Citation Nr: 0300859 Decision Date: 01/15/03 Archive Date: 01/28/03 DOCKET NO. 02-03 960 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for a bilateral hearing loss. 2. Entitlement to service connection for tinnitus. 3. Entitlement to an increased evaluation for post-traumatic stress disorder (PTSD), currently rated 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. E. Smith, Counsel INTRODUCTION The veteran had active military service from February 1966 to January 1968. This matter came before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Huntington, West Virginia, Regional Office (RO). A March 2000 and later rating decision denied the veteran entitlement to an increased evaluation for his service-connected PTSD. A May 2000 rating decision denied the veteran entitlement to service connection for bilateral hearing loss and tinnitus. In September 2002 the veteran was afforded a video conference hearing before the undersigned member of the Board. A transcript of the veteran's hearing testimony has been associated with his claims file. FINDINGS OF FACT 1. Bilateral hearing loss was first clinically demonstrated many years after service separation and is not shown to be due to any inservice occurrence or event. 2. Tinnitus was first clinically demonstrated many years after service separation and is not shown to be due to any inservice occurrence or event. 3. The evidence is in relative equipoise as to whether the veteran's clinical signs and manifestations of PTSD have resulted in no more than social and occupational impairment with reduced reliability and productivity due to symptoms such as impaired judgment, flattened affect, impairment of short and long term memory and mood associated with anxiety and depression. CONCLUSIONS OF LAW 1. Bilateral hearing loss was not incurred or aggravated by service, nor may sensorineural hearing loss be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1112, 1113, 1154, 5103, 5103A, 5107, (West 1991 & Supp. 2001); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2002). 2. Tinnitus was not incurred in or aggravated by service. 38 U.S.C.A. § 1110, 1154, 5103, 5103A, 5107 (West 1991 & Supp. 2001); 38 C.F.R. § 3.303 (2002). 3. Resolving all reasonable doubt in favor of the veteran, the criteria for a rating of 50 percent, but no more, for post-traumatic stress disorder are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 1991 & Supp. 2001); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, and Part 4, Diagnostic Code 9411 (2002). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act (VCAA) of 2000 The Board observes the recently enacted law and its implementing regulations essentially eliminate the requirement that a claimant submit evidence of a well- grounded claim, and provide that VA will assist the claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. 38 U.S.C.A. §§ 5103A, 5107(a) (West Supp. 2001); 38 C.F.R. §§ 3.102, 3.159(c)-(d) (2002). The new law and regulations also include new notification provisions. Specifically, they require VA to notify the claimant and the claimant's representative, if any, of any information and any medical or lay evidence not previously provided to the Secretary, that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. 38 U.S.C.A. § 5103 (West Supp. 2001); 38 C.F.R. § 3.159(b) (2002). The record reflects that the veteran has received the degree of notice, which is contemplated by law. Specifically VA provided the veteran and his representative copies of the appeal rating decisions and a February 2002 statement of the case. These documents provide notice of the law and governing regulations, the evidence needed to support the claims for service connection for hearing loss and tinnitus as well as the claim for an increased rating for the veteran's service- connected PTSD and furthermore provided the reasons for the determination made regarding these claims. The record discloses that VA has also met its duty to assist the veteran in obtaining evidence necessary to substantiate his claim. Most notably, copies of the veteran's relevant VA outpatient treatment records have been associate with the claims file. In February 2001 the RO provided the veteran a letter identifying the information needed from him to substantiate his claim and informed him of the evidence VA would attempt to obtain. There is no identified relevant evidence that has not been accounted for and the veteran and his representative have been given the opportunity to present testimony in support of the veteran's claim and the veteran has done so. Therefore, under the circumstances, VA has satisfied both its duties to notify and assist the veteran in this case and adjudication of this appeal at this juncture poses no risk of prejudice to the veteran. See e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); see also Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Factual Background The veteran's DD Form 214, Armed Forces of the United States Report of Discharge, shows that the veteran's military occupational specialty was field artillery fire control man and that his decorations included the Vietnam Service Medal and Vietnam Campaign Medal as well as the Presidential's Unit Citation. The veteran's service medical records are negative for any complaints, findings, and/or diagnoses of a hearing disorder to include tinnitus. On the veteran's January 1968 medical examination for service separation, a clinical evaluation of the veteran's ears found no abnormality. The veteran's hearing was 15/15 whispered voice bilaterally. VA initially examined the veteran in September 1994 in connection with his claim for service connection for PTSD. On this examination it was noted that the veteran had been employed for the last 24 years as a maintenance man for a metal's company. It was further noted that the veteran denied any physical problems. The veteran reported that he spent about 13 months in Vietnam and was "one of five guns" located on Hill Number 65. The veteran complained that he gets irritable and angry and that he feels both nervous and edgy. He says that he does not like big crowds and has some hopeless, helpless feelings with occasional feelings of depression. He noted that he has no problems with the law and reported that he lives with his second wife and that they have been married for 22 years. He denied any major problems with his spouse. On objective examination the veteran was noted to be casually dressed and to have a trimmed beard. He was generally pleasant and cooperative with appropriate flow and content of his conversation. He was oriented to time, place and person. There was no evidence of active hallucinations or delusions and his attention and concentration were normal. His memory and recall for recent events were intact and there was no evidence of looseness of associations, flights of ideations, or pressured speech. There was no obsessive thoughts or compulsive actions. Generalized anxiety disorder was diagnosed and the veteran's highest level of adaptive function was noted to appear to be 75 on the Global Assessment of Functioning (GAF) scale. The examiner commented that he felt the veteran had problems with recurrent anxiety disorder and that he did not demonstrate enough symptomatology to justify a diagnosis of PTSD. At a personal hearing in July 1997 the veteran testified that he was assigned to the 1st Marines, 3rd Battalion while in Vietnam and that he had experienced enemy shelling, which resulted in the death of one his service colleagues. In a letter dated in April 1978 and received in December 1997 the Department of the Navy forwarded the veteran a Combat Action Ribbon to which he was informed he was entitled. On a VA examination in April 1998 the veteran complained of nightmares, inability to sleep, agitation and anger. The veteran reported that he had served in Vietnam for 13 months and saw active combat. He stated that following service he worked in warehouses in Charleston for one year then went to work for a private company and still works for this company now. He noted that the people at his place of employment pick on him, stating that he felt they picked on him because he takes too much time off of work for hunting. On mental status examination the veteran was noted to be neat, tidy and cooperative. His mood was noted to be labile and his guard suspicious. The veteran was able to recall the last three Presidents and do serial 7's. Abstract thinking showed some concretization. The veteran appeared to be limited in intelligence, "possibly in the dull-normal clinically". A sense of reference and ideas of persecution were present. The veteran denied any auditory or visual hallucinations and a sense of helpless/hopelessness prevailed. His fund of general knowledge was keeping with his intellectual capacity. There were no active homicidal or suicidal plans entertained and insight in his general problems seemed to be rather poor. The veteran said he had been married for 26 years in his second marriage and that the relationship with his wife is stable. He further stated that he is angry and animated towards his children and that he has no particular hobbies and does not belong to any club or organization. Major depression recurrent, moderate to moderately severe in nature with paranoid ideation was the diagnostic assessment. The veteran's GAF was assessed as 70. Service connection for PTSD was established by an RO rating action in May 1998. This disorder was rated 30 percent disabling under Diagnostic Code 9411 of VA Schedule for Rating Disabilities, effective from April 1994. On a VA PTSD examination in February 2000 in connection with his current claim the veteran stated that he has continued to work at a steel mill for over 30 years and is currently having problems with his work. He said he could not get along with the people he worked with and noted that there was 13 employees in his maintenance section. He said that he had been married for 26 years and denied any major problems during his marriage. With respect to his daily activities the veteran indicated that he was able to dress, clean and wash himself and goes to work for eight hours per day. He said that in the summer he goes fishing and hiking and also has a hunting cabin that he uses. He further said that he belongs to the VFW but does not attend meetings often. The veteran complained that he has great difficulty in coping with things and cannot sleep too well at night. The veteran further related that he gets very angry and irritable and has episodes of depression. He also stated that he was not sure as to how long he would be able to continue working and indicated that a physician had advised him in the past to retire early. On objective examination the veteran was noted to be casually dressed in jeans and shirt. He had a trimmed beard. He walked into the interview room unassisted and was pleasant and cooperative with appropriate flow and content of his conversation. He was well oriented to time, place and person. There was no evidence of any active hallucinations or delusions. Attention and concentration were impaired. He had difficulty with mental calculations and serial 7's. He was able to give the days of the week in the reverse order. His memory and recall for recent events was slightly impaired. He was able to recall two out of three objects after five minutes. Judgment was intact. There was no evidence of any looseness of association, flight of ideas, or pressured speech. His fund of knowledge was appropriate for his education level and background. There were no obsessive thoughts or compulsive absence. The veteran denied being actively suicidal or homicidal. Post-traumatic stress disorder and episodic excessive drinking were the Axis I diagnoses. The veteran's GAF was assessed as 60. The examiner commented that he felt the veteran continued to have problems with PTSD. He noted that the veteran continued to work but that the veteran had said that he is having more and more problems and gets easily irritable and cannot get along with people. He said he tries to avoid people and related that his co- workers had even threatened to shoot him. The veteran was examined in May 2000 by a private psychiatrist, F. Joseph Whelan, M.D., M.S. On this evaluation it was noted that the veteran's psychiatric signs and symptoms included depression with crying spells, a short drop in energy and stamina, and both an initial and terminal sleep disorder. The examiner noted that the veteran described what sounds like feeling helpless, hopeless, worthless and useless much of the time. He noted that the veteran had problems with concentration and memory and had lost interest in many things and suffers from fleeting suicidal thoughts. It was observed that the veteran was shaken visibly throughout the evaluation and in particular when describing events that occurred to him through the Vietnam War. It was further observed that the veteran had difficulty coping with life and is much more easily irritated, aggravated and angry than prior to the Vietnam War. It was noted that the veteran's past medical history was significant for diabetes mellitus. The veteran's occupational history was noted to reveal that the veteran had worked for 30 years as a maintenance man at a metal's company. The veteran stated that he gets a lot of abuse by his employers but that he is the second longest employee there. The veteran noted further that his hobbies included hunting and fishing and that he belongs to a hunting club. Severe chronic post-traumatic stress disorder, delayed type was the Axis I diagnosis. Dr. Whelan commented that it was his opinion to a reasonable medical certainty that the veteran does indeed suffer from significant PTSD and that he considered the disorder to be of the delayed type and to be progressive and continuing to progress. He opined that the veteran is at a minimum of 70 percent permanently and partially disabled as a result of service-connected psychiatric disability. The veteran's GAF score was assessed as 60. VA outpatient treatment records compiled between April 2000 and December 2001 showed that the veteran receives routine treatment at a VA mental health clinic for PTSD, which is treated with medications to include Zoloft and Trazodone. In April 2000 the veteran reported that his situation at his employment had somewhat improved as his groups were segregated, although he continues to have some problems with his employer. On mental status examination at this time it was noted that the veteran continued to be somewhat irritable and anxious and to have a labile mood. His affect was noted to be broad and he appeared to have continued paranoia and depression, as well as evidence of PTSD. His judgment appeared intact but his insight was poor. PTSD was the diagnostic assessment and his current GAF was assessed as 60. In July 2000 the veteran's speech was noted to be clear, relevant and goal-directed and his mood to be mildly dysphoric. His affect was narrow and there were no suicidal or homicidal ideations and no evidence of hallucinations or delusions. Post-traumatic stress disorder and anxiety disorder were the diagnostic assessments and the veteran's GAF was again assessed as 60. The veteran's GAF in November 2000 was assessed as 60 and the veteran at that time was noted to have a normal affect with clear relevant and goal-directed speech although it was also noted to be moderately anxious. When seen in the mental health clinic in February 2001 the veteran's mood was again mildly dysphoric and his affect was normal. Speech remained clear, relevant and goal- directed. The veteran was not suicidal or homicidal and his judgment and insight were assessed on this occasion as good although he appeared to be again moderately anxious. PTSD was the diagnostic assessment and current GAF was noted to be 60. When seen in May 2001 the veteran's mood remained mildly dysphoric. His affect was normal and speech was clear, relevant and goal-directed. The veteran had fair eye contact and was noted to be not suicidal or homicidal. He was also noted to have fair judgment in insight and to appear mild to moderately anxious. PTSD was diagnosed the veteran's current Global Assessment of Functioning was reported to be 55. His Global Assessment of Functioning was also 55 in August 2001. His mood at that time was noted to be mildly dysphoric and his affect to be normal to mood. His speech was clear, relevant and goal-directed and there was no suicidal or homicidal ideations and no hallucinations or delusions. The veteran's showed fair memory, insight and judgment. In December 2001 it was noted that the veteran was on Social Security disability and had problems with carpal tunnel syndrome and complaints of breathing problems due to his belief he was exposed to toxic metal fumes while working at a metal company for 31 years. On objective examination the veteran's mood remained mildly dysphoric and his affect was normal to mood. Speech remained clear, relevant and goal-directed. There was no audio or visual hallucinations or delusions and the veteran was noted to be not suicidal or homicidal. Insight and judgment and memory were assessed as fair. PTSD was diagnosed and the veteran's Global Assessment of Functioning was noted to be 60. A VA audiological consultation dated in October 2001 notes that the veteran's pure tone threshold testing had revealed a mild sensorineural hearing loss rising to normal and then falling to moderately-severe in the left ear. The veteran was noted also to have an essentially mild hearing loss progressive to a moderate sensorineural hearing loss in the right ear. Bilateral amplification was recommended. Private treatment records received in July 2001 and compiled between November 1986 and October 2000 show treatment provided to the veteran by his private physician, Donald Newell, Jr., M.D., for various complaints to include skin lesions, urinary tract infections, diabetes and flu like symptoms. These records however are negative for any complaints and/or clinical findings of hearing loss and/or tinnitus. In October 2001 Dr. Whelan again evaluated the veteran. On this evaluation it was noted that the veteran was very depressed, very anxious and to have a blunted affect. Remote and recent memory as well as insight and judgment were reported to be flawed. The veteran's fund of general information and I.Q. appeared to be within the average range clinically. It was noted that the veteran does suffer all the bizarre signs and symptoms associated with a chronic, severe PTSD. The veteran was able to do serial 3's and 7's adequately. Digit span was essentially normal however proverb abstraction was concrete at best. Severe chronic, progressive type PTSD was the Axis I diagnosis and the veteran's GAF was assessed as 40. His prognosis was noted to be very guarded. Dr. Whelan opined to a reasonable medical certainty that the veteran does indeed suffer severe PTSD. He further stated that from an employment standpoint he considered the veteran to be permanently and totally disabled for any type of gainful work currently available on the U.S. employment market on a sustained basis. On file is a graph of an audiological evaluation provided to the veteran in October 2001. In the remarks section of this graph there is notation that states tinnitus bilaterally (constant). At his personal hearing in September 2000 the veteran described his PTSD symptoms and his social life. He noted that he had difficulty sleeping and experiences nightmares. He also stated that he becomes easily angered. He testified that the relationship between him and his children is strained because of his PTSD and that his social activities are limited. He said that he does not like large crowds and shops infrequently with his wife. He further testified that while in service he was responsible for coordinating the firing of 105 Howitzers and that he was not provided any hearing protection. He noted that the blast noise associated with these weapons was loud and that on occasion he would help to load these weapons because his unit was short handed. He said that following service he noticed that he had a slight hearing loss and recalls having ringing in his ears while in Vietnam. He further testified that he currently has a hearing aid that was issued to him by VA. Analysis A. Service Connection for Hearing Loss and Tinnitus For a grant of service connection it must be shown by the evidence of record that a disorder or disease was incurred in or aggravated by service. 38 U.S.C.A. § 1110. Furthermore, where a veteran served ninety (90) days or more during a period of war and sensorineural hearing loss becomes manifested to a degree of 10 percent within one year from date of termination of such service, such disease will be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Furthermore, in those cases where the evidence shows, as it does here, that the veteran engaged in combat with the enemy, VA will accept as sufficient proof of service connection of any disease or injury alleged to have been incurred in or aggravated by such service, satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease if consistent with the circumstances, conditions or hardship of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service, and to that end, shall resolve any reasonable doubt in favor of the veteran. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). This provision does not establish a presumption of service connection, but it eases the combat veteran's burden of demonstrating the occurrence of some inservice incident to which the current disability may be connected. See Collette v. Brown, 82 F.3d 389, 392 (Fed. Cir. 1996). In analyzing the veteran's claim for service connection for bilateral hearing loss and tinnitus in light of the evidence summarized above, the Board observes that there is no clinical evidence demonstrating a hearing loss disability or tinnitus in service or of a sensorineural hearing loss within one year of service. Here, the clinical record in its entirety including the private audiological evaluation provided to the veteran in October 2001, while noting tinnitus, does not indicate whether such is a diagnosis of tinnitus or the veteran complaint of this disorder. Nonetheless, the results of the audiogram testing, which were made in conjunction with the October 2001 private audiological evaluation, do tend to indicate that the veteran presented with a bilateral hearing loss disability within VA standards, and also appear to suggest a finding of tinnitus more than 30 years after the veteran's discharge from service. Similarly, the evidence of record shows that the first clinical documentation of a bilateral sensorineural hearing loss was in October 2001, when VA provided the veteran an audiological evaluation. Furthermore, assuming arguendo that the veteran has a current disability manifested by tinnitus, as such disorder was recorded on the October 2001 audiological evaluations, the first indication of either disorder was many years after service and is too remote in time from service to support a claim that either is service connected. Here, the Board finds it significant that there is an extended period of time between service discharge and any showing of complaints and/or clinical documentation referable to the veteran's assertion that he suffers hearing loss and/or tinnitus. The absence of such objective or subjective evidence to support recent contention that the veteran has a hearing loss disability and/ or tinnitus related to events in service is highly probative evidence against the claims for these disorders. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991). While the veteran contends that he has a hearing loss disability and tinnitus attributable to acoustic trauma in service related to his duties there, he is a lay person and his opinion is not competent to provide the nexus between his current disability and service. See Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). Furthermore, although lay statements pursuant to 38 U.S.C.A. § 1154(b) may be satisfactory for establishing the inservice incurrence of an event that ultimately resulted in hearing loss and/or tinnitus, it is not sufficient to link etiology a present hearing condition to service. See Velez v. West, 11 Vet. App. 148, 153 (1998) (citing Libertine v. Brown, 9 Vet. App. 521, 524 (1996) (§ 1154(b) provides a factual basis upon which determination can be made that particular disease or injury was incurred or aggravated in service but not basis to link etiologically a condition in service to current condition). In sum, it would not be reasonable for the Board to conclude that a disability first clinically shown so many years after service is in any way related to service given the paucity of confirmatory in-service and post-service data or establishing that this was the case. B. Increased Evaluation for PTSD The veteran contends that his service-connected PTSD is more disabling than currently evaluated and thus warrants an increased disability rating. Entitlement to service connection for PTSD was granted in a May 1998 rating decision and a 30 percent disability evaluation was assigned for this condition, effective from April 1994 under 38 C.F.R. § 4.130, Diagnostic Code 9411. In December 1999 the veteran filed a new claim for an increased evaluation in his PTSD. In general, disability evaluations are assigned by applying a schedule of ratings (rating schedule) which represents as far as can practically be determined the average impairment of earning capacity. 38 U.S.C.A. § 1155. Although the regulations require that in evaluating a disability, that disability be viewed in relations to its whole recorded history, 38 C.F.R. § 4.1, 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 which is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Also, 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. A 30 percent rating for PTSD is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: Repressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: Flattened affect; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete task); impaired judgment; impaired abstract thinking; disturbances or motivation in mood; difficulty in establishing or maintaining effective work and social relations. A 70 percent rating is warranted when there is 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 activity; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression infecting the ability to function independently, appropriately ineffectively; 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 or maintain effective relationships. 38 C.F.R. Part 4, Diagnostic Code 9411. The veteran was assigned GAF scores of 60 on VA examination in February 2000 and on a psychiatric evaluation by Dr. Whelan in May 2000. He furthermore has been given GAF scores of 55 to 60 by a VA physician's assistant at a VA mental health clinic on routine follow up treatment between April 2000 and December 2000. On his most recent psychiatric evaluation by Dr. Whelan in October 2001 his GAF score was 40. The GAF scale considers psychological, social and occupational function on a hypothetical continuum of mental illness. American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), 46-47 (1994). A GAF score of 51 to 60 indicates that the examinee has moderate symptoms of moderate difficulty in social, occupational, or school functioning. A GAF score of 41 to 50 indicates that the examinee has serious symptoms or a serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). A GAF score of 31 to 40 indicates that the examinee has some impairment in reality testing or communications or major impairment in several areas, such as work or school. Based upon a close review of the above applicable VA rating criteria and the Global Assessment of Functioning scores provided to the veteran as noted in the medical evidence in this case the Board determines that a reasonable doubt currently exists regarding the issue of whether a rating in excess of 30 percent is in fact warranted for the veteran's PTSD. Specifically, the evidentiary record during the period under consideration contains both favorable and unfavorable medical findings pertaining to the veteran's level of disability. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990) ("[a] reasonable doubt is one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove a claim"). Indeed the evidence of record shows that following VA psychiatric examination in February 2000 the veteran's GAF score was 60 indicating that the symptomatology associated with his PTSD was productive of moderate symptoms. See 38 C.F.R. § 4.130 (incorporating by reference the VA's adoption of the American Psychiatric Association Diagnostic and Statistical Manual on Mental Disorders, 3rd and 4th Editions (DSM-IV), for rating purposes. On this examination while the veteran was noted to have impaired attention and concentration as well as some slight impairment of his memory and recall of recent events his speech was normal and his judgment was intact. He furthermore exhibited no obsessive thoughts or compulsive actions. The veteran also, while expressing that he had difficulty in getting along with his co-workers, nevertheless was continuing with his long-term employment as a maintenance man for a metals company. VA mental health clinic notes compiled following his VA examination in February 2000 recalled that the veteran demonstrates moderate anxiety but that his affect, speech and grooming were essentially normal with no evidence of any suicidal or homicidal ideation. Further his memory, insight and judgment were assessed as fair. His GAF score between April 2000 and December 2001 remained essentially unchanged from the 60 assessed on his VA examination in February 2000. However on a psychiatric examination provided to the veteran in October 2001 by a private physician the veteran's GAF score was assessed as 40. Mental status examination at that time revealed that the veteran's insight and judgment were flawed and that he was very depressed and anxious with a flattened affect. His examiner emphasized that the veteran's PTSD was progressing in a downhill course and had a significant affect on his employability. It was further opined that any rehabilitative treatment would be futile. Therefore, in light of all the above medical findings and opinions, which are both favorable and unfavorable regarding the disability picture for the veteran's PTSD, the Board determines that 38 C.F.R. § 4.3 is for application in this case. Under 38 C.F.R. § 4.3, when a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the veteran. In resolving all reasonable doubt in favor of the veteran, the Board determines that the disability picture associated with the veteran's PTSD more nearly approximates the criteria for a 50 percent evaluation under Diagnostic Code 9411. An evaluation in excess of 50 percent is not warranted, as there is no evidence of increased symptomatology, which is consistent with a 70 percent rating. Notably, the evidentiary record does not support a finding that the veteran has social and occupational impairment, with deficiencies in most areas such as work, family relations, judgment and thinking. The veteran on VA and private psychiatric examination is well oriented as to person, place and time. There is no evidence of a thought process disorder or that the veteran presently has suicidal or homicidal ideation or that he neglects his personal appearance and hygiene. Finally, in regard to social relationships, the evidence indicates the veteran has continued to maintain an effective relationship with his wife and children although sometimes his relationship with his children is strained. Furthermore, he does participate in some social activities including his participation in a hunting club. The Board concludes for these reasons and bases that a rating in excess of 50 percent for the veteran's PTSD is not warranted. ORDER Entitlement to service connection for hearing loss is denied. Entitlement to service connection for tinnitus is denied. Entitlement to an increased evaluation of 50 percent for post-traumatic stress disorder is granted, subject to the laws and regulations governing the award of monetary benefits. DEBORAH W. SINGLETON Member, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.