Citation Nr: 1304552 Decision Date: 02/07/13 Archive Date: 02/19/13 DOCKET NO. 10-01 368 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to service connection for a skin disorder, to include chloracne and eczema, claimed as due to Agent Orange (herbicide) exposure. 2. Entitlement to an effective date earlier than January 5, 2006 for the grant of service connection for posttraumatic stress disorder (PTSD) with depression. 3. Entitlement to an initial rating in excess of 70 percent for PTSD with depression. REPRESENTATION Appellant represented by: California Department of Veterans Affairs ATTORNEY FOR THE BOARD T. Sherrard, Counsel INTRODUCTION The Veteran, who is the Appellant in this case, had active service from March 1967 to January 1980. This matter comes before the Board of Veterans' Appeals (BVA or Board) from May 2008 and December 2009 rating decisions by the above Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded this case for further development in April 2012. As described below, the development requested has been completed, and the case is now appropriate for appellate review. The Board further notes that the evidence in this case demonstrates unemployability. However, a total rating based on individual unemployability due to service-connected disabilities (TDIU) has already been awarded, effective from April 26, 2008. The Board acknowledges the evidence in this case suggests unemployability, and thus, the issue of TDIU is raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (the issue of TDIU is appropriately considered by the Board in the first instance during the determination of an increased rating claim when the issue is raised by the record). However, the Board notes that a TDIU was granted and made effective from April 26, 2008. Thus, the issue of entitlement to a TDIU has already been adjudicated, as distinguished from Rice, and is further rendered moot by the grant of a 100 percent schedular rating herein; thus, the Board will not consider it herein or refer it to the RO for further action. See Green v. West, 11 Vet. App. 472, 276 (1998) (holding that, if a 100 percent schedular rating is warranted, a veteran is not also entitled to TDIU). The Board is cognizant of the decision of the U.S. Court of Appeals for Veterans Claims (Court) in Bradley v. Peake, 22 Vet. App. 280 (2008), in which the Court held that, although no additional disability compensation may be paid when a total schedular disability rating is already in effect, a separate award of TDIU predicated on a single disability may form the basis for an award of special monthly compensation. In view of the issuance by the Court of its decision in Bradley, which recognized that it was possible for a veteran to be awarded TDIU based on a single disability and subsequently receive schedular disability ratings for other conditions that would not duplicate in the count of disabilities for special monthly compensation purposes, in November 2009 the VA General Counsel withdrew VAOPGCPREC 6-99. The facts in this Veteran's case distinguish the current appeal from the Court's holding in Bradley, where only a 70 percent disability rating for PTSD was granted, a TDIU ("total rating") was granted based primarily on the PTSD disability, the TDIU substituted for the "total" rating, and the Veteran only later claimed and was granted service connection and multiple separate disability ratings that, apart from the PTSD, combined to at least 60 percent. In the current Veteran's case, as distinguished from Bradley, the Veteran has been granted a 100 percent ("total") schedular disability rating for PTSD herein (from July 27, 2009, forward), as distinguished from a less than total schedular rating (of 70 percent) in Bradley that was only made "total" by operation of TDIU. In the current Veteran's case, subsequent to the grant of the combined "total" (100 percent schedular) disability rating for his service-connected PTSD, the Veteran also has not claimed or been granted service connection and/or ratings that combined to a separate 60 percent disability rating. In the current case, where the claim for TDIU was received on March 3, 2009, there is no subsequent claim for TDIU following the date of grant of increased rating. Moreover, TDIU was made effective on April 26, 2008, prior to the grant of a combined 100 percent schedular rating herein; thus, the 100 percent schedular rating covers the remainder of the TDIU period on appeal. In November 2009, the VA General Counsel interpreted that the logic of Bradley suggested that, if a veteran had a schedular total rating for a particular service-connected disability and subsequently claimed TDIU for a separate disability, VA must consider the TDIU claim despite the existence of the schedular total rating (100 percent schedular) and award special monthly compensation if VA finds the separate disability supports a TDIU rating independent of the other 100 percent disability rating. The Veteran's case currently on appeal is factually distinguished from even the logical extension of Bradley indicated by the VA General Counsel because neither the Veteran nor the evidence has in fact subsequently claimed TDIU based on a separate service-connected disability (other than his service-connected PTSD). At the time of his TDIU claim, service connection was only in effect for PTSD, evaluated at 70 percent. Service connection has not been granted for any other disabilities. In contrast to the hypothetical scenario in which the VA General Counsel (in November 2009) interpreted a logical extension of Bradley where a veteran had a schedular total rating for a particular service-connected disability and subsequently claimed TDIU for a separate disability, in this case, first, the Veteran did not first have a total schedular rating for any service-connected disability and then make a subsequent claim for TDIU. Second, the Veteran has neither claimed nor asserted that unemployability is due to any disability other than PTSD, nor does he have any other service-connected disabilities. In this case, the Veteran has not in fact subsequently claimed TDIU based on a separate disability (other than PTSD). For these reasons, and in light of the grant of TDIU that still remains in effect, the TDIU claim was rendered moot by the grant of a combined 100 percent disability rating for PTSD, with no remaining questions of law or fact to be decided regarding TDIU. FINDINGS OF FACT 1. The Veteran served in Vietnam from June 1970 to August 1970 and March 1971 to February 1972, and is thus presumed to have been exposed to herbicides during active service. 2. The Veteran does not have a diagnosis of chloracne or any other skin disorder presumptively associated with herbicide exposure. 3. The Veteran did not incur a skin injury or disease during active service. 4. Symptoms of a skin disorder were not chronic in service. 5. Symptoms of a skin disorder have not been continuous since service separation. 6. The Veteran filed an informal claim of entitlement to service connection for PTSD on January 5, 2006, which was later granted with an effective date of January 5, 2006, the date of claim. 7. Prior to receipt of the claim on January 5, 2006, there were no pending requests for service connection for PTSD that remained unadjudicated. 8. For the initial rating period prior to July 27, 2009, the Veteran's PTSD was productive of complaints including occupational and social impairment with deficiencies in most areas due to such symptoms as: depressed mood, anxiety, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, suicidal ideation, and difficulty in adapting to stressful circumstances. 9. For the rating period from July 27, 2009, forward, the Veteran's PTSD was productive of total occupational and social impairment due to such symptoms as: depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, suicidal ideation, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, and difficulty in adapting to stressful circumstances. CONCLUSIONS OF LAW 1. The criteria for service connection for a skin disorder have not been met, including presumptively based on herbicide exposure. 38 U.S.C.A. §§ 101, 1101, 1110, 1112, 1113, 1116, 1131, 1137, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). 2. The criteria for an effective date earlier than January 5, 2006 for the grant of service connection for PTSD with depression have not been met. 38 U.S.C.A. §§ 5103(a), 5103A, 5107, 5110 (West 2002); 38 C.F.R. §§ 3.102, 3.155, 3.157, 3.159, 3.160, 3.400 (2012). 3. The criteria for entitlement to an initial schedular evaluation in excess of 70 percent for PTSD have not been met for any period prior to July 27, 2009. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2012). 4. Resolving reasonable doubt in the Veteran's favor, the criteria for a 100 percent rating for PTSD have been met for the rating period on appeal from July 27, 2009, forward. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353 -356 (April 30, 2008). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The notice included provisions for disability ratings and for the effective date of the claim. Because the appeal as to the appropriate effective date and rating for PTSD arises from the Veteran's disagreement with the effective date and initial evaluation following the grant of service connection for PTSD, no additional notice with regard to those claims is required. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the United States Court of Appeals for Veterans Claims (Court) have held that, once service connection is granted and the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App.112 (2007); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims). With regard to the skin disorder claim, in a timely July 2007 letter, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate a claim for service connection, what information and evidence must be submitted by the Veteran, and what information or evidence VA will attempt to obtain. The letter also described how VA determines disability ratings and effective dates. The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA and private treatment records, VA examination reports and opinions, and the Veteran's statements. A VA examination was obtained in July 2007 with regard to the question of the nature and appropriate diagnosis of the Veteran's current skin disorder. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the July 2007 VA examination obtained in this case is adequate as to the question of the appropriate diagnosis of the Veteran's current skin disorder. The opinion was predicated on a full reading of the private and VA medical records in the Veteran's claims file, as well as a thorough physical examination and interview of the Veteran. The VA opinion as to diagnosis considered all of the pertinent evidence of record, to include VA treatment records, comprehensive physical examinations, and the statements of the Veteran, and provides a complete rationale for the opinion stated, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination with respect to the skin disorder claim decided herein has been met. 38 C.F.R. § 3.159(c)(4). The Board acknowledges that the July 2007 VA skin examination did not provide a nexus opinion; however, the Board finds that a VA nexus opinion is not necessary in order to decide this issue. Two pivotal Court cases exist that address the need for a VA examination. Those are Duenas v. Principi, 18 Vet. App. 512 (2004) and McLendon v. Nicholson, 20 Vet. App. 79 (2006). In McLendon, the Court held that in disability compensation claims, the Secretary must provide a VA medical examination when there is: (1) competent evidence of a current disability or persistent or recurring symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on a claim. In Duenas, the Court held that a VA examination is necessary when the record: (1) contains competent evidence that the veteran has persistent or recurrent symptoms of the claimed disability, and (2) indicate that those symptoms may be associated with her active military service. In this case, the Veteran's service treatment records are negative for any complaints of or treatment for a skin disorder. Thus, the weight of the evidence demonstrates that the Veteran did not sustain an injury, disease, or event relating to a skin disorder in service, and there is no duty to provide a VA medical examination. See Bardwell v. Shinseki, 24 Vet. App. 36, 40 (2010) (holding that that where the evidence has failed to establish an in-service injury, disease, or event, VA is not obligated to provide a medical examination). As explained in this decision, the Board also finds that the weight of the evidence demonstrates no chronic symptoms of a skin disorder in service and no continuity of symptoms of a skin disorder since service separation. Because there is no in-service injury or disease to which a competent medical opinion could relate the current disability, there is no reasonable possibility that a VA examination or opinion could aid in substantiating the current claim for service connection for a skin disorder. See 38 U.S.C.A. § 5103A(a)(2) (VA "is not required to provide assistance to a claimant . . . if no reasonable possibility exists that such assistance would aid in substantiating the claim"); 38 C.F.R. § 3.159(d) (VA to discontinue assistance where there is "no reasonable possibility that further assistance would substantiate the claim"). The Board has considered the decision in Charles v. Principi, 16 Vet. App. 370, 374-75 (2002); however, in the absence of evidence of an in-service disease or injury, referral of this case to obtain an opinion as to the etiology of the Veteran's skin disorder would in essence place the examining physician in the role of a fact finder, would suggest reliance on an inaccurate history of occurrence of an in-service injury or disease, and could only result in a speculative opinion or purported opinion of no probative value. In other words, any medical opinion which purported to provide a nexus between the Veteran's skin disorder and military service would necessarily be based on an inaccurate history regarding what occurred in service, so would be of no probative value. The Court has held on a number of occasions that a medical opinion premised upon an unsubstantiated account of a claimant is of no probative value. See, e.g., Swann v. Brown, 5 Vet. App. 229, 233 (1993) (generally observing that a medical opinion premised upon an unsubstantiated account is of no probative value, and does not serve to verify the occurrences described); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (the Board is not bound to accept a physician's opinion when it is based exclusively on the recitations of a claimant that have been previously rejected). The holding in Charles was clearly predicated on the existence of evidence of an in-service injury, disease, or event and a current diagnosis. Referral of this case to obtain a medical opinion would be a useless act. The duty to assist by providing a VA nexus opinion is not invoked in this case because there is no reasonable possibility that such assistance would aid in substantiating the claim. See 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d). The Veteran has been afforded an adequate examination on the issue of rating his PTSD. VA provided the Veteran with examinations in April 2008, November 2009, and June 2012. The Veteran's history was taken, and complete examinations with interviews were conducted. Conclusions reached and diagnoses given were consistent with the examination report. Therefore, the Veteran has been afforded an adequate examination on the PTSD rating issue decided herein. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board further finds that there has been substantial compliance with the Board's April 2012 remand directives. Specifically, subsequent to the Board's remand, a letter was sent to the Veteran in May 2012 requesting the names of any additional treatment providers whose records had not already been provided to VA. In addition, updated VA treatment records have been associated with the Veteran's virtual claims file. Moreover, additional attempts were made to secure the Veteran's Social Security Administration (SSA) records; however, a negative response was received by the SSA, and the RO made a Formal Finding regarding the unavailability of the SSA records. The Board also finds that further attempts to obtain SSA records would be futile. Finally, the Veteran was afforded a VA examination to assess the severity of his PTSD, as described above. Therefore, the development requested by the Board in April 2012 has been completed to the extent possible, and no further development is necessary prior to appellate review. Notably, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist 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). Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (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 present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). In certain cases, service connection can be presumed if a veteran was exposed to a herbicide agent during active service. Under the current Code of Federal Regulations (C.F.R.), presumptive service connection is warranted for the following disorders: AL amyloidosis; chloracne or other acneform disease consistent with chloracne; Type II diabetes; Hodgkin's disease; chronic lymphocytic leukemia; multiple myeloma; non-Hodgkin's lymphoma; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx, or trachea); ischemic heart disease; Parkinson's disease; hairy cell leukemia; and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e) (2012). Presumptive service connection for these disorders as a result of Agent Orange exposure is warranted if the requirements of 38 C.F.R. § 3.307(a)(6) are met. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.309(e). The governing law provides that a "veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent . . . unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service." 38 U.S.C.A. § 1116(f). Pursuant to Section 3 of the Agent Orange Act of 1991, Pub. L. No. 102-4, 105 Stat. 11, the Secretary of Veterans Affairs (Secretary) entered into an agreement with the National Academy of Sciences (NAS) to review and summarize the scientific evidence concerning the association between exposure to herbicides used in Vietnam and various diseases suspected to be associated with such exposure. The NAS was to determine, to the extent possible, whether there was a statistical association between the suspect disease and herbicide exposure, taking into account the strength of the scientific evidence and the appropriateness of the methods used to detect the association; the increased risk of disease among individuals exposed to herbicides during the service in the Republic of Vietnam during the Vietnam era; and whether there is a plausible biological mechanism or other evidence of a causal relationship between herbicide exposure and the suspect disease. The NAS was required to submit reports of its activities every two years. The Secretary, under the authority of the Agent Orange Act of 1991 and based on studies by the NAS, has determined that there is no positive association between exposure to herbicides and any condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-346 (1994); see also Notice, 61 Fed. Reg. 41,442-449, and 61 Fed. Reg. 57,586-589 (1996); Notice, 64 Fed. Reg. 59,232-243 (Nov. 2, 1999); Notice, 67 Fed. Reg. 42,600-608 (June 24, 2002); Notice, 72 Fed. Reg. 32,395-407 (June 12, 2007); 74 Fed. Reg. 21,258-260 (May 7, 2009). When a disease is first diagnosed after service but not within an applicable presumptive period, service connection may nevertheless be established by evidence demonstrating that disease was in fact incurred during service. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). If there is no presumptive service connection available, direct service connection can be established if the record contains competent medical evidence of a current disease process with a relationship to exposure to an herbicide agent while in military service. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303; Combee at 1043-44. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." See Layno, 6 Vet. App. at 469; 38 C.F.R. § 3.159(a)(2). The Court has emphasized that when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); 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). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of a veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service Connection for a Skin Disorder The Veteran contends that his current skin disorder is due to exposure to Agent Orange during active service. Specifically, he avers that he has been diagnosed with chloracne, which is among the diseases specified in 38 C.F.R. § 3.309(e) for diseases specific to herbicide-exposed veterans. His service personnel records confirm that he served in Vietnam from June 1970 to August 1970 and from March 1971 to February 1972; therefore, he is entitled to a presumption of exposure to herbicides. 38 U.S.C.A. § 1116(f). However, the Board finds that the weight of the evidence demonstrates that the Veteran has not been diagnosed with chloracne or any skin disorder presumptively associated with herbicide exposure. A June 2005 VA treatment note indicates the Veteran reported a rash with a pruritic plaque on his right shin, which then spread to other areas of his body, including his penis and arms. Physical examination revealed a five centimeter diameter of thick plaque on the right shin, with a couple of areas in the rest of his body, all of which appeared to the VA clinician to be eczema. Specifically, the VA clinician surmised that the rashes were primary eczema with a developing secondary infection, although he acknowledged that the Veteran could have a rare dermatologic problem requiring a biopsy to make a definitive determination. The Veteran continued to report a rash on his shins in April 2006, and the VA clinician stated that it was probably eczema. The clinician took a culture of his skin to determine if the eczema was being complicated by staphylococcus aureus. An August 2006 VA treatment note indicates the eczema had responded to Triamcinolone. The Veteran was afforded a VA skin examination in July 2007. The Veteran reported that the condition started with a red pimple on his right leg and developed into spots on his legs, back, chest, and neck. He further reported that the lesions had resolved, but there was hyperpigmentation at the areas of involvement. Physical examination of the skin was negative. The VA examiner noted that the lesions were not comedonal or inflamed papules, pustules, or cysts to suggest acne or chloracne. The examiner further noted that, although the Veteran described the original lesions as pimples, his description and rash were more consistent with dermatitis. The VA examiner assessed nummular eczema/dermatitis with no evidence of chloracne. The 2007 VA skin examination is competent and probative medical evidence because it is factually accurate, and is supported by an adequate rationale. The VA examiner was informed of the pertinent evidence, reviewed the claims file, interviewed and examined the Veteran, and fully articulated the opinion as to the appropriate diagnosis. For these reasons, the Board finds that the weight of the evidence demonstrates that the Veteran does not have a diagnosis of chloracne, and the presumptive service connection regulations pertaining to Agent Orange exposure do not apply, as the Veteran does not have a current skin disorder listed among the diseases specified in 38 C.F.R. § 3.309(e) for diseases specific to herbicide-exposed veterans. Notwithstanding the inapplicability of the Agent Orange presumptive service connection regulations, the Board is obligated to fully consider the Veteran's service connection claim on a direct basis. See Combee, 34 F.3d at 1043-1044. After a review of all the evidence of record, lay and medical, the Board finds that the weight of the evidence demonstrates that no relevant injury or disease manifesting a skin disorder occurred during active service, and that symptoms of a skin disorder were not chronic in service. The Veteran's service treatment records are silent as to any symptoms, complaints, history, treatment, or diagnosis of a skin disorder. Although the service separation examination is not available, a December 1978 examination report is negative for any report or diagnosis of a skin disorder, and clinical examination of the skin was marked as "normal." For these reasons, the Board finds that the weight of the evidence demonstrates that no relevant disease or injury manifesting a skin disorder occurred during active service, and that symptoms of a skin disorder were not chronic in service. The Board next finds that the weight of the evidence demonstrates that symptoms of a skin disorder have not been continuous since separation from active service in January 1980. Following service separation in January 1980, the evidence of record does not show any complaints, diagnosis, or treatment for a skin disorder until June 2005, when the Veteran reported that he had had a rash for two months. The absence of post-service complaints, findings, diagnosis, or treatment for 25 years after service separation until 2005 is one factor that tends to weigh against a finding of continuous symptoms of a skin disorder after service separation. See Buchanan, 451 F.3d 1336 (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible). Additional evidence showing that skin disorder symptoms have not been continuous since service separation includes the Veteran's statement in June 2005 that the rash began only two months prior, placing its inception many years after service separation. In addition, at the July 2007 VA examination, the Veteran reported that the onset of his rash occurred two years prior, again, placing its inception many years after service separation. Finally, on his VA Form 21-526, the Veteran wrote that he began treatment for his skin disorder in 2005. Thus, he has consistently stated that the skin disorder did not begin until 2005, providing factual evidence against his own claim. To the extent that the Veteran's more recent assertions made as part of the current compensation claim can be interpreted as a contention that he has had symptoms of a skin disorder since separation from service in January 1980, the Board finds that, while the Veteran is competent to report the onset of skin disorder symptoms, his recent report of continuous skin disorder symptoms since service is outweighed by the other, more contemporaneous, lay and medical evidence of record, both in service and after service, and is not reliable. See Charles, 16 Vet. App. at 374-75. The Board finds that the Veteran's statements as to continuous skin disorder symptoms after service are not credible because they are outweighed by other evidence of record that includes the more contemporaneous service treatment records which are negative for any complaints, findings or diagnoses of a skin disorder, the lack of any post-service documentation of treatment or diagnoses of a skin disorder for 25 years after service separation until 2005, and the Veteran's multiple statements made in the context of seeking treatment that his skin disorder did not begin until 2005, as outlined above. Based on the evidence of record, the weight of the competent evidence demonstrates no relationship between the Veteran's current skin disorder and his military service, including no credible evidence of either an in-service skin disease or injury, chronic symptoms of a skin disorder during active service, or continuity of symptomatology of a skin disorder, which would serve either as a nexus to service or as the factual basis for a favorable medical nexus opinion; therefore, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the claim for service connection for a skin disorder, and outweighs the Veteran's more recent contentions regarding in-service chronic skin disorder symptoms and post-service skin disorder symptoms. For these reasons, the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Earlier Effective Date Laws and Regulations The assignment of effective dates of awards is generally governed by 38 U.S.C.A. § 5110 and 38 C.F.R. § 3.400. Unless specifically provided otherwise, the effective date of an award based on an original claim, a claim reopened after final adjudication, or a claim for increase, of compensation, dependency and indemnity compensation, or pension, "shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor." 38 U.S.C.A. § 5110(a). The implementing regulation clarifies this to mean, except as otherwise provided, that the effective date of an evaluation and award of pension, compensation, or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400. Under 38 C.F.R. § 3.155(a), a veteran or a representative of a veteran can file an informal claim by communicating an intent to apply for one or more VA benefits. See also 38 C.F.R. § 3.1(p). A communication received from a service organization, an attorney, or agent may not be accepted as an informal claim if a power of attorney was not executed at the time the communication was written. 38 C.F.R. § 3.155(b). The Board notes effective dates may also be changed when a prior rating decision is found to have "clear and unmistakable error" as described in 38 C.F.R. § 3.105. That is, pursuant to 38 C.F.R. § 3.104(a), "[a] decision of [an RO] shall be final and binding on all field offices of [VA] as to conclusions based on the evidence on file at the time VA issues written notification in accordance with 38 U.S.C. § 5104." 38 C.F.R. § 3.104(a). In this case, the Veteran has not articulated CUE with any prior rating decision, so the Board will not address the issue of CUE herein. Thus, with respect to the earlier effective date claim on appeal here, the Board will focus the analysis on determining the proper date of the claim and the proper date of when entitlement arose. Thereafter, the proper effective date is determined by taking the latter of the two dates determined. See 38 C.F.R. § 3.400. Earlier Effective Date for the Grant of Service Connection of PTSD The Veteran filed an original informal claim of entitlement to service connection for PTSD in January 2006. He subsequently filed a formal claim in November 2006. In the May 2008 rating decision that is the subject of this appeal, the RO granted service connection for PTSD, effective from January 5, 2006, the date the Veteran's informal claim for service connection was received. The Veteran contends that he is entitled to an earlier effective date for the grant of service connection for PTSD, presumably because his PTSD is related to his military service. Thus, the question before the Board is whether there is any evidence in the claims file that can be construed as a claim for service connection prior to the filing of the informal claim for service connection filed on January 5, 2006. The Board concludes there is not. Any communication or action, indicating intent to apply for one or more benefits under the laws administered by VA, from a claimant, his or her duly authorized representative, a Member of Congress, or some person acting as next friend of a claimant who is not sui juris may be considered an informal claim. Such informal claim must identify the benefit sought. 38 C.F.R. § 3.155. After reviewing the record, the Board concludes that there are no testimonial documents submitted prior to January 5, 2006, indicating intent to file a claim of entitlement to service connection for PTSD. It is further noted that, under 38 C.F.R. § 3.157, a report of examination or hospitalization by VA or one of the uniformed services will be accepted as an informal claim for benefits. However, the provisions of 38 C.F.R. § 3.157 only apply after a formal claim for compensation or pension has been allowed or compensation disallowed because the disability is not compensable. The Board acknowledges the June 2005 VA treatment records which demonstrate a diagnosis of PTSD. However, the Veteran in this case was not awarded service connection (or denied compensation because the disability was not compensable) for any disabilities prior to June 2005. Thus, the provisions of 38 C.F.R. § 3.157 do not apply so as to enable the June 2005 VA treatment records to constitute an informal claim for benefits. The Board concludes that the date of claim here is January 5, 2006. To reiterate the statement of the law above, under 38 C.F.R. § 3.400(b)(2), the later either of the date of the claim (in this case, January 5, 2006) or the date upon which entitlement arose controls, and is the appropriate effective date. Currently, the effective date is January 5, 2006, which is the date of claim for reasons explained above. The January 5, 2006 effective date currently assigned is the date the RO received the Veteran's informal claim of entitlement to service connection for PTSD. To the extent the Veteran is arguing the date on which entitlement arose pre-dated his current effective date, his claim must fail. Even if the date entitlement arose pre-dated the date of claim, under the law, the proper effective date is the latter of the two. See 38 C.F.R. § 3.400(b)(2). For the reasons already discussed, an effective date prior to January 5, 2006 is not justified. As the preponderance of the evidence is against a grant of an earlier effective date, the benefit-of-the-doubt doctrine is inapplicable and the claim must be denied. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Disability Rating Criteria Disability evaluations (ratings) are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. Evaluations for PTSD are assigned pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. Under the general formula for rating mental disorders, a rating of 70 percent is assigned where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine 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); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. A 100 percent schedular evaluation contemplates total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. In assessing the evidence of record, it is important to note that the GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). A GAF score in the range of 31 to 40 represents "Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). Id. A GAF score in the range of 41 to 50 represents "Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)." Id. A GAF score in the range of 51-60 indicates "Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers)." Id. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive. The Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). On the other hand, if the evidence shows that a veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. The U.S. Court of Appeals for the Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2012). At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." See Layno, 6 Vet. App. at 469; 38 C.F.R. § 3.159(a)(2). The Court has emphasized that when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). PTSD Disability Rating Analysis In the present case, service connection for PTSD was granted in a May 2008 rating decision. An initial 50 percent evaluation was assigned, effective from January 5, 2006, the date the Veteran's claim for service connection was received. The Veteran filed a timely notice of disagreement to the initial rating assigned, and, in the December 2009 rating decision that is the subject of this appeal, the RO assigned a 70 percent rating for PTSD, effective from January 5, 2006. The Veteran, including through his representative, contends that that his PTSD symptoms warrant an initial rating in excess of 70 percent. Specifically, he avers that his PTSD has left him totally disabled. Initial Rating Period Prior to July 27, 2009 The Board has reviewed all the lay and medical evidence of record pertaining to the initial rating period on appeal prior to July 27, 2009, and finds that the criteria for a disability rating for PTSD in excess of 70 percent have not been met for the rating period on appeal prior to July 27, 2009. Prior to July 27, 2009, the Veteran's PTSD has been productive of occupational and social impairment with deficiencies in most areas due to symptoms such as suicidal ideation, near-continuous panic or depression affecting the ability to function independently, appropriately, or effectively, difficulty in adapting to stressful circumstances, and difficulty in establishing and maintaining effective work and social relationships. Such degree of impairment of symptoms does not more nearly approximate the criteria for the next higher, 100 percent, evaluation under Diagnostic Code 9411. 38 C.F.R. § 4.130. The Board finds that the requirements for a 100 percent rating have not been demonstrated for any period. For the initial rating period prior to July 27, 2009, the Veteran's PTSD has not been productive of total occupational and social impairment, as required for a 100 percent rating under Diagnostic Code 9411. 38 C.F.R. § 4.130. The weight of the lay and medical evidence of record relevant to the rating period prior to July 27, 2009, does not demonstrate gross impairment in thought processes or communication. A September 2005 VA treatment note indicates the Veteran was coherent, and that no mannerisms, postures, or unusual behaviors were noted. Further, his thoughts were well developed in form and content, and speech was normal with regard to production, volume, content, and clarity. The April 2008 VA examiner noted speech of normal rate, rhythm, and fluency, and no impairment of thought processes or communication. Speech was noted to be normal in November 2008, and thought processes were linear and logical. The evidence does not show persistent delusions or hallucinations. A September 2005 VA treatment note indicates that no delusions or hallucinations were detected. At the April 2008 VA examination, the Veteran reported that, at times, but "not that often," he thought he heard a voice that sounded like a voice from service calling his name. However, he denied acute psychotic symptoms. In November 2008, the Veteran denied audio or visual hallucinations and delusions. The evidence does not demonstrate grossly inappropriate behavior. A September 2005 VA treatment note indicates the Veteran was cooperative and calm throughout his treatment visit. The Veteran denied any obsessive or ritualistic behavior at the April 2008 VA examination, and no inappropriate behavior was noted. The evidence does not demonstrate persistent danger of hurting self or others. The Veteran denied suicidal ideation at a June 2005 VA visit. A September 2005 VA treatment note indicates there was no risk of imminent harm to self or others. The Veteran denied suicidal and homicidal ideation at the April 2008 VA examination. A November 2008 VA treatment note indicates the Veteran admitted to having suicidal thoughts, but had no plan or intent. The evidence does not show intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene). A September 2005 VA treatment note indicates the Veteran appeared to be well-groomed. At the April 2008 VA examination, when asked about his activities and leisure pursuits, he said he worked on his computer and around the house. The VA examiner noted that he was casually attired, and that he was independent with activities of daily living. A November 2008 VA treatment note indicates the Veteran was neatly dressed and groomed. The evidence does not demonstrate disorientation to time or place. The April 2008 VA examiner noted that the Veteran was oriented to person, place, time, and to what he was doing. The evidence does not show memory loss for names of close relatives, own occupation, or own name. At the April 2008 VA examination, the Veteran denied any memory problems, and memory testing was normal. Finally, the evidence does not demonstrate total occupational and social impairment due to the above symptoms. Indeed, the Veteran worked several part-time jobs until April 2008; thereafter, he began to study for a new career. At the April 2008 VA examination, the Veteran reported that he was currently working part-time as a merchandiser at a store where he had been employed for three years. The Veteran stated that he performed his job "well," and that his attendance record was good. He further stated he had minimal contact with others in his job capacity. He stated he had either not been able to find or did not like previous full-time positions due to stress, not liking the managers, and anger. He had last worked full-time in 1999, when his company relocated and he was laid off. A November 2008 VA treatment note indicates the Veteran was working three part-time jobs, but quit working in April 2008 due to stress and job cuts. In a February 2009 letter, the Veteran wrote that he had experienced increasing pressure from his employer to perform to strict guidelines, which caused uncontrollable anger, anxiety, and severe depression; thus, he stated he was unable to continue to work due to the mental and physical pressures that the job entailed. He also stated that he was receiving early Social Security benefits because he was no longer able to work due to physical disabilities. A February 2009 VA treatment note indicates that the Veteran wanted to earn his M.B.A. and start a website business. Thus, while he quit working in April 2008, the evidence indicates that he did so, at least in part, due to physical disabilities, and that his PTSD symptoms did not prevent him from planning a new career. The evidence demonstrates significant, but not total, social impairment as well. An August 2005 VA treatment note indicates that the Veteran was living with his domestic partner of nineteen years, but that the relationship had not been as close since his partner's daughter came to live with them two years prior. The Veteran stated he did not have close friends and did not communicate with his family very often. However, he did report feeling close to a neighbor who died of a heart attack two months after their friendship began. The VA clinician assessed moderate to severe impairment in social functioning. At the April 2008 VA examination, the Veteran reported that he was unable to get emotionally close to others, although he stated that he had two friends who were veterans. He also stated that he was somewhat close to his mother, but that she now lived in a nursing home. However, he said he was not really close to his siblings because they did not understand his Vietnam-related issues. A November 2008 VA treatment note indicates that the Veteran was closest to his mother and brother, and that his girlfriend provided "some support." In addition, the symptoms listed in the 100 percent rating category as contributing to total occupational and social impairment were entirely absent from the evidence relating to the period on appeal prior to July 27, 2009. As described above, none of the seven symptoms of the 100 percent rating category - gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger or hurting self or 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 - were demonstrated by the evidence. Further, while a certain number of symptoms (or any symptoms at all) are not required for a higher rating, the Board finds that most of the PTSD symptoms have been consistent with the degree of occupational and social impairment consistent with the assigned evaluation of 70 percent. For example, the evidence demonstrates occupational and social impairment with deficiencies in most areas due to symptoms such as suicidal ideation, near-continuous depression, difficulty in adapting to stressful circumstances, and difficulty establishing and maintaining effective work and social relationships. For instance, the Veteran fairly consistently reported a depressed mood. He stated that he experienced difficulty adjusting to strict guidelines at work, and had difficulty getting along with supervisors and coworkers. In addition, he reported few close friends and few close relationships with family members, preferring to be alone. In concluding that an initial disability rating of 70 percent, but no higher, is warranted for the rating period on appeal prior to July 27, 2009, the Board has also relied, in part, upon the GAF scores assigned throughout the rating period on appeal. The April 2008 VA examiner assigned a GAF score of 50. In November 2008, a VA clinician also assigned a GAF score of 50. The GAF score of 50 does not warrant a rating in excess of 70 percent, as it reflects symptoms that are more severe than those actually demonstrated by the evidence. While suicidal ideation was shown by the evidence, there was no evidence of severe obsessional rituals or frequent shoplifting. Moreover, the Veteran reported he had a few friends and was able to maintain his job and perform it well (per his own report) during the rating period on appeal prior to July 27, 2009, until he quit in April 2008 due to physical disabilities. Based upon the foregoing, the Board finds that the criteria for a higher initial disability rating for PTSD in excess of 70 percent have not been met for any period prior to July 27, 2009. In reaching this conclusion, the benefit-of-the-doubt doctrine has been considered, but the preponderance of the evidence is against the claim for an initial rating in excess of 70 percent for the period prior to July 27, 2009. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Appeal Period from July 27, 2009, Forward After reviewing all the lay and medical evidence of record relevant to the rating period from July 27, 2009, forward, the Board finds that the criteria for a higher evaluation of 100 percent have been more nearly approximated for the rating period on appeal from July 27, 2009, forward. Although the evidence does not show the presence of any of the symptoms listed in the 100 percent rating category, it indicates that the Veteran's PTSD symptoms worsened to the extent that he has total occupational and social impairment, which more nearly approximates the criteria for a 100 percent rating under Diagnostic Code 9411. 38 C.F.R. § 4.130. The weight of the lay and medical evidence of record for the period from July 27, 2009, forward, does not demonstrate gross impairment in thought processes or communication. A July 2009 VA treatment note indicates that thought process and content were within normal limits. The November 2009 VA examiner noted the Veteran's thinking was clear and speech was normal. Moreover, his thoughts were clear, logical, goal-directed, and linear. The June 2012 VA examiner noted the Veteran's speech was of normal rate, quiet volume, and had a soft/meek tone. Thought processes were linear and content was normal. The VA examiner concluded there was no gross impairment in thought processes or communication. The evidence does not show persistent delusions or hallucinations. In July 2009, the Veteran denied audio or visual hallucinations and delusions. The November 2009 and June 2012 VA examiners also noted no indication of hallucinations or delusions. The evidence does not demonstrate grossly inappropriate behavior. The November 2009 VA examiner noted that no bizarre or unusual behaviors were observed during the interview. However, the Veteran reported that he had increased difficulty with anger and irritability, and found himself lashing out at people verbally, at times inappropriately. The June 2012 VA examiner noted no grossly inappropriate behavior. The evidence does not demonstrate persistent danger of hurting self or others. At the June 2012 VA examination, the Veteran reported occasional thoughts of suicide, but denied any intention to harm himself or others. The evidence does not show intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene). A July 2009 VA treatment note indicates that the Veteran was independent in his care. The November 2009 VA examiner noted that the Veteran's PTSD symptoms had not interfered with his activities of daily living. The June 2012 VA examiner noted the Veteran was neatly dressed and groomed. The evidence does not demonstrate disorientation to time or place. A July 2009 VA treatment note indicates the Veteran was alert and oriented to person, place, time, and purpose of his visit. The November 2009 VA examiner noted the Veteran was fully oriented. The June 2012 VA examiner noted that there was no disorientation to time or place. The evidence does not demonstrate memory loss for names of close relatives, own occupation, or own name. The November 2009 VA examiner noted that the Veteran's recent, intermediate, and remote memory were intact. However, the Veteran reported difficulty with his memory, stating that if he did not write things down on a daily basis, he would forget them. Thus, while some memory loss is shown by the evidence, it is not to the degree required for a 100 percent rating. Despite the lack of the presence of any symptoms listed in the 100 percent rating category, the evidence does demonstrate total occupational and social impairment due to the above symptoms. A July 2009 VA treatment note indicates that the Veteran spent some time every day learning web programming in preparation for a new career. It was also noted that he had associates' degrees in electrical and computer science. However, the November 2009 VA examiner noted that, in the past, the Veteran had PTSD symptoms of anger and irritability at work, as well as difficulty getting along with bosses, supervisors, and fellow workers, with no history of missing any time from work. Currently, the Veteran reported that he found it too stressful to work. The VA examiner opined that the Veteran met the criteria for individual unemployability due to his PTSD symptoms that caused difficulty getting along with others, difficulty getting out of bed in the morning, lack of motivation and energy due to severe PTSD symptoms, and difficulty focusing his attention. Further, although the June 2012 VA examiner noted that none of the symptoms in the 100 percent rating category were present, she opined that the Veteran's PTSD symptoms resulted in total occupational and social impairment. Specifically, the VA examiner stated the Veteran was unable to tolerate the pressures of maintaining a work schedule or tolerating coworkers and customers. Moreover, she stated that his symptoms of irritability and anergia would be exacerbated if he was employed, leading him to have negative social interactions and diminished productivity. Further, his pace and persistence in a work setting would be diminished and nonproductive. With regard to social impairment, a July 2009 VA treatment note indicates the Veteran married his long-term girlfriend in March of that year. At the November 2009 VA examination, the Veteran reported that his marriage was "okay." The VA examiner concluded that the Veteran's PTSD symptoms interfered with his ability to function effectively in social situations, and that the Veteran had difficulty establishing and maintaining social relationships that involved any level of intimacy. At the June 2012 VA examination, it was noted that the Veteran continued to live with his wife and that he got along well with her. He had infrequent contact with family, had few friends, but preferred to be alone. He spent his free time on the computer and went to the gym three times per week. In sum, the entire record of evidence, including the lay evidence report of symptoms and impairments by the Veteran, is at least in relative equipoise as to whether a higher 100 percent evaluation is warranted by the evidence for the rating period on appeal from July 27, 2009, forward. While the symptoms listed in the 100 category are absent, the overall evidence does demonstrate total occupational and social impairment due to PTSD symptoms, for the reasons outlined in the 2009 and 2012 VA examination reports. The Veteran's PTSD symptoms - which include depressed mood, anxiety, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or worklike settings, and suicidal ideation - have resulted in an inability to maintain employment and have negatively affected his relationships with family and friends. As noted above, the Board need not find all or even some of the symptoms in order to assign a particular rating. See Mauerhan, 16 Vet. App. 436. In light of the 2009 and 2012 VA examiners' opinions that the Veteran's PTSD symptoms have resulted in total occupational and social impairment, resolving any reasonable doubt in favor of the Veteran, the Board finds that the criteria for a 100 percent evaluation for PTSD with depression have been more nearly approximated for the rating period on appeal from July 27, 2009, forward. 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. In concluding that an initial disability rating of 100 percent is warranted for the rating period on appeal from July 27, 2009, forward, the Board has also relied, in part, upon the GAF scores assigned throughout the rating period on appeal. In July 2009, a VA clinician assigned a GAF score of 41. The following month, in August 2009, his GAF score was 51. The November 2009 VA examiner assigned a current GAF score of 39, and a GAF score of 43 for the past year. VA clinicians assigned GAF scores of 40, 44, 48, and 50 in January 2010, March 2010, May 2010, and March 2011, respectively. The June 2012 VA examiner assigned a GAF score of 50. The GAF scores of 39 and 40 are commensurate with the criteria for the newly assigned 100 percent rating. Although the evidence in this case did not demonstrate impairment in reality testing or communication, there is major impairment in several areas, including work, family relations, and mood. The GAF scores in the range between 41 and 50 are also commensurate with the newly assigned 100 percent rating, in that the evidence demonstrates serious symptoms, including suicidal ideation, and serious impairment in social and occupational functioning, such as no friends and an inability to keep a job. The GAF score of 51 reflects symptoms that are less severe than those reflected by the evidence; however, there is only one GAF score in the range from 51 to 60. The remaining lower GAF scores reflect symptoms that are commensurate with the 100 percent rating assigned herein. Extraschedular Consideration The Board has considered whether an extraschedular evaluation is warranted for PTSD with depression. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, Diagnostic Code 9411, specifically provides for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence for the entire rating period on appeal, the Veteran's PTSD manifested depressed mood, anxiety, chronic sleep impairment, suicidal ideation, near-continuous panic or depression affecting the ability to function independently, appropriately, or effectively, difficulty in adapting to stressful circumstances (including work or a worklike setting), difficulty in establishing and maintaining effective work and social relationships, and disturbances of motivation and mood. These symptoms are part of the schedular rating criteria. In addition, the levels of occupational and social impairment are explicitly part of the schedular rating criteria. The GAF scores are also incorporated as part of the schedular rating criteria as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. Moreover, all the Veteran's psychiatric symptomatology is contemplated by the schedular rating criteria, which rates by analogy psychiatric symptoms that are "like or similar to" those explicitly listed in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with PTSD, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER Service connection for a skin disorder is denied. Entitlement to an effective date earlier than January 5, 2006 for the grant of service connection for PTSD is denied. An initial evaluation in excess of 70 percent for PTSD is denied for the initial rating period on appeal prior to July 27, 2009; a 100 percent evaluation for PTSD is granted for the rating period on appeal from July 27, 2009, forward. ____________________________________________ MARK W. GREENSTREET Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs