evidence of pain (125 degrees flexion, 30 degrees extension, 60 degrees external rotation, 40 degrees internal rotation, 25 degrees adduction, and 45 degrees abduction.)  His range of motion was not altered after three repetitions.  The Veteran did not report flare ups.  The examiner found no functional loss in the right hip or thigh.  There was no localized tenderness or pain on palpation, no ankylosis, no malunion or nonunion of the femur, no flail hip joint and no leg length discrepancy.  The Veteran did not regularly use an assistive device.  The examiner found that the hip did not affect the Veteran’s ability to work, and he reported that the hip was normal.
In a June 2015 Notice of Disagreement, the Veteran said that his hip is painful when he tries running as exercise or when he jumps at a concert.  He said that his employment requires him to move very heavy patients at times and that doing so can lead to pain in his hip.  The Veteran said that he walks with a limp and falls for no reason.
In June 2015, the VA performed x-rays on the Veteran’s right hip and back.  The imaging showed normal bone structure and the VA physician recommended that the Veteran use heat and stretch and perform physical therapy exercises.  The Veteran complained of continued hip pain in July 2015.  In a June 2016 VA treatment, the Veteran reported cramps in his hip.  A VA physical therapist recommended hip abduction and adduction and extension exercises.
Weighing the evidence, the Board places the greatest amount of weight of probative value on the VA examiner’s findings, the VA treatment records showing a full range of motion of the hip with no functional impairment, and the June 2015 X-ray results showing normal bone structure.  The VA examination findings were based on a full examination of the Veteran with consideration of whether right hip pain caused him any functional impairment.  The VA examiner found no pain on range-of-motion testing or following repetitive motion, and no functional impairment of the joint.  The U.S. Court of Appeals for the Federal Circuit recently held in Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) that if pain alone results in functional impairment, even if there is no identified underlying diagnosis, such pain can constitute a disability.  Here, the objective medical evidence does not show any functional impairment from the Veteran’s right hip pain.  Therefore, a preponderance of the evidence is against a finding that the Veteran currently has a diagnosed right hip disability or any right hip pain that causes functional impairment that would be considered a disability for compensation purposes.
While the Veteran is competent to report on the symptoms he experiences, whether he has a right hip disability falls outside the realm of the common knowledge of a lay person.  See Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau, 492 F.3d at 1376-77.  As such, the Board places greater weight of probative value on the medical evidence that does not show a diagnosis of a right hip condition or evidence of functional impairment from pain in the right hip.
A current disability is a cornerstone of a service connection claim.  Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).  As such, without a diagnosis of a hip disability or evidence of functional impairment from right hip pain, service connection cannot be established on any basis.  A preponderance of the evidence is therefore against the claim, the benefit of the doubt doctrine does not apply, and the claim is denied.  38 U.S.C. § 5107; 38 C.F.R. § 3.102.
2. Entitlement to an Increased Rating for PTSD
Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule).  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.  See 38 U.S.C. § 1155; 38 C.F.R. § 4.1.
In evaluating the severity of a particular disability, it is essential to consider its history.  38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991).  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 importance.  Francisco v. Brown, 7 Vet. App. 55, 58 (1994).  Separate ratings may be assigned for separate periods of time based on the facts found, a practice known as “staged” ratings.  Hart v. Mansfield, 21 Vet. App. 505 (2007).
PTSD is rated under Code 9411 and the General Rating Formula for Mental Disorders, which provide the following criteria:
A 50 percent rating 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 rating 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); and/or inability to establish and maintain effective relationships.
A 100 percent rating is warranted 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; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and/or memory loss for names of close relatives, own occupation, or own name.  38 C.F.R. § 4.130, Diagnostic Code 9411.
The list of symptoms in the General Rating Formula for Mental Disorders is not intended to constitute an exhaustive list, but rather provides examples of the type and degree of symptoms, or their effects, that would justify a particular rating.  Mauerhan v. Principi, 16 Vet. App. 436 (2002).  However, “a [V]eteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration.”  Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013).  Furthermore, 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 solely on the basis of social impairment.  38 C.F.R. § 4.126.
Entitlement to a disability rating in excess of 50 percent prior to April 13, 2016
The Veteran contends that the severity of his PTSD symptoms for this period warrants a higher disability rating than the 50 percent rating assigned by the RO.
Turning to the evidence, a March 2014 VA treatment record reflects that the Veteran appeared for an appointment alert, oriented, and adequately groomed.  He denied suicidal ideation, homicidal ideation and audio or visual hallucinations at that time.  He had pressured speech and elevated volume.  He had an irritable affect.  The psychologist noted that she was late to the appointment due to another emergency and that the Veteran displayed strong irritation at the beginning of the appointment and throughout.  The psychologist noted that she consulted with the Veteran’s psychiatrist after the appointment, who indicated that the Veteran can be loud and irritable if he feels rejected or mistreated.
A September 2014 VA Mental Health Note stated that the Veteran reported feeling manic and staying awake for 36 hours once a week and 54 hours once or twice per month.  He reported working more hours recently and said that his thoughts were racing.  The Veteran said that he was seeing a woman and requested STD and HIV testing.  He denied suicidal or homicidal ideations and auditory or visual hallucinations.  The Veteran denied marijuana or alcohol use and said that he had lost some weight.  He said that he had reunited with his father, who he had not seen in over 20 years.  The Veteran said that he was complying with his medication directions and had no side effects.  He reported anhedonia, an irritable mood, sparse and irregular sleep, a fair energy level, a good appetite, no weight change (contrary to his earlier statement), and fair concentration.  The Veteran was alert and oriented, appropriately dressed and groomed.  He was pleasant and cooperative and appeared his stated age.  His gait and station were normal, showing no signs of instability, and the Veteran ambulated without difficulty.  The Veteran’s speech was spontaneous and fluent and he showed no psychomotor disturbances.  He had a good mood but the examiner described his affect as somewhat labile, irritable, and congruent.  His thoughts were logical and coherent, his attention and concentration and memory were intact, his fund of knowledge was average, his abstract thinking good, and his insight and judgment were fair.
The Veteran underwent a VA examination for PTSD in November 2014.  The examiner diagnosed moderate PTSD and bipolar I disorder.  The examiner noted symptoms of reexperiencing, hyperarousal, and avoidance were attributable to PTSD, and manic and depressive episodes attributable to bipolar disorder.  The examiner found there was not a likely clinical association between the two diagnoses.  The examiner found that the Veteran’s symptoms led to 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 said that he was sexually abused as a child and reported that he was currently in a good dating relationship.  After leaving the Army due to a Medical Evaluation Board for mental health issues, the Veteran got a degree in sociology.  The Veteran reported that he has worked as a respiratory therapist since 2007 (part-time while in the Army).  He said that he performs his job well but has been disciplined for administrative issues.  He said that he enjoyed the work and that mental health issues have not affected him at work.  The Veteran checked himself into psychiatric ward in 2011 for acute depression and was released after 3 days.  The Veteran reported that he was fired from a different hospital for having marijuana in his system, and said that he was later charged with DWI and possession of marijuana during a manic episode.  The Veteran said that he stopped using cocaine in approximately 2012 and stopped using marijuana in July 2014.  The Veteran was currently using four prescription drugs for mental health issues.  The examiner noted the following symptoms: depressed mood, anxiety, suspiciousness, panic attacks more than once a week, and chronic sleep impairment.  The Veteran said that he sleeps approximately 4-5 hours per night, and that during manic episode he sleeps less (awake 36-40 hours at a time), and during depressive episodes he sleeps up to 8 hours.
In a June 2015 Notice of Disagreement, the Veteran said that he likes to attend concerts and when he does so he needs a friend to help him deal with anxiety.  The Veteran said that he uses drugs at concerts when he does not have a friend with him.  The Veteran reported that he continued to work as a respiratory therapist at a hospital.  He reported that he was charged with DUI in February 2012, charged with possession in June 2012, and then charged with a second DUI in February 2015.  The Veteran said that he continues to drive while intoxicated “a lot.”  He reported that he has used drugs and engaged in sexual intercourse at work and has been disciplined for outbursts, yelling, and insubordination.  The Veteran stated that he has episodes of road rage and at times follows other drivers and beats on their windows and yells at them while waving a knife.  The Veteran reported that he has gotten violent at concerts.  He said that he had no relationships since 2007, contrary to his statements in the November 2014 VA examination.  The Veteran believes that he is bipolar.  He said that he has panic attacks, insomnia, and confrontations with people who brush against him in a crowd and he curses at restaurant servers.  He said that he has suicidal ideations.  The Veteran reported that he has only two friends and rarely speaks with his mother or sister.  The Veteran reported that he has nightmares and intrusive thoughts.
In April 2016, the Veteran submitted four journal articles showing that alcohol dependence can be caused by combat exposure, detailing mental health problems among military personnel returning from Iraq War (finding a greater number of soldiers requiring mental health treatment), showing that combat veterans with PTSD report engaging in a higher number of violent acts than combat veterans without PTSD, and examining symptoms of PTSD.
In April 2016, the Veteran submitted twelve letters from friends and family members discussing his behavior.  These letters stated that the Veteran has yelled in peoples’ faces, screamed obscenities at them, thrown items, consumed alcohol excessively, had no memory of his offensive behavior, had panic attacks, had confrontations at concerts, and has tattooed 60 percent or more of his body and rips his body piercings out in order to be re-pierced.  Friends and family members said that the Veteran cannot stay on one topic of conversation, has expressed suicidal ideations, fits of rage and crying spells, has threatened drivers with a knife, shown irritability and nervousness, has slashed car tires with his knife, becomes angry quickly, verbally abuses his mother, and has relationship problems.
The Veteran submitted a 36-page written statement in April 2016.  He described attacking drivers in their cars with a baseball bat and cursing them, destroying mirrors of cars, and banging on their windows with knives.  The Veteran said that he is fearful in restaurants.  He reported that he would attack people for questioning his parking in handicapped spots and said that he confronts people about parking spots.  The Veteran reported that he has only had three relationships exceeding four months since divorcing in 2007.  He stated that he throws items, destroying his own television set and said that he attacks girls and does not remember it.  The Veteran said that he is angry when he is asked about Iraq and said that he was charged with DUI in 2011 and 2015.  The Veteran reported suicidal ideations as recently as February 2016.  The Veteran reported the death of one of his pet dogs in February 2016.  The Veteran reported that he has schizophrenia and sees things.  He said that he has outbursts of profanity at veterinarians, grocery stores, and fast food restaurants and reported that he was involuntarily committed to a psychiatric hospital at one time.  The Veteran reported that he has difficulty using public bathrooms.  He described his PTSD trigger events and said that his work as a respiratory therapist and the sight of amputees, blood, and meat trigger his PTSD.  He described current erratic and violent behavior and said that he had no memory afterward.  The Veteran said that he wants to be dead and said that civilians deserve to die and have their limbs amputated.  The Veteran reported heavy drinking since leaving the military, including his two DUIs and also drinking in class in college.  He reported daytime hallucinations, nightmares, insomnia and dreams of suicide.  The Veteran said that he feels angry and isolated and said that he spent all of his disposable income on concert tickets, drugs, and alcohol.  The Veteran also stated that he had an eating disorder and described difficulties urinating and defecating.  The Veteran described a panic attack he had while driving in March 2016.
The evidence indicates that the Veteran has experienced symptomatology from the rating criteria for 30 percent, 50 percent, 70 percent, and 100 percent ratings for PTSD.  These symptoms include depressed mood, anxiety, and chronic sleep impairment (30 percent criteria); disturbances of motivation and mood, panic attacks more than once a week, and difficulty establishing and maintaining effective work and social relationships (50 percent rating criteria); and impaired impulse control, neglect of personal appearance and hygiene, inability to establish and maintain effective relationships, and suicidal ideation (70 percent rating criteria); and grossly inappropriate behavior and persistent danger of hurting self or others (100 percent rating criteria).  The record shows that the frequency, severity, and duration of these symptoms have caused the Veteran occupational and social impairment with deficiencies in most areas, as he told a VA examiner that he had few friends and he had numerous confrontations and altercations during this period.  The Veteran has spoken of passive suicidal ideation throughout this period.  He also reported neglecting his personal hygiene for four days at a time when he is not working.  The Board finds that the frequency, duration, and severity of these symptoms are consistent with the functioning contemplated by a 70 percent rating.  
The evidence, however, does not show that the Veteran’s occupational and social impairment more nearly approximates total occupational and social impairment as contemplated by a 100 percent rating.  The evidence for this period shows grossly inappropriate behavior and being a persistent danger to himself or others, but there has been no evidence of gross impairment of thought process or communication, persistent delusions or hallucinations, disorientation to time or place, memory loss for names of close relatives, own occupation, or own name, or any other symptoms of similar frequency, severity, or duration.  Regarding social impairment, the Veteran is divorced and lives with one pet dog.  The Veteran reported that since his 2007 divorce he has had three relationships of more than four months.  The Veteran stated that he has two friends, and the Veteran submitted several letters from people identifying themselves as the Veterans’ friends.  Although the Veteran has had passive suicidal ideation, the evidence does not reflect that he is a persistent danger to himself.  Additionally, although he has reported neglecting his personal hygiene when he is not at work, the September 2014 physician found his appearance and grooming to be normal.  Although the Veteran retains relations with some family and friends, in this instance, the Board concludes that his grossly inappropriate behavior, including violent behavior, and being a persistent danger to himself and others, more nearly approximates total social impairment.
However, the frequency, severity, and duration of the Veteran’s symptoms do not more nearly approximate total occupational impairment.  The Veteran was employed full-time as a respiratory therapist at a hospital for this entire period.  Although the Veteran reported that he was disciplined for administrative infractions during this period, he was not terminated.  The Veteran found the work rewarding, having told the November 2014 VA examiner that the job was his “salvation.”  Therefore, the evidence does not more nearly approximate that the Veteran’s PTSD causes him to have total occupational impairment.
Thus, when considering the frequency, severity, and duration of all of the Veteran’s symptoms on both occupational and social impairment, the Board concludes that symptoms of his psychiatric disorder cause him to have deficiencies in most areas but not total occupational and social impairment; hence, they are not characteristic of the next higher, 100 percent rating. 
The Board has also considered the Veteran’s statements regarding the severity of his psychiatric disorder, particularly concerning his suicidal ideations and his altercations with drivers in parking lots, at concerts, and at work.  The Veteran is competent to report the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation, and the Board has considered these statements in assigning an increased 70 percent rating.  38 U.S.C. § 1154(a); 38 C.F.R. § 3.159(a)(2); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006).
The November 2014 VA examination report also included a diagnosis of bipolar I disorder, and, although the examiner indicated that manic episodes and depressive episodes were attributable to bipolar disorder, he did not explain the exact symptoms that would arise from these episodes.  See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (holding that the Board is precluded from differentiating between the symptomatology attributable to a nonservice-connected disability and a service-connected disability in the absence of medical evidence that does so); see also 38 C.F.R. § 4.14 (pyramiding, that is the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability).  As such, the Board has attributed all symptoms shown in this case to the service-connected PTSD, which is not prejudicial to the Veteran as all psychiatric symptoms will be rated pursuant to the General Rating Formula for Mental Disorders under 38 C.F.R. § 4.130.
In sum, the evidence as a whole shows that the frequency, severity, and duration of the Veteran’s PTSD symptoms most nearly approximate social and occupational impairment with deficiencies in most areas, and a preponderance of the evidence is against a finding that such impairment more nearly approximated the criteria warranting a 100 percent rating.  Accordingly, the Board concludes that the Veteran is entitled to a 70 percent, but no higher, rating for PTSD prior to April 13, 2016.

Entitlement to a disability rating in excess of 70 percent for the period beginning April 13, 2016
The Veteran also contends that the severity of his PTSD merits a disability rating of more than 70 percent for the period beginning April 13, 2016.
The Veteran was afforded a VA examination in March 2018 to assess the current severity of the Veteran’s PTSD.  The examiner diagnosed PTSD, bipolar I disorder, alcohol use disorder in sustained remission, and cannabis use disorder in sustained remission.  The examiner found that the Veteran’s symptoms led to occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood.  The Veteran is divorced, has no children, speaks with his father once every few months, speaks with his sister occasionally, and said he has not dated since 2015.  The Veteran said that his life is focused on his pet dog and attending concerts.  He worked at the same hospital for approximately nine years and continued to do so in spite of finding it stressful.  He continued to take prescription Prazosin, Zolpidem, Trazodone, Lithium, Clonazepam, and Lamotrigine.  The Veteran said that he was charged with DUI in 2015 and stopped using alcohol and illicit drugs that year.  The examiner found the following symptoms: depressed mood, anxiety, panic attacks more than once a week, disturbance of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, impaired impulse control, such as unprovoked irritability with periods of violence, and intermittent inability to perform activities of daily living including maintenance of minimal personal hygiene.  The Veteran’s appearance was clean and casually dressed, his psychomotor activity unremarkable, his speech unremarkable, and his attitude toward the examiner cooperative and friendly.  The Veteran’s mood was neutral, his affect within normal range, his attention intact, and his orientation good toward person and time and place.  The Veteran’s thought process and thought content were unremarkable and the examiner found no delusions.  The Veteran understood the outcome of behavior, understood that he had a problem, and showed no hallucinations or inappropriate behavior.  He reported nightmares once or twice a week and said that he sweats or urinates in bed and has intrusive thoughts.  The Veteran also stated that he was suspicious of people and that he slept 4-5 hours nightly.  He reported depression and lack of personal hygiene when not working.  The Veteran said that at times he becomes manic and spends money excessively on concert tickets.
VA treatment records during this time period reflect similar reports of symptomatology.
The March 2018 VA examiner determined that the Veteran’s psychiatric symptoms manifested in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood.  This description fits squarely within the criteria for the currently-assigned 70 percent evaluation for PTSD under the General Rating Formula.  See 38 C.F.R. § 4.130.  The evidence does not show that the duration, frequency, or severity of the Veteran’s symptoms approaches total occupational and social impairment as contemplated by a 100 percent rating.  
Of the criteria warranting a 100 percent rating, the evidence for this period shows only intermittent inability to perform activities of daily living including maintenance of minimal personal hygiene.  There was no evidence of grossly inappropriate behavior, gross impairment of thought process or communication, persistent delusions or hallucinations, disorientation to time or place, memory loss for names of close relatives, own occupation, or own name, or any other symptoms of similar frequency, severity, or duration.  There is no evidence of the violent behavior demonstrated by the evidence for the period prior to April 13, 2016.  And, although the March 2018 VA examiner found intermittent inability to perform activities of daily living including maintenance of minimal personal hygiene, he described the Veteran as clean and casually dressed at the examination.  The evidence for this period does not demonstrate total social impairment.  
Similarly, the frequency, severity, and duration of the Veteran’s symptoms for this period also do not approximate total occupational impairment.  The Veteran continued his full-time work as a respiratory therapist at a hospital for this entire period.  He had been with this employer for nine years at the time of the March 2018 VA examination.  The Veteran reported that he found his work stressful but there is no evidence of disciplinary issues or job termination during this period.  Therefore, the evidence does not more nearly approximate that the Veteran’s PTSD causes him to have total occupational impairment.
Thus, when considering the frequency, severity, and duration of all of the Veteran’s symptoms and their impact on both occupational and social impairment, the Board concludes that symptoms of his psychiatric disorder cause him to have deficiencies in most areas but not total occupational and social impairment; hence, they are not characteristic of the next higher, 100 percent rating.
As discussed in the section above, the March 2018 VA examination also includes a diagnosis of bipolar I disorder, alcohol use disorder in sustained remission, and cannabis use disorder in sustained remission, but the report states that it is not possible to differentiate which symptoms are attributable to each diagnosis.  See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (holding that the Board is precluded from differentiating between the symptomatology attributable to a nonservice-connected disability and a service-connected disability in the absence of medical evidence that does so); see also 38 C.F.R. § 4.14 (pyramiding, that is the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability).  As such, the Board has attributed all symptoms shown in this case to the service-connected PTSD, which is not prejudicial to the Veteran as all psychiatric symptoms will be rated pursuant to the General Rating Formula for Mental Disorders under 38 C.F.R. § 4.130.
The Board has also considered whether any staged ratings are appropriate.  See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (holding that at the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as “staged ratings”).  The Board finds that the Veteran’s symptoms have been consistent with a 70 percent rating for this entire period.  The record does not indicate any significant increase or decrease in such symptoms during the period under consideration.  Accordingly, staged ratings are not warranted and the 70 percent rating is appropriate for the entire appeal period.
Accordingly, the Board finds that the preponderance of the evidence is against the Veteran’s claim.  Consequently, the benefit-of-the-doubt rule is not applicable, and the claim for entitlement to a disability rating in excess of 70 percent for PTSD from April 13, 2016, is denied.  38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990).  

 
M. SORISIO
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	R. Dean, Associate Counsel

For A Complete Guide To VA Disability Claims and to find out more about your potential VA disability case and how to obtain favorable VA Rating Decision! Visit: VA-Claims.org

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