Citation Nr: 1313014 Decision Date: 04/18/13 Archive Date: 05/02/13 DOCKET NO. 08-35 658 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUE Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD), to include whether alcohol dependence is secondary to PTSD. REPRESENTATION Appellant represented by: Katrina J. Eagle, Attorney at Law WITNESSES AT HEARING ON APPEAL Appellant and his daughter ATTORNEY FOR THE BOARD John Kitlas, Counsel INTRODUCTION The Veteran served on active duty from May 1962 to April 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions promulgated in April and July 2008 by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. By the April 2008 rating decision, the RO granted service connection for PTSD, evaluated as 10 percent disabling, effective from December 7, 2007. Thereafter, the July 2008 rating decision increased the assigned rating to 30 percent, effective from December 7, 2007. The Veteran appealed, contending that a higher rating was warranted. He does not appear to have appealed the effective date assigned for the establishment of service connection. The Veteran and his daughter testified at a hearing before the undersigned Veterans Law Judge (VLJ) in December 2009. A transcript of this hearing has been associated with the Veteran's claims file. This case was previously before the Board in January 2010 and July 2011. In January 2010, the Board issued a decision in which it denied the Veteran's claim for a rating in excess of 30 percent for his service-connected PTSD. The Veteran appealed the Board's January 2010 decision to the United States Court of Appeals for Veterans Claims (Court). By a January 2011 Order, the Court, pursuant to a Joint Motion, vacated the Board's decision and remanded the case for compliance with the directives of the Joint Motion. As noted by the Board in July 2011, the Joint Motion contended that the issue of alcohol dependency as secondary to PTSD had been raised by the record in the context of the Veteran's PTSD increased rating claim and that it was therefore appropriate for the Board to conduct further development of this issue. Although the Board was unclear as to the jurisdictional basis that would allow its assumption of this issue on appeal, as the issue has not been adjudicated in any RO action, the Board was nevertheless bound by the mandates of the Joint Motion instructing the Board to develop this issue on appeal. In July 2011, the Board remanded this case, in part, for a new VA medical examination to address the severity of the Veteran's service-connected PTSD and the potential relationship between his PTSD and alcohol dependence. Such an examination was accomplished in June 2012, and as detailed below the Board finds the examination is adequate for resolution of this case. All other development directed by the Board's remand appears to have been substantially accomplished. Accordingly, a new remand is not required to comply with the holding of Stegall v. West, 11 Vet. App. 268 (1998). See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (Remand not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran's alcohol dependence was caused or aggravated by his service-connected PTSD. 2. The Veteran's service-connected PTSD is manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. However, his occupational and social impairment is not of such severity as to constitute reduced reliability and productivity. CONCLUSIONS OF LAW 1. The criteria for a grant of service connection for alcohol dependence as secondary to service-connected PTSD are not met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.310 (2012). 2. The criteria for a rating in excess of 30 percent for the Veteran's service-connected PTSD are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.10, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Preliminary Matters The Board notes at the outset that, in accord with the Veterans Claims Assistance Act of 2000 (VCAA), VA has an obligation to notify claimants what information or evidence is needed in order to substantiate a claim, as well as a duty to assist claimants by making reasonable efforts to get the evidence needed. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A and 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The Board notes that this appeal originates from a disagreement with the initial rating assigned for the Veteran's PTSD following the establishment of service connection. In Dingess v. Nicholson, 19 Vet. App. 473, 490-1 (2006), the Court held that in cases where service connection has been granted and an initial disability rating and effective date have been 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 that the notice is intended to serve has been fulfilled. Thus, VA's duty to notify in this case is satisfied. See also Dunlap v. Nicholson, 21 Vet. App. 112 (2007); Goodwin v. Peake, 22 Vet. App. 128 (2008). Despite the foregoing, the Board notes that the Veteran was sent VCAA-compliant notification regarding his original service connection claim in February 2008. Although this letter was not in regard to the current appellate issue, it did describe VA's general duties to assist, as well as the information and evidence used by VA to determine disability rating(s). In addition, a July 2008 letter included the schedular criteria used to evaluate PTSD. The Veteran was also sent a VCAA-compliant notification letter in August 2011 which addressed the issue of whether alcohol dependence is secondary to his PTSD. This case was last adjudicated below by a July 2012 Supplemental Statement of the Case (SSOC). In view of the foregoing, the Board finds that the Veteran was notified and aware of the evidence needed to substantiate his appeal and the avenues through which he might obtain such evidence, and of the allocation of responsibilities between himself and VA in obtaining such evidence. Accordingly, there is no further duty to notify. In any event, the Veteran has not demonstrated any prejudice with regard to the content or timing of any notice. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). The Board also notes that the Veteran has actively participated in the processing of his case, and the statements submitted in support of his appeal, to include from his attorney, have indicated familiarity with the requirements for the benefits sought on appeal. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006) (VA can demonstrate that a notice defect is not prejudicial if it can be demonstrated ... that any defect in notice was cured by actual knowledge on the part of the appellant that certain evidence (i.e., the missing information or evidence needed to substantiate the claim) was required and that the appellant should have provided it.); see also Overton v. Nicholson, 20 Vet. App. 427 (2006). The Board further notes that it previously determined in January2010 that the duty to notify had been satisfied. Although the Joint Motion indicated the duty to assist had not been satisfied as it was asserted a February 2008 VA examination was inadequate, no such deficiency was noted in regard to the duty to notify. The Court has stated that advancing different arguments at successive stages of the appellate process does not serve the interests of the parties or the Court, and that such a practice hinders the decision-making process and raises the undesirable specter of piecemeal litigation. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) 9"Court will [not] review BVA decisions in a piecemeal fashion"); see also Fugere v. Derwinski, 1 Vet. App. 103, 105 (1990), aff'd, 972 F.2d 331 (Fed. Cir. 1992) ("Advancing different arguments at successive stages of the appellate process does not serve the interests of the parties or the Court"). The Board is therefore confident that if the Court had any substantive comments concerning the Board's findings regarding the duties to assist and notify, such would have surfaced in the Joint Motion or the Court Order so that any deficiencies could be corrected. In addition, the Board finds that the duty to assist a claimant in the development of his or her case has been satisfied. The Veteran's service treatment records are on file, as are various post-service medical records to include from the Social Security Administration (SSA). Further, the Veteran has had the opportunity to present evidence and argument in support of his claims, to include at the December 2009 Board hearing. Nothing indicates he has identified the existence of any relevant evidence that has not been obtained or requested. For example, he has not identified outstanding evidence showing symptoms of his service-connected PTSD that are not reflected by the evidence already of record. Moreover, the Veteran has reported, to include in a February 2012 statement from his attorney, that all of his recent treatment has been through VA, and such records are one file. With respect to the December 2009 hearing, the Court held in Bryant v. Shinseki, 23 Vet. App. 488 (2010), that 38 C.F.R. 3.103(c)(2) requires that the RO official or VLJ who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ noted the current appellate issue, and asked questions to clarify the Veteran's contentions. Moreover, the testimony of the Veteran, as well as the statements submitted in support of his claim, demonstrated that he had actual knowledge of the elements necessary to substantiate his appeal. Finally, neither the Veteran nor his attorney has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor has he identified any prejudice in the conduct of the December 2009 hearing. As such, the Board finds that, consistent with Bryant, the duties set forth in 38 C.F.R. 3.103(c)(2) have been satisfied. The Board further notes that the Veteran was accorded VA examinations in February 2008 and June 2012 which detailed the symptomatology of his PTSD. In addition, the examiners expressed opinions regarding whether the Veteran's alcohol dependency was secondary to his service-connected PTSD. Although the Joint Motion contended that the 2008 examination was inadequate, no deficiency or prejudice has been asserted regarding the June 2012 examination. Moreover, the June 2012 examiner's opinion is supported by stated rationale consistent with the evidence of record, and is based upon an accurate understanding of these disabilities from an examination of the Veteran and review of his VA claims folder. Accordingly, the Board finds that the June 2012 VA PTSD examination is adequate for resolution of this case. In view of the foregoing, the Board finds that the duty to assist the Veteran has been satisfied in this case. The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (The Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (Noting that 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). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C.A. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Legal Criteria Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations applies, assigning the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). However, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Diagnostic Code 9411 provides that PTSD is evaluated under the general rating formula used to rate psychiatric disabilities other than eating disorders, pursuant to 38 C.F.R. § 4.130. When a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication, a noncompensable (zero percent) evaluation is warranted. Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication warrants a 10 percent evaluation. A 30 percent disability rating is in order when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintain effective work and social relationships. A 70 percent rating is warranted 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted where there is 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. In addition, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b). Analysis In this case, the record reflects that the Veteran has been treated on multiple occasions over the years for both PTSD and alcohol dependence. For example, an October 2007 VA treatment record reflects that the Veteran reported that he was experiencing "tough times," reporting difficulty sleeping, irritability, and difficulty with personal relationships. The Veteran reported having been married seven times and that he was been separated from his current spouse for six to seven years prior to the time of this treatment. The Veteran stated that he was socially isolated, as is his preference, and that he sees his daughter who lives in town once every seven to ten days when she cleans his apartment. The Veteran's eye contact, thought processes and content, memory, concentration, and judgment were assessed as normal, and his mood and affect were noted to be appropriate to his depression. The Veteran denied any suicidal or homicidal ideations, and based on screening tests, he was noted to have severe depression and high anxiety, as well as a positive PTSD screening. The Veteran underwent a VA PTSD examination in February 2008, and the examination report reflects that the examiner reviewed the claims file in conjunction with the examination. During the examination, the Veteran reported a history of seven marriages and having been separated from his current wife since 2003. The Veteran reported frequent Vietnam-related nightmares, a startle response to sudden sounds, and preferred social isolation. The Veteran also reported having been unemployed since 1999 and receiving SSA disability payments for his chronic obstructive pulmonary disease (COPD) and neuropathy since 2000. The Veteran also reported his work history, which involved a thirty-year sales career, with the exception of a five-to-six month leave of absence due to his alcoholism. Based on this information, the examiner opined that the Veteran's PTSD did not affect his employment functioning. The examiner also found no deficiencies in the Veteran's speech, eye contact, personal hygiene, judgment, or insight. The Veteran repeated serial threes with one mistake and was able to remember two of three after five minutes. The examiner noted the Veteran's mood to be fair, with no evidence of suicidal or homicidal ideations, auditory or visual hallucinations, or paranoid thoughts, delusions, grandiosity, or obsessive-compulsive symptoms. The examiner diagnosed the Veteran with chronic PTSD, mild in nature, and assigned a Global Assessment of Functioning (GAF) score in relation to his PTSD of 75. A statement received in March 2008 appears to reflect the Veteran's assessment of the severity of his PTSD symptoms, and his notations reflect that he believes he has "heavy" irritability with shaking, difficulty in adapting to stressful circumstances, periods of inability to perform occupational tasks (due to shaking that leads into nerve "flustrations"), and impairment of self care and self esteem. The Veteran also reported occasional panic attacks; frequent mood swings and depression; and mild memory loss of names, dates, and places; a chronic sleep disorder; impaired communication with his family; and flash backs. A March 2008 letter from the Veteran's former employer reflects that during the Veteran's employment from 1969 to 1996, the Veteran was involved in two severe commercial truck accidents in which alcohol use was suspected and that the Veteran was finally terminated in 1996 due to alcohol use and poor attendance. A June 2008 VA mental health treatment record reflects the Veteran's report of experiencing anxiety when someone knocks on his door or rings his doorbell. The treating medical professional noted normal grooming, eye contact, thought processes, coping skills, and judgment, and found that the Veteran's mood and affect were appropriate to the situation. The Veteran denied any suicidal or homicidal ideations and reported sufficient sleep with the assistance of a prescription sleep aid. A subsequent June 2008 VA mental health treatment record reflects that the Veteran reported recent alcohol consumption, irritability, poor sleep, nightmares, and frequent intrusive memories related to his Vietnam experiences. The treating medical professional noted that the Veteran's mental status, including his appearance, hygiene, affect, mood, speech, thinking, and sensorium, were all normal. A July 2008 VA treatment record reflects that the Veteran had a depressed mood at the time of treatment (assessed as severe based on the results of a questionnaire); however, the Veteran was alert and oriented to time, place, person, and situation, with no evidence of imminent dangerous behavior or psychosis. Additionally, the Veteran denied having any suicidal or homicidal ideations, and the Veteran was assessed with a depressive disorder, not otherwise specified, and alcohol dependence. An August 2008 VA treatment record reflects that the Veteran's antidepressant medication dosage was increased. A February 2009 VA mental health telephonic treatment record reflects that the Veteran reported feeling fine at that time, and the treating medical professional noted that the Veteran seemed to be in good spirits and was speaking in a normal rate and tone. A subsequent February 2009 VA mental health treatment record reflects the Veteran's report of experiencing some increased depression in December 2008 due to the hospitalization of one of his daughters and the seasonal depression he experiences each December due to his experiences that month while in Vietnam. The treating medical professional noted that the Veteran was oriented to all spheres and demonstrated normal grooming, eye contact, thought processes, coping ability, and judgment. The Veteran's affect and mood were assessed as appropriate, initially hopeless but improving as the session progressed. The Veteran reported poor sleep, but he denied any suicidal or homicidal ideations. A June 2009 VA suicide prevention progress note reflects that the Veteran called the VA hotline to discuss his life stressors, reporting suicidal ideation with no plan or intent to harm himself. The Veteran reported sleep disturbances due to nightmares, and he reported that his grandson was ill. The Veteran was apparently intoxicated at the time he placed this phone call and requested an increase in his counseling services and a referral to alcoholism services. A follow-up June 2009 VA suicide prevention progress note reflects that the Veteran report that he was feeling better, despite having to deal with the death of his 17-year-old grandson. The Veteran reported living alone with little familial support but that he was not suicidal. A subsequent June 2009 VA mental health treatment record reflects that the Veteran reported feeling fine but that his grandson's death (he apparently died after having a brain aneurysm) had triggered recollections of the Veteran's experiencing feeling a fellow soldier's brain in his hands. The mental health provider found the Veteran to be alert and oriented to all spheres with normal grooming, eye contact, thought processes and content, concentration, memory, logical organization, fair judgment, and resilient coping skills. A July 2009 VA mental health treatment record reflects that the Veteran was having some difficulty breathing due to his severe COPD (the Veteran uses a portable oxygen tank to treat his condition). The treating medical professional noted that the Veteran was alert and oriented to all spheres with normal grooming, eye contact, thought processes and content, fair insight, judgment, and resilient coping skills. The Veteran's affect and mood were appropriate to his overwhelming medical condition. At his December 2009 hearing, the Veteran reported being haunted by several Vietnam experiences, including killing a man at close range and seeing this man's eyes in the mirror when he shaves each morning, and his involvement in an ambush during which one of his squad leaders was killed. The Veteran testified that when he tried to move the soldier's body, the soldier's brains spilled onto him, and that he re-experiences this traumatic event when cracking eggs. The Veteran reported that he has avoided responsibility since his experience in this ambush, as he feels that he led his company into the ambush. The Veteran also reported experiencing anger, which has led to unstable personal relationships, including seven marriages and his separation from his current spouse. The Veteran reported weekly visits from his daughter, who cleans his apartment, and that he has daily suicidal ideation but no intent based on his religious convictions. The Veteran's daughter testified that she visits the Veteran three to four times per week (and speaks with him on the telephone two to three times per day) but that he is easily irritated and that her longer visits end in a confrontation. Based on the foregoing, the Board denied a rating in excess of 30 percent for the Veteran's service-connected PTSD in the January 2010 decision. In making this determination the Board acknowledged that the Veteran's health problems and alcohol dependence have been noted to affect his mental health, and his treatment records reflect his reports of depression due to his physical limitations and advisories that the Veteran cease his alcohol consumption based on the link between alcohol consumption and depression. However, the Board found that the February 2008 VA PTSD examiner parsed out the Veteran's PTSD symptomatology from any other factors affecting the Veteran's mental health and opined that the Veteran's PTSD was mild in nature. The Board also noted that the examiner assigned a GAF score of 75 for his PTSD symptoms, which is indicative of no more than slight impairment in social, occupational, or school functioning. The Joint Motion in this case, however, asserted that the 2008 VA medical opinion was insufficient, and therefore the Board's reliance on this medical opinion when denying the Veteran's claim was prejudicial error. Specifically, the parties found that the Board's erred when determining that the VA examiner had parsed out the Veteran's PTSD symptoms from those of his alcohol dependency based on the examiner's assignment of a PTSD specific GAF score, as the psychiatric examination portion of the report fails to specifically delineate the associated symptoms of each disorder. The Joint Motion also asserted that the VA examiner made inconsistent statements regarding the onset and etiology of the Veteran's alcohol dependency. Accordingly, the Joint Motion concluded that a new examination and related medical opinion should be obtained. The Board further acknowledges that the Veteran's attorney submitted a private medical opinion from a Dr. Smith, a psychiatrist, dated in June 2011, and asserted that with the addition of this newly submitted private medical opinion, the record is now sufficient for the Board to adjudicate the Veteran's claims, thus inferring a waiver of any development mandated by the Court's Order granting the parties' Joint Motion. However, the Board noted in the July 2011 remand that this request to adjudicate the Veteran's claim, without first ensuring the completion of the development mandated by the Joint Motion, appears to have been predicated upon an assumption that the newly submitted medical opinion was sufficient to satisfy the Court-ordered directives that both a new psychiatric examination and medical opinion be obtained. As the private psychiatric opinion was made without the benefit of a psychiatric examination of the Veteran and does not reflect any current medical findings relevant to the current severity of the Veteran's PTSD, the Board concluded that the claim must nevertheless be remanded for compliance with the mandates of the Joint Motion. The Board does note that in the June 2011 statement, Dr. Smith opined that the Veteran's alcohol dependency and symptoms of severe depression had been caused by the primary psychiatric condition, PTSD, and that these conditions would have been less likely to occur in the absence of PTSD. In support of this opinion, Dr. Smith stated, and attached medical treatise evidence, to the effect that patients with PTSD commonly self-medicate with alcohol to gain relief from these distressing symptoms; that combat veterans with PTSD have been particularly susceptible to the development of alcohol dependence; and that recent research results showed that the risk for alcohol abuse occurs because veterans turn to alcohol as a means to cope with traumatic battlefield experiences; and that because PTSD predated and directly led to the onset of the depressive disorder, the causative factor for the development of alcohol dependence was the PTSD and not the secondary disorder of major depressive disorder. Dr. Smith further opined that the level of the Veteran's service-connected PTSD was consistent with a rating of 70 percent due to significant occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Additionally, Dr. Smith criticized the findings of the February 2008 VA PTSD examiner. In addition to the new VA PTSD examination conducted in June 2012, additional VA treatment records were added to the file which cover a period through May 2012. The Board also reiterates that the Veteran has indicated, to include a February 2012 statement from his attorney, that all of his recent treatment for PTSD was through VA. An October 2009 VA mental health treatment record noted, in part, that he was tolerating the medications fluoxetine and trazodone without any major side effects; that he continued to feel much better with the increase in fluoxetine; and that his appetite was stable. On mental status examination, he was found to be alert and oriented to time, place, person, and situation. He was also found to be cooperative, good eye contact, appropriately dressed and groomed. Psychomotor activity was found to be neutral; there was no evidence of involuntary movements. His mood was described as less depressed. His affect was appropriate to the speech content and stated mood. His speech had normal amount, rate and rhythm. Thought process showed no loose association, flight of ideas, circumstantiality or tangentiality. In fact, it was found to be goal directed and coherent. Thought content showed no evidence of delusional thinking. The Veteran denied auditory/visual/olfactory hallucinations; as well as suicidal or homicidal ideation, intent, or plan. There was no evidence of obsessions/compulsions. It was noted that he continued to binge drink, and that he reported drinking about one-half pint of whisky at a time. It was noted that the connection between depression and alcohol dependence was discussed, as well as the danger of mixing alcohol with psychotropic medications and that this should not be done. A December 2009 VA mental health treatment record noted that the Veteran reported his situation has not improved and he had been thinking about his Vietnam experiences lately. He was found to be alert/oriented to all spheres with normal grooming, eye contact, thought process/content, attention, memory, concentration, cooperative attitude, and resilient coping ability. His mood and affect were appropriate to situation with occasional smiles. He seemed less depressed when discussing traumatic incident but also indicated he was not interested in discussing it. Appetite was good while energy level continues to be low. He denied thoughts to harm self/others. A January 2010 mental health treatment record noted that the Veteran reported he was feeling better and apologized for his tone/frustration via voicemail the past Sunday night. He reported 5 hours of uninterrupted sleep last night, stated this continues to be routine. He admitted to drinking at least twice weekly, stated the alcohol helps him relax/sleep. He was given the opportunity to discuss his irritable moods, nightmares and other areas of his life that has been affected by his "Bad mood." He reported medication compliance, as well as occasional communication with his wife and adopted child and added he's grateful for their relationship. He was found to be alert/oriented to all spheres with normal grooming, eye contact, thought process/content, speech flow, attention, cooperative attitude, fair judgment and resilient coping ability. His affect/mood were appropriate to situation with occasional smiles. He seemed less anxious, depressed and overwhelmed. He denied current thoughts of harming self/others, reported having a good appetite and low energy. A March 2010 VA treatment record noted that the Veteran reported that he has not been doing well, and that his PTSD symptoms have become worse. His reported symptoms included depressed mood, insomnia, intrusive thoughts, flashbacks, and combat-related nightmares. There was a conscious effort to avoid experiences that bring back memories of war, isolation and restriction in activities. Other symptoms included irritability, poor concentration, hypervigilance, and an exaggerated startle response. It was also noted that he was currently prescribed fluoxetine daily and trazodone as needed for sleep. He denied experiencing any intolerable side effects from these medications. His appetite was decreased. On mental status examination he was found to be alert and oriented to time, place, person, and situation. He was cooperative, good eye contact, appropriately dressed and groomed. Psychomotor activity was decreased. There was no evidence of involuntary movements. His mood was depressed. His affect was appropriate to the speech content and stated mood. Speech had normal amount, rate and rhythm. Thought process had no loose association, flight of ideas, circumstantiality or tangentiality. He was goal directed and coherent. Thought content showed no evidence of delusional thinking. He denied auditory/visual/olfactory hallucinations, as well as suicidal or homicidal ideation, intent, or plan. There was no evidence of obsessions/compulsions. In addition, similar mental status examination findings were noted in a July 2010 VA treatment record. A September 2010 VA mental health treatment record noted that the Veteran reported feeling better that day, that he continued to maintain contact with his daughter, while adding the other daughter visited him over the weekend. He reported no changes in his situation, stated at times, it helps to talk about it while adding other times, it hurts to think about Vietnam/post war situation. It was noted that his sleep varies, that it was fair some times and poor other times. He was oriented. His appearance was within normal limits. His behavior was noted as being alert/calm/cooperative. His speech was within normal limits. His mood was described as euthymic, and his affect congruent. Perception was within normal limits. Thought process was goal directed, while content was appropriate. His intellect was found to be average and above. Concentration was intact. Remote, short, and immediate memory were found to be fair. Insight and judgment were also found to be fair. There was no homicidality or suicidality. A November 2010 VA mental health treatment record noted, in part, the Veteran was calm and cooperative, although he appeared sad and solemn at times. Affect was congruent with mood. He denied any suicidal ideation, homicidal ideation, and hallucinations. However, he continued to report difficulty sleeping due to nightmares and flashbacks of Vietnam during the day. A March 2011 VA mental health treatment record reported that nothing has changed regarding his condition. He reported still having flashbacks and nightmares. However, he stated he had learned how to cope with his situation, and just having someone to talk with was very helpful. He reported that he was still having breakfast and lunch with some of his friends. He reported talking with one of them on the phone last night. He also reported that he had three grandchildren and a daughter locally whom he enjoys spending time with. Additionally, he reported he had two great grandchildren, and his family makes a fuss regarding which family member he should spend the night with first. He was in a calm mood, and his affect was congruent. He had good eye contact but did not display his humor as much as on previous meeting. A June 2011 VA mental health treatment record indicated that the Veteran reported he had an "accident" over the weekend after he had consumed approximately half a fifth of whiskey and lost his balance. When he fell he said that his arm went in between the refrigerator and the wall resulting in a cut to his inner arm. He stopped the bleeding himself and went to bed. He denied that his behavior was self-directed violence, and having thoughts of wanting to cause harm to himself. However, he agreed that his behavior was dangerous. He denied active suicidal ideation, but agreed to put his gun in the care of someone else for safety reasons. VA mental health treatment record dated later in June 2011 reflects the Veteran reported that he still has depressive thoughts and has had a plan to drive his truck off a bridge for many years, but he denied that he has taken any action to accomplish his plan. He reported improved mood, with thoughts and plans about the future. On evaluation, he was found to have much brighter affect this week. Thought content was more positive and containing thoughts and plans for the future. He denied suicidal and homicidal ideation, but admitted to some feelings of hopelessness/helplessness, in regards to his painful memories never going away. VA mental health treatment records dated in June, July, and August 2011 continued to show treatment for PTSD and alcohol dependence. One August 2011 record noted that he was cooperative to mental status examination. His mood was tense with some depression. Thought processes are coherent. He denies audio/visual hallucination except for flashbacks to combat incidents. He denied current suicidal or homicidal ideation but admitted recently having had suicidal ideation without plan. Cognition was grossly intact. Another record dated later in August 2011 noted that the Veteran was clean and well-groomed, alert and oriented. His affect was appropriate, and his behavior was cooperative. His speech was normal. Recent and remote memory were ok. It was indicted that he had visual hallucination, but no details were provided. He also reported a plan to drive his car into a bridge. The VA treatment records also indicate the Veteran underwent an alcohol detox program in August 2011. His GAF was noted as 24 prior to the program, and 50 after completion. A September 2011 VA treatment record reflects the Veteran reported he had resumed alcohol consumption, However, he reported that had only drank 2 nights and had not resumed his pre-detox drinking pattern. On one occasion he drank 4 beers and 2 large whiskey drinks. On another occasion he consumed a fifth of whiskey. He did not engage in self injurious behavior, according to him, however, he drove after 4 beers consumed in a 1.5 hour time frame. He is aware that he could have gotten a DUI, but, denies intoxication. He was assessed with irritability, but denied suicidal ideation, homicidal ideation, and psychosis. It was also noted that he was receptive to therapeutic confrontation intervention. Later that month his mood was noted as improved. He had suicidal ideation, but no intent. There was no homicidal ideation or psychosis. His appearance was noted as being improved. Thereafter, records from that month found him to be alert, oriented x 4 and stable. He was clean and cooperative. His mood was stable. His affect was appropriate. He did not have loose association, flight of ideas, or evidence of hallucinations. He denied homicidal or suicidal ideation, but he complained he stays depressed and is easily startled. It was also noted that he isolates. He admitted to past fleeting thoughts of dying, but none in several days. An October 2011 VA treatment record noted, in part, that the Veteran endorsed having regular thoughts of suicide. He endorsed having a plan (drive off bridge), but denied having intentions of suicide or homicide. He also stated that he could never attempt suicide due to his religious beliefs. A GAF of 48 was assigned. Additional records dated in October, November and December 2011 continue to show treatment for complaints of PTSD and alcohol dependence. These records note that the Veteran denied suicidal or homicidal ideation or psychosis. In addition, a November 2011 record notes that mental status examination found the Veteran to be averagely groomed. His speech had regular rate and rhythm with normal volume. His mood "comes and goes." Affect was stable, congruent to mood. Thought content showed no active suicidal or homicidal ideation; no psychosis. Thought process was coherent, linear and directed. He was alert and oriented times 3. Memory both recent and past was grossly intact. Attention and concentration was fair. Insight was limited. Judgment was adequate for basic needs. A February 2012 VA treatment record noted treatment for alcohol dependence. A May 2012 VA treatment record found the Veteran to be alert, oriented x 4 and stable. He was clean and cooperative. His mood was stable. His affect was appropriate. He did not have loose association, flight of ideas, or evidence of hallucinations. He denied homicidal and suicidal ideation. He did not have observed medication side effects. He presented with no new complaints. He continued to experience difficulties managing PTSD symptoms and alcohol consumption. The June 2012 VA PTSD examination diagnosed the Veteran with both PTSD and alcohol dependence. Further, the examiner stated it was possible to differentiate what symptoms were attributable to each diagnosis. In regard to the Veteran's level of occupational and social impairment from all mental diagnoses, the examiner stated that it was best summarized as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with routine behavior, self-care and conversation. In reviewing the Veteran's history, the examiner noted that the Veteran was first seen in 2000 with a diagnosis of alcohol dependence, and that the 2009 VA examination diagnosed mild PTSD. The examiner also noted the Veteran's current treatment and alcohol intake, and that intake dated from around 1969. Other symptoms included constant dreams and flashbacks, easily startled by loud noises. Upon further inquiry, the Veteran offered no other PTSD symptoms. It was noted that he drinks to forget and aid with sleep. It was also noted that PTSD was first diagnosed in 2008 but that the Veteran gave the onset as 35 to 40 years ago. Further, it was noted that the Veteran worked as a salesman of welding supplies; was fired twice for alcohol use, but was till successful in his career and enjoyed his work; his outgoing personality and knowledge of the product made him a success; He had had seven marriages and was not living with his current wife; alcohol had "everything" do with his marriages and was the reason that his marriages ended. Moreover, the Veteran did not mention PTSD as a factor in his work or marriages. He was found to be irritable and fatigued. He had past thoughts of suicide, but intends his own safety. He had no current plans to change his intake of alcohol. Following examination of the Veteran, the examiner noted that the presence of the Veteran's sleep apnea added complexity as sleep apnea could account for many of the symptoms recounted on examination, especially irritability. Moreover, the examiner opined that the effects of alcohol dependence were the break up of marriages, poor relations with sister, previous work trouble, and inability to moderate use. Effects of PTSD were said by the Veteran to be increased alcohol use, but the examiner opined that the Veteran's alcohol dependence was not due to, a result of, or aggravated by his service-connected PTSD. In support of this opinion, the examiner noted that in relating his post-Vietnam life, the Veteran did not identify PTSD effects in his work or personal life. Rather, untoward consequences were due to alcohol intake. The examiner also reiterated that PTSD was not diagnosed until 2008, and that only a few symptoms of PTSD were given on that day's examination. The examiner stated that any disability is due more to physical illness and alcohol dependence. Combined GAF was 60; GAF due to PTSD alone was 75; and to alcohol dependence alone was 50. Finally, the examiner opined that the Veteran's PTSD left him employable. Analysis In this case, the Board finds that the Veteran does not meet or nearly approximate the criteria for a rating in excess of 30 percent for his PTSD. As detailed above, it is clear that the Veteran has been treated for PTSD concurrent with alcohol dependence throughout the pendency of this case. The significance as to whether the alcohol dependence is secondary to the service-connected PTSD is because service connection may not be granted for substance abuse on the basis of service incurrence or aggravation. However, the law does not preclude a veteran from receiving compensation for an alcohol disability acquired as secondary to, or as a symptom of, a veteran's service-connected disability. 38 U.S.C.A. §§ 105; 38 C.F.R. § 3.301(a), 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). The Board acknowledges that the Veteran has reported drinking alcohol as a result of his PTSD symptoms. However, given the concurrent and complex nature of these disabilities, competent medical evidence is required to determine whether the alcohol is secondary to the PTSD. Here, nothing on file shows that the Veteran has the requisite knowledge, skill, experience, training, or education to render a medical opinion. Consequently, his contentions cannot constitute competent medical evidence. 38 C.F.R. § 3.159(a)(1). The Board observes that there is competent medical evidence which both supports and refutes a finding that the Veteran's alcohol dependence is secondary to his PTSD. For example, the June 2011 opinion from Dr. Smith supports the claim, while the June 2012 VA examiner's opinion is against the claim. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). In evaluating the aforementioned medical opinions, the Board observes that both Dr. Smith and the June 2012 VA examiner reviewed medical records in conjunction with their opinions. Dr. Smith also noted studies showing that patients with PTSD often use alcohol to self-medicate, particularly combat veterans. However, while these studies show the possibility of such a relationship, Dr. Smith's opinion regarding this specific case was based upon the Veteran's PTSD symptoms predating his alcohol use. Conversely, the June 2012 VA examiner's opinion indicated that alcohol use predated the PTSD. A review of the other evidence of record supports the June 2012 VA examiner that the alcohol use predated service. For example, an August 2011 VA treatment record discussing the Veteran's alcohol use noted that he starting drinking at age 16. As the Veteran was born in 1939, this would indicate his alcohol use started in 1955 or 1956, which is years prior to his entry into active duty in 1962. The VA examiner also noted that the Veteran's reported history focused more upon the effects of his alcohol dependence, which indicated it was the predominant disability. Further, the Board observes that the VA examiner had the benefit of actually evaluating the Veteran in conjunction with this case. Therefore, the Board finds that the June 2012 VA examiner's opinion on this matter is entitled to more weight than that of Dr. Smith in June 2011. In view of the foregoing, the Board finds that the preponderance of the evidence is against a finding that the Veteran's alcohol dependence was caused or aggravated by his service-connected PTSD. Therefore, the impairment attributable to this disability is not for consideration in assigning the disability rating. The Board acknowledges that the Veteran has reported various symptomatology over the years in regard to both his PTSD and alcohol dependence. For example, he has reported chronic sleep impairment to include nightmares, flashbacks, exaggerated startle response, irritability, and thoughts of suicide. Granted, unprovoked irritability (with periods of violence) and suicidal ideation are symptoms referenced as part of the schedular criteria for a 70 percent rating. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). Of particular importance in evaluating the Veteran's level of occupational and social impairment are the GAF scores he has been assigned, because such designations are based on a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). GAF scores ranging between 71 and 80 reflect that if symptoms are present they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument; no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). GAF scores ranging between 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A score from 21 to 30 is indicative of behavior which is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. A score of 11 to 20 denotes some danger of hurting one's self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e. g., largely incoherent or mute). A GAF score of 1 to 10 is assigned when the person is in persistent danger of severely hurting self or others (recurrent violence) or there is persistent inability to maintain minimal personal hygiene or serious suicidal acts with clear expectation of death. See 38 C.F.R. § 4.130 (incorporating by reference the VA's adoption of the DSM-IV, for rating purposes). As detailed above, the Veteran has been assigned various GAF scores during the pendency of this case, predominantly in the 51 to 60 range. Nevertheless, there have been GAFs as low as 24 and as high as 75. The Board reiterates, however, that it has already been determined that the Veteran's alcohol dependence is not secondary to his service-connected PTSD. As such, the impairment attributable to the alcohol dependence is not for consideration in evaluating the PTSD to include his GAF score. The Board acknowledges that the Court held in Mittleider v. West, 11 Vet. App. 181 (1998), that VA regulations require that when the symptoms and/or degree of impairment due to a veteran's service-connected psychiatric disability cannot be distinguished from any other diagnosed psychiatric disorders, VA must consider all psychiatric symptoms in the adjudication of the claim. The Board also reiterates that the Joint Motion contended that the February 2008 VA examination was not adequate for the Board to differentiate the symptoms of the PTSD from the alcohol dependence. Moreover, it does not appear the treatment records made any such distinction, and the evaluation from Dr. Smith attributed the alcohol dependence to the PTSD. The testimony from the Veteran and his daughter did not make any such distinction at his hearing in this case. Despite the foregoing, the Board notes, as detailed above, the June 2012 VA examiner did make such a distinction. For example, the examiner indicated that the PTSD symptoms included constant dreams and flashbacks, easily startled by loud noises. More significantly, the examiner stated that overall GAF was 60; GAF due to PTSD alone was 75; and to alcohol dependence alone was 50. As already stated, GAF scores from 71 to 80 indicate that if symptoms are present they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument; no more than slight impairment in social, occupational, or school functioning. The Board also notes that the June 2012 VA examiner stated that the occupational and social impairment from all mental diagnoses was best summarized as occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with routine behavior, self-care and conversation. This description is consistent with schedular criteria for a 30 percent rating. The Board also reiterates that the GAF scores in this case have predominantly been in the 51 to 60 range, which indicates no more than moderate impairment. Therefore, the Board finds that the level of occupational and social impairment attributable to the Veteran's service-connected PTSD is consistent with the current 30 percent schedular rating. The Board also observes that the evidence on file has consistently shown the Veteran to be alert and fully oriented. He appeared to have little to no impairment of thought content or processes. In view of the foregoing, the Board finds that the Veteran's service-connected PTSD is adequately reflected by the current 30 percent schedular rating, and does not meet or nearly approximate the criteria for a higher evaluation. the Board notes that it took into consideration the applicability of "staged" rating(s) pursuant to Fenderson, supra, and Hart, supra, but found no distinctive period(s) where the Veteran met or nearly approximated the criteria for a higher rating so as to assign such a rating(s). In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). In this case, the Board acknowledges that not all of the Veteran's specific symptoms from his PTSD are noted in the general rating formula. However, as noted by the holding in Mauerhan, supra, the focus is not the specific symptomatology but the overall impact a claimant's symptoms have upon his occupational and social functioning. Here, the Board has already determined that the Veteran's level of such impairment from his service-connected PTSD is adequately reflected by the current schedular evaluation. The rating criteria are therefore adequate to evaluate the Veteran's service-connected PTSD and referral for consideration of extraschedular rating is not warranted. Lastly, the Board notes that notes that, in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim of entitlement to a total rating based upon individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In this case, however, the record does not reflect that the Veteran is unemployable due solely to his service-connected PTSD. As noted above, the June 2012 VA examiner found that the Veteran's PTSD had left him employable. The Board also reiterates that the record indicates the Veteran had past employment difficulties, including being fired, due to alcohol use which it has already been determined is not for consideration. Moreover, the SSA records reflect that the Veteran was able to work successfully until 1999 when he had to stop due to the nonservice-connected COPD. Therefore, no further discussion of entitlement to a TDIU is warranted based upon the facts of this case. ORDER Service connection for alcohol dependence as secondary to PTSD is denied. A rating in excess of 30 percent for service-connected PTSD is denied. ____________________________________________ MCHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs