Citation Nr: 0309353 Decision Date: 05/20/03 Archive Date: 05/27/03 DOCKET NO. 95-30 032 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUE Entitlement to an initial evaluation in excess of 50 percent for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Military Order of the Purple Heart WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD David T. Cherry, Counsel INTRODUCTION The veteran had active military service from May 1969 to February 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 1991 rating decision by the Department of Veterans' Affairs (VA) Regional Office (RO) in San Francisco, California (that office later moved to Oakland, California). The RO granted service connection for PTSD, effective November 14, 1990, the date of receipt of the claim for service connection, and assigned a 10 percent evaluation for the disorder, effective that same day. The RO denied an evaluation in excess of 10 percent for residuals of a GSW to the right elbow. The veteran and his spouse provided oral testimony before a Hearing Officer at the RO in November 1995, a transcript of which has been associated with the claims file. In November 1996, the RO granted an increased evaluation of 30 percent for PTSD, effective November 14, 1990, and continued the evaluation for residuals of a GSW to the right elbow at 10 percent disabling. In June 1997 and December 2000, the Board remanded the claims to the RO for additional development and adjudicative action. In an August 2001 statement, the veteran states "The reason this letter is being written so late is I expected help from my representative. None has been forth coming. I, therefore relive them from any further responsibility and am sending a copy of this letter to them." It does not appear that the representative ever received a copy of the veteran's letter, and in any event, has continued to represent him. There exists the possibility that the veteran never sent a copy of his letter and changed his mind about representation. This matter is referred to the RO for clarification as the record remains devoid of a specific "revocation" of the service organization's representation. In a September 2002 rating decision, the RO granted an increased evaluation of 50 percent for PTSD, effective November 14, 1990, and an increased evaluation of 40 percent for residuals of a GSW to the right elbow under 38 C.F.R. § 4.73, Diagnostic Code 5305 (2002), effective November 14, 1990, the date of receipt of the claim for an increased evaluation. The 40 percent evaluation under Diagnostic Code 5305 is the maximum schedular evaluation assignable under this code and represents a full grant of the benefit sought on appeal. Neither the veteran nor his representative have further pursued an increased evaluation for the GSW of the right elbow. In his subsequent correspondence to the RO, the veteran continued disagreement with the 50 percent evaluation assigned for PTSD, and has not further pursued the previous claim of entitlement to an increased evaluation for the right elbow GSW. The RO issued a supplemental statement of the case on the issue of an initial evaluation in excess for PTSD but not on the issue of an increased evaluation for residuals of a GSW to the right elbow. In a March 1993 statement, the veteran indicated that he had recently had a stroke due to his stress condition. Therefore, he has raised the issue of service connection for residuals of a stroke as secondary to the service-connected PTSD. Also, the June 1998 VA examiner noted that X-rays of the right elbow revealed some malposition of the humerus, and the March 2002 VA fee basis orthopedic examiner made a diagnosis of mild malunion of the right humerus, status post gunshot wound. Accordingly, the issue of service connection for malunion of the right humerus has been raised. Additionally, in a statement faxed to someone in March 2000, which may not have been received by the RO until January 2001, the veteran indicated that there was extra strain on his back and shoulder, in compensating for his arm, and that such strain was probably the reason he ruptured a disc in his back. Therefore, the issue of secondary service connection for residuals of a ruptured disc has been raised. In its mid-September 2002 correspondence to the veteran the RO included VA Form 21-8940, an application for a claim of entitlement to a total disability rating for compensation purposes on the basis of individual unemployability (TDIU). While the veteran claimed he was unemployable in his late October 2002 correspondence to the RO, he never returned the application form for a TDIU. Also, later dated statements on his behalf from his representatives at the RO and at the Board, while conveying his contentions, are negative for any references to a claim for a TDIU. As the above discussed service connection and TDIU issues have been neither procedurally prepared nor certified for appellate review, the Board is referring them to the RO for initial consideration and appropriate adjudicative action. Godfrey v. Brown, 7 Vet. App. 398 (1995). FINDINGS OF FACT 1. VA has met its duty to notify and assist the veteran. 2. From November 14, 1990, to November 6, 1996, PTSD was not productive of severe social and industrial impairment. 3. Since November 7, 1996, PTSD has not been productive of severe social and industrial impairment. 4. Since November 7, 1996, PTSD has not been productive of an 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 difficulty in establishing and maintaining effective work and social relationships. CONCLUSION OF LAW The criteria for an initial evaluation in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 1991 & Supp. 1997); 38 C.F.R. §§ 4.3, 4.7, 4.132, Diagnostic Code 9411 (effective prior to November 7, 1996); 38 C.F.R. § 4.130; Diagnostic Code 9411; 61 Fed. Re. 52695-52702 (Oct. 8, 1996) (effective November 7, 1996). REASONS AND BASES FOR FINDINGS AND CONCLUSION Factual Background On separation examination, the veteran denied having had any psychiatric symptomatology, and the psychiatric evaluation was normal. Vet Center records show that the veteran underwent an intake evaluation in November 1990. The Vet Center authorized treatment with a contracting psychologist. The veteran was afforded a VA psychiatric examination in May 1991. He reported that he was currently married to his third spouse, and described his marriage in positive terms. He stated that he had owned his own towing business for a number of years and had two employees. Mental status examination showed that he was well oriented in all spheres. He showed no signs of delusions or hallucinations. His affect was appropriate, and his memory was intact. There were no signs of a thought disorder and no evidence of any psychotic process. There were no psychiatric signs of an organic brain syndrome. He did not shown any overt signs of any pathological depression or anxiety; this was true even when he spoke of his Vietnam experiences. PTSD was diagnosed. The examiner noted that insofar as objective psychiatric examination was concerned, the veteran currently appeared to be in relatively good emotional balance. The examiner indicated, however, that he veteran stated he still had nightmares every night about Vietnam and that seeing any Southeast Asians made him more upset than usual and brought back memories of Vietnam. The examiner indicated that it appeared that he was still showing some residuals of PTSD. The examiner reported that he was mentally competent and able to handle funds on his behalf. The veteran underwent a VA fee basis psychiatric examination in August 1992. He reported that he was very hyper and short-fused. He spoke of difficulties with sleep and of having nightmares about Vietnam almost every night. He stated that he had flashbacks about Vietnam and that they occurred about two to three times a month. He indicated that he had been married to his current and third wife since around 1983. He reported that he continued to operate his own towing business as he had for the past fifteen years and had two employees. The examiner noted that the veteran did not show any overt signs of any emotional turmoil, emotional distress, anxiety, or depression. The examiner indicated that he continued to have PTSD. The veteran was afforded a VA PTSD examination in December 1994. He reported that he suffered from a number of distressing symptoms. Those symptoms included intrusive thoughts, insomnia and nightmares pertaining to combat. He related that he had nightmares four to five times a month. He reported suffering occasional flashback experiences and having exaggerated startle response and hypervigilance. He denied any feelings of survivor guilt but reported considerable emotional numbing as well as feelings of estrangement from others. He related that he at times had homicidal ideation directed towards people from Southeast Asia, although he had no current intent whatsoever of acting on those thoughts. He also reported significant avoidance of stimuli that remind him of Vietnam, particularly people from Southeast Asia. He indicated that he planned to move to Oregon in a few months to avoid such people. The veteran reported that he had owned a towing business for the past eighteen years, and indicated that he was planning to leave his current line of business because he felt that it required too much contact with the public. He related that he had gotten very angry with clients in the past, and feared that if he did not leave this line of business, he might become violent with one of his future clients. As for social history, he reported that he lived with his current wife and their child. Mental status examination revealed that the veteran was very pleasant and cooperative. He was neatly dressed and had good hygiene. His mood was dysphoric, and his affect was restricted. His speech was normoproductive and spontaneous, and his thought process was sequential. He reported a history of suicidal and homicidal ideation, but did not have any current suicidal or homicidal intent. He denied any auditory or visual hallucinations, apart from his flashback experiences. He verbalized no delusional beliefs. He was alert and oriented to all spheres. He could recall three out of three objects in five minutes. His calculation skills and fund of knowledge were both within normal limits. The examiner noted that the veteran was capable of managing his benefit payments in his own best interest without restriction. The Axis I diagnoses included PTSD. Under Axis IV, it was reported that current stressors were concerns about occupational and health problems. Under Axis V, a Global Assessment of Functioning (GAF) rating of 60 based on current functioning was assigned. The examiner noted that the veteran clearly suffered from PTSD and that it appeared that his PTSD had resulted in significant impairment of both social and occupational functionings. The examiner reported that although the veteran continued to work at the present time, he was planning to leave his current line of work in the near future because of problems stemming from PTSD. At the November 1995 RO hearing, the veteran described the interference in his self-employed job as a tow truck operator caused by PTSD, and indicated that it precluded him from working as an employee of someone else or an organization. Transcript. The veteran underwent another VA PTSD examination in May 1996. His claim file was available for review by the examiner. The veteran reported that he had had recurring nightmares for the past two years, which had been more frequent than previous episodes of nightmares. He experienced flashbacks and had had problems with relationships. He noted problems with anger outbursts. He indicated that he had problems falling asleep, which he attributed to the pain in the right arm. He stated that at times, he had problems concentrating and that he daydreamed a lot. He said that he was hypervigilant and had an exaggerated startle response. The veteran reported one suicide attempt in 1980 after his second wife left him. He indicated that he had been married to his third wife for approximately thirteen years and that he lived with his current wife and their child. He noted that he had been self-employed in his own tow truck business for the past nineteen years and was still currently employed. Mental status examination revealed that the veteran was cooperative and alert. His hygiene was intact. He had no difficulty in sitting, standing, moving about, walking, or hearing. His speech was spontaneous with normal prosody. He exhibited normal associations and was goal oriented. He denied auditory or visual hallucinations and did not exhibit any signs or symptoms of psychosis. He denied suicidal ideation, intent or plan. He described his mood as being a "grizzly bear the last couple of weeks," but his affect was broad during the entire interview. He was oriented to person, place and time. He could recall three of three words immediately and three of three words after five minutes. He could spell the word "world" forward and backward correctly. He correctly did subtraction. He indicated that he would alert everyone if he was the first one in a movie theater to notice a fire. He knew who the current U.S. President was. The Axis I diagnosis was PTSD. Under Axis IV, the current stressors were PTSD symptoms and pain in the right arm. Under Axis V, a GAF rating of 75 for current level of functioning was assigned. The examiner indicated that the veteran appeared to be moderately impaired, both socially and occupationally, from PTSD. The examiner noted that the veteran was having difficulty maintaining his self-employment because of the pain in the right arm. The examiner reported that the veteran was currently worried whether he would be able to remain self-employed because of his physical and mental problems. In October 1997, the veteran was afforded another VA fee basis psychiatric examination. The examiner noted that he did a complete review of the claims file. The veteran reported that he had recurrent intrusive thoughts about Vietnam daily. He stated that he had a marked psychological response to stimuli reminding him of Vietnam. He said that he worried about everything, but made equivocal statements regarding his worry being excessive. He admitted that his worry was unrealistic. He denied any anxiety but then admitted to hypervigilance. He made equivocal statements regarding an exaggerated startle response. He stated that he had difficulty concentrating. He reported that his wife thought he had difficulty with his memory. The veteran stated that he had depressive feelings every once in a while, but denied any symptoms of a depressive disorder. He indicated that he had difficulty recalling his dreams, but that he was aware that he had them. He noted that he had difficulty getting asleep and had early morning awakenings as well. He stated that he had physical pain from his war- related right elbow injury. He indicated that he only ate twice a day, but denied any weight changes. He said that he angered easily, approximately every other day, and that his anger sometimes occurred spontaneously. He stated that he had been angry enough to want to kill others, but it was unclear as to when he had last felt that way. He reported that he had actually "reacted on" these thoughts but without successfully killing anyone. He denied any history of manic or psychotic symptomatology. The veteran reported that he owned his own towing service and that he was still married to his third wife. He stated that he contributed to the upkeep and maintenance of the household. He said that he related "fine" with people with whom he had daily contact, but he also noted that he had a marked estrangement from others after Vietnam. He indicated that this estrangement was present only at times. He made equivocal statements regarding having difficulty showing loving feelings. Mental status examination revealed that the veteran appeared to be his stated age and was well groomed. He had a broad expression and affect with a subdued manner. His speech was spontaneous, normoproductive, relevant, and coherent without deviations. His motor activity was normal with a relaxed posture, and he maintained a 7/10 eye contact. The veteran recalled four out of five objects with prompting at one and five minutes. He performed a digit span of six forward and five in reverse. His recent memory was grossly intact, and as for remote memory, he recalled five out of the last six U.S. Presidents. The veteran was alert and oriented to person, place, time, and purpose. He performed serial sevens with mild difficulty. His judgment and mathematical operations were grossly intact. His fund of knowledge appeared to be normal for his age and education. He was unable to describe his mood but was cooperative during the examination. He denied delusions, hallucinations, thought broadcasting, and thought insertion. No ideas of reference were elicited. The examiner indicated that the veteran presented with a performance on the cognitive examination that was indicative of his being able to perform detailed instructions while maintaining adequate attention and concentration. The examiner noted that he described his successful management of his self-employed towing business and described himself relating well with people whom he had daily contact. The examiner reported that PTSD symptoms did not appear to significantly impair his level of functioning, although he would benefit from treatment. The Axis I diagnoses included PTSD. Under Axis IV, it was noted that the veteran was a combat survivor and that he had psychosocial stressors created by his psychopathology. Under Axis V, the current GAF rating was 70 with the highest GAF rating over the past year being unspecified. The examiner noted that he was competent to handle his own funds at that time. The veteran was afforded another VA psychiatric examination in March 2002. The examiner indicated that he had reviewed the claims file prior to the examination and described in extensive detail his review of the claims file. The veteran denied any psychiatric treatment since 1997 or taking any kinds of psychiatric medication. It was noted that in actuality he had not received any psychiatric treatment since 1990. The veteran's first and most troublesome symptom was flashbacks, which now occurred three to four times a week, whereas prior to 1996, they only occurred four to five times a year. His second symptom was anger and irritability in the form of "outburst" of verbal behavior. He reported that he had learned to walk out of the room before he responded or hurt someone. He indicated that he had daily anger outbursts, and that prior to 1996, those anger outbursts only occurred two times a week. The veteran's third symptom was nightmares. He said that he could recall his nightmares, but that he wakes up every night in a sweat and that his wife reported that he talked in his sleep. He indicated that three years ago, these nightmares occurred only every other night. His fourth set of symptoms was palpitations, anxiety, excessive alertness, and feelings of being ready to go. He stated that symptoms were triggered or provoked by noises of helicopters, aircraft and jets; by cars backfiring; and by seeing Vietnamese people. The veteran's fifth symptom was that he avoided public gatherings. However, he indicated that he went to theaters and restaurants, but that he always had to face the door with his back to the wall. He noted that he was able to tolerate crowds, but that he had to keep a distance from them. His sixth symptom was experiencing extreme tension watching war movies. His seventh and eight symptoms were insomnia and concentration problems, respectively. The veteran reported that he was still married to his third wife. As for work, he indicated that he had to work in the office of his tow truck business instead of on the road because of his March 2002 surgery to the right big toe. He said that 95 percent of his relationships outside of family were with Vietnam veterans and that he had difficulty relating to other people. He noted that he served in a lot of veterans' organizations. He stated that he and his wife only went out with other couples two to three times a year, but that 85 percent of evenings he went out to eat with his wife and child. The examiner noted that there appeared to mild-to-moderate inference in psychosocial functioning from the veteran's PTSD status alone. Mental status examination revealed that the veteran was wearing a T-shirt, pullover shirt and casual clothes in place. He was able to laugh, joke, and smile throughout the interview. He described several episodes of having road rage, with the last one four months ago. He was relaxed and comfortable throughout the interview with his back to the wall and the door immediately available. He reported carrying a gun while working and sleeping near one. He indicated that he did a perimeter search of his home every night. His stream of thought or speech was spontaneous, coherent and relevant. The veteran described a euthymic mood at that time, except for outbursts of anger. He did not show any outbursts of anger or hostility during this particular interview. He did not have any immediate mood complaints. He did not currently exhibit suicidal or homicidal ideations. He reported that he had anger at previous employees, and indicated that while he did not seek them out in terms of wanting to hurt or kill them, he might harm them considerably if he interfaced with them. He described a somewhat "thrill" in scaring people. There was no evidence of any kind of a psychotic process noted. The veteran reported that he heard voices in 1996 and that he now only occasionally heard the voice of a fellow soldier in a flashback of a combat situation. The examiner indicated that, therefore, voices occurred only occasionally during that flashback. There was no evidence of any grossly auditory or visual hallucinations or any kind of delusional experiences. He had no referential thoughts. His sensorium, mental grasp and capacity were fairly intact. He was oriented to time, place and person. He showed diminution in concentration ability. His general fund of knowledge was good, and he abstracted proverbs well. His insight and judgment were adequate, and he showed no deficit in memory. The examiner noted that there was no impairment of his thought processes or communications and that there was no evidence of delusions, hallucinations or other persistence. The examiner indicated that the veteran was fairly relaxed and showed no inappropriate behavior during the interview, but that he did have anger outbursts and had exhibited inappropriate behavior outside of the interview. The examiner reported that he did not exhibit any current suicidal or homicidal thoughts, but that he had both in the past, with both homicidal and suicidal attempts in the 1970s and 1980s. The examiner noted that from a psychiatric point of view, the veteran was able to maintain his minimal personal hygiene and perform other activities of basic daily living. The examiner indicated that his main limitations seemed to be physical in nature in terms of the recent removal of the right big toe, the back surgery, and the right shoulder and arm problems. The examiner noted that he was oriented to time, place and person, and that he did not show any memory loss. The examiner stated that he did show some ritualistic behavior in terms of closing off the perimeter of his home and sleeping with a weapon under his pillow. The examiner reported that his rate of flow of speech was goal directed, logical and relevant. The examiner indicated that the veteran did not exhibit any specific panic attacks, but that he did exhibit palpitations and a variety of hyperalertness and alarm reactions with certain trigger events. The examiner noted that he did not describe any mood problems, but that he did report that he was depressed all of the time because of his financial situation. The examiner reported that the only episode of major depression was in 1980 when he tried to commit suicide. The examiner stated that the veteran had significantly impaired impulse control in the form of daily angry outbursts and a reported road rage episode four months ago. The examiner reported that he described significant sleep impairment of four hours of sleep a night. The examiner indicated that there was no need for any kind of psychometric testing. The examiner indicated that the veteran had PTSD manifested by reexperiencing a stressor, avoidance symptomatology, and heightened physiological arousal. The examiner noted that there were no other psychiatric disorders that were present, that there were no other psychiatric symptoms that interfered with activities, and that all of the psychiatric symptomatology was related to PTSD. The Axis I diagnosis was PTSD. Under Axis IV, it was indicated that current psychosocial functioning showed that there were some financial stressors because his business income was declining. The examiner noted that his current physical state from the view of organic mental disorders had not left any residual psychological effect from the traumatic events in 1991 and 1996. Under Axis V, the examiner noted that the veteran showed mild-to-moderate symptomatology in the range of a GAF rating from 55 to 65. A GAF rating of 60 was assigned based on the fact that outside of his family, he only had meaningful interpersonal relationships with veterans and through veterans' organizations. The examiner reported that he had daily anger outbursts, which significantly impaired some of his functioning and interfered with other relationships. The examiner noted that he had had homicidal ideation in the past regarding conflicts with past employees, but that he did not seek out said employees. The examiner indicated that he had difficulty with groups of people and with Asians and showed significant insomnia, along with interpersonal conflict with strangers and people who were not Vietnam veterans. The examiner stated that the veteran had much more serious symptomatology from his PTSD in the 1970s and 1980s when it was associated with alcohol use, but that since his basic sobriety in 1983, his symptomatology seemed to leveled off at a GAF rating of 60, even though two other major symptoms of flashbacks and anger outbursts had increased since 1996 and he had time alone to ruminate while recuperating in bed from his lumbar surgery. The examiner opined that he was competent to manage his own benefits as he managed his own business and still was self-employed in a tow truck business. The examiner noted that the veteran was currently employed and that there was no evidence that his PTSD along with other service-connected physical injuries would cause any unemployment. The examiner reported that the veteran was planning to move to Oregon and perhaps start a car dealership or other business. The examiner indicated that there was some reduced reliability in productivity related to the veteran's PTSD symptoms, which were mild-to-moderate in nature and related to his problems in concentrating and daily anger outbursts. The examiner stated that he did not appear to deficient in most areas of his mental functioning and that he did not appear to be totally occupationally impaired due to PTSD. Criteria Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2002). Separate diagnostic codes identify the various disabilities. The Board may only consider those factors that are included in the rating criteria provided by regulations for rating that disability. To do otherwise would be error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). It is essential that each disability is viewed in relation to its history, and that medical examinations are accurately and fully described emphasizing limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.1 (2002). Medical evaluation reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2 (2002). 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 (2002). Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2002). When, after consideration of all of the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 C.F.R. §§ 3.102, 4.3 (2002). The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002). PTSD Where the issue involves the assignment of an initial rating for a disability following the initial award of service connection for that disability - such as this claim for an initial evaluation in excess of 50 percent for PTSD - the entire history of the disability must be considered and, if appropriate, staged ratings may be applied. Fenderson v. West, 12 Vet. App. 119 (1999). The criteria for rating mental disorders were amended effective November 7, 1996. Where a law or regulation changes after a claim has been filed or reopened, but before the administrative judicial process has been concluded, the version more favorable to an appellant applies unless Congress provided otherwise or permitted the Secretary to do otherwise and the Secretary does so. Marcoux v. Brown, 9 Vet. App. 289 (1996); Karnas v. Derwinski, 1 Vet. App. 308 (1991); Bernard v. Brown, 4 Vet. App. 384 (1993). Since the veteran's claim was filed prior to November 7, 1996, his psychiatric disorder must be evaluated under both the old and new criteria, as appropriate, to determine which version is more favorable to him. See VAOPGCPRC 3-00. As to the effective date of disability compensation award, 38 U.S.C. 5110(g) provides: "[W]here compensation, dependency and indemnity compensation, or pension is awarded or increased pursuant to any Act or administrative issue, the effective date of such award shall be fixed in accordance with the facts found but no earlier than the effective date of the Act or administrative issue." DeSousa v Gober, 10 Vet. App. 461, 467 (1997). See also McCay v. Brown, 9 Vet. App. 183, 187 (1996) ("plain language of section 5110(g) prohibits a retroactive award prior to the effective date of the legislation"), aff'd, 106 F.3d 1577 (Fed. Cir. 1997). Prior to November 7, 1996, the provisions of 38 C.F.R. § 4.129 pertaining to social inadaptability provided that social integration was one of the best evidences of mental health and reflected the ability to establish (together with the desire to establish) healthy and effective interpersonal relationships. However, in evaluating impairment resulting from the ratable psychiatric disorders, social inadaptability was to be evaluated only as it affected industrial adaptability. Id. The principle of social and industrial inadaptability as the basic criterion for rating disability from the mental disorders contemplated those abnormalities of conduct, judgment and emotional reactions that affect economic adjustment, i.e., that produce impairment of earning capacity. Id. Prior to November 7, 1996, the provisions of 38 C.F.R. § 4.130 pertaining to evaluation of psychiatric disability provided that the severity of disability was based upon actual symptomatology, as it affected social and industrial adaptability. Two of the most important elements to consider were time lost from gainful work and decrease in work efficiency. Id. The provisions of 38 C.F.R. § 4.130 provided that the rating board must not underevaluate the emotionally sick veteran with a good work record, nor must it overevaluate his or her condition on the basis of a poor work record not supported by the psychiatric disability picture. Id. It was for this reason that great emphasis was placed upon the full report of the examiner's description of actual symptomatology. Id. The examiner's classification of the disease as "mild," "moderate," or "severe" was not determinative of the degree of disability, but the report and the analysis of the symptomatology and the full consideration of the whole history by the rating agency would be. Id. The old schedular provisions of Diagnostic Code 9411, applicable to PTSD claims, require that evaluation would be based on certain criteria. A 100 percent evaluation was warranted for the existence of one of the following conditions: the attitudes of all contacts except the most intimate were so adversely affected as to result in virtual isolation in the community; there were totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities resulting in profound retreat from mature behavior; or the veteran was demonstrably unable to obtain or retain employment. Hence, these rating criteria set forth three independent bases for granting a l00 percent evaluation, pursuant to Diagnostic Code 9411. See Johnson v. Brown, 7 Vet. App. 95 (1994). When the ability to establish and maintain effective or favorable relationships with people was severely impaired, and the psychoneurotic symptoms were of such severity and persistence that there was severe impairment in the ability to obtain or retain employment, a 70 percent rating was assignable. 38 C.F.R. § 4.132, Diagnostic Code 9411 (1996) (repealed effective November 7, 1996). When the ability to establish or maintain effective or favorable relationships with people was considerably impaired, and by reason of psychoneurotic symptoms, the reliability, flexibility and efficiency levels were so reduced as to result in considerable industrial impairment, a 50 percent rating was assigned. Id. Under the old criteria, there were additional guidelines for evaluating PTSD, i.e., social impairment per se was not to be used as the sole basis for any specific percentage evaluation, but was of value only in substantiating the degree of disability based on all the findings. 38 C.F.R. § 4.132, Note (1) (1996) (repealed effective November 7, 1996). Additionally, social inadaptability was to be evaluated only as it affects industrial adaptability. 38 C.F.R. § 4.129 (1996) (repealed effective November 7, 1996). The revised rating criteria for PTSD under Diagnostic Code 9411 contemplate that a 50 percent evaluation is to be assigned 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; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2002). A 70 percent evaluation is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation 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; memory loss for names of close relatives, own occupation, or own name. Id. The use of the term "such as" in the general rating formula for mental disorders in 38 C.F.R. § 4.130 (2002) demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Id. The evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 (2002) is not restricted to symptoms provided in that diagnostic code. Id. at 443. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, as revised in the 1994, fourth edition (DSM-IV). Id. If the evidence demonstrates that a claimant suffers symptoms or effects that cause an occupational or social impairment equivalent to what would be caused by the symptoms listed in that diagnostic code, the appropriate, equivalent rating will be assigned. Id. Under the revised criteria when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126 (2002). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. 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. Id. The GAF is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) [citing American Psychiatric Association, Diagnostic And Statistical Manual For Mental Disorders 32 (4th ed. 1994)] (DSM-IV)]. GAF scores ranging between 71 to 80 reflect that if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument) and result in no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). DSM-IV at 32. GAF scores ranging between 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Id. Scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Id. Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Id. Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). Id. Analysis Preliminary Matter: Duty to Assist At the outset, it should be noted that on November 9, 2000, the President signed into law the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000). The law eliminates the concept of a well-grounded claim, redefines the obligations of VA with respect to the duty to assist, and supercedes the decision of the United States Court of Appeals for Veterans Claims (CAVC) in Morton v. West, 12 Vet. App. 477 (1999), withdrawn sub nom. Morton v. Gober, 14 Vet. App. 174 (2000) (per curiam order) (holding that VA cannot assist in the development of a claim that is not well grounded). This law also includes an enhanced duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The VCAA is applicable to all claims filed on or after the date of enactment, November 9, 2000, or filed before the date of enactment and not yet final as of that date. VCAA, Pub. L. No. 106-475, § 7(a), 114 Stat. 2096, 2099 (2000). See also Karnas v. Derwinski, 1 Vet. App. 308 (1991). VA has issued final rules to amend adjudication regulations to implement the provisions of the VCAA. See 38 C.F.R § 3.159 (2002). The regulations pertaining to these claims merely implement the VCAA and do not provide any rights other than those provided by the VCAA. See 66 Fed. Reg. 45,620, 45,629 (Aug. 29, 2001). In that regard, the RO provided the veteran notice of the VCAA in an April 2001 letter, and in a September 2002 supplemental statement of the case provided the provisions and fully adjudicated his claims with this law in mind. Through the August 1991 rating decision, a statement of the case, supplemental statements of the case, and letters from the RO dated in July 1992, January 1996, June 1997, and April 2001, the RO informed the veteran of the information and evidence necessary to substantiate his claim and his responsibilities for providing evidence. He was advised of evidence he could submit himself or to sufficiently identify evidence and if private in nature to complete authorization or medical releases so that VA could obtain the evidence for him. Such notice sufficiently placed the veteran on notice of what evidence could be obtained by whom and advised him of his responsibilities if he wanted such evidence to be obtained by VA. See 38 U.S.C.A. § 5103 (West 2002); Quartuccio v. Principi, 16 Vet. App. 183 (2002); 38 C.F.R. § 3.159 (2002). In the July 1992 and January 1996 letters, the RO asked the veteran to complete and return a copy of the VA Form 21-4142 so that the RO could obtain records from AHM (initials), Ph.D. In a February 1996 report of contact, it was noted that the veteran reported that he had not received any treatment from Dr. AHM. In that regard, treatment records from a Vet Center contain a statement from Dr. AHM revealing that the veteran had one session with him and that the in- take was not completed because the veteran failed to report for follow-up visits. In the June 1997 letter, the RO asked the veteran to identify the names and addresses of all health care providers from whom he had received treatment for PTSD from August 1992 to the present. The RO enclosed medical history forms for the veteran to provide a medical history of treatment at VA and private medical facilities. The RO also enclosed two copies of the VA Form 21-4142 and asked the veteran to complete the forms for any treatment records not previously provided. The veteran did not respond. In the April 2001 letter, the RO notified the veteran about the VCAA. The RO informed him that they would make reasonable efforts to get the evidence necessary to support his claim. The RO indicated that it would try to obtain records, such as medical records, but that the veteran must give it enough information about such records so that it could request them from the person or agency that has them. The RO noted that it was still the veteran's responsibility to make sure that it received such records. The RO indicated that to establish entitlement to an increased evaluation for PTSD, the evidence must show that it became worse or increased in severity. The RO noted that this could be shown by medical evidence or other evidence showing increased severity or worsening of his condition. The RO asked the veteran to do the following: complete and return an enclosed medical history form for the disability claimed; provide the name of the person, agency, or company that has relevant records; provide the address of this person, agency, or company; provide the approximate time frame covered by the records; and, in the case of medical records, provide the condition for which he was treated. The RO noted that the veteran could help it with his claim by telling it about any additional information or evidence that he wanted the RO to try to obtain. In the August 2001 letter, the veteran noted that the RO should, pursuant to the December 2000 Board remand, obtain any outstanding VA treatment records. The veteran did not identify any VA or non-VA treatment for his claim, nor did he submit any VA Form 21-4142's authorizing the release of records. As for the duty to assist, the service medical records and reports of VA examinations and studies are of record. As to the treatment records, the RO obtained records from a Vet Center where the veteran received some treatment. The RO also contacted a local VA medical center, and was informed that while the veteran underwent several examinations at that facility, he had not had any treatment there. In light of the above, VA has fulfilled its duty to assist in obtaining relevant records. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R § 3.159 (2002). The veteran has been afforded several VA examinations with regard to his claim. Accordingly, VA has satisfied its duty to assist by providing a medical examination. See 38 U.S.C.A. § 5103A; 38 C.F.R § 3.159(c)(4). In light of the above, VA has complied with the directives of the Board remands. See Stegall v. West, 11 Vet. App. 268 (1998). In light of the foregoing, the Board is satisfied that all relevant facts have been adequately developed to the extent necessary; no further assistance to the veteran in developing the facts pertinent to his claims is required to comply with the duties to notify and to assist under both the former law and the new VCAA. 38 U.S.C.A. §§ 5107(a), 5103, 5103A; 38 C.F.R. § 3.159. Additionally, the Board finds that the duty to notify has been satisfied. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159(b). As for the hearing officer's duty to assist, for the same reasons as noted above with regard to the VCAA, the hearing officer's duty under 38 C.F.R. § 3.103(c)(2) has been satisfied. See Stuckey v. West, 13 Vet. App. 163 (1999); Costantino v. West, 12 Vet. App. 517 (1999). Having determined that the duties to notify and to assist have been satisfied, the Board turns to an evaluation of the veteran's claims on the merits. Initial Evaluation in Excess of 50 Percent for PTSD Prior to November 7, 1996 The Board notes that since the veteran filed a notice of disagreement with the determination in the August 1991 rating decision assigning an initial evaluation of 10 percent effective November 14, 1990, it must consider the entire time period in question - from the date of the original grant of service connection, November 14, 1990, to the present. The Board is required to examine the evidence pertinent to the period of November 14, 1990, to November 6, 1996 solely under the "old" criteria as pursuant to VAOPGCPREC 3-00. Evaluating the disability picture presented by the medical evidence accumulated during that period in relation to the criteria in effect prior to November 7, 1996, the Board finds that the preponderance of the evidence is against an evaluation in excess of 50 percent for the period from November 14, 1990, to November 6, 1996. The probative evidence of record does not show a severe social and industrial impairment. The report of the May 1991 VA psychiatric examination reflects that the examiner noted that insofar as objective psychiatric examination was concerned, the veteran currently appeared to be in relatively good emotional balance. As for residuals of PTSD, the examiner only indicated the veteran reported having nightmares every night about Vietnam and that seeing any Southeast Asians made him more upset than usual and brought back memories of Vietnam. He was considered mentally competent and able to handle funds on his behalf. During the August 1992 VA fee basis examination, the veteran reported being very hyper and short-fused, and having difficulties sleeping, nightmares about Vietnam almost every night, and flashbacks about Vietnam two to three times a month. However, the VA fee basis examiner noted that veteran did not show any overt signs of any emotional turmoil, emotional distress, anxiety, or depression. During the December 1994 VA PTSD examination, the veteran reported a number of distressing symptoms. While the examiner noted that PTSD resulted in significant impairment of both social and occupational functioning, that examiner assigned a GAF rating of only 60 for current functioning. Such a GAF rating represents moderate symptoms or moderate difficulty in social, occupational, or school functioning. See DSM-IV at 32. As for a possible change in employment noted by the December 1994 VA examiner, the Board notes that as of October 2002, the veteran was still self-employed as the owner of a tow truck business. The report of the May 1996 VA PTSD examination reflects that a GAF rating of 75 for current functioning was assigned. The examiner indicated that the veteran appeared to be moderately impaired, both socially and occupationally, from PTSD. As for occupational impairment, the examiner noted that the veteran was having difficulty maintaining his self-employment because of the pain in the right arm. The examiner reported that the veteran was currently worried whether he would be able to remain self-employed because of his physical and mental problems. However, the examiner did not indicate that such concerns with regard to his mental problems were valid. The competent medical evidence fails to demonstrate that the psychoneurotic symptoms were of such severity and persistence that there was severe impairment in the ability to obtain or retain employment. A severe impairment in the ability to establish and maintain effective or favorable relationships is not shown. The veteran has not demonstrated the more extensive and severe symptomatology described in the rating schedule to qualify for a 70 percent rating. The Board concludes that the symptomatology due to service-connected PTSD does not equal or more nearly approximate severe social and industrial impairment under Diagnostic Code 9411 as previously in effect. See 38 C.F.R. 4.7. Moreover, the competent medical evidence fails to demonstrate total social and industrial impairment under Diagnostic Code 9411 as previously in effect. Accordingly, the preponderance of the evidence is against a finding that for the period from November 14, 1990, to November 6, 1996, the veteran's PTSD was productive of severe social and industrial impairment. Therefore, the Board finds no basis for granting a rating in excess of 50 percent for PTSD for the period from November 14, 1990, to November 6, 1996, solely under the "old" criteria. From November 7, 1996, to the Present With respect to the period on and after November 7, 1996, the Board is required to examine the evidence under the "old" and "new" criteria, and apply the rating criteria more favorable to the veteran. See VAOPGCPREC 3-00. Focusing on the period from November 7, 1996, to the present, the Board finds that on the facts of this case, neither criteria are found to be more favorable. The evidence simply continues to support no more than a 50 percent evaluation. The report of the October 1997 VA fee basis psychiatric examination reflects that a GAF rating of 70 for current functioning was assigned. Such a GAF rating shows that the veteran had some mild symptoms but that he was generally functioning pretty well and had some meaningful interpersonal relationships. See DSM-IV at 32. The October 1997 VA fee basis examiner indicated that the veteran presented with a performance on the cognitive examination that was indicative of him being able to perform detailed instructions while maintaining adequate attention and concentration. The examiner noted that the veteran described his successful management of his self-employed towing business and described himself relating well with people with whom he had daily contact. The examiner reported that his PTSD symptoms did not appear to significantly impair his level of functioning, although he would benefit from treatment. The report of the March 2002 VA fee basis examination shows that a GAF rating of 60 was assigned for the veteran's mild- to-moderate symptomatology and impairment. The examiner stated that the veteran had much more serious symptomatology from his PTSD in the 1970s and 1980s when it was associated with alcohol use, but that since his basic sobriety in 1983, his symptomatology seemed to level off at a GAF rating of 60, even though two other major symptoms of flashbacks and anger outbursts had increased since 1996, and he had time alone to ruminate while recuperating in bed from his lumbar surgery. The examiner noted that the veteran was currently employed and that there was no evidence that his PTSD along with other service-connected physical injuries would cause any unemployment. While there was some degree of industrial impairment, the veteran's symptoms were not at a level of severity and persistence that constituted severe impairment. His psychoneurotic symptoms were not of such severity and persistence that there was severe impairment in the ability to obtain or retain his employment. Also, the Board is unable to conclude that the veteran's ability to establish or maintain effective or favorable relationships during this time period was severely impaired. While there may be some social impairment, the Board does not find that his ability to establish and maintain social relationships was severely impaired in light of the evidence of record to the contrary. The Board stresses that the evidence, as discussed above, does not reflect symptomatology that meets or more nearly approximates the criteria required for a 70 percent evaluation or higher under the old criteria of Diagnostic Code 9411 in effect prior November 7, 1996. See 38 C.F.R. § 4.7. Accordingly, the preponderance of the evidence is against a finding that since November 7, 1996, the veteran's PTSD has been productive of severe social and industrial impairment. Likewise, under the new criteria for rating mental disorders on and after November 7, 1996, the evidence is against a higher evaluation. Occupational and social impairment is currently recognized as per the assignment of a 50 percent evaluation for PTSD. Competent evidence of deficiencies in most areas as would support a higher evaluation has not been presented. The competent and probative evidence does not show any of the following: suicidal ideation; speech being intermittently illogical, obscure, or irrelevant; spatial disorientation; neglect of personal appearance and hygiene; gross impairment in thought processes or communication; persistent delusions or hallucinations; 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. On the October 1997 VA fee basis examination it was not noted that the veteran had any current suicidal or homicidal ideation. He reported his suicide attempt in 1980, and it was indicated that it was unclear when he last felt angry enough to want to kill someone. The October 1997 VA fee basis examiner indicated that the veteran presented with a performance on the cognitive examination that was indicative of his being able to perform detailed instructions while maintaining adequate attention and concentration. The examiner noted that the veteran described his successful management of his self-employed towing business and described himself relating well with people whom he had daily contact. The examiner reported that his PTSD symptoms did not appear to significantly impair his level of functioning, although he would benefit from treatment. The mental status evaluation done during the October 1997 examination revealed that the veteran was well groomed, alert and oriented to person, place, time and purpose. He denied delusions, hallucinations, thought broadcasting, and thought insertion. No ideas of reference were elicited. The March 2002 VA fee basis examiner noted that while there were suicidal and homicidal attempts in the 1970s and 1980s, the veteran did not exhibit any current suicidal or homicidal thoughts. The examiner described the veteran's speech as spontaneous, normoproductive, relevant, and coherent. The examiner indicated that there was no impairment of his thought processes or communications, and that there was no evidence of delusions, hallucinations or other persistence. The examiner noted that the veteran was oriented to place and time and had no memory loss. Mental status evaluation done during the March 2002 examination revealed that the veteran was wearing a T-shirt, pullover shirt and casual clothes in place. The examiner noted that he was able to maintain minimal personal hygiene and perform other activities of basic daily living. As for obsessional rituals that interfere with routine activities, the March 2002 VA fee basis examiner merely noted that at night the veteran checked the perimeter of his house and slept near a gun. No other obsessional rituals were described. With regard to near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, the veteran stated during the October 1997 VA fee basis examination that he had depressive feelings every once in a while, but he denied any symptoms of a depressive disorder. The March 2002 VA fee basis examiner noted the veteran reported that he was depressed all of the time because of his financial situation but did not describe any mood problems. That examiner also indicated that the only episode of major depression was in 1980 when the veteran tried to commit suicide. As to near-continuous panic, the March 2002 VA fee basis examiner indicated that while the veteran did exhibit palpitations and a variety of hyperalertness and alarm reactions with certain trigger events, he did not exhibit any specific panic attacks. With regard to impaired impulse control, such as unprovoked irritability with periods of violence, on the October 1997 VA fee basis examination it was indicated that it was unclear when the veteran last felt angry enough to want to kill someone. The March 2002 VA fee basis examiner noted that the veteran had significantly impaired impulse control in the form of daily angry outbursts and a reported road rage episode. As to grossly inappropriate behavior, on the March 2002 VA fee basis examination, he showed no inappropriate behavior. However, the examiner noted that the veteran had anger outbursts and a history of inappropriate behavior. In particular, the veteran had reported an episode of road rage. With regard to difficulty in adapting to stressful circumstances, including work and a worklike setting, the Board notes that as of October 2002 the veteran was still operating his own tow truck business, even though he reported in an October 2002 statement that he deferred all stressful situations to his business partner or his spouse. As to an inability to establish and maintain effective relationships, as of October 2002, the veteran was still married to his third spouse. The March 2002 VA examiner noted that although the veteran had very few meaningful social and interpersonal relationships outside that of his family, he did have interpersonal relationships with veterans and through veterans' organizations. The veteran's symptoms of PTSD are anger outbursts, difficulty concentrating, flashbacks, nightmares, palpitations, anxiety, excessive alertness, feelings of being "ready to go," avoiding public gatherings, tension watching war movies, and insomnia. The October 1997 VA fee basis examiner indicated that the veteran's PTSD symptoms did not appear to significantly impair his level of functioning. The March 2002 VA fee basis examiner stated that the veteran had much more serious symptomatology from his PTSD in the 1970s and 1980s when it was associated with alcohol use, but that since his basic sobriety in 1983, his symptomatology seemed to level off at a GAF rating of 60, even though two other major symptoms of flashbacks and anger outbursts had increased since 1996 and he had time alone to ruminate while recuperating in bed from his lumbar surgery. That examiner noted that the veteran was currently employed and that there was no evidence that his PTSD along with other service-connected physical injuries would cause any unemployment. That examiner indicated that there was some reduced reliability in productivity related to the veteran's PTSD symptoms, which were mild-to-moderate in nature and related to his problems in concentrating and daily anger outbursts. That examiner also stated that the veteran did not appear to be deficient in most areas of his mental functioning and that he did not appear to be totally occupationally impaired due to PTSD. Even with consideration of all of the veteran's symptomatology, to include obsessional rituals, anger outbursts, any inappropriate behavior, difficulty in adapting to stressful situations, and any inability to establish and maintain effective relationships, the Board finds that the veteran does not suffer symptoms or effects that cause an occupational or social impairment equivalent to what would be requisite to meet the new criteria for a 70 percent rating. Mauerhan, 16 Vet. App. at 442. Accordingly, the preponderance of the evidence is against a finding that since November 7, 1996, PTSD has been productive of an occupational and social impairment with reduced reliability and productivity. As required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has considered the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they were raised by the veteran; however, the Board finds no basis upon which to assign a higher disability evaluation for PTSD. Although the veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for an initial evaluation in excess of 50 percent for PTSD. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Extraschedular Consideration The CAVC has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance. Floyd v. Brown, 9 Vet. App. 88 (1996). The Board, however, is still obligated to seek all issues that are reasonably raised from a liberal reading of documents or testimony of record and to identify all potential theories of entitlement to a benefit under the law or regulations. In Bagwell v. Brown, 9 Vet. App. 337 (1996), the CAVC clarified that it did not read the regulation as precluding the Board from affirming an RO conclusion that a claim does not meet the criteria for submission pursuant to 38 C.F.R. § 3.321(b)(1), or from reaching such conclusion on its own. VAOPGCPREC 6-96 (Aug. 16, 1996). In the veteran's case at hand, the RO provided the criteria for assignment of an extraschedular evaluation and considered them, but did not grant entitlement to an increased evaluation on this basis. The CAVC has further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only where circumstances are presented which the Under Secretary for benefits or the Director of the VA Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The Board does not find the veteran's disability picture to be so unusual or exceptional in nature as to warrant referral of his case to the Director or Under Secretary for review for consideration of extraschedular evaluation pursuant to the provisions of 38 C.F.R. § 3.321(b)(1). See Floyd, 9 Vet. App. at 94-96; Shipwash, 8 Vet. App. at 227. The current schedular criteria adequately compensate the veteran for the nature and extent of severity of his PTSD. Having reviewed the record with these mandates in mind, the Board finds no basis for further action on this question. ORDER Entitlement for an initial evaluation in excess of 50 percent for PTSD is denied. ____________________________________________ RONALD R. BOSCH Veterans Law Judge, 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.