Citation Nr: 1308941 Decision Date: 03/15/13 Archive Date: 03/25/13 DOCKET NO. 06-11 233A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUE Entitlement to an initial disability rating higher than 70 percent for posttraumatic stress disorder (PTSD) from March 16, 2005, to December 27, 2007, and since July 1, 2008. (In the interim, the Veteran had 100 percent ratings for this service-connected disability, including under the provisions of 38 C.F.R. § 4.29.) WITNESSES AT HEARING ON APPEAL The appellant and his spouse ATTORNEY FOR THE BOARD Robert E. O'Brien, Counsel INTRODUCTION The veteran had periods of active military service from June 1985 to August 1985, from September 1990 to August 1991, and from December 2003 to March 2005. A service department memorandum of record dated in January 2006 reflects that he had met all of the criteria for the award of the Purple Heart Medal based on having received multiple injuries in December 2004 after his vehicle was hit with an improvised explosive device (IED) while he was deployed to Iraq. He was awaiting the return of his final paperwork from higher command. He therefore clearly was exposed to significant combat action while serving in Iraq. Service connection resultantly since has been granted for a number of disabilities associated with his military service. In addition to PTSD, service connection is in effect for sleep apnea, rated as 50-percent disabling; chronic lumbar muscle strain, rated as 20-percent disabling; tinnitus, rated as 10-percent disabling; peripheral neuropathy of the right lower extremity, rated as 10-percent disabling; peripheral neuropathy of the left lower extremity, rated as 10-percent disabling; hearing loss of the left ear, rated as 0-percent disabling, so noncompensable; hypertension associated with the PTSD, also rated as noncompensable; left ulnar neuritis with cubital tunnel syndrome, noncompensable; and hearing loss of the right ear, also noncompensable. So with consideration of the bilateral factor, he has had a combined rating of 90 percent for these several service-connected disabilities effectively since July 1, 2008. As specifically concerning his PTSD, his initial rating for this disability was 70 percent effective March 16, 2005, so as of the day following the conclusion of his service. But he had a higher 100 percent schedular rating for this disability as of December 28, 2007, immediately succeeded by a temporary 100 percent rating as of May 19, 2008, under the provisions of 38 C.F.R. § 4.29, so based on having been hospitalized for more than 21 days for treatment of this disability. The prior 70 percent rating resumed as of July 1, 2008, and has remained in effect ever since. This appeal to the Board of Veterans' Appeals (Board/BVA) concerns his belief that the Department of Veterans Affairs (VA) Regional Office (RO) and the Appeals Management Center (AMC), which further developed the claim following the Board's February 2012 remand, should have rated his PTSD as permanently and totally, i.e., 100-percent disabling for all times at issue, not just in the interim for what amounted to merely a temporary basis. FINDING OF FACT Ever since his discharge from service, the Veteran has had what amounts to total occupational and social impairment because of his PTSD. CONCLUSION OF LAW The criteria have been met for the highest possible rating of 100 percent for the PTSD effectively since March 16, 2005. 38 U.S.C.A. §§ 1155, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Duties to Notify and Assist The Veterans Claims Assistance Act (VCAA) was signed into law in November 2000, and it enhanced VA's obligations in terms of notifying and assisting claimants with claims for VA benefits. The VCAA was codified as amended at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126, and the implementing VA regulations were codified as amended at 38 C.F.R. §§ 3.102, 3.156 a, 3.159, 3.326. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his representative, if any, of all information and medical or lay evidence not of record that is necessary to substantiate the claim, including apprising him of the information and evidence he is responsible for providing versus the information and evidence VA will obtain for him. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159 (b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In this decision the Board is granting the highest possible rating for the PTSD, 100 percent, for all times at issue. The Veteran's appeal therefore is being granted to the fullest extent permissible. The Board therefore need not discuss whether there has been compliance with the duty to notify and assist provisions of the VCAA because even if, for the sake of argument, there has not been, this still ultimately would be inconsequential and therefore amount to no more than nonprejudicial, i.e., harmless error because the claim is being granted, regardless. 38 C.F.R. § 20.1102. The U.S. Supreme Court has made clear that VCAA notice and assistance errors, even when shown to have occurred, are not presumptively prejudicial, rather, must be determined on a case-by-case basis, and that, as a leading party attacking the agency's decision, the Veteran, not VA, bears the burden of proof of not only establishing there is a VCAA notice or assistance error but also, above and beyond that, showing how the error is unduly prejudicial, meaning outcome determinative of the claim. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). There simply is no such possibility in this instance. Consider also that, with regards to this claim for a higher rating for the PTSD, the Veteran is challenging the initial evaluation assigned following the granting of service connection for this disability. In Dingess v. Nicholson, 19 Vet. App. 473, 486 (2006); aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007), the Court held that in cases, as here, where service connection has been granted and an initial disability rating and effective date assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering Section 5103 (a) notice no longer required because the purpose the notice is intended to serve has been fulfilled. Id., at 490-91. Thereafter, once a Notice of Disagreement (NOD) has been filed contesting a "downstream" issue such as the initial rating assigned for the disability, the notice requirements of 38 U.S.C.A. §§ 5104 and 7105 regarding a rating decision and statement of the case (SOC) control as to any further communications with the appellant, including as to what evidence is necessary to establish a more favorable decision with respect to the downstream element of the claim. See Goodwin v. Peake, 22 Vet. App. 128 (2008). The Veteran is seeking the highest possible rating and maximum benefit available under the law. See AB v. Brown, 6 Vet. App. 35, 38-39 (1993). As recently as November 2012, he stated that he should be awarded a 100 percent permanent and total rating for his PTSD. He claims he cannot sleep because of this disability, has memory loss, and even thoughts of suicide. He received the required SOC in response to his NOD with the rating for this disability. He also since has received a supplemental SOC (SSOC) in October 2012 citing the criteria for establishing his entitlement to a higher rating for his PTSD and containing a discussion of the reasons and bases for assigning the lesser 70 percent rating when he did not, instead, have the 100 percent rating. He therefore has received all required notice concerning this claim. Regarding the duty to assist, his pertinent medical and other records have been obtained to the extent available. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. There is no indication that any additional evidence relevant to this claim needs to be obtained, especially, again, since the Board is granting this claim in full. The Board previously remanded this claim in February 2012 for a VA psychiatric examination reassessing the severity of the Veteran's PTSD, and he had this additional mental status evaluation for compensation purposes in March 2012. Caffrey v. Brown, 6 Vet. App. 377 (1994); Olson v. Principi, 3 Vet. App. 480, 482 (1992); Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992); Allday v. Brown, 7 Vet. App. 517, 526 (1995). There is no suggestion there has been a material change in the severity of this disability during the year since that most recent evaluation. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded, especially again, solely because of the mere passage of time since an otherwise adequate VA examination was performed. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). The report of that most recent March 2012 VA examination included review of the claims file for the history of this disability dating back to the Veteran's service, also consideration of his subjective complaints and the objective clinical findings in relation to the applicable rating criteria. The examination report therefore provides the information needed to assist in deciding this claim. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (holding that once VA undertakes the effort to provide an examination, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). And see Stefl v. Nicholson, 21 Vet. App. 120, 123-25 (2007) (VA's duty to assist includes providing an adequate examination when such an examination is indicated.). Furthermore, in having the Veteran undergo that additional VA examination to obtain the additional information needed to properly rate his disability, there was compliance with this remand directive. See Stegall v. West, 11 Vet. App. 268 (1998) (indicating the Veteran is entitled, as a matter of law, to compliance with a remand directive and that the Board, itself, commits error in failing to ensure this compliance). See also Dyment v. West, 13 Vet. App. 141, 146-47 (1999); and D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (discussing situations when it is acceptable to have "substantial", even if not "exact" or "total" compliance with a remand directive). In sum, the Board finds it difficult to discern what additional guidance VA could have provided the Veteran regarding what further evidence he should submit to substantiate his claim. See Livesay v. Principi, 15 Vet. App. 1565, 178 (2001) (en banc) (observing that the "VCAA is a reason to remand many, many claims, but it is not an excuse to remand all claims"); Reyes v. Brown, 7 Vet. App. 113, 116 (1994); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (observing circumstances as to when a remand would not serve any useful or meaningful purpose or result in any significant benefit to the Veteran). Governing Statutes, Regulations, and Precedent Cases Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity resulting from service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt material to the determination is resolved in the Veteran's favor. 38 C.F.R. §§ 3.102, 4.3. Separate diagnostic codes identify the various disabilities. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's disability. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). If the disability has had different and distinct levels of severity during the pendency of the claim for a higher rating for the disability, then the Board must "stage" the rating to compensate the Veteran for this variance, irrespective of whether it is an established or initial rating. Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). Mental disorders are evaluated under a General Rating Formula found at 38 C.F.R. § 4.130. In addition, the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) provides guidance for the nomenclature employed within 38 C.F.R. § 4.130. When evaluating a mental disorder, the evaluation must be based on all of the evidence of record bearing on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). A 70 percent rating is warranted when 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, or 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 an inability to establish and maintain effective relationships. Id. The maximum schedular rating of 100 percent requires total occupational and social impairment due to such symptoms as: gross impairment of thought processes of communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides only guidance as to the severity of symptomatology contemplated for each rating. So use of this terminology permits consideration of items listed as well as other symptoms and, most importantly, contemplates the effect of those symptoms on the claimant's occupational and social functioning. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). It therefore is not necessary that he have all, or even some, of the symptoms specifically listed to satisfy the requirements for a particular rating. In determining whether the Veteran meets the criteria for a higher rating, the Board must consider whether he has deficiencies in most of the following areas: work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11 (2001). Psychiatric examinations often include the assignment of a Global Assessment of Functioning (GAF) Score. A GAF score is a scaled rating reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score, like an examiner's assessment of the severity of a condition at the time of a particular evaluation, is not altogether dispositive or determinative of the evaluation to be assigned; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating to be assigned. 38 C.F.R. § 4.126(a); VAOPGCPREC 10-95. The higher the score, the higher the overall functioning of the individual is. According to the DSM-IV, a GAF score of between 41 and 50 is assigned when there are "serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment of social, occupational or school functioning (e.g., no friends, unable to keep a job)." Scores between 51 and 60 are indicative of moderate symptoms (e.g., flattened 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). A score of 61 to 70 indicates some milder symptoms or some difficulty in social, occupational, or school functioning, but generally functioning well, with some meaningful interpersonal relationships. Factual Background and Analysis The relevant evidence of record includes the report of a VA PTSD examination provided the Veteran in June 2005, so very shortly after the conclusion of his military service. The examiner reviewed the claims file for the pertinent history of the events that had occurred during the Veteran's service. The Veteran was in his second marriage. He had had a child from his first marriage, a daughter, and reported having a good relationship with her. But he also reported very limited social contact. His general appearance was described as clean and neatly groomed. His speech was unremarkable and his affect normal. His mood was dysthymic, however, although attention intact. He also was properly oriented to time, place, person and situation, and his judgment was intact. There were no delusions. His thought content was unremarkable and thought processes remarkable. He complained of difficulty sleeping. No panic attacks were reported and no inappropriate behavior observed. Memory was normal. Psychological testing results contradicted his assertions through the course of the interview and the examiner resultantly described the results as invalid. The examiner stated the Veteran did not meet the criteria for a diagnosis of PTSD. The Axis I diagnosis, instead, was alcohol abuse. The examiner explained that the Veteran had been able to work for over 20 years as a correctional officer and that there were no consequences from that experience which the examiner noted often included using physical force to restrain inmates and witness violence. The Veteran had another VA PTSD examination in March 2007, however. The claims file was reviewed by that examiner, as well. It was noted that during 2006 the Veteran had been involved in ongoing individual and group therapy for PTSD symptoms. He was continuing to work as a prison guard. He reported several symptoms, including irritability, difficulty relating to other people, sleep difficulty, nightmares and dreams about his combat experiences, anxiety, and irritability. He was then currently taking 40 milligrams of Prozac and Trazodone at bedtime to help him sleep. He stated that he had been having panic attacks at least once a week, and sometimes several times a week. He also had episodes of feeling down and stated he had suicidal ideation, so thoughts of it, but never any actual attempts. He indicated he was able to keep his job, despite his various symptoms. Outside of work, though, he found himself interacting very little with others and had difficulty even relating to his wife. On objective mental status examination his mood was described as mildly depressed. He rated his current depression as an 8 and his anxiety as a 7 on a scale of 1-10. He noted he constantly had trouble concentrating and remembering things due to his persistent anxiety. He gave no evidence of a speech or thought disorder. He was fully oriented and recent and remote memory was described as intact. Notation was made that, during 2006, while involved in group and individual therapy, his treating psychiatrist had written a letter requesting the Veteran's assignment to a less stressful job so he could still continue working. The transfer in job assignment was granted. The Veteran said it had been a real struggle for him to keep his job, although he had not missed any work because of his strong work ethic. The Axis I diagnosis was PTSD with depression and panic attacks. Alcohol abuse in remission was also diagnosed. There was no Axis II diagnosis. He was given a GAF score of 50, which, according to the DSM-IV, confirms there was "serious" occupational and social impairment. Indeed, the examiner pointed out the Veteran had "a high level of subjective stress and has had to struggle to maintain employment and found his ability to relate to others and his enjoyment of leisure time to be moderately to severely impaired." The Veteran as mentioned has on two occasions, albeit in succession, had 100 percent ratings for his PTSD, hence, the highest possible evaluation, and he asserts this condition always has been this disabling, never the lesser 70-percent disabling. His initial 100 percent rating was effective as of December 28, 2007. He also subsequently was hospitalized for treatment and evaluation of this disability, however, from February to March 2008 and again from May 19 to June 27, 2008, so another 100 percent rating was granted as of the date of that latter inpatient admission - May 19, 2008 - under the provisions of 38 C.F.R. § 4.29 because that hospitalization exceeded 21 days. That 100 percent rating, however, like the prior one, was only temporary because, at the time of his discharge on June 27, 2008, he was described as casually and appropriated dressed. He also was described as calm and polite. He displayed no abnormal involuntary movements and no psychomotor disturbances. His speech was low in tone, but normal in speed. He was properly oriented in all spheres and his memory was intact. His thought processes were logical and organized without flights of ideas or loose associations. He denied any hallucinations or homicidal or suicidal ideation. Impulse control was described as appropriate. Mood and affect were euthymic. Insight and judgment were described as fair. It was noted that he had participated fully in the PTSD treatment program and had learned how to deal a little bit better with his tension and anger as well as his worries. He acknowledged that he had benefitted from the program as he was better at controlling his signs and symptoms of PTSD. He was prescribed 50 milligrams of Trazodone to be taken at bedtime and 20 milligrams of Fluoxetine to be taken in the morning. The prognosis for his PTSD recovery was described as "fair". His activity level was as tolerated. He was to continue seeing his private psychiatrist and another physician for individual counseling. The final Axis I diagnoses were chronic PTSD and depressive disorder. There was no Axis II diagnosis. He again was given a GAF score of 50, so the same score as he had received even the preceding year, before that hospitalization. VA outpatient records in the file reflect ongoing treatment and evaluation of the PTSD. During one particular mental health clinic visit in February 2009, the Veteran had presented for follow-up. He believed his sleep had gotten worse and he attributed this to the deaths of some friends who were the same age as him. He indicated that he was also stressed by an audit that was coming up at his correctional facility, noting also that his wife claimed he could still be restless in his sleep. On then current mental status examination, however, he was described as alert and oriented, despite having a depressed mood. He made fair eye contact. Speech was normal in tone, range, and content. No suicidal or homicidal ideation was voiced. There were no signs of hallucinations or thought disorder. He was to continue his medications, as is, for the time being, which consisted of 40 milligrams of Prozac each day, Trazodone as needed, and Vistaril as needed. When seen for another consultation in April 2009, there were essentially the same findings. He was to continue his medication as previously prescribed. He had another VA PTSD examination in November 2009. The claims file again was reviewed by the examiner. Reference was made to previous outpatient visits earlier that year. One notation concerned a visit in October 2009 when the Veteran had referred to worsening symptoms because of a phone call from a friend that had triggered memories of Iraq. Work and home life were described as stressful. Reference to a September 2009 visit noted work frustration and stress and that he had had to assume additional work responsibilities. He stated the work stress was straining his marriage. He was continuing to take Prozac and Trazodone. He said that therapy had helped and that the physicians he talked to understood his problems more so than anybody else. He referred to continuing depression, however. He stated that he thought about suicide about a couple of times a month, but denied actual desire or plan or intent to harm himself or anyone else. He continued to complain of difficulty sleeping. It was noted that he managed his hygiene "every other day", thus not necessarily daily as he should. Moreover, although he was still married, he explained that he was often separated from his wife. He had a lot of nightmares and angry outbursts and because of that she stayed with her mother for periods of time. He indicated she would stay gone for as much as one and a half to two months. With regards to his daughter, he said he had not seen her at all in 2009, so none during that year. He noted there was no hostility between them, but that they did not communicate. He had several siblings but hardly ever talked to them, either. He had no friends, and he indicated he spent most of his time alone. On objective mental status examination, he was described as neatly groomed and appropriately dressed. Speech was spontaneous, clear, and coherent. Affect was flat. Mood was dysphoric. He was properly oriented. Thought content was appropriate. Judgment and insight were intact. It was noted he exhibited no inappropriate behavior. As for panic attacks, he described himself as getting nervous and his heart feeling like it was rushing. He indicated this would persist for 5 to 10 minutes. He stated these were triggered by certain thoughts or times when someone would walk into the room unexpectedly. He stated they seemed more dictated by circumstance and occurred three to four times a week. Although there was some suicidal ideation, he had no plan or intent to harm himself. He was able to maintain minimum personal hygiene. As for activities of daily living, slight impairment with driving and moderate impairment with recreational activities was noted. But no impairment with household chores, toileting, grooming, shopping, self-feeding, bathing, or dressing was noted. Memory was normal. He was still employed on a full-time basis as a correctional supervisor, but during the past year he had missed 13 weeks of work. He explained that 6 weeks were lost because of his hospital stays in 2008, 3 weeks lost because of his feeling depressed and not being motivated to go to work, and 4 weeks because of keeping VA appointments. Problems related to occupational functioning included decreased concentration, difficulty following instructions, increased absenteeism, and poor social interaction. He stated that his performance evaluations were just average. The Axis I diagnosis was chronic severe PTSD with depression and panic. There was no Axis II diagnosis. He was given an even lesser GAF score of 45, which, according to the DSM-IV, suggest "major" impairment in several areas such as work or school, family relations, judgment, thinking or mood. The examiner even confirmed as much, stating the Veteran's condition had worsened as evidenced by his occupational impairment, including problems making decisions, not completing tasks on a timely basis, being passed over for promotion due to poor performance, poor concentration, missing a lot of work and social impairment, including being separated from his wife, no social interaction, distance from his daughter and his siblings. The prognosis was described as guarded and his symptoms were described as worse. The examiner noted the Veteran was now reporting depression in addition to the panic he previously had reported. Ongoing reports of periodic mental health clinic visits thereafter include one dated in June 2010. The Veteran reiterated that he was depressed. He discussed having a dream in which he was being taunted by a devil. He relived that dream by feeling that his church was recently taken advantage of by a person who requested too much money for the services that she rendered. He reported compliance with and satisfaction with his medications. He was described as alert and oriented. Mood was dysphoric. Affect was congruent. He made fair eye contact. Speech was normal in tone, range, and content. No suicidal or homicidal ideation was voiced. There were no signs of a thought disorder. He was continuing to take his medications. His principal treating physician was leaving VA and options for treatment were discussed. The Board as mentioned remanded this claim in February 2012 to have the Veteran undergo yet another VA compensation examination concerning his PTSD, to reassess its severity, and he had this most recent evaluation in March 2012. He continued to experience recurrent and intrusive distressing recollections, insomnia, irritability, anger, impaired concentration, hypervigilance, and exaggerated startle response. Avoidance of symptoms included a preference of being alone. His affect was restricted. He also struggled with a sense of a foreshortened future and as well with depression. On objective mental status examination, the Veteran was described as casually dressed and appropriately groomed. He was pleasant and cooperative. He was properly oriented. Affect was downcast. He denied suicidal or homicidal ideation. He stated that he felt a little paranoid during the interview, but there was no overt absence of psychosis. Speech was appropriate. He maintained good eye contact. There was no tangentiality, circumstantiality, flight of ideas, or loosening of associations to his speech. Thought processes were linear and logical. Insight and judgment were intact. He gave no overt evidence of a cognitive deficit. In summarizing his findings, the examiner determined the psychiatric disorder did not impair the Veteran's ability to engage in physical and sedentary forms of employment. He was given a GAF score of 54 and the examiner explained this indicated mild-to-moderate impairment in social and industrial (occupational) functioning. The prognosis for improvement and/or stimulation was described as guarded. The Veteran indicated he was receiving individual psychotherapy from a doctor at the VA medical center in Memphis. He previously had been treated by a private psychiatrist, but was not currently seeing a psychiatrist. The Veteran described depression associated with his PTSD. Obviously, this most recent examiner did not consider the PTSD as severely disabling as those who have had occasion to examine or evaluate the Veteran in years past. But, as explained, the Board does not consider this most recent examination in isolation or a vacuum, rather, must consider all of the evidence in the file bearing on the Veteran's occupational and social functioning and try to reconcile the differences of opinion. An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation instead is to be based on all of the evidence bearing on occupational and social impairment. See generally 38 C.F.R. § 4.126; VAOPGCPREC 10-95. While the Veteran has continued to work as a correctional officer, in fact, apparently even in a managerial capacity, the affect his PTSD has had on his work performance has been well documented in terms of not receiving even more promotions, the extent of his absenteeism for the several reasons mentioned, and perhaps most importantly his apparent need to transfer to a position with different responsibility in part because of the amount of stress that he could not deal or cope with in the other position. According to 38 C.F.R. § 4.1, however, 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. Indeed, in Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993), the Court reiterated that the disability rating, itself, is recognition that industrial capabilities are impaired. So merely because his employment is adversely affected in some tangible way by his service-connected disability is not tantamount to concluding he is entitled to a 100 percent rating for the disability because even the lesser 70 percent rating contemplates as much, particularly since it, too, is in the higher end of the rating spectrum. One must also consider, though, that he has demonstrated a whole litany of symptoms, while admittedly not evidencing several notable others. But, again, the holding in Mauerhan makes clear that VA adjudicators are not to engage in merely a one-to-one, direct, comparison of the symptoms shown with those specifically enumerated in the rating criteria, since this does not represent an exhaustive list of the type, manner, and extent of symptoms necessarily required for a particular rating. What again is more important is the effect of the symptoms, whatever they may be, on the Veteran's occupational and social functioning. The occupational effect already has been discussed, but the Veteran also has experienced social impairment on account of his PTSD, as evidenced by the repeated mention that he does not socialize much, if at all, has a strained marriage (his second one) that often results even in physical separation for lengthy periods of time, and no longer even interacts with his daughter as he once did. On the whole, then, the Board concludes he has had what amounts to total occupational and social impairment since March 16, 2005, so since the day after he separated from service. This is especially true when resolving all reasonable doubt in his favor, as required by 38 C.F.R. §§ 3.102, 4.3, so he has at all times at issue been entitled to a 100 percent rating for his PTSD with depression and panic attacks. ORDER A higher 100 percent rating is granted for the PTSD with depression and panic attacks retroactively effectively from March 16, 2005, so the Veteran now has this maximum possible rating for this disability for all time periods that were at issue in this appeal. ____________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs