Citation Nr: 0810513 Decision Date: 03/31/08 Archive Date: 04/09/08 DOCKET NO. 03-22 712 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUE Entitlement to higher initial evaluations for post-traumatic stress disorder than the 30 percent assigned effective February 3, 2003, and than the 50 percent assigned effective March 8, 2004. REPRESENTATION Appellant represented by: West Virginia Department of Veterans Affairs WITNESSES AT HEARING ON APPEAL Appellant and his Spouse ATTORNEY FOR THE BOARD D. Schechter, Counsel INTRODUCTION The veteran served on active military duty from August 1970 to June 1973. The appeal comes before the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. By an initial rating action in March 2003 the RO assigned a 30 percent evaluation for PTSD effective February 3, 2003. By an October 2004 determination, a decision review officer (DRO) assigned a 50 percent evaluation for PTSD effective March 8, 2004. In February 2008, the veteran and his spouse testified before the undersigned Acting Veteran's Law Judge at a Central Office hearing, a transcript of which is associated with the claims file. The veteran and his representative at the February 2008 hearing raised a claim of entitlement to a total disability rating based on unemployability due to service-connected disabilities (TDIU). That claim is not developed for appeal and is referred to the RO for appropriate action. FINDINGS OF FACT 1. For the initial rating period up to December 31, 2003, the veteran's service-connected PTSD was manifested by no more than occupational and social impairment with reduced reliability and productivity. 2. For the initial rating period beginning January 1, 2004, the veteran's service connected PTSD was manifested by occupational and social impairment, most nearly approximated by deficiencies in most areas including work, family relations, judgment, thinking, or mood absent such symptoms productive of total occupational and social impairment such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, and intermittent inability to perform activities of daily living. CONCLUSIONS OF LAW 1. For the rating period from February 3, 2003, through December 31, 2003, the criteria for a disability rating of 50 percent, but no more, are met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2007); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2007). 2. For the rating period beginning January 1, 2004, the criteria for a disability rating of 70 percent, but no more, are met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2007); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist a claimant in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2007). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (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 in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (herein, the RO). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, if complete notice is not provided until after the initial adjudication, such a timing error can be cured by subsequent complete VCAA notice, followed by readjudication of the claim, as in a statement of the case (SOC) or a supplemental statement of the case (SSOC). Mayfield; Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In a February 2003 letter addressing the veteran's claim for service connection for PTSD, the RO informed the veteran of its duty to assist him in substantiating that claim under the VCAA. Because that issue of service connection has been granted, any development issue associated strictly therewith is moot, as there is no reasonable possibility of furthering that claim. However, in Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Thus, appropriate notice was required as to downstream issues of initial ratings and effective dates for those ratings for PTSD. While the February 2003 VCAA letter did not address these downstream issues, the veteran was subsequent afforded VCAA notice and assistance letters in April 2005 and February 2007, addressing Dingess downstream requirements of evidence required to support initial ratings for PTSD, and criteria for assignment of effective dates. The veteran's initial rating claim was thereafter readjudicated by a SSOC in October 2007, thereby curing the notice deficiency. Mayfield; Prickett. These two subsequent letters satisfied all four above-noted notice requirements of the VCAA, and addressed evidence required to support both higher initial ratings and effective dates. See 38 C.F.R. Parts 3 and 4. They also informed what evidence VA would seek to provide and what evidence the veteran was expected to provide. Also by these letters, the veteran was requested to submit pertinent evidence, and was effectively asked to submit any evidence in his possession. He was also told that it was ultimately his responsibility to see that pertinent evidence not in Federal possession is obtained. A recent decision of the Court requires that VCAA notice include notice that evidence of increased severity of the disorder or of greater interference with work or activities of daily life is required to support a claim for increased evaluation; that it include at least general notice of more particularized bases of granting increased evaluations where, as here, particular criteria beyond mere increase in severity may be required for assignment of a higher disability rating; that it include notice that a particular rating will be assigned by applying diagnostic codes; and that it include notice, in the form of examples, of the kinds of evidence required to support the increased rating claim. Vazquez- Flores v. Peake, 22 Vet. App. 37 (2008). The Board finds that while the February 2003 and April 2005 VCAA notice letters did not satisfy these requirements, the February 2007 development notice letter did, and this subsequent notice and the SSOC issued thereafter in October 2007 thereby cured this deficiency. VA has a duty to assist the veteran in the development of claims. This duty includes assisting the veteran in the procurement of service medical records (SMRs) and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The February 2003, April 2005, and February 2007 VCAA letters requested that the veteran advise of any VA and/or private medical sources of evidence pertinent to his claims, and to provide necessary authorization to obtain those records. They also requested evidence and information about treatment after service, in support of the claims. VA treatment records from indicated sources have been obtained, and the veteran was afforded VA examinations February 2002, March 2004, and April 2005 to evaluate the nature and severity of his PTSD. Submitted in February 2006 were private treatment and evaluation records associated with the veteran's memory impairment. The veteran did not provide authorization to obtain additional private treatment or evaluation records. The Board notes that the duty to assist in the development and adjudication of a claim is not a one-way street. Wamhoff v. Brown, 8 Vet. App. 517, 522 (1996). If a veteran wishes help, he cannot passively wait for it in circumstances where he may or should have evidence that is essential in obtaining the putative evidence. Wood v. Derwinski, 1 Vet. App. 190, 193, reconsideration denied, 1 Vet. App. 406 (1991) (per curiam). See also Olson v. Principi, 3 Vet. App. 480, 483 (1992). Thus, while some past treatment records inform of private therapy not reflected in the record, to include marital counseling sessions, the veteran did not inform of the probity of such treatment to further his claim, and again, did not provide authorization for obtaining such records despite specific notice in the VCAA letters of types of evidence relevant or potentially relevant to his claim and specific request in those VCAA letters for authorization to obtain such records. At the February 2008 hearing before the undersigned, the veteran testified to an increase in severity of his PTSD since the last VA evaluation in April 2005, and the veteran's representative at that hearing argued both that additional records of treatment subsequent to that examination should be obtained, and that the veteran should be afforded an additional VA examination in furtherance of his claim. However, the Board observes that more recent VA mental health treatment records have been obtained in furtherance of the claim, up to June 2007, and that records underlying a Social Security disability determination were obtained in February 2007. All that evidence was reviewed by the RO, with issuance of a SSOC in October 2007 readjudicating the appealed claim. The Board has reviewed the entire record and concludes that the three VA examinations already afforded the veteran, taken together with more recent VA treatment records and records of evaluation for Social Security purposes, afford ample and sufficient evidence upon which to base the present determination of initial ratings for the veteran's service-connected PTSD. All records received were associated with the claims folders, and the veteran was duly informed, including by the VCAA letters, the appealed rating actions, and the SOC and SSOCs, of records obtained in furtherance of the appealed claim, and thus by implication of records not obtained. The veteran was adequately informed of the importance of obtaining all relevant records. Neither the veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence presenting a reasonable possibility of furthering the appealed claims for higher initial evaluations for PTSD. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Further development and associated expenditure of VA resources is not warranted. The veteran and his representative were afforded appropriate opportunity to address the claims, and did so by written submissions, as well as by testimony at the veteran's February 2008 hearing before the undersigned. There is no indication that the veteran or his representative has expressed a further desire to address his claims which has not been fulfilled. The U.S. Court of Appeals for the Federal Circuit recently held that any error in a VCAA notice should be presumed prejudicial. The claimant bears the burden of demonstrating such error. VA then bears the burden of rebutting the presumption, by showing that the essential fairness of the adjudication has not been affected because, for example, actual knowledge by the claimant cured the notice defect, a reasonable person would have understood what was needed, or the benefits sought cannot be granted as a matter of law. Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). Here, the claimant has not demonstrated any error in VCAA notice, and therefore the presumption of prejudicial error as to such notice does not arise in this case. Id.; see Vazquez-Flores. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Claim for Higher Initial Ratings for PTSD While the veteran's representative at the veteran's February 2008 hearing characterized the claim as one of an increased evaluation for PTSD from the 50 percent assigned, the veteran perfected an appeal of the original March 2003 rating action granting service connection for PTSD, and the veteran has not withdrawn any portion of that claim on appeal. Accordingly, the Board here evaluates the appropriate initial disability ratings to be assigned for the entire rating period, beginning from the February 2, 2003, date of service connection for PTSD. The RO has assigned an initial 30 percent evaluation up to March 7, 2004, and a 50 percent evaluation beginning March 8, 2004. For purposes of assigning initial evaluations for the veteran's PTSD, based on the claim downstream from the initial grant of service connection, staged ratings must be considered. Fenderson v. West, 12 Vet. App. 119 (1999). Disability ratings are based upon schedular requirements that reflect the average impairment of earning capacity occasioned by the state of a disorder. 38 U.S.C.A. § 1155. Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. In all cases, the Board attempts to determine the extent to which the veteran's disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10. In determining the level of impairment, the disability must be considered in the context of the entire recorded history. 38 C.F.R. § 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Medical evidence is generally required to establish a medical diagnosis or to address questions of medical causation; lay assertions of medical status do not constitute competent medical evidence for these purposes. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). However, lay statements may serve to support a claim by supporting the occurrence of lay- observable events or the presence of disability or symptoms of disability subject to lay observation. 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, No. 07-7029, slip op. at 7 (Fed. Cir. July 3, 2007); See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The veteran's PTSD is rated under the General Rating Formula for Mental Disorders, which provides percentage ratings as follows: Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 50% 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. 70% Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 100% 38 C.F.R. § 4.130 (2007). The Court in Mauerhan v. Principi, 16 Vet. App. 436 (2002) issued important guidance on the application of the current psychiatric rating criteria. The Court stated that the specified factors for each incremental rating were examples rather than requirements for a particular rating. The court also stated that the analysis should not be limited solely to whether the claimant exhibited the symptoms listed in the rating scheme. Consistent with the foregoing, the Court also found it appropriate for a rating specialist to consider factors outside the specific rating criteria in determining the level of occupational and social impairment. A Global Assessment of Functioning (GAF) Scale, and a score assigned thereon, reflects the "psychological, social, and occupational functioning on a hypothetical continuum of mental health - illness." Richard v. Brown, 9 Vet. App. 266, 267, quoting the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV) p. 32. GAF scores ranging between 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. 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). GAF 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 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 young children, is defiant at home, and is failing at school). See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). Resolving reasonable doubt in claims adjudication is to be rendered in the veteran's favor. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2007); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1991). Medical evidence is generally required to establish a medical diagnosis or to address other medical questions; lay assertions of medical status do not constitute competent medical evidence for these purposes. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). However, lay statements may serve to support claims by supporting the occurrence of lay- observable events or the presence of disability or symptoms of disability subject to lay observation. 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, No. 07-7029, slip op. at 7 (Fed. Cir. July 3, 2007); See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The veteran was afforded an initial VA psychiatric consultation in December 2002 to assess whether PTSD was present. At that examination, the veteran's history of in- service stressor was assessed, the details of which will not be dwelt on here, as not specifically material to the question of severity of the veteran's PTSD over the rating period. The examiner found all requisite symptoms for a diagnosis of PTSD. At the examination, the veteran was not in distress, and he described his mood as good. Brief mental testing did not identify significant issues. The examiner assessed PTSD as well as adjustment reaction with mixed emotional features, and assigned a GAF of 60. Upon VA examination for rating purposes in March 2004, the veteran complained of insomnia, nightmares, night sweats, intrusive and recurring thoughts, hypervigilance with exaggerated startle response, avoidant behaviors, irritability, feelings of estrangement and detachment from others, self-isolation, panic attacks, and depressed mood. At the examination, the veteran appeared depressed, but he denied suicidal or homicidal ideation, and mental functioning appeared intact. The examiner assessed that PTSD had seriously impacted his life in many ways and had produced serious impairment in social and occupational functioning. The examiner assigned a GAF of 50. The veteran was most recently afforded a VA examination in April 2005 to assess the nature and severity of his service- connected PTSD. The veteran's claims folder and clinical record were reviewed, and the veteran's ongoing VA mental health treatment was noted. The examiner noted that the veteran had suffered an increase in severity of his mental illness, including in October 2004 taking an overdose of medication, resulting in his hospitalization for four days. As the veteran explained, he had been fired from his employment as a funeral director due to difficulty functioning including memory problems and making mistakes, and this firing was very difficult for him, playing a role in his overdose. At the examination the veteran complained of very significant memory impairment. His wife, present at the examination, reported that the veteran suffered from extreme memory loss, lacked self-esteem and motivation, and avoided crowds. The examiner noted the veteran's and his wife's reports of marital difficulties, including arguments which caused the veteran to become more upset and irritable. The examiner recounted a history of the veteran's status upon recent treatments. Following treatment after the October 2004 overdose, the veteran showed some improvement in mood by December 2004, but his memory and concentration remained very poor. Sleep was then fair but flashbacks and nightmares continued. Upon treatment in February 2005, marital conflict had increased nearing a point of divorce, and the veteran exhibited extreme anxiousness and nervousness. He was then started on medication for his anxiety. In March 2005 he had ongoing depression and anhedonia, as well as memory problems. His medications for depression were then accordingly increased. At the April 2005 examination, continued depression was observed despite the veteran's report that his increased antidepressant dose was helpful. The veteran continued to have difficulties communicating with family members in the face of conflicts. He complained of worsening symptoms since losing his job, including sleep disturbances and nightmares, as well as waking up hollering and jerking. He complained of panic attacks three to four times per week which were significantly symptomatic with heart pounding and shortness of breath, and feeling at times as though he would lose control. He reported being last suicidal two months prior. The April 2005 examiner assessed chronic and severe PTSD, with forgetfulness and impaired quality of functioning causing him to lose his last employment. The examiner noted that the veteran's significant presenting symptoms included ongoing depression, memory problems, and intense and frequent panic attacks. Other notable symptoms included hypervigilance with startle response, and virtual social isolation with isolation from friends and crowd avoidance. The examiner concluded that the veteran had both social and industrial impairment, and that this included impaired impulse control and difficulties dealing with situations, associated with panic attacks. The examiner emphasized that the veteran's PTSD had worsened despite medication. The April 2005 VA examiner did not assign a GAF score. However, some treatment records do provide GA F assessments. Upon hospitalization in October 2004 following the veteran's overdose, a GAF of 40 was assigned, but once stabilized through hospitalization, the veteran's GAF was assessed to be 50 to 55. As shown by the above-noted criteria, a GAF of 50 is associated with serious symptoms such as suicidal ideation, or serious impairment of social or occupational functioning. Notably, treatment records prior the veteran's firing in October 2004 reflected difficulties with depression but with responsiveness to medication. Upon treatment in March 2003 the veteran reported that his depression was lifting, and mood was observed to be better. However, the veteran then continued to report nightmares and intrusive thoughts about military trauma, as well as hypervigilance and exaggerated startle response. Other treatment records note the veteran's significant difficulties dealing with his wife. The veteran had noted difficulties with depression and some anxiousness, as well as memory issues. At a June 2003 psychiatric consultation with testing of mental functioning, the veteran's memory deficits were assessed as mild. While the veteran complained of terrible sleep, physical and situational factors may have played a role, including the veteran's wife recently breaking her hip, significant marital discord, their having difficulty selling their house, and the veteran's diagnosed sleep apnea with breathing difficulties for which he was to receive a CPAP shortly. Other than the mild memory impairments, tested mental functioning was generally within normal limits. The examiner opined that the veteran's sleep apnea played a role in his memory deficits, due to hypoxia. A January 2004 treatment record appears to reflect some significant worsening of the veteran's mental condition, with reported considerable worsening of symptoms, with complaints of severe and regular nightmares, night sweats, torn bed sheets, vivid and intense flashback, and possibly worsening memory problems. The treating psychologist observed a nearly full-blown panic attack during the visit. A July 2004 treatment record noted some reports of difficulties with twitching as a side-effect of medication. However, when he switched medications due to the twitching his depression worsened. The medical record fails to clarify the precise cause of the veteran's memory impairment, which reportedly played a primary role in his loss of employment in October 2004. Implicated are not only the veteran's PTSD with associated depression, but also hypoxia as associated with sleep apnea, possible chemical toxicity as associated with solvent used in embalming work, and other possible physiological causes, either environmental or infectious or genetic in origin. The veteran underwent evaluation by multiple specialists in occupational or environmental medicine, but these failed to identify a definite cause. It is sufficient, for purposes of this determination, that the veteran's mental disorders as associated with PTSD have been found by mental health practitioners to play a role in the memory loss. Because a more definite answer cannot be obtained, the Board here affords the veteran the benefit of ascribing that memory impairment to his PTSD. 38 U.S.C.A. § 5107(b). Treatment records in recent years have noted mental impairments principally to consist of depression, anxiety, some panic, and memory loss. Recent VA mental health treatment records in 2006 and 2007 fail to note any symptoms or complaints addressing PTSD or memories, flashbacks, etc., related to his military service, but do document significant mental difficulties related to his marital situation. This domestic situation appears by recent treatment records to be fairly intractable, with the veteran manifesting associated depression and anxiety symptoms, as assessed in these records. However, notwithstanding the absence of noted symptoms or findings specific to PTSD (e.g., nightmares, flashbacks, or startle response), the veteran's ongoing psychological difficulties cannot be differentiated from his PTSD based on the present record, and the Board will not endeavor to try to do so. Reviewing the record as a whole, the Board notes that depression, anxiety, panic, social self-isolation, and memory problems all impair the veteran's social and occupational functioning, with this impact roughly assessed as serious or significant through 2003, and becoming severe around the start of 2004, as reflected in the January 22, 2004 treatment, detailed above. The Board finds that for the rating period prior to January 2004, the veteran's PTSD was manifested generally by reduced reliability and productivity due to impaired memory, disturbances of motivation and mood, and difficulties with interpersonal relationships. The Board finds that the criteria for a 50 percent disability evaluation were then met on those bases. However, deficiencies in most areas were not then shown so as to warrant assignment of the next-higher, 70-percent evaluation for PTSD for the period prior to January 2004. 38 C.F.R. § 4.130. Over that interval, the veteran's symptoms inclusive of depression, anxiety, panic, self-isolation and difficulties with relationships, as well as memory problems, were not so severe as to produce significant deficiencies in judgment, thinking, or work, though impairments in family relationships and mood were certainly noted. The Board accordingly concludes that the veterans' PTSD for the rating period up to December 31, 2003, most nearly approximated that warranting a 50 percent evaluation and not a 70 percent evaluation. 38 C.F.R. §§ 4.7, 4.130. For the period beginning January 1, 2004, the Board finds that the veteran's PTSD was manifested by deficiencies in most areas, including work, family relations, thinking, and mood, due to his symptoms of depression affecting ability to function independently, appropriately, and effectively, impaired impulse control with frequent irritability, anxiety with frequent panic, and memory loss. This level of impairment equates most nearly to a 70 percent evaluation. 38 C.F.R. §§ 4.7, 4.130. However, for this entire most recent period beginning January 2004, the Board finds the preponderance of the evidence against total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130. These levels of impairment are simply not shown in this case. The Board has duly considered the veteran's and his spouse's lay statements, including as presented in hearing testimony and as documented in written submissions as well as in reports of medical treatment and examination. While symptoms of mental impairment are frequently subjective, the Board looks to these lay statements as supportive of or indicia of disability, including limitations of functioning. Jandreau. The Board has duly considered the evidence of record, and finds that the staged ratings assigned by virtue of this decision reflect the most disabling the veteran's PTSD has been since the veteran submitted his claim for service connection, which is the beginning of the appeal period. Thus, the Board concludes that the staged ratings here assigned are all that are appropriate in this case. Fenderson v. West, 12 Vet. App Vet. App. 119 (1999). The preponderance of the evidence is against assignment of higher initial disability ratings for PTSD than those assigned here. Therefore, the benefit of the doubt doctrine does not apply to warrant still higher ratings. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert. ORDER A higher evaluation for PTSD of 50 percent, and no greater, is granted effective from February 3, 2003, through December 31, 2003, subject to the laws and regulations governing the payment of monetary awards. A higher evaluation for PTSD of 70 percent, and no greater, is granted effective January 1, 2004, subject to the laws and regulations governing the payment of monetary awards. ____________________________________________ LILA J. BAKKE Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs