Citation Nr: 0810437 Decision Date: 03/28/08 Archive Date: 04/09/08 DOCKET NO. 03-00 224 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for right ear hearing loss. 2. Entitlement to service connection for residuals of a right wrist fracture. 3. Entitlement to service connection for alcoholism. 4. Entitlement to a rating higher than 70 percent before January 16, 2007, and a rating higher than 70 percent from January 16, 2007, for post-traumatic stress disorder. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Debbie A. Riffe, Counsel INTRODUCTION The veteran, who is the appellant, served on active duty from August 1966 to April 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal of a rating decision in July 2002 of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. In March 2004, the veteran appeared at the RO and testified at a hearing before the undersigned Veterans Law Judge, who has been designated to make the final disposition of this proceeding for VA. A transcript of that hearing is associated with the claims file. In October 2004, the Board remanded the case to the RO for additional development. FINDINGS OF FACT 1. There is no competent medical evidence of a current right ear hearing loss disability for VA purposes. 2. There is no competent evidence showing that the veteran currently has residuals of a right wrist fracture that are related to injury of service origin. 3. There is competent evidence showing that the veteran's alcoholism, now in remission, is a result of his service- connected post-traumatic stress disorder. 4. From the date of a claim in March 2002 to January 16, 2007, post-traumatic stress disorder is shown to be productive of a disability picture that more nearly approximates that of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood without evidence of total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication, persistent delusions or hallucinations, persistent danger of hurting self and others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss (for names of close relatives, own occupation, or own name). CONCLUSIONS OF LAW 1. Hearing loss of the right ear is not due to an injury or disease that was incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.385 (2007). 2. Residuals of a right wrist fracture are not due to disease or injury that was incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. § 3.303 (2007). 3. Alcoholism is proximately due to or the result of, the service-connected PTSD. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. § 3.310(a) (2007). 4. From the date of a claim in March 2002 to January 16, 2007, the criteria for a 70 have been met for post-traumatic stress disorder; the criteria for a rating higher than 70 percent from January 16, 2007, have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.130, Diagnostic Code 9411 (2007). The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claims. As the claim of service connection for alcoholism is favorable to the veteran, no further action is required to comply with the VCAA. The remaining issues are discussed below. Duty to Notify Under 38 U.S.C.A. § 5103(a), VA must notify the claimant of the information and evidence not of record that is necessary to substantiate the claims, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. Under 38 C.F.R. § 3.159, VA must request that the claimant provide any evidence in the claimant's possession that pertains to the claims. Also, the VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: 1) veteran status; 2) existence of a disability; (3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In a claim for increase, the VCAA notice requirements are the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Also, if the Diagnostic Code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect of that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the VA must provide at least general notice of that requirement to the claimant. Vazquez- Flores v. Peake, No. 05-355 (U.S. Vet. App. Jan. 30, 2008). The VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO provided pre- and post- adjudication VCAA notice by letters, dated in March 2002, in December 2004, and in March 2006. The veteran was notified of the evidence needed to substantiate the claims of service connection, namely, evidence of current disability, evidence of an injury or disease in service or event in service, causing injury or disease; and evidence of a relationship between the current disability and the injury, disease, or event in service causing injury or disease; and evidence of a relationship between the current disability and the injury, disease, or event in service. The veteran was notified of the evidence needed to substantiate the claim for a higher rating for the post-traumatic stress disorder, namely, evidence showing that his disability had increased in severity and the effect that worsening has on the claimant's employment and daily life. The veteran was also notified that VA would obtain service records, VA records, and records of other Federal agencies and that he could submit private medical records or authorize VA to obtain private medical records on his behalf. He was asked to submit any evidence in his possession that pertained to the claims. The notice included the provisions for the effective date of the claims and for the degree of disability assignable. As for content of the VCAA notice, the documents substantially complied with the specificity requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002) (identifying evidence to substantiate a claim and the relative duties of VA and the claimant to obtain evidence); of Charles v. Principi, 16 Vet. App. 370 (2002) (identifying the document that satisfies VCAA notice); of Pelegrini v. Principi, 18 Vet. App. 112 (2004) (38 C.F.R. § 3.159 notice); of Dingess v. Nicholson, 19 Vet. App. 473 (notice of the elements of the claim); and of Vazquez-Flores v. Peake, No. 05-0355, (U.S. Vet. App. Jan. 30, 2008) (evidence demonstrating a worsening or increase in severity of a disability and the effect that worsening has on employment and daily life, except general notice of the criteria of the Diagnostic Code under which the claimant is rated). To the extent that the VCAA notice was provided after the initial adjudication, the timing of the notice did not comply with the requirement that the notice must precede the adjudication. The procedural defect was cured as after the RO provided substantial content-complying VCAA notice the claims were readjudicated as evidenced by the supplemental statement of the case, dated in September 2007. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007) (Timing error cured by adequate VCAA notice and subsequent readjudication without resorting to prejudicial error analysis.). As for the claim for increase, although the veteran was not provided adequate VCAA notice in compliance with the United States Court of Appeals for Veterans Claims (Court) recent holding in Vazquez-Flores v. Peake, No. 05-0355 (U.S. Vet. App. January 30, 2008), such procedural defect does not constitute prejudicial error in this case because the record reflects that the veteran had actual knowledge of the evidence necessary to substantiate his claim. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007); see also Vazquez- Flores v. Peake, No. 05-0355, slip op. at 12 (U.S. Vet. App. January 30, 2008) ("Actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrates an awareness of what was necessary to substantiate his or her claim."). Specifically, in certain statements, such as his notice of disagreement in August 2002 and his March 2004 hearing testimony, the veteran articulated his understanding of the rating criteria applicable to his claim. In particular, with the assistance of his representative, the veteran demonstrated through his testimony his awareness of the criteria necessary for a higher rating for PTSD. At his hearing, he discussed the specific symptoms, and the severity and effect of those symptoms on his daily life and his employability, that are reflective of the criteria for a higher rating. This demonstration of "actual knowledge" of the evidence necessary to substantiate a claim for a higher rating satisfies the requirements of Vazquez-Flores. Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claims. The veteran was afforded the opportunity to testify at a personal hearing at the RO in March 2004 before the undersigned Veterans Law Judge. The RO has obtained the veteran's service medical records and VA records. The veteran himself has submitted reports from the Vet Center. He has not identified any additional records, such as private medical records, for the RO to obtain on his behalf. Further, VA has conducted necessary medical inquiry in an effort to substantiate the claims. 38 U.S.C.A. § 5103A(d). The veteran was afforded VA examinations in May 2002 (for post-traumatic stress disorder), December 2004 (for the right wrist and post-traumatic stress disorder), January 2005 (for right ear hearing loss), and January 2007 (for post-traumatic stress disorder), to evaluate the nature and etiology of the disabilities at issue. While the VA compensation examination regarding the right wrist does not fully address the etiology question, further development in this respect is not required for the following reasons. There is no record of right wrist pathology, or complaints relative thereto, during or contemporaneous with service. Further, there is no competent evidence of persistent or recurrent symptoms relative to the right wrist from the time of service until many years later when the veteran sustained a wrist fracture. In short, the evidence does not indicate that right wrist fracture residuals may be associated with service. Under these circumstances, a medical examination or medical opinion is not required for the service connection claim under 38 C.F.R. § 3.159(c)(4). As there is no indication of the existence of additional evidence to substantiate the claims, no further assistance to the veteran is required to comply with the duty to assist. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection Principles of Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Where a veteran who served for ninety days develops hearing loss of the sensorineural type to a degree of 10 percent or more within one year from separation from service, service connection may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). Service connection may also be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000, and 4,000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. In order to establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may also be warranted for disability proximately due to or the result of a service-connected disorder and where aggravation of a nonservice-connected disorder is proximately due to or the result of a service- connected disability. 38 C.F.R. § 3.310(a). Effective October 10, 2006, the provision of 38 C.F.R. § 3.310 was amended to implement the holding in Allen v. Brown, 7 Vet. App. 439 (1995), for secondary service connection on the basis of the aggravation of a nonservice-connected disorder by service-connected disability. The amendment essentially codifies Allen with language that requires that a baseline level of severity of the nonservice- connected disease or injury must be established by medical evidence created before the onset of aggravation. In any case, as VA has been complying with Allen since the decision was issued in 1995, the amendment is not a liberalizing change in the law and does not otherwise change the application of the 38 C.F.R. § 3.310. Secondary service connection requires (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). Analysis Right Ear Hearing Loss The veteran claims that he has hearing loss in the right ear as a result of in-service acoustic trauma. Service connection for left ear hearing loss was established by rating decision in November 2005, based on in-service noise exposure. He served on active duty from August 1966 to April 1969. Service medical records do not show any complaints, clinical findings, or diagnosis of right ear hearing loss. At the time of an enlistment physical examination in March 1966, audiogram findings indicated the following pure tone thresholds, in decibels (the numbers in parentheses are ASA units converted to ISO (ANSI) units), at 500, 1,000, 2,000, and 4,000 Hertz: 10 (25), 5 (15), 0 (10), and 0 (5) in the right ear. At the time of a separation physical examination in April 1969, audiogram findings indicated the following pure tone thresholds, in decibels, at 500, 1,000, 2,000, 3,000, 4,000 and 6,000 Hertz: 15, 10, 5, 10, 10, and 30 in the right ear. At the time of an enlistment physical examination for the Army Reserve in May 1974, audiogram findings indicated the following pure tone thresholds, in decibels, at 500, 1,000, 2,000, 4,000, and 8,000 Hertz: 15, 15, 15, 25 and 40 in the right ear. On all physical examinations, the veteran's ears were clinically evaluated as normal. Post-service medical records show that at the time of a February 1995 VA examination, the veteran complained of decreasing hearing thresholds in the past 15 to 20 years. An audiogram indicated the following pure tone thresholds, in decibels, at 500, 1,000, 2,000, 3,000, and 4,000 Hertz: 25, 30, 25, 40, and 40 in the right ear. Speech recognition score, using the Maryland CNC word list, was 96 percent for the right ear. The diagnosis was normal to moderate sensorineural hearing loss. In March 2002, the veteran filed his claim for service connection for hearing loss. At that time of the most recent VA examination in January 2005, an audiogram indicated the following pure tone thresholds, in decibels, at 500, 1,000, 2,000, 3,000, and 4,000 Hertz: 25, 25, 30, 30, and 25 in the right ear. Speech recognition score, using the Maryland CNC word list, was 100 percent for the right ear. The diagnosis was mild to moderate sensorineural hearing loss. In other words, the medical evidence shows that his right ear hearing loss actually improved in the period between his 1995 and 2005 examinations. One of the requirements for service connection is that the claimed disability currently exists. Degmetich v. Brown, 104 F.3d 1328 (1997). A diagnosis of a condition must be made by competent medical evidence. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). On the basis of the audiograms during service, right ear hearing loss disability under the standards of 38 C.F.R. § 3.385 was not present during service. After service, while the veteran's right ear hearing loss met the regulatory standards for hearing loss for VA purposes on one occasion in February 1995, there is no current evidence of right ear hearing loss that meets the regulatory standards of 38 C.F.R. § 3.385. Thus, there is no current medical evidence of any right ear hearing loss. As the record now stands, there is no satisfactory proof that the veteran has a current right ear hearing loss disability that meets the VA standard of hearing disability under 38 C.F.R. § 3.385, that is, an auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000, and 4,000 Hertz of 40 decibels or greater; or auditory thresholds for at least three of the tested frequencies of 26 decibels or greater; or speech recognition scores using the Maryland CNC Test of less than 94 percent. In the absence of proof of present right ear hearing loss disability under 38 C.F.R. § 3.385, there is no valid claim of service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Regarding the veteran's statements and testimony to the effect that his right ear hearing loss is attributable to noise during service, he is competent to describe such symptoms as difficulty in hearing, but he is not competent to diagnose hearing impairment under VA standards, or relate any right ear hearing loss back to service. Once the veteran goes beyond the description of the symptoms or features of hearing loss to expressing an opinion that involves a question of medical diagnosis or causation, competent medical evidence is required to substantiate the hearing loss claim. This is so because the question of medical diagnosis or causation of hearing loss involves medical knowledge of accepted medical principles pertaining to the history, manifestation, clinical course, and character of hearing loss, which is beyond the competency of a layperson because such is not capable of lay observation. For these reasons, the Board rejects the veteran's statements and testimony as competent evidence sufficient to establish a diagnosis of right ear hearing loss for VA purposes. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In this case, as the Board may consider only independent medical evidence to support its findings and as there is no favorable medical evidence of a current right ear hearing loss disability under VA standards, the preponderance of the evidence is against the claim, and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Residuals of a Right Wrist Fracture The veteran claims that he currently has residuals from a right wrist fracture that happened while he was on leave during service. There is no service medical evidence to show complaints, findings, treatment, or diagnosis of a right wrist fracture, or any right wrist disability. At the time of an enlistment physical examination in March 1966, on a report of medical history, the veteran indicated that he had a history of broken bones ("broken arms"). An examiner elaborated that the veteran had reportedly fractured his right wrist and that there was no sequelae. At the time of a separation physical examination in April 1969, on a report of medical history, the veteran indicated again that he had a history of broken bones. He stated that he received treatment for a "broken arm" at the Bluefield Sanatorium. An examiner elaborated that the veteran's comments were reviewed and found to be of no medical significance at that time. Examination at that time showed that the upper extremities were clinically normal. At the time of an enlistment physical examination for Reserve purposes in May 1974, the veteran noted only his history of broken bones; examination at that time showed that the upper extremities were clinically normal. The service medical records, including the physical examination reports, do not indicate the presence of any scars, deformities, or other abnormalities pertinent to the right wrist. After service, private medical records dated in March 1986 show that the veteran sustained a right wrist injury (one record notes that it was a right hand injury) on the job at a mine and was due to be admitted for surgery that month, but that the surgery was canceled as a result of a pre-operative consultation that discovered a blood disorder. The veteran was eventually admitted to the hospital in July 1986 with a diagnosis of nonunion of the right scaphoid. He underwent right wrist surgery (bone grafting to the right scaphoid cystic lesion and removal of a loose body). Private hospital records dated in April 1987 indicate that his right wrist was initially injured at work in November 1985 when a "scoop" fell on his arm. None of the private records indicate a prior history of a right wrist fracture or injury. At the time of a December 1994 VA general medical examination, it was reported by the veteran that he had fractured his right arm three times; there was no diagnosis given relevant to the right arm or wrist. At the time of a February 1995 VA orthopedic examination, it was noted that the veteran fractured his right wrist when he was struck by a mine car in 1985 and underwent surgery in 1986. The diagnosis was status post open reduction and bone graft of old fracture of navicular carpal bone of the right wrist, healed. On another VA examination a few days later in February 1995, it was reported that he had fractured his right arm two times. X-rays of the right wrist showed a deformity of the posterior aspect of the proximal pole of the carpal navicularis suggesting an old healed fracture or postoperative change, and a questionable deformity of the distal pole of the carpal navicularis that raised the question of an old injury or postoperative change. VA outpatient records dated in October 1998 show that the veteran fell from a ladder that month and sustained a right wrist sprain, which was subsequently noted to be resolving. At the time of a December 2004 VA examination, the veteran reported that he sustained a right wrist injury while home on leave from Vietnam in late 1967 or early 1968. He stated that during an altercation he struck another person with his fist and sustained a fracture to the wrist, which then required open reduction internal fixation by Dr. Rob (now deceased) at the Bluefield Sanatorium. He further stated that the records from Bluefield Sanatorium were unavailable, as it had long since closed. The assessment was scar, described as S-shaped over the radial border of the volar surface of the right wrist, consistent with an open reduction internal fixation type incision. There was no medical opinion offered concerning the date of onset of the right wrist findings. Although the evidence shows that the veteran is currently diagnosed with a residual scar on his right wrist, which is consistent with a surgical scar, there is no record of a scar during service or for many years thereafter. And although the veteran had reportedly fractured his right wrist prior to service, as noted at the time of the enlistment physical examination, there is absolutely no record of any residuals of a fracture, or any right wrist disability for that matter, at the time he entered service or at any time during service. Moreover, following service, there is no documented evidence - in terms of complaints, clinical findings, and diagnosis - of a right wrist disability for many years after his separation from service in April 1969. It is not until the veteran sustained a right wrist injury on the job in 1985 that the record initially discloses clinical findings pertaining to the right wrist. Further, the file contains no medical opinion associating his current right wrist fracture residuals, consisting of a scar, to an undocumented injury during service. The current residual scar was related to surgical intervention, which is clearly documented as having taken place many years after service, and the veteran's report to the VA examiner in December 2004 of wrist surgery at Bluefield Sanatorium during service is not substantiated by any medical records. For example, even though records from Bluefield Sanatorium are unavailable, there is no other evidence such as clinical findings of scar or post-operative clinic visits in the service medical record to suggest that the veteran underwent wrist surgery, or even had right wrist pathology, at any time during service. Additionally, at the time of his service enlistment physical examination, the veteran reported a history of a right wrist fracture. The absence of continuity of right wrist complaints from the time of enlistment until his 1985 wrist injury is persuasive evidence against continuity of symptomatology. 38 C.F.R. § 3.303(b); Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (It was proper to consider the veteran's entire medical history, including a lengthy period of absence of complaints.). As stated, there is simply no documented complaint referable to the right wrist throughout the veteran's entire period of service until more than 15 year after service. The Board finds the absence of medical evidence of continuity of symptomatology outweighs any statements of continuity, rendering the veteran's lay evidence less probative than the medical evidence on the question of continuity of symptomatology. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). For this reason, service connection for residuals of a right wrist fracture based on continuity of symptomatology is not established. To the extent that the veteran relates his right wrist fracture residuals to an injury during service, where as here the determinative issue involves a question of a medical diagnosis or medical causation, competent medical evidence is required to substantiate the claim. A layperson is competent to identify a medical condition where the condition is a simple one, such as a broken leg as opposed to a form of cancer, but a lay person is not qualified through education, training, and expertise to offer an opinion on a medical diagnosis or on medical causation, which is not capable of lay observation. 38 C.F.R. § 3.159; Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In this case, the veteran is competent to identify a right wrist injury, even possibly a right wrist fracture, such as when he testified about a fracture occurring while on leave during his period of military service, which is not substantiated by the service records. However, his statements and testimony are not competent evidence on the question of a medical diagnosis and causation of current right wrist fracture residuals in a case such as this where there is clear, documented evidence of a (possibly intercurrent) right wrist fracture 15 years after service. It is beyond the competency of the veteran to opine as to the etiology of his particular fracture residuals, given that he would be required to distinguish between any residuals of an in-service wrist injury (which he claims but is unsubstantiated by medical records) and residuals from a post-service wrist fracture requiring surgical intervention (which is documented in the record). In short, the questions in this case involve medical knowledge of accepted medical principles pertaining to the history, manifestation, clinical course, and character of a wrist fracture, and the veteran's lay observations would not suffice as competent medical evidence. As the Board may consider only independent medical evidence to support its findings as to a question involving a medical diagnosis or medical causation, which are not capable of lay observation, and as there is no favorable medical evidence to support the claim as articulated above, the preponderance of the evidence is against the claim of service connection for residuals of a right wrist fracture, and the benefit-of-the- doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Alcoholism In this case, in written statements and personal hearing testimony, the veteran asserts that his alcohol abuse was a result of his service-connected post-traumatic stress disorder. Specifically, he maintains that to treat symptoms of post-traumatic stress disorder he had self-medicated with alcohol for many years. The relevant evidence includes VA examination reports and private and VA treatment records. Private medical records in 1986 note the veteran's alcohol use. VA treatment records show in part that the veteran was admitted in July 1996 for detoxification for chronic alcohol abuse. The diagnosis was alcohol dependence and withdrawal. At the time of a May 2001 VA examination, the examiner noted that the veteran had been sober for six years, and that his problems with alcohol did not appear to be a problem at that time. At the time of a May 2002 VA examination, the examiner remarked that the veteran needed to continue outpatient psychiatric treatment, including complete abstinence from alcohol. The diagnoses were post-traumatic stress disorder and history of alcoholism in remission for the past seven years as related by the veteran. At the time of a December 2004 VA examination, the examiner stated that the veteran had been sober for about 10 years, and that his problems with alcohol were secondary to post-traumatic stress disorder. The same examiner in a January 2007 examination report diagnosed the veteran with post-traumatic stress disorder and alcohol dependence in remission for 10 years. VA outpatient records confirm that the veteran no longer used alcohol. Based on the foregoing medical records, the Board finds the veteran's alcoholism, now in remission, is causally related to the service-connected post-traumatic stress disorder on a secondary basis under 38 C.F.R. § 3.310. Higher Rating for Post-Traumatic Stress Disorder Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2007). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The criteria for post-traumatic stress disorder are found at 38 C.F.R. § 4.130, Diagnostic Code 9411. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 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 the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in Diagnostic Code 9411. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). Post-traumatic stress disorder is currently rated under 38 C.F.R. § 4.130, Diagnostic Code 9411, as follows: 30 percent before December 23, 2004; 50 percent before January 16, 2007, and 70 percent from January 16, 2007. The criteria for a 70 percent rating are 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 worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. The criteria for a 100 percent rating are 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 and 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. In this case, separate ratings have been assigned for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Analysis The relevant evidence in this case consists of VA records, Vet Center records, three reports of VA examinations, and statements and testimony of the veteran. The veteran was afforded VA examinations in May 2002, in December 2004, and in January 2007. On these occasions, the Global Assessment of Functioning (GAF) scores were 60, 50, and 45, respectively. In VA records, GAF scores were 45 for the period of April 2001 to March 2002 and ranged from 40 to 45 for the period of March 2002 to April 2005, and ranged from 39 to 45 for the period of April 2005 to June 2006. The veteran also received counseling at the Vet Center, and the GAF scores, dated in December 2004 and January 2007, were 35 to 40 and 35, respectively. The GAF is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness. GAF 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). 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). In this case, the veteran's GAF scores vary, but one common feature among the VA records, VA examination reports, and Vet Center reports is that the scores decreased over time, reflecting a progressive worsening of his mental condition. With the exception of the first VA examination in May 2002, the GAF scores were indicative of serious impairment as the GAF scores were in the range of 45 down to 35, which reflected serious occupational and social impairment in most areas, such as work, family relations, thinking, and mood. In evaluating all the evidence, the Board finds that the VA medical records and Vet Center reports reflect that before January 16, 2007, dating to the date of claim in March 2002, the veteran's symptoms of post-traumatic stress disorder were so severe as to affect his everyday life and his ability to function to a degree that more nearly approximates the schedular criteria for a 70 percent rating. In March 2004, the veteran testified that he had frequent panic attacks, 5 to 6 weekly, that he had no social life beyond his Vet Center group once a week, and that he had problems with controlling his anger and with his short-term memory. In February 2002, records of a Vet Center show that the veteran's post-traumatic stress disorder was chronic and severe with generalized anxiety disorder and major depression as additional disabilities that were sequelae of the primary diagnosis of post-traumatic stress disorder. He had a depressed and anxious mood, paranoia, suicidal and homicidal ideation, severe social isolation and panic attacks. The veteran's functioning was considered to be guarded, and there was an inability to maintain effective social and work relationships. While this report characterizes the veteran's post-traumatic stress disorder as severe, the clinical findings from a VA examination in May 2002 were not as severe. At that time of the VA examination in May 202, the veteran's symptoms were depression, anxiety, expressions of anger, and isolation from others. However, the VA examiner noted that the veteran appeared neat and he was cooperative and oriented, but he was guarded and suspicious. He also had a sense of helplessness and hopelessness, but there were no signs or symptoms of a bizarre thought processes or tangential, circumstantial speech. His judgment seemed fair. He was able to stay home and care for his children, but he did not have any particular hobby and did not belong to any social group. The examiner remarked that the veteran had been socially and industrially compromised due to post-traumatic stress disorder and his overall psychological functioning or GAF was 60, that is, in the range of moderate symptoms or moderate impairment in social and occupational functioning. The records also show that in August 2002 and thereafter he veteran was seen on a regular basis at a VA outpatient clinic, and his overall psychological functioning (GAF) was rated primarily 45, denoting serious impairment, much of the clinical findings are consistent with those of the VA examination in May 2002. The record shows that the veteran exhibited occupational and social impairment with deficiencies in most areas due to such symptoms as anxiety, suicidal and extreme homicidal ideation, dissociation, panic attack, and chronic major depression with intermittent explosive rage that affected his ability to function independently, appropriately, and effectively. The veteran had been unable to establish and maintain effective relationships and had no friends. He relied heavily on his wife for support but reported a great deal of marital conflict. He continued to report great difficulty in adapting to stressful circumstances, which resulted in behaviors of avoidance, isolation, paranoia, and irritability. The counseling therapist indicated that since coming to see him the veteran's functioning had grown increasingly worse. His overall psychological functioning (GAF) was rated 35 to 40. Another clinical update summary report of the Vet Center, dated in January 2007, indicates that the veteran's level of functioning continued to deteriorate since the last summary report. The overall psychological functioning (GAF) was rated 35 at that point. These findings were echoed by those of the VA outpatient records and VA examination reports. On a VA outpatient record dated in December 2004, the veteran reported that he had not been doing too well lately. His overall psychological functioning (GAF) was rated 40, denoting serious impairment in several areas. In July 2005, the veteran reported that he frequently forgot things. The VA therapist noted that he seemed a bit paranoid and had marginal insight. This was also noted on an outpatient visit in November 2005 with possibly worsening insight. In April 2006, the therapist increased the veteran's medication for paranoia and strongly urged the veteran go to the hospital, but the veteran refused. His overall psychological functioning (GAF) was rated 39, denoting major impairment in several areas. The therapist in June 2006 related the veteran's recurrent depression and intermittent explosive disorder to post-traumatic stress disorder. The VA examination reports of December 23, 2004 and January 2007 (by the same examiner), reflected overall psychological functioning (GAF) scores of 50 and 45, respectively, to denote serious impairment, and acknowledged that the veteran was easily irritated and upset, that he had a bad temper and felt like he could not socialize, and that his problems were worsening due to his inability to work and to his poor support systems. In sum, the symptoms of post-traumatic stress disorder, as shown from the date of claim in March 2002 are more characteristic of a disability picture that is contemplated by a 70 percent rating under Diagnostic Code 9411. The Board notes that different examiners, at different times, will not describe the same disability in the same language. Features of the disability which must have persisted unchanged may be overlooked, or a change for the better or worse may not be accurately appreciated or described. It is the responsibility of fact finder to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. After reconciling the various reports and treatment records into a consistent disability picture, the Board finds that from the date of claim in March 2002 the veteran's post- traumatic stress disorder, although there was some disparity in the GAF scores, did not change in the level of overall impairment and the criteria for a 70 percent rating under Diagnostic Code 9411 have been demonstrated. Despite the severity of the veteran's condition, the objective evidence does not show that his post-traumatic stress disorder meets the criteria for a 100 percent rating under Diagnostic Code 9411 at any time during the appeal. There is no objective evidence of 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. The medical record does not show that any of the foregoing symptoms, or any other symptoms of the same type and degree, is clinically present. It is acknowledged that on the January 2007 Vet Center summary report, it was noted that more often than not the veteran internalized his irritability and rage, making him extremely volatile and a potential danger to himself and those around him, but a persistent danger of hurting self or others is not shown as not a documented event that the veteran tried to hurt himself or others. And although the Vet Center shows that the veteran had a poor memory, there is no evidence that the memory impairment is so severe that the veteran has forgotten such personal information as the names of close relatives or his own name. In relation to the present claim for a higher schedular rating, a 100 percent schedular evaluation requires that the mental disorder result in total occupational and social impairment from such symptoms that are essentially characterized by generally being out of touch with reality, that is, persistent delusions or hallucinations, disorientation to time or place, persistent danger of hurting himself or others, grossly inappropriate behavior, memory loss for names of close relatives, own occupation, or own name. The clinical findings in the pertinent medical reports do not depict the veteran as one being out of touch with reality. Rather, he is shown to have great difficulty in such areas as focusing his concentration, controlling his anxiety and anger, managing his panic attacks, and socializing with others outside of his immediate family. He has taken numerous medications to help him with his symptomatology, and several VA outpatient records indicate that he finds the medications to be beneficial. In the Board's view, the veteran's disability picture does not approximate that for a 100 percent rating. Although the evidence clearly demonstrates that since the date of claim in Mach 2002 the veteran has severe social and occupational impairment, his overall symptomatology is not consistent with the schedular criteria for a 100 percent disability rating under Diagnostic Code 9411. (The Order follows on the next page.). ORDER Service connection for right ear hearing loss is denied. Service connection for residuals of a right wrist fracture is denied. Service connection for alcoholism is granted. From the date of claim in March 2002, a 70 percent rating for post-traumatic stress disorder is granted, subject to the law and regulations, governing the award of monetary benefits. A rating higher than 70 percent for post-traumatic stress disorder is denied. ____________________________________________ George E. Guido Jr. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs