Citation Nr: 1233484 Decision Date: 09/26/12 Archive Date: 10/09/12 DOCKET NO. 00-15 830 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in White River Junction, Vermont THE ISSUE Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: New York State Division of Veterans' Affairs ATTORNEY FOR THE BOARD L. Kirscher Strauss, Counsel INTRODUCTION The Veteran served on active duty from April 1968 to March 1970. This appeal to the Board of Veterans' Appeals (Board) arises from a June 1999 rating decision in which the RO in New York, New York granted service connection for PTSD and assigned an initial, 30 percent rating effective January 29, 1996. The Veteran filed a notice of disagreement (NOD) in September 1999, and the New York RO issued a statement of the case (SOC) in April 2000. The Veteran filed a substantive appeal (via a VA Form 9, Appeal to Board of Veterans' Appeals) in June 2000. During the pendency of the appeal, in a November 2003 rating decision, the New York RO granted a higher, 50 percent rating effective February 7, 2002. Then, in an August 2004 rating decision the New York RO granted the 50 percent rating back to the initial effective date of service connection, January 29, 1996. In February 2005, the Board remanded the Veteran's claim to the New York RO to schedule the Veteran for a Board hearing at the RO. A hearing was initially scheduled for July 18, 2006 but the Veteran failed to report. The hearing was rescheduled for December 11, 2007 and a hearing notification letter was sent to the Veteran on November 2, 2007. Although the hearing notification was not returned by the U.S. Postal Service as undeliverable, the Veteran failed to report for the scheduled hearing, and has not requested rescheduling of the hearing. As such, his hearing request has been deemed withdrawn. See 38 C.F.R. § 20.704(d) (2011). In July 2009 (after the case had been transferred to the jurisdiction of the White River Junction, Vermont RO), the RO issued a supplemental SOC (SSOC) continuing the 50 percent rating. Thereafter, the RO returned the matter on appeal to the Board for further consideration. In November 2009, the Board remanded the claim on appeal to the RO , via the Appeals Management Center (AMC) in Washington, DC , to obtain additional relevant private and VA treatment records that were identified, but not associated with the claims file. After accomplishing further action, the RO continued to deny the claim (as reflected in a September 2010 supplemental SOC (SSOC), and returned this matter to the Board for further appellate consideration.. Because the Veteran disagreed with the initial rating assigned following the award of service connection for PTSD, the Board has characterized this claim in light of the distinction noted in Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service-connected disability). Moreover, although the RO granted a higher initial rating during the pendency of the appeal, as higher ratings for this disability are available, and the Veteran is presumed to seek the maximum available benefit for a disability, the claim for a higher rating remains viable on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). FINDINGS OF FACT 1. All notification and development needed to fairly adjudicate the claim on appeal has been accomplished. 2. At many times during the appeal, the Veteran's psychiatric symptoms and behaviors, specifically his frequent hypomanic presentation, agitation, impaired judgment, risky behavior, and alteration or instability in mood and behavior, have been attributed by medical practitioners to abuse of antiparkinsonian medications, particularly Pramipexole and Sinemet, and possibly to multiple sclerosis and Parkinson's Plus syndrome associated with fronto-temporal dementia. 3. Prior to November 7, 1996, the Veteran's PTSD was primarily manifested by bland mood and affect varying from irritable to depressed, impaired recent memory; superficial insight; nightmares, intrusive memories, increased startle response, increased irritability leading to explosiveness, and a mention of homicidal ideation; collectively, these symptoms are indicative of no more than considerable industrial impairment. 4. Since November 7, 1996, the Veteran's PTSD has primarily been manifested by pressured, rapid, and loquacious speech; racing, slightly scattered, circumstantial, and irrational thoughts; anxious and depressed mood; anxious, constricted, blunt, and dysphoric affect; difficulty concentrating; and somewhat disorganized thought process, collectively, these symptoms are indicative of no more than occupational and social impairment with reduced reliability and flexibility. CONCLUSION OF LAW The criteria for a rating in excess of 50 percent for PTSD are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.126(a), 4.130, Diagnostic Code 9411 (2011) and 38 C.F.R. § 4.132, Diagnostic Code 9411 (as in effect prior to November 7, 1996). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2011)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2011). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1) . The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353 - 23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO, to include the AMC). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, following the award of service connection for PTSD, and the Veteran's disagreement with the initial rating assigned, in a December 2002 post-rating letter, the RO provided notice to the Veteran explaining what information and evidence was needed to substantiate the claim for a higher initial rating for his service-connected PTSD, what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. In March 2006, the RO also provided the Veteran with general information pertaining to VA's assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. After issuance of the December 2002 letter, subsequent rating decisions, including the November 2003 decision that increased the initial rating to 50 percent, and SSOCs reflect readjudication of the claim. Hence, the Veteran is not shown to be prejudiced by the timing of this notice. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in an SOC or SSOC, is sufficient to cure a timing defect). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the claim on appeal. Pertinent medical evidence associated with the claims file consists of the Veteran's service treatment records, VA and private treatment records, the reports of VA examinations, records from the Social Security Administration, and lay statements. Also of record and considered in connection with the appeal are the various statements submitted by the Veteran and by his representative, on his behalf. The Board also finds that no additional RO action to further develop the record in connection with the claim, prior to appellate consideration. is required. In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO/AMC, the Veteran has been notified and made aware of the evidence needed to substantiate the claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter on appeal, at this juncture. See Mayfield, 20 Vet. App. at 543 (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Background During a March 1996 VA PTSD examination, the Veteran described stressful military experiences and reported having nightmares, intrusive memories, increased startle response, and increased irritability leading to explosiveness. He stated that he had one adult daughter and that his marriage had been difficult due to his behavior. On mental status examination, he appeared somewhat "stone-faced," but agitated and angry; he had difficulty with the examination; he was not hallucinating, delusional, or psychotic; mood and affect were bland, but varied from irritable to depressed; recent and remote memory were only grossly intact, and recent memory was impaired; insight was superficial, and judgment was fair. He denied depressive ideation or suicidal ideation, but mentioned homicidal ideation. The diagnosis was PTSD, and a Global Assessment of Functioning (GAF) score of 38 was assigned. During an initial primary care visit at the Albany VA Medical Center (VAMC) in June 1998, the Veteran identified his two principal health problems as Parkinson's disease since 1992 and manifestations of peripheral neuropathy. His Parkinson's medications included Mirapex (Pramipexole) and Sinemet (Carbidopa-Levodopa). An initial VA mental health clinic note dated in February 1999 reflects that the Veteran indicated that he was referred by his probation officer for evaluation after being arrested and accused of stalking; he also stated that he was "roughed up" by police officers at the time. Reported mental status findings included the following: neat, cooperative, and coherent; no thought broadcasting or insertion; no auditory or visual hallucinations; insight and judgment were fair; no suicidal or homicidal ideation; no paranoid delusions; and guarded and suspicious demeanor. The diagnosis was rule out personality disorder. In several addendum notes, the examiner indicated that the Veteran reported being diagnosed with PTSD and that one must also consider the contribution of multiple sclerosis (should this be established [after completing evaluation for this disability]) to his current mental status because multiple sclerosis is associated with mood and personality change. The Veteran denied having nightmares, night sweats, or flashbacks, but did endorse exaggerated startle responses. The examiner observed that the Veteran evidenced anxiety at the sight of a VA police office as he left and remarked that the Veteran had an obvious fear of personal injury with police encounters. The Veteran was referred to the mental health clinic for follow-up care. Subsequent VA psychology notes reflect that the Veteran described his legal, mental health, and medical problems. In May 1999, he indicated that he was arrested for stealing postal money orders from work and cashing them. In June 1999, he stated that he had filed a claim for service connection for PTSD and was involved in combat operations. The Veteran was evaluated for Parkinson's disease by a private neurologist in December 1999. The neurologist noted that the Veteran had had Parkinson's symptoms for about seven years [since 1992] and had a tendency to be somewhat overmedicated. The Veteran's wife explained that during the day the Veteran had been quite manic and his mood was out of control. As a result, she reduced his medication, which included Sinemet and Mirapex. The neurologist also noted the Veteran's long history of PTSD and that the Veteran had been plagued by personal, social, and legal problems over the past year. He denied hallucinations, but endorsed nightmares and feeling depressed and irritable. The neurologist's impression was that the Veteran's most disabling problem at present was his psychiatric situation, which had been worse lately in part because of side effects from his antiparkinsonian medication. He believed that Veteran would require antipsychotic medication in the future to help him tolerate his Parkinson's medications. Four days later, during a December 1999 VA mental disorders examination, the Veteran stated that he believed an increased disability rating was warranted based on PTSD and multiple physical ailments. He reported that he currently suffered from Parkinson's disease, peripheral neuropathy, multiple sclerosis, and Wilson's disease. He stated that he had no history of psychiatric diagnosis, psychiatric hospitalization, or treatment with psychotropic medication; however, he began outpatient psychotherapy approximately three to four months prior for "stress." He indicated that he had worked for the Department of Motor Vehicles from 1994 until he resigned in May 1999 because he could not keep up with the workload. He admitted that he had conflict with his coworkers, stating that "they set me up" and "framed me." He explained that he cashed money orders, decided to plea to a lesser charge, and was unemployed as a result. He reported that he had been married for 28 years with a brief separation for four months in 1991. His wife described him as "arrogant and controlling." He also stated that although he had some conflict with his adult daughter, he regularly saw her. The examiner observed that the Veteran displayed good grooming and hygiene, spoke in a clear voice and tone with average rate of speed without speech impediment, spoke logically and was focused at all times, and was polite and cooperative without attempting to exaggerate symptoms. On mental status examination, he was alert and fully oriented; described his general mood as "confused" and admitted to being irritable and moody; he admitted to experiencing extremes in anger over his present legal problems and the necessity of him resigning from his job; and he did not display significant deficits in immediate, short, or long term memory. The Veteran reported that he experienced anxiety attacks, and his wife believed that the Veteran was chronically anxious and dysphoric and at times despondent. The Veteran also described insomnia, poor concentration, and flashbacks. He denied compulsions, suicidal ideation, or any history of homicidality. The examiner summarized that the Veteran continued to suffer from chronic, moderate PTSD, and although it appeared that the Veteran had been generally able to cope with PTSD for most of his life, now due to his weakened physical state and loss of his employment, perhaps his PTSD symptoms were worse. A GAF score of 55 was assigned, which the examiner indicated was indicative of moderate impairment of functioning. A January 2000 VA psychology note reflects that the Veteran and his wife described marital problems due to the Veteran going out practically every night for the past year. The Veteran stated that he was "going out to do God's ministry until 2 AM," and his wife tended to believe him. More recently, the Veteran had told his wife that he was being abducted by demons. According to the psychologist, they tried to blame this behavior on the medications he was taking for Parkinson's disease. In November 2000, the Veteran presented with his wife to the VA emergency department for voluntary admission. They both reported that the Veteran had episodes of leaving his house in the middle of the night without returning for days, and was missing for three days before the present admission. He reported doing this behavior over the years, but more frequently recently. He stated that he walks until his feet are raw. He admitted that during these episodes, he abuses his Parkinson's medication, disclosing that he "took a week's worth in three days to stay awake while out on the streets." He also complained of poor sleep and nightmares related to Vietnam. He was alert and fully oriented, admitted to paranoia especially after ingesting extra doses of his medications, and denied current suicidal or homicidal ideation and audio or visual hallucinations. During an initial psychiatric admission assessment the next day, the Veteran again described taking extra medication to stay awake and denied that the excessive use of the medication could represent a suicide attempt. When asked for details about his service-connected PTSD, he replied that he would probably have startle responses from loud noises, but was noted to be vague as to present symptomatology. When asked about panic symptoms, flashbacks, ruminations, etc., he replied, "Yeah, I had all that. But it didn't bother me." Objective findings included thought content notable for an unusual constellation of experiences and some impoverishment (vagueness), which appeared to the psychiatrist to be willful in nature; thought processes were logical to circumstantial. After completion of the assessment, the admission diagnosis was psychotic disorder not otherwise specified (NOS) with a current GAF score of 50. The psychiatrist explained that the Veteran did not present with PTSD-related symptoms. He also observed that the antiparkinsonian agents prescribed to the Veteran carried an elevated risk of psychiatric symptoms, including hallucinations, and he believed that the record suggested alternative motives for some of the Veteran's behaviors. A November 2000 in-patient neurological consultation report details that the Veteran had a parkinsonian extrapyramidal (hypokinetic) movement disorder, and the neurologist indicated that the current therapy of Carbidopa/L-dopa and Pramipexole was appropriate, but the dose of Pramipexole appeared quite large. The neurologist noted that the reason for this psychiatric admission was a non-accidental ingestion of an excess of both of these medications and that the Veteran denied suicidal intent. The impression was Parkinsonism and schizoid personality (questionable pseudoneurotic schizophrenia). The discharge summary from the three-day hospitalization notes that both the Veteran and his wife reported that the Veteran knowingly took excessive amounts of his prescribed antiparkinsonian medications in an attempt to amplify his alertness and energy level. The Veteran's wife reported that the Veteran's episodes of loosely structured wandering, sometimes for several days, had occurred since he began taking medication for Parkinson's disease, which was diagnosed in 1995. The summary also notes that the Veteran's wife provided valuable information that steered the psychiatric differential diagnosis acutely in favor of a substance-induced psychosis (or personality change) as opposed to a primary personality disorder or psychosis. The discharge diagnosis was substance-induced psychotic disorder due to dopaminergic agonists with a discharge GAF score of 55. A January 2001 VA mental health clinic note indicates that the Veteran and his wife discussed past relationship difficulties due to the Veteran's mental health and medical issues, but seemed to have resolved many of the issues, particularly medication management, as it was noted that the Veteran's wife was now distributing his medications and assessing his behavior. During a VA general medical examination in January 2001, the Veteran indicated that he was still taking Sinemet and Mirapex for Parkinson's and that he was granted Social Security disability for his Parkinson's disease. The examiner noted that the Veteran was service connected for PTSD, but the Veteran's wife reported that the Veteran's anxiety had certainly increased due to his Parkinsonism and the disability it engenders. Objective mental status findings were not reported. In February 2001, the Veteran and his wife expressed concern about the effects of PTSD and its role in the Veteran's unusual behaviors. His wife also described some conflict that had turned hostile, but without physical aggression, over medication issues and driving issues. The social worker noted that signs or symptoms of PTSD by the Veteran were not evident during the session. A few days later, the wife called a VA social worker to report that the Veteran was missing, living on the streets, and that she suspected huge gambling and Internet porn use. In another February 2001 note, the Veteran reported that he and his wife and an altercation, which resulted in the Veteran leaving the home and seeking residence at a homeless shelter. The Veteran was noted to be fully oriented, but presented as disheveled, scattered and hypomanic as seen by bizarre behaviors. In March 2001, he disclosed that he had filed for Chapter 13 bankruptcy, but anticipated receiving 100 percent service connected disability within a couple weeks. He reported that he continued to take Sinemet and Mirapex. He stated that he was extremely anxious about his situation; however, the social worker noted that some of his behaviors tended to contradict his statement. He denied feeling depressed. Objective findings included rapid speech that was unclear at times and pressured, and somewhat disheveled dress. A June 2001 VA psychiatry note reflects that the Veteran presented for a medicine evaluation for "racing speech and thoughts." The psychiatrist noted that the Veteran carried a diagnosis of PTSD, but indicated that symptoms currently were no longer as pronounced and included efforts to avoid movies and other things that reminded him of Vietnam; exaggerated startle response to noise; and chronically fitful sleep, but no longer with nightmares. He denied a history of prolonged periods of depression or suicide attempts or gestures. He also did not give a clear history of episodes of agitation or hypomania/mania, but had a history of risky behavior such as gambling. He also frequently mentioned prostitutes, which he called acquaintances, but denied having used their services. He gave a history of impulsively helping others even though he may not be able to afford to do so. After a mental status examination, the psychiatrist concluded that the current presentation was hypomanic, but not psychotic. There was no obtainable information supporting past depressive or manic episodes. PTSD was present, but not acutely symptomatic presently. The Veteran denied substance abuse, but the psychiatrist strongly suspected that the Veteran may be again abusing the Pramipexole, which may have contributed to the hypomanic presentation. In October 2001, the Veteran described being under a lot of stress due to an eviction notice. He denied depression, sleep problems, or nightmares, but endorsed concentration problems due to the eviction. The psychiatrist noted that although the Veteran presented as hypomanic at times, including on present examination, he did not have a history compatible with bipolar disorder. The psychiatrist added that the picture was also greatly complicated by the Veteran not being a reliable historian and having a history of abuse of certain medications in the past, which the psychiatrist was not totally convinced that the Veteran was not doing this now. In November 2001, he was admitted to the Albany VAMC for ataxia and confusion. He was noted to be a poor historian, but stated that he had not taken his Parkinson's medications for one month because he ran out and a friend locked away his medications. He reported that he got his medications back last night and was unsure which pills or how many he took the previous night. The differential diagnosis was withdrawal from lack of antiparkinsonian medications, overdose on one of his other medications, or cardiovascular accident [stroke]. He was restarted on Sinemet and Pramipexole and discharged the next day. In a nursing note later the same month, he insisted that he was missing a prescription (Mirapex), but on further discussion admitted that he had received the full supply, but left it at a health care giver's home. In a February 2002 VA psychiatry note, the Veteran stated that he had been doing fairly well. However, his speech was noted to be mildly pressured and thoughts were slightly scattered. The psychiatrist explained that she was not convinced that the Veteran had true bipolar disorder because the diagnosis was difficult to make in light of the history of past abuse of his Pramipexole, which incidentally the Veteran reported was recently increased by his private neurologist, and which was just accordingly increased by his VA neurologist. In a behavioral health note the same month, the Veteran complained of depression and medical stressor of Parkinson's disease. On mental status examination, he was alert and oriented; speech was of normal flow and tone, clear and coherent, and content was logical and intact; he denied audio/visual [hallucinations] or suicidal or homicidal [ideation]; no delusions were evident; sleep and appetite were reported as intact. The diagnosis was depression, adjustment reaction. Following a mental status examination in June 2002, the diagnosis was bipolar disorder. In correspondence dated in June 2002, the Veteran stated that he was experiencing increased nightmares and was almost always irritable and depressed. In July 2002, the Veteran attempted to refill his Mirapex prescription at the VA pharmacy in Albany, but was told that it could not be refilled because another pharmacy in the Midwest was in the process of filling the same prescription. The medicine resident informed the pharmacist that there had been several extra prescriptions for this medication lost or spilled, and the pharmacy suspected abuse of this medication. It was decided to dispense no more than one week's worth of Mirapex to avoid a possible withdrawal syndrome, if such exists. In an addendum, it was noted that the Veteran had gone from five Pramipexole pills a day to eight in a day in a short time span, and the Veteran indicated that he was actually taking 14 pills a day. In a July 2002 VA pharmacy general note, the pharmacist stated that it remained unclear to him why the Veteran was receiving Pramipexole if abuse of the drug was an apparent problem. He explained that he discouraged the use of this agent given the Veteran's history of bipolar disorder and PTSD because dopamine agonists can precipitate mania and PTSD symptoms. He added that with the possible precipitation of mania, which often can result in increased sexual libido, he believed that allowing the Veteran to obtain extra doses of Pramipexole would lead to trouble. In a September 2002 VA emergency department note, the Veteran alleged that he was approached sexually by a 13 year-old girl in the laundromat and pursued by her with a malevolent intent. He stated that she pursued him on her bicycle and hit him in the back with a heavy sack of garbage. In an October 2002 psychiatry note, the Veteran was seen for follow up for PTSD and bipolar disorder NOS. He expressed anger over his upcoming eviction. The psychiatrist noted that the Veteran blamed the eviction in a rather convoluted way on his primary care provider for his reported reluctance to renew Pramipexole for Parkinson's in the recent past, which caused the Veteran to have to get that medication filled outside of the VA, leaving him with insufficient funds to pay rent. The psychiatrist emphasized that the Veteran had a past psychiatric hospitalization for mania with confusion, which was believed to be due to overuse of Pramipexole and that the Veteran has admitted that he likes to feel "energized/hyper," which is intensified by this medication. He added that the Veteran usually presents with a hypomanic affect. Following a mental status examination, the psychiatrist indicated that although the Veteran may be service-connected for PTSD, and although this may be present, PTSD was never evident on examination, as the predominant presentation was one of hypomania. She added that it was still unclear to her whether the Veteran had underlying bipolar disorder, or whether affect and thought disorder were due to abuse of the Pramipexole, or just exacerbated by it. She concluded that in either case, the Veteran's coexisting Parkinson's treatment complicated treatment of his mental illness. The Veteran presented for a VA PTSD examination in January 2003. He then indicated that he had been married until two years ago and believed that the marriage was damaged in part because he gambled away his savings. He stated that he had an adult daughter with whom he gets along and sees regularly. On mental status examination, he described his mood as "pissed off;" however, he appeared to the examiner to be somewhat anxious at times, and affect was consistent with appearing anxious. He was dressed appropriately with fair hygiene; attitude was entirely cooperative, and he maintained rapport with the examiner quite easily; speech was spontaneous, but quite loquacious at times and usually quite logical. The Veteran complained of recent memory deficits. The examiner commented that the reported deficit might be due in part to the multiple physical problems as well as PTSD and Parkinson's disease; however, on examination remote memory remained relatively intact. Other findings included no indication of any thought disorder except for some hallucinatory experiences while on a medication for Parkinson's and another ten years earlier, full orientation, and admitting to being depressed and anxious. He denied current suicidal or homicidal ideation. He reported severe sleep impairment and nightmares twice a week. The examiner summarized that the Veteran's PTSD symptoms were moderate in nature, but had become exacerbated secondary to his increasingly debilitated state from Parkinson's and having more time on his hands. He also noted that the Veteran can be relatively isolated at times. A GAF score of 51 was assigned. Disability records from the Social Security Administration were received in March 2003. In a January 2001 statement, the Veteran's ex-wife, she indicated that the Veteran did not make good judgments due to his Parkinson's disease. Disability benefits were awarded on the basis of the primary diagnosis of Parkinson's disease and the secondary diagnosis of multiple sclerosis. The Veteran appeared for a review VA PTSD examination in March 2003 by the same examiner who conducted the VA examination two months earlier. The examiner remarked that the Veteran was able to recall fewer details about his treatment and other things in his life than during the previous examination and believed it may be a reaction to some deterioration secondary to his Parkinson's disease. He reported that he was divorced, but got along with his adult daughter. He stated that he shoots pool and does not have many friends because he chooses them poorly. Upon detailing the Veteran's occupational history, the examiner remarked that she did not believe that the Veteran was unemployable due to his PTSD, but that Parkinson's was the main disability that would interfere with employment. Objectively, he appeared somewhat anxious with loquaciousness and pressured speech at times, but was obviously intelligent and spoke in a generally logical and relevant manner; there was no indication of thought disorder or delusions, and hallucinations were denied except for on one occasion in the past; he was fully oriented; he denied impulse control problems; he readily admitted to being depressed but denied any suicidal or homicidal ideation; he appeared anxious at times; he stated that his sleep was quite impaired and that he had nightmares two to three times a month. The examiner concluded that the Veteran fully met the criteria for PTSD as described in the DSM-IV, adding that the Veteran experiences distressing recollections, difficulty concentrating, and hypervigilance with exaggerated startle response. She characterized his PTSD as manifested by moderate symptoms with a slight increase since January secondary to him not working and having more time on his hands; a GAF score of 50 was assigned. An April 2003 VA addendum note advised a treatment team to re-read the July 2002 pharmacy general note. The author of the addendum indicated that there was no other patient who was "shorted" or "loses" medications like this Veteran. In spite of this, he continued to receive large quantities of these two drugs, and the situation clearly needed to be resolved. The author emphasized that this amounted to 9249 Carbidopa/Levodopa and 4768 Pramipexole in the past year and that even taking eight tablets daily of these medications, the amount used per year should only be 2920 of each. [In other words, he received 14,017 (combined) pills of these two prescribed medications in one year, but should have received only 5840 pills total. Instead, due to the shorted and lost medications, he received more than 8000 extra pills combined of these two medications in one year]. In an April 2003 psychiatry note, the psychiatrist recognized the recent pharmacy note that correctly pointed out the Veteran's numerous early fills of his antiparkinsonian medications. The psychiatrist re-emphasized that the Veteran had basically dropped out of mental health treatment, which was significant because he had a history of presenting with a mental status with various degrees of mania. Very notable, the psychiatrist continued, was that the Veteran had required hospitalizations due to mania, which were felt to be medication-induced from abuse of Pramipexole. The psychiatrist recommended a treatment plan be developed for the Veteran, to include referral back to the mental health clinic. A July 2003 nurse triage note reflects that the Veteran complained of racing thoughts and thoughts of killing himself. Following a mental status examination and conversation with his case manager during which the Veteran stated that his medication noncompliance and out-of-control behavior had created financial issues, the diagnosis was alteration in mood and thought to be related to medication noncompliance. In a VA psychiatry note the same day, the Veteran stated that he was anxious and suicidal. The psychiatrist again noted that the Veteran was service connected for PTSD, but presentation was usually for difficulty handling some acute stressor, rather than for symptoms referable to PTSD. She also noted the Veteran's history of Parkinson's, for which he was prescribed Sinemet and Pramipexole, and a history of abusing Pramipexole. She further observed that the Veteran had called a VA doctor, who was not listed as his primary care provider, today stating that he had "lost" his antiparkinsonian medications due to moving. The Veteran disclosed that he was presently stressed because he had spent most of his disability check on a used car that needed much repair, a slot machine that he purchased (the psychiatrist noted a history of pathological gambling), and that he "partied" with some friends at a hotel. On mental status examination, the Veteran was calmer after speaking with a triage nurse; he now denied suicidal or homicidal ideation, adding that the initial suicidal thoughts were never accompanied by intent; chronically marginal judgment; and no evidence of psychosis. The psychiatrist emphasized to providers involved with the patient to exercise caution when prescribing and especially filling early the Pramipexole, which she believed the Veteran was still abusing. She highlighted that his mental status was significantly different when he had some versus when he reported being out of it, i.e., hypomanic when on it, which indicated overuse. In an August 2003 telephone contact, the Veteran's power of attorney described the Veteran's bizarre behaviors, including using money for prostitutes, taking little girls to be alone with him, and writing bad checks. He was advised to bring the Veteran to the emergency room for psychiatric evaluation and a prescription of Haldol. The Veteran presented to the emergency room in August approximately one week later, stating that he lost his Parkinson's medication when he moved into his new apartment and had been out of his medications for three days. In an August 2003 treatment note, the Veteran reported that he was homeless again after enlarging a hole in the wall of his rented room and being accused of pedophilia by his landlady, who had power of attorney over the Veteran's affairs. He stated that his Parkinson's symptoms had been worsening lately and that he was taking his Pramipexole up to seven times instead of the prescribed five times per day for the past two to three months. The psychiatrist indicated that it was impossible for her to determine whether the Veteran really had underlying bipolar disorder, or whether symptoms were mainly due to Pramipexole, which she believed the Veteran was still abusing. A September 2003 VA emergency department note reflects that the Veteran's daughter brought him in after discovering he was exercising poor judgment on multiple fronts. The emergency physician noted that the Veteran's medication compliance had been called in to question by multiple practitioners and by his daughter and that he had experienced periods of paranoid delusions and hallucinations that were a mix of medication-related effects and psychiatric comorbidity. The impression was personality disorder. Later in September, the Veteran again arrived at the emergency department, stating that he ran out of his Parkinson's medications, which were refilled. He failed to appear for his psychiatry appointment the next day. The psychiatrist indicated that she continued to feel strongly that the Veteran's abuse of Pramipexole likely contributed to his impaired judgment and risky behavior. In an April 2004 VA treatment note, the Veteran complained that he had lost his medications, alleging that his girlfriend threw them out. The physician noted that this was the "100th or so time" that the Veteran lost his medications. The physician renewed Carbidopa-Levadopa, but did not renew Pramipexole as the Veteran had a history of abusing this medication. Also in April 2004, the Veteran's treating psychiatrist terminated treatment of the Veteran because he had recently been [verbally] abusive and threatening to another of the psychiatrist's patients, and she believed that counter-transferance and conflict of interest may prevent her objective treatment of the Veteran. The Veteran saw a new VA psychiatrist in June 2004. The Veteran was observed to be speaking in an excited fashion, interrupting himself and stuttering; a story he told about giving $20 to a kid to give a message to a lady he was in love with was noted to be circumstantial and irrational. The psychiatrist remarked that both the Sinemet and the Pramipexole that the Veteran was taking for Parkinson's disease could cause agitation, thought, mood, and behavior changes. The psychiatrist emphasized that mood disorder could not be clearly evaluated. Other findings were reported as speech content had little truth value, no hallucinations were elicited, no clear delusional state was evident, no depression was evident, and the Veteran denied intent to harm himself. A separate note identified a GAF score of 40. An August 2004 emergency department note indicates that the Veteran was referred by his primary care physician for mental status changes. He was stabbed on his hand two days ago and arrived very agitated because he missed a court appearance. The impression was agitation. In a mental health nurse triage note, mental status examination findings included the following: casual appearance; guarded attitude; angry affect; irritable mood; pressured, fast speech; intact thought process; no hallucinations, delusions, or suicidal or homicidal orientation; full orientation; intact immediate, recent, and remote memory; and intact cognitive function, judgment, and insight. In an addendum, the emergency examiner related that the Veteran was malingering his symptoms of agitation, continued to disobey comments, security was called to help chemically restrain him, and he walked out of the emergency room during the psychiatric evaluation. In a June 2005 VA preventive medicine note, PTSD and depression screens were negative. In an August 2005 neurology note, the neurologist mentioned a relationship between compulsive gambling and dopa therapy noted in a small article in a popular journal; the Veteran had recently gambled away an inheritance. In an August 2005 primary care note, the Veteran's sister expressed concern about the Veteran's sexually hyperactive behavior. She was trying to help the Veteran with his medication and trying to get him straightened around. An August 2005 VA psychiatry note reflects that the psychiatrist reviewed the Veteran's medical and psychiatric history and conducted a mental status examination. The impression was bipolar disorder NOS, and a GAF score of 50 was assigned. The psychiatrist observed that, in reviewing the notes of other doctors, there seemed to be an instability of mood that at times has been related to abuse of Pramipexole, which was documented extensively. At present, the Veteran was noted to be in a stable mood, unlike other times he had presented to the behavioral health clinic. The impression also included combat related PTSD, which was described as not active at this time. A September 2005 VA psychiatry note reflects that the Veteran's sister, who accompanied him to the appointment, indicated that she hoped the Veteran could be declared incompetent, so she could manage his finances. On mental status examination, the Veteran was calm and cooperative throughout even as his sister politely told him she thought he was a "sociopath." The Veteran's occasional participation during the session was noted to be appropriate and in simple terms, reflecting limited psychological-mindedness and slight poverty of content. There was no evidence of perceptual disturbances or delusions, and he denied suicidal or violent impulses, plans, or intent. He was consistently and fully alert and oriented in all spheres. A GAF score of 50 was assigned. Statements from the Veteran and records in the claims file indicate that he was admitted to a state-run Veteran's Home in January 2006, and that he began to receive medical care at the White River Junction VAMC rather than the Albany VAMC. A January 2006 admission history and physical report from the Veterans Home was located among the Veteran's VA treatment records. He was admitted for long term care after several hospitalizations [for physical health problems]. He had been homeless for years with failing health and multiple addictions (gambling, sex, food according to his sister), until his sister recently became involved in his life. In a review of symptoms, the Veteran reported some depressed mood since his daughter married and moved to another state. He denied suicidal ideation, suicide attempt, or homicidal ideation, stating that "life is too nice." Regarding PTSD, he stated that he had nightmares related to an incident in service, but fewer nightmares now, no intrusive thoughts or isolation, but an active startle response. He denied any active treatment now. The assessment included PTSD/addictive disorder. A February 2006 teleconference psychiatry note, indicates that the Veteran presented for evaluation of PTSD, reporting that he was feeling relatively well with some depressive symptoms and PTSD. He described himself as irritable. The staff member who accompanied the Veteran had no specific questions or concerns. On mental status examination (as seen through teleconference system), he was casually dressed and groomed with good eye contact; affect was full and euthymic; speech was without abnormality; thought process was logical and goal directed; thought content was without suicidal or homicidal ideations, audiovisual hallucinations, or paranoia or delusions; and insight and judgment were intact. A GAF score of 50 was assigned. A March 2006 VA psychiatry note documents the Veteran's medical history to include service-connected PTSD and previously diagnosed idiopathic Parkinson's disease, which was now deemed erroneous by the outpatient neurologist consulting to the Veterans Home. The Veteran had been off his Parkinson's medications for three to four weeks, and after observing him off his medications, the private consulting neurologist determined that the Veteran did not have Parkinson's. The Veteran identified his current symptoms as depression and irritability. On mental status examination, hygiene appeared good; eye contact was appropriate at times, but at other times, the Veteran appeared to stare off into the distance; voice was somewhat monotone and minimally spontaneous and low monotone groans (that were not suggestive of distress) throughout the interview; affect was very constricted with masked faces; mood was anxious; thoughts were goal-oriented without delusional content; there was no gross psychotic stigmata; and no suicidal or homicidal ideation. The assessment was service connected for PTSD, currently being treated for depressive symptoms. A January 2007 VA addendum note indicated that the Veteran had expressed suicidal ideation the previous night and repeated the same today. He reported he had a plan, but would not tell the nurses what it was. Then, he reported that he said he was suicidal because he was mad that the heat in his room was too high and could not be adjusted and reported that he was not suicidal and did not have a plan. The nurse practitioner did not believe that he was suicidal. A February 2007 VA mental health note reflects the Veteran's statement that he became angry and that he would kill himself when he was prevented from covering a radiator style heater to block heat due to safety concerns. He reported that it was not his intent to harm himself, but to get attention because he was angry. He stated that his current dose of Celexa had been helpful for past history of PTSD, and his current mood was mostly good. On mental status examination, he was casually dressed with good eye contact and pleasant demeanor; speech was sparse with grunting at times; thoughts were goal oriented; there was no suicidal ideation, homicidal ideation, or audiovisual hallucinations; insight and judgment were intact; mood was okay; and affect was mildly restricted. The impression included PTSD and some anxiety/depression/anger problems. The Veteran was admitted to White River Junction VA Medical and Regional Office Center (VAMROC) in May 2007 after nursing staff at the Veterans Home voiced concern over the Veteran's worsening anxiety and compulsive behavior, described as hyperphagia, cleanliness, and orderliness, along with increased irritability with staff. He reportedly gained about 50 pounds over four months. Mental status findings on admission included the following: very anxious, pleasant at times, irritable at others; good hygiene; quasi-cooperative to noncooperative; poor eye contact; speech with some latency and overall paucity; mood described as "overwhelmed;" restricted affect with mood congruence; somewhat disorganized thought process; insight and judgment fair; no suicidal or homicidal ideation or audiovisual hallucinations; intact cognition; and full orientation. The diagnosis was PTSD, anxiety disorder NOS, and rule out obsessive compulsive disorder with an assigned GAF score of 25. Later that day, a psychiatry note indicated that the Veteran's main psychiatric symptoms were pain and anxiety. A nursing addendum described the Veteran as "very anxious." During his May 2007 hospitalization, the Veteran was evaluated by the Chief of the Neurology section, a neurology resident doctor, and a medical student. In a detailed report, the Chief of Neurology explained his belief that the Veteran likely had a Parkinson's Plus syndrome associated with fronto-temporal dementia due to his odd behavior as the Veteran's presentation was not classic for Parkinson's disease. He indicated that many of the known types of Parkinson's Plus produce presentations in which the patient shows various signs of sociopathy and disinhibition. The report included an overview of hereditary frontotemporal dementia with Parkinsonism-17 (FDTP) along with the neurologist's comments. Some associated behavioral symptoms associated with FDTP were reported to include hyperoral behaviors including overeating; stereotyped and/or repetitive behaviors including walking to the same location day after day; deteriorating personal hygiene habits; hyperactive behavior exhibited by agitation, wandering, outbursts of frustration, and aggression; hypersexual behavior; impulsive acts including shoplifting and impulsive buying. Emotional symptoms could include abrupt and frequent mood changes, distractability, and poor financial judgment. Neurological symptoms were reported to be similar to those seen in Parkinson's disease. In another psychiatry note during the hospitalization, mental status examination findings included anxious appearance at times; cooperative attitude with fair eye contact; some speech latency and overall paucity; restricted, blunted affect; logical, linear thought process with no suicidal or homicidal ideation or audiovisual hallucinations; fair insight and judgment; intact cognition; and full orientation. The assigned GAF score was 40. The diagnosis at discharge four days after he was admitted was anxiety disorder and unspecified neurological disorder. In a June 2007 mental health note, the psychiatrist noted the recent, possible diagnosis of frontotemporal dementia by neurology and behavioral problems that included paranoia, impatience, anxiety, and irritability. The Veteran reported that new medications had been helpful. Mental status examination findings were similar to those recently reported. A July 2007 mental health note indicates that the Veteran had worsening behavioral problems, paranoia, and agitation since the last visit. The psychiatrist noted that the recent VA inpatient psychiatric treatment resulted in improvement mostly due to environmental change and a change in Sinemet dosing allowed for better sleep. He also recounted that as per neurology, the Veteran had a possible diagnosis of fronto-temporal dementia; and behavioral problems had included paranoia, impatience, anxiety, and irritability. On mental status examination, the Veteran had limited eye contact; speech had grunting, but was clear when communicating with providers; mood was depressed; affect was blunted; thoughts were linear; there was no evidence of suicidal or homicidal ideation, audiovisual hallucinations, or delusions; and insight and judgment were fair. The impression was history of multiple medical problems, PTSD, Parkinson's plus and now with adjustment disorder with anxiety/depression/anger problems. The Veteran filed a claim for service connection for Parkinson's disease in April 2008, and the claim was denied in an October 2008 rating decision. Treatment records from the Veterans Home dated from October 2006 to December 2009 were received in December 2009. The records documented regular psychological treatment for depressive disorder, not elsewhere classified. Presenting behavior and symptoms typically included depression, irritability, behavior and conduct problems, hopelessness, nervousness, grief and loss issues, anxiety, withdrawal, fatigue, stress, and interpersonal problems. His risk of suicide or self injury and of homicide was consistently assessed as "none." In December 2009, the Veteran reported that he did not sleep well because he has bad dreams and nightmares. He stated that he felt angry every day because he believed his Parkinson's disease was due to exposure to Agent Orange in Vietnam. The diagnosis was PTSD. Presenting symptoms included anger, depression, fatigue, anxiety, and sleep disturbance. The psychologist did not believe the Veteran presented a suicidal or homicidal risk. Subsequent records included a couple reports of nightmares and flashbacks. In a December 2009 VA psychiatry note, the Veteran's most acute issue was identified as anxiety with a high baseline level and escalations, and with the cognitive part being worry about being unattended, alone, and unable to get his needs met. He indicated that his anxiety was worse during the day, and sleep was fragmented but without regular PTSD nightmares, which occurred approximately once per month. Reported objective findings included the following: alert and fully oriented; prominent parkinsonian movements; occasional eye contact; speech slow with latency, speaking in short phrases, and generally linear responses; anxious mood; affect restricted, anxious, and dysphoric; linear thought process; and no suicidal or homicidal ideation or audiovisual hallucinations. A PTSD screen was deferred because the Veteran had temporary cognitive impairment, which was attributed to the complexity of communication with his neurological impairment. In correspondence received in July 2011, the Veteran stated that he had trouble keeping his temper, suddenly lashing out at people and being very irritable; that he experienced disorientation to his surroundings, which he found to be very stressful; that his worsening Parkinson's was making his life unbearable; and that he felt very paranoid and that his mind was clouded. III. Analysis Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2011). When a question arises as to which of two ratings applies under a particular Diagnostic Code (DC), the higher rating is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating applies. 38 C.F.R. § 4.7 (2011). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of a veteran. 38 C.F.R. § 4.3 (2011). A veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the question for consideration is entitlement to a higher initial rating assigned following the grant of service connection, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson, 12 Vet. App. at 126. The RO awarded service connection for PTSD, conceding the occurrence of an in-service stressor on the basis of the receipt of the Combat Action Ribbon for service in Vietnam. An initial 50 percent rating for PTSD is assigned under Diagnostic Code 9411, effective from January 29, 1996 (the date of receipt of the claim). However, the actual criteria for evaluating psychiatric impairment other than eating disorders is set forth in a General Rating Formula. Prior to November 7, 1996, the rating criteria for mental disorders were found at 38 C.F.R. § 4.132. Pursuant to the general rating formula then in effect, a 50 percent rating is assigned when the ability to maintain effective or favorable relationships with people is considerably impaired and by reason of psychoneurotic symptoms the reliability, flexibility and efficiency levels are so reduced as to result in considerable industrial impairment. A 70 percent rating is assigned where the ability to establish or maintain effective or favorable relationships with people is severely impaired and the psychoneurotic symptoms are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. A 100 percent rating requires that attitudes of all contact except the most intimate be so adversely affected as to result in virtual isolation in the community, that there be totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes (such as fantasy, confusion, panic, and explosions of aggressive energy) associated with almost all daily activity resulting in profound retreat from mature behavior; or that the veteran is demonstrably unable to obtain or maintain employment. These criteria represent three independent bases for granting a 100 percent rating. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Effective November 7, 1996 (during the pendency of the appeal), the criteria for evaluating psychiatric disabilities were revised. See 61 Fed. Reg. 52695-52702 (Oct. 8, 1996). As there is no indication that the revised criteria are intended to have a retroactive effect, the Board has the duty to adjudicate the claim only under the former criteria for any period prior to the effective date of the revised criteria and to consider the revised criteria for the period beginning on the effective date of the new provisions. See Wanner v. Principi, 17 Vet. App. 4, 9 (2003); DeSouza v. Gober, 10 Vet. App. 461, 467 (1997). See also VAOPGCPREC 3- 2000 (2000) and 7-2003 (2003). Under the revised, applicable criteria (set forth at 38 C.F.R. § 4.130), a 50 percent rating requires 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 per 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. A 70 percent rating requires occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126. Psychiatric examinations frequently include assignment GAF score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown , 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). Considering the pertinent evidence in light of the governing legal authority, the Board finds that the preponderance of the evidence reflects that the Veteran's PTSD symptoms, including psychiatric symptoms that cannot be distinguished from other psychiatric and physical disorders, have more nearly approximated the criteria for the initial 50 percent rating assigned. At the outset, the Board notes that, in addition to PTSD, the medical evidence reflects diagnoses of rule out personality disorder, psychotic disorder not otherwise specified (NOS), substance-induced psychotic disorder due to dopaminergic agonists, schizoid personality, depression, adjustment reaction, bipolar disorder, and anxiety disorder. Physical disabilities that were noted to produce psychological symptoms included multiple sclerosis and a possible diagnosis of Parkinson's Plus syndrome associated with fronto-temporal dementia. In addition, psychiatric effects from the abuse of antiparkinsonian medications were noted extensively. Where it is not possible to distinguish the effects of a nonservice-connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). In many instances during the course of this appeal, medical practitioners have specifically attributed the Veteran's symptoms and objective manifestations of psychiatric disability to disabilities or factors other than PTSD. In those instances where medical practitioners have indicated that the Veteran's symptoms were related to psychiatric or physical disorders other than PTSD, the Board does not consider those symptoms in evaluating his service-connected PTSD. However, in other instances where there is no indication that it is possible to distinguish the symptoms from the Veteran's various psychiatric and physical disorders, the Board has considered all of his psychiatric symptoms in evaluating his PTSD. As indicated above, prior to the November 7, 1996 regulatory change pertaining to mental disorders, the Veteran's psychiatric symptoms were objectively manifested, primarily, by bland mood and affect, varying from irritable to depressed; impaired recent memory; and superficial insight. Subjectively, PTSD was manifested by nightmares, intrusive memories, increased startle response, increased irritability leading to explosiveness, and a mention of homicidal ideation. He was also working full time. In this case, the Board finds that the initial 50 percent rating for PTSD is appropriate under the prior rating criteria. On VA examination in March 1996, the Veteran described difficult relationships with his daughter and wife due to his behavior. In addition, while the Veteran later reported problems at work, he maintained his full time employment for three more years until he resigned in May 1999 after cashing money orders from work. A higher, 70 percent rating, is not warranted under the old diagnostic criteria in effect prior to November 7, 1996 because neither lay evidence nor medical evidence during that time period reflects severe impairment in establishing or maintaining effective or favorable relationships, or psychoneurotic symptoms of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. Again, the Veteran maintained relationships and his job. Since the November 7, 1996 regulatory change, the aforementioned medical evidence reflects that the Veteran's psychiatric symptoms have been objectively manifested, primarily, by pressured, rapid, and loquacious speech; racing, slightly scattered, circumstantial, and irrational thoughts; anxious and depressed mood; anxious, constricted, blunt, and dysphoric affect; difficulty concentrating; and somewhat disorganized thought process. His subjective complaints have included exaggerated startle response, nightmares ranging from two per week to one per month, some intrusive memories (that decreased over time), some depression, irritability, some avoidant behavior, recent memory deficits, severe sleep impairment, paranoia, and disorientation. At no point has the Veteran's PTSD more nearly approximated the criteria for at least the next higher, 70 percent, rating. As noted above, under the General Rating Formula, the 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. However, the objective medical evidence does not show such symptoms as obsessional rituals that interfere with routine activities; near-continuous panic or depression affecting ability to function independently, appropriately and effectively; impaired impulse control such as unprovoked irritability with periods of violence; spatial disorientation; impaired abstract thinking; impaired judgment; or inability to establish and maintain effective work relationships that are characteristic of the 70 percent rating. Rather, the medical evidence of record from this period indicates that, while the Veteran reported suicidal ideation in July 2003 and in January 2007, on both occasions he later denied that he was suicidal or that he had a plan. While he and his wife divorced during the pendency of the claim, the Veteran maintained a relationship with his daughter and reestablished and maintained a relationship with his sister, reflecting an ability to establish and maintain relationships. The Veteran's VA examiners have described his PTSD as moderate. It is also noteworthy that, on multiple occasions, VA clinicians have specifically noted that the Veteran did not present with PTSD symptoms or that PTSD was not evident (November 2000, February 2001, June 2001 [reported as not acutely symptomatic], October 2002, June 2005, and August 2005). Moreover, treatment records dated from October 2006 to December 2009 from the Veterans Home, reflect treatment only for depressive disorder until the Veteran first reported having nightmares and flashbacks in December 2009, at which time PTSD was listed as a diagnosis. Moreover, on other occasions VA clinicians, the Veteran, and/or his ex-wife have attributed the Veteran's psychiatric symptoms and manifestations to other disabilities or factors. For example, in February 1999, a VA mental health clinician noted that multiple sclerosis, which the Veteran was being evaluated for at the time, was associated with mood and personality change. In December 1999 the Veteran and his wife at the time attributed the Veteran's nighttime walks "doing God's work" and "being abducted by demons" to his Parkinson's medications. In November 2000, the Veteran admitted abusing his Parkinson's medications to stay awake, and his symptoms were attributed to substance-induced psychotic disorder. The Veteran's VA psychiatrists and other VA medical personnel suspected that the Veteran's Pramipexole, and to a lesser extent Sinemet, abuse likely contributed to the Veteran's frequent hypomanic presentation, agitation, impaired judgment, risky behavior, and alteration or instability in mood and behavior (June 2001, October 2001, April 2003, July 2003, August 2003, September 2003, June 2004, and August 2005). Similarly, an August 2005 VA neurologist noted a relationship between compulsive gambling and dopa therapy, and a May 2007 VA neurologist believed that the Veteran's odd behavior was the result of Parkinson's plus syndrome associated with fronto-temporal dementia. Likewise, VA pharmacy notes document extensive Pramipexole abuse and warn that his antiparkinsonian medications can precipitate mania and PTSD symptoms. Collectively, the aforementioned medical evidence reflects that, the Veteran's PTSD symptoms, including psychiatric symptoms that have not been attributed to other psychiatric or physical disabilities or factors, have resulted in no more considerable industrial impairment prior to November 7, 1996, or no more than occupational and social impairment with reduced reliability and productivity since that date. This is a level of occupational and social impairment consistent with the currently assigned 50 percent disability rating. The Board further finds that none of the GAF scores assigned at any point since the effective date of the award of service connection provides a basis for assigning a higher rating. As indicated, the Veteran was assigned the following scores during this period: scores primarily between 50 and 55 on VA examinations and during VA treatment, 38 on VA examination in March 1996, 40 by a treating VA psychiatrist in June 2004, and 25 upon admission to the VAMROC in May 2007 with an increase to 40 upon discharge. Under the DSM-IV, GAF scores from 51 to 60 are indicative of 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). 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). 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). GAF scores ranging from 21 to 30 are indicative of behavior that is considerably influenced by delusions or hallucinations OR serious impairment, in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends). The Board finds that GAF scores ranging from 50 to 55, reflecting serious to moderate symptoms, are consistent with the currently assigned 50 percent rating. The Board acknowledges that the scores of 38 and 40 as assigned by the March 1996 VA examiner and VA psychiatrists in June 2004 and May 2007, which indicates some impairment in reality testing or communication or major impairment in several areas, could be considered suggestive of a higher rating. Similarly, the score of 25 on admission to the VAMROC in May 2007, which indicates behavior that is considerably influenced by delusions or hallucinations OR serious impairment, in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends), could be considered suggestive of a higher rating. The Board notes that since the March 1996 VA examination, however, the Veteran's PTSD symptoms have generally improved, as reflected by objective medical evidence and the Veteran's reports to medical personnel. In June 2004, for example, a VA psychiatrist again noted the effects of Sinemet and Pramipexole on contributing to agitation, thought, mood, and behavioral changes, and in May 2007 the neurologist suggested that many of the Veteran's behavioral problems were due to Parkinson's plus associated with frontero-temporal dementia, with the GAF score of 25 increasing to 40 upon discharge with a diagnosis of anxiety disorder and unspecified neurological disorder. Similarly, the Veteran reported in November 2000 that while he had nightmares, his PTSD symptoms in the past did not really bother him; and in January 2006, he stated that he was having fewer nightmares, no intrusive thoughts, and no isolation. Therefore, the Board finds the GAF scores ranging from 50 to 55 hold more probative value than the outlying scores of 25, 38, and 40 because they were generally attributed to PTSD and not to other problems such as substance-induced mood disorder. In any event, the Board emphasizes that a GAF score is not dispositive of the evaluation question; rather as indicated above, the symptoms shown provide the primary basis for an assigned rating. Here, as indicated above, the Veteran primarily exhibited symptoms typically associated with a 50 percent rating. Hence, the assigned GAF scores of 40 and below are not considered accurate indicators of the overall level of psychiatric impairment due to PTSD. In this case, as indicated above, the Board assigns more probative weight to the VA examiners' opinions that the Veteran's PTSD is moderate and to his treating psychiatrists' and physicians' assessments that some of his symptoms were attributable to other disabilities or factors, and at times PTSD was not evident on examination. Indeed, the examiners' and treating psychiatrists' observations and specific statements regarding the Veteran's symptoms of PTSD are more probative in the evaluation of the Veteran's PTSD than the Veteran's lay statements, particularly in light of the fact that the Veteran has admitted to abusing his antiparkinsonian medications, which were noted to precipitate psychiatric symptoms and hypomania, and the extensive abuse of these medications is documented in detail. In determining that the criteria for a 70 percent rating for the Veteran's psychiatric symptoms shown are not met, the Board has considered the rating criteria in the General Rating Formula for Mental Disorders not as an exhaustive list of symptoms, but as examples of the type and degree of the symptoms, or effects, that would justify a particular rating. The Board has not required the presence of a specified quantity of symptoms in the rating schedule to warrant the assigned rating for PTSD. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). As a final point, the Board notes that, the Veteran's and his wife's own assertions, advanced in written statements, have been considered. However, the Board finds that the lay assertions made in support of his claim for higher rating are not entitled to more weight than the objective findings rendered by trained medical professionals in evaluating the Veteran's PTSD, to include the findings of the various VA examiners and treating physicians. See 38 C.F.R. § 3.159(a)(1) (competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). See also Bostain v. West, 11 Vet. App. 124, 127 (1998) (citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992)). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). As indicated above, the persuasive evidence indicates that the Veteran's PTSD symptomatology is consistent with the initial 50 percent rating assigned. Under the circumstances of this case, the Board finds that, since the January 1996 effective date of the award of service connection, the Veteran's PTSD symptomatology has not met or more nearly approximated the criteria for a 70 percent rating. See 38 C.F.R. § 4.7. As the criteria for the next higher, 70 percent, rating are not met, it follows that the criteria for an even higher rating (100 percent) likewise are not met. On these facts, the Board concludes that there is no basis for staged rating, pursuant to Fenderson, and the claim for an initial rating in excess of 50 percent for PTSD must be denied. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against assignment of any higher rating, that doctrine is not applicable. See 38 U.S.C.A § 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2011); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER An initial rating in excess of 50 percent for PTSD is denied. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs