Citation Nr: 1313989 Decision Date: 04/26/13 Archive Date: 05/03/13 DOCKET NO. 09-00 226A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for a skin disorder of the arms, back and wrist, to include as due to in-service herbicide exposure. 2. Entitlement to an initial disability rating in excess of 50 percent from July 16, 2007 to November 17, 2009, and in excess of 70 percent since November 17, 2009 for posttraumatic stress disorder. REPRESENTATION Veteran represented by: Oklahoma Department of Veterans Affairs ATTORNEY FOR THE BOARD J. W. Kim, Counsel INTRODUCTION The Veteran served on active duty from January 1968 to February 1971. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma that granted service connection for posttraumatic stress disorder (PTSD), assigning a 50 percent rating effective July 16, 2007, and denied service connection for a skin disorder of the arms, back and wrist, to include as due to in-service herbicide exposure. In January 2011, the Board remanded the appeal for further development. As the appeal involved a request for a higher initial rating following the grant of service connection, the Board characterized the PTSD rating issue as an initial rating. See Fenderson v. West, 12 Vet. App. 119 (1999). In an April 2012 rating decision, the Appeals Management Center (AMC) increased the rating for PTSD to 70 percent effective November 17, 2009. As the Veteran had not been granted the maximum benefit permitted under the regulations, the initial rating claim remained on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). In June 2012, the Board again remanded the appeal for further development. The case is now returned for appellate review. FINDINGS OF FACT 1. A skin disorder of the arms, back and wrist did not have its onset during active service, and it is not causally related to such service, to include herbicide exposure. 2. From the July 16, 2007 effective date of service connection to October 6, 2008, the Veteran's PTSD had not more nearly approximated occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood. 3. Resolving reasonable doubt in the Veteran's favor, from October 6, 2008 to November 17, 2009, his PTSD had been manifested by occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood. 4. Since November 17, 2009, the Veteran's PTSD has not more nearly approximated total occupational and social impairment. CONCLUSIONS OF LAW 1. A skin disorder of the arms, back and wrist was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2012). 2. The criteria for an initial disability rating in excess of 50 percent for PTSD from July 16, 2007 to October 6, 2008 have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2012). 3. The criteria for an initial disability rating of 70 percent, but no higher, for PTSD from October 6, 2008 to November 17, 2009 have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2012). 4. The criteria for an initial disability rating in excess of 70 percent for PTSD since November 17, 2009 have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.326(a) (2012). In this regard, proper notice from VA must inform the claimant and his or her representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2012); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's PTSD claim arises from an appeal of the initial evaluation following the grant of service connection. A notice letter addressing the elements of the Veteran's service connection claim for PTSD was provided in July 2007. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Thus, no further notice is needed. With respect to the skin disorder claim, neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. The Veteran was notified via letter dated in January 2008 of the criteria for establishing service connection, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. He also was notified of how VA determines disability ratings and effective dates if service connection is awarded. This letter accordingly addressed all notice elements and predated the initial adjudication by the RO in June 2008. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012). In this case, all necessary development has been accomplished and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination, including those from the Social Security Administration (SSA). The Veteran's statements in support of the claims are of record. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the claims. VA has provided the Veteran with examinations in March 2011 to determine the etiology of his skin disorder and the severity of his PTSD. 38 C.F.R. § 3.159(c)(4). To that end, when VA undertakes to provide an examination or obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). As the Board found the examination report on skin diseases to be inadequate, the Board requested another examination. The Board finds the March 2011 examination report on PTSD and the July 2012 examination report on skin diseases, along with the adequate portions of the March 2011 examination report, to be thorough and adequate upon which to base decisions on the claims. The examiners personally interviewed and examined the Veteran, eliciting a history from the Veteran, and provided the information necessary to decide his service connection claim and evaluate his PTSD under the applicable rating criteria. Brief but relevant and important opinions were provided. The Board finds the opinions to be adequate, as they were based on a full reading of the private and VA medical records in the claims file as well as the Veteran's own statements. In the January 2011 remand, the Board requested that the AMC obtain the Veteran's updated treatment records from the Muskogee VA Medical Center (VAMC) and afford the Veteran examinations for his skin disorder and PTSD. VA treatment records were associated with the claims file or scanned into the Virtual VA record system and examinations were completed in March 2011. As noted above, the Board found the opinion on the skin disorder to be inadequate. Thus, in the June 2012 remand, the Board requested another examination. As the record indicated that the Veteran may be receiving disability benefits from the SSA, the Board also requested that the AMC obtain his SSA records. SSA records were obtained and an examination was completed in July 2012. As discussed above, the report of that examination is substantially responsive to the Board's request. See Dyment v. West, 13 Vet. App. 141 (1999). Given the above, no further notice or assistance is required to fulfill VA's duty to assist. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303(a) (2012). Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). In this case, a skin disorder is not a "chronic disease" listed under 38 C.F.R. § 3.309(a) (2012). Therefore, 38 C.F.R. § 3.303(b) (2012) does not apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection requires competent evidence of (1) a current disability; (2) the in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). If a veteran was exposed to an herbicide agent during active military, naval, or air service, certain diseases, including chloracne or other acneform diseases consistent with chloracne and porphyria cutanea tarda, shall be service connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e) (2012). Chloracne and porphyria cutanea tarda shall have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii) (2012). In this case, the Veteran contends that he has a skin disorder of the arms, back and wrist due to exposure to Agent Orange in service. The Veteran's service treatment records are predominantly negative for any findings, treatment for or diagnosis of a skin condition. However, a May 1970 record reflects complaints of a rash on the chest, and he was seen two days later for complaints of chest pain for three days. During his September 1970 separation examination, he denied having had any type of skin disease or tumor, growth, or cyst on his body, and clinical evaluation of his skin was normal. In a February 1971 statement, he indicated that there had been no change in his medical condition since his separation examination. The record reflects that the Veteran subsequently served with the National Guard for over twenty years. His treatment records with the National Guard are negative for any complaints or diagnosis of or treatment for a skin condition. During his March 1972 examination for enlistment with the National Guard, he denied any history of a skin condition and clinical evaluation of his skin was normal. A December 1991 periodic examination also shows that clinical evaluation of his skin was normal. While he noted having a plantar wart on his right foot, he did not mention having any skin condition, to include a rash, blisters and/or acne, on his arms, wrist, back or face. On his December 1991 report of medical history, he noted a history of a growth or cyst, which the physician specified as a wart on the right foot. Post service, VA medical records show treatment for skin conditions. A May 2004 treatment note reflects that the Veteran underwent an excision of an abscess on his right chest wall. It was noted that he had had lesions associated with the abscess on his chest wall for four years without symptoms but that within the last two to three months the right chest abscess had appeared with purulent discharge. The biopsy of the abscess revealed an epidermal inclusion cyst which was removed entirely. During an August 2007 treatment visit, he underwent a general examination, and it was noted that he had multiple areas of cyst formation on his skin, with old excisions and blackhead formations on the anterior and posterior chest and back. The nurse practitioner also noted that the Veteran had red scaling dermatitis on both arms and diagnosed him with cystic acne and bullous dermatoses. An October 2007 treatment note reflects that the Veteran had a lesion on his left chest examined and was diagnosed with seborrheic keratosis on the left chest. A June 2008 treatment note reflects complaints of a rash on his arms which "never goes away" and of "blisters at times." In October 2008 a treatment note reflects a notation that the Veteran gets comedones around the eyes and on the back that he feels are due to his exposure to Agent Orange. The Veteran was seen for an Agent Orange Registry interview and examination in November 2008, during which he claimed that his skin lesions broke out while he was in Vietnam. He denied any involvement in the handling or spraying of Agent Orange. However, he was uncertain if he was in a recently sprayed area, if he was exposed to herbicides other than Agent Orange, or if he ate or drank something that may have been sprayed with Agent Orange while in Vietnam. Examination of the Veteran's skin showed evidence of old acne scars at the anterior and posterior chest area as well as bullous dermatitis on his arms. The nurse practitioner diagnosed the Veteran with chloracne and bullous dermatitis on the bilateral arms. In a February 2008 statement, the Veteran asserted that, during a check up at the VA, he was informed that the skin condition on his back, arms and wrists may be related to his exposure to Agent Orange while in Vietnam. He further explained that he also had blackheads on the side of his face, as well as oily skin and acne around his nose and cheeks, which he believed to be the result of his in-service Agent Orange exposure. In his July 2008 Notice of Disagreement (NOD), he maintained that he has had a skin condition since service, which includes bumps and rashes on his chest and back, and that he has self-medicated and treated his condition throughout the years. He made similar contentions on a statement in January 2009 associated with his VA Form 9 indicating that he has had oily skin around his face and blackheads around his eyes, temples, and ears, in addition to cysts, since his service in Vietnam. Given the nature of the Veteran's condition and its observable symptoms, the Board finds him to be competent to report that he has suffered from a skin condition since service. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting competent lay evidence requires facts perceived through the use of the five senses). Based on the evidence submitted and lay assertions provided in support of his claim, the Board also finds him credible with respect to his assertions. Thus, in January 2011, the Board requested a VA examination to determine the etiology of his skin disorders. The Veteran was afforded a VA examination in March 2011. Based on his discussion with, and evaluation of, the Veteran, the VA examiner diagnosed the Veteran with seborrheic dermatitis and epidermal inclusion cyst, and determined that the Veteran's current epidermal inclusion cyst "is less likely as not permanently aggravated or a result of any event and/or condition that occurred and/or expressed in-service and/or within one year of discharge including alleged Agent orange exposure and is at least as likely as not a result of his predisposition to epidermal inclusion cyst and/or seborrheic dermatitis and was not caused by and/or worsened by an already service connected disability." The examiner ultimately concluded that "it is less likely as not that exposure in 1991 would result in an epidermal cyst that started in 2004." In the June 2012 remand, the Board noted that the examiner did not provide a thorough rationale in support of his opinion, mistakenly referred to the "excision of the sebaceous and/or epidermal inclusion cysts" as in-service events, appeared to have cited the wrong date of the Veteran's exposure to herbicides, and failed to provide an etiological opinion regarding the Veteran's seborrheic dermatitis. The Veteran was afforded a new examination in July 2012 by the same examiner who conducted the above examination. The VA examiner noted having reviewed the Veteran's history with the Veteran. The examiner highlighted the red bumpy rash thought to be heat rash on the chest and abdomen in May 1970 that was treated with a spray and cleared in two days, and the recent excision of sebaceous cysts from the chest and back. Based on his discussion with, and evaluation of, the Veteran, the examiner diagnosed the Veteran with a sebaceous cyst and seborrheic keratosis. The examiner noted that the Veteran has mild erythema of the upper chest consistent with chronic sun exposure that was, by the Veteran's report, not the rash present in May 1970. The examiner noted having reviewed his prior examination report and stated his conclusions are confirmed except for the error in the date of the Veteran's exposure to herbicides. The examiner stated that "it is less likely as not that exposure in 1971 would result in an epidermal cyst that started in 2004." The examiner explained that sebaceous cysts are caused by blocked sweat glands, they are not chloracne, and they are more common with advanced age. The examiner also explained that seborrheic dermatitis is caused by sun exposure. The examiner further explained that eruptions are representative of sebaceous cysts. With respect to the rash in service in May 1970, the examiner stated that the resolution of the rash with a spray treatment indicates that it was contact dermatitis. Lastly, a February 2009 VA treatment note reflects the Veteran's primary care physician's opinion that the Veteran has "acne which in my opinion is as likely as not due to exposure to agent orange." In a February 2011 VA treatment note, the same physician stated that the Veteran has "multiple sebaceous cysts probably due to agent orange exposure." In addressing this claim, initially, the Board observes that the Veteran served in the Republic of Vietnam during the Vietnam Era; therefore, exposure to herbicide agents in service may be presumed. However, the Veteran was not diagnosed with chloracne, or any other acneform diseases consistent with chloracne, until November 2008, over thirty-seven years after his service in Vietnam. There are no earlier findings to show that the chloracne manifested to a degree of 10 percent within one year of the Veteran's last exposure to herbicides, as required by 38 C.F.R. § 3.307. Even though the Veteran is competent to state he has had rashes since service, he is not competent to attribute the rashes to an underlying diagnosis, such as chloracne. Moreover, as will be discussed below, the diagnosis of chloracne may not have been accurate. Thus, service connection is not warranted on a presumptive basis. Notwithstanding the presumptive provisions, service connection may be established by showing that a disorder resulting in disability is, in fact, causally linked to such exposure. See Brock v. Brown, 10 Vet. App. 155 (1997); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Given the above, the Board finds that the weight of the probative evidence shows that the Veteran's skin disorder is not causally related to active service, to include exposure to herbicides. The Board notes the favorable 2009 and 2011 opinions from the Veteran's VA treating physician. However, there is no indication that the physician reviewed the Veteran's claims file or otherwise had an accurate account of the Veteran's medical history; nor did the physician provide a rationale. Thus, the opinions are of limited probative value. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). A medical opinion must support its conclusions with analysis. Stefl v. Nicholson, 21 Vet.App. 120, 124 (2007). "Neither a VA medical examination report nor a private medical opinion is entitled to any weight in a service-connection or rating context if it contains only data and conclusions [without reasoning or rationale]." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Moreover, the 2011 opinion, as phrased, is too speculative. Morris v. West, 13 Vet. App. 94, 97 (1999); Bloom v. West, 12 Vet. App. 185, 186-87 (1999). The Board acknowledges the October 2008 VA treatment note containing the statement that the Veteran gets comedones that he feels are due to his exposure to Agent Orange. However, the Board observes that a bare transcription of lay history, unenhanced by additional comment by the transcriber, does not become competent medical evidence merely because the transcriber is a health care professional. LeShore v. Brown, 8 Vet. App. 406, 409 (1995). On the other hand, the VA examiner opined that the Veteran's skin disorders are not related to service, specifically ruling out herbicide exposure as a cause of each skin disorder. With respect to the rash in service in May 1970, the examiner opined that it was contact dermatitis. Thus, the examiner essentially ruled out the possibility that it was an early manifestation of the later diagnosed skin conditions. Here, the Board notes that the Veteran conceded that his current chest rash is not the same as the one he had in service. The Board finds the VA examiner's opinions to be of great probative value as they were based on examination of the Veteran and his documented medical history. See Hayes, 5 Vet. App. at 69-70. The Board notes that the nurse practitioner who conducted the Agent Orange Registry examination provided a diagnosis of chloracne. However, the Board finds the diagnoses of the VA examiner to be of greater probative value as they were supported by the medical literature, as cited in the March 2011 examination report. See Hayes, 5 Vet. App. at 69-70. Even if the prior diagnosis of chloracne were correct, given the VA examiner's opinion that herbicide exposure in 1971 would not cause an epidermal cyst in 2004, the Board finds that the chloracne diagnosed even later in 2008 would also not be due to in-service herbicide exposure. The Board notes that the Veteran is competent to give evidence about observable symptoms such as a rash. Layno, 6 Vet. App. at 469. The Board also notes that a lay person may speak as to etiology in some limited circumstances in which nexus is obvious merely through lay observation, such as a fall leading to a broken leg. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In this case, although the Veteran has asserted that he has suffered from a skin condition since service, during the July 2012 VA examination the Veteran acknowledged that his current rash on the chest is not the same rash he had in service in May 1970. Also it was noted in May 2004 that the lesions associated with the abscess on his chest had only been present for four years, and only symptomatic for two to three months. With respect to his current skin disorders, the question of causation extends beyond an immediately observable cause-and-effect relationship and, as such, he is not competent to address etiology. As discussed above, the medical evidence shows that his skin disorder is not related to service, to include conceded exposure to herbicides. Accordingly, based on this evidentiary posture, the Board concludes that service connection for a skin disorder of the arms, back and wrist, to include as due to in-service herbicide exposure, is not warranted. The preponderance of the evidence is against the claim, and the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Initial Rating Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). However, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204 (1994). But see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher evaluation; otherwise, the lower evaluation will be assigned. See 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). A veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1 (2012); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). When the veteran has disagreed with the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of "staged" ratings (i.e., assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119 (1999). The analysis below is therefore undertaken with consideration of the possibility that different "staged" ratings may be warranted for different time periods. The Veteran's PTSD has been evaluated under Diagnostic Code 9411, 38 C.F.R. § 4.130 (2012). A 50 percent rating contemplates occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating contemplates 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 applies 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. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a GAF is a scale 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, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). GAF scores from 51 to 60 indicate 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). GAF scores 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). The GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; 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 assigned. See 38 C.F.R. § 4.126(a) (2012). Prior to October 6, 2008 After a careful review of the record, the Board finds that an initial disability rating in excess of 50 percent for PTSD prior to October 6, 2008 is not warranted. An October 2007 statement from the Veteran's wife documents her relationship struggles with the Veteran over the years, which she attributes to his PTSD, including nightmares, anger problems, and isolative behavior. During a June 2008 VA examination, the Veteran stated that over the past year he has received psychotherapy and the response has been fair. Objectively, he was oriented with appropriate appearance, hygiene and behavior. Mood was depressed but noted as not significantly impacting activities of daily living. Communication, speech and concentration were normal. There were no delusions or hallucinations and no obsessional rituals. Thought processes were appropriate. Judgment was not impaired. Abstract thinking was normal. Memory was normal. The Veteran endorsed suicidal and homicidal ideations but denied intent. The examiner assigned a GAF score of 60. The examiner noted that the Veteran occasionally has some interference in performing activities of daily living because of depression. The examiner concluded that the Veteran's psychiatric symptoms cause occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks although generally functioning satisfactorily with routine behavior, self-care and normal conversation. The examiner noted that the above statement is supported by symptoms of depressed mood, suspiciousness, panic attacks weekly or less often and chronic sleep impairment. The examiner added that the Veteran has no difficulty understanding commands and does not appear to pose any threat of danger or injury to self or others. In his July 2008 NOD, the Veteran asserted that his symptoms meet the criteria for a 70 percent rating. However, he did not provide any further explanation. The Veteran's SSA records essentially mirror the complaints and findings in the VA medical records and examination report. In an August 2008 report, a physician noted the Veteran's report that he is unable to work because he cannot handle stressful situations but stated that he was unable to objectify the complaint. A September 2008 assessment reflects that he can perform simple tasks with routine supervision, relate to supervisors and peers on a superficial work basis, and adapt to a work situation, but cannot relate to the general public. The GAF scores were 46-50. In correspondence subsequently received on October 6, 2008, the Veteran's wife indicates that the Veteran had recently been experiencing increasing outbursts of anger. She described several incidents throughout the summer during which the Veteran acted extremely suspicious and paranoid while they were in various public venues, and was prone to fits of rage while out at a restaurant and with friends. The Veteran's wife wrote that these episodes scared her and at times she felt fear for her safety due to the Veteran's explosive temper. She explained that the Veteran was beginning to isolate himself more, that lately he has no appetite, and that he constantly speaks about death and dying. She further wrote that she had been married to the Veteran for thirty-seven years and had never seen him as depressed as he was then. Also, in a statement received in January 2009, the Veteran indicated that his eating habits had changed recently and that he does not eat as much as he used to because he does not feel hungry very often. He also wrote that he does not like to go places where there may be a lot of people because he feels that people are looking at him. VA treatment notes through July 16, 2009 essentially note the same symptoms and findings as the VA examination report. A November 12, 2009 administrative note from the VA Tulsa Outpatient Clinic reflects that the Veteran's wife called to say that the Veteran was having problems, looking at the gun cabinet and talking about death and killing and asked that the Veteran be seen in the mental health clinic. The Veteran indicated that he would not mind being seen. A suicide prevention note later that day reflects that the Veteran thinks about suicide sometimes but was not currently suicidal and did not have a plan or intent. The assessment was that the Veteran had a depressed mood with intermittent suicidal ideation but was fully oriented with no apparent thought disorder and was able to show some sense of humor and problem solving ability. Initially, the Board observes that the Veteran's psychiatric condition seems to have worsened in November 2009. Indeed, the AMC increased the rating for PTSD to 70 percent based on a November 17, 2009 VA treatment note, to be discussed later. Also as will be seen below, his depression has been associated with his service-connected PTSD. Thus, manifestations due to the depression will be considered in the evaluation of his PTSD. See 38 C.F.R. § 4.14 (2012). In this context, the November 12, 2009 VA administrative note and subsequent suicide prevention note appear to represent the increase in symptoms that are later documented in the November 17, 2009 treatment note. However, the Veteran's wife statement in October 6, 2008 also seems to reflect the later symptoms that were documented in VA treatment records in November 2009. Specifically she stated that the Veteran was constantly talking about death and dying and that he was having episodes of anger with an explosive temper that were causing her to fear for her safety. Considering the totality of the evidence, and resolving reasonable doubt in the Veteran's favor, the Board finds that from October 6, 2008 to November 16, 2009, his PTSD and related depression resulted in occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation and impaired impulse control. Thus, a 70 percent rating is warranted from October 6, 2008. With respect to the period prior to October 6, 2008, the evidence fails to show that the Veteran's PTSD had resulted in occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood. While the Veteran's wife documented in her October 2008 letter that the increase in symptoms for the Veteran's PTSD had started over the summer, the contemporaneous medical evidence does not conform to a rating higher than 50 percent prior to October 6, 2008. The June 2008 VA examiner concluded that the Veteran's PTSD causes occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks. The Board observes that the above is reflective of a 30 percent rating. See Diagnostic Code 9411. Further, the September 2008 report from the SSA shows that while the Veteran indicated that he would get nervous, anxious, and short-tempered when around people, he could perform simple tasks, relate to supervisors and peers, and adapt to a work situation. The August 2008 report from the SSA also indicates that the Veteran can adapt to stressful circumstances and that even though the Veteran reported being unable to work because he could not handle stressful situations, the examiner could not objectively confirm this assertion. Socially, the September 2008 report notes the Veteran was married and had regular contact with his family and others and that his regular activities including watching television, doing minor house repairs, and yard work. The Veteran's wife submitted a statement in October 2007 that the Veteran's PTSD had strained their relationship over the years in that the Veteran had anger problems, suspiciousness, and isolative behavior. However, prior to October 2008, she did not indicate, nor does the medical evidence support that the Veteran met the criteria for a 70 percent rating for his PTSD. In June 2008, it was noted that the Veteran's depression caused some interference in performing activities of daily living but that generally he functioned satisfactorily with routine behavior and self-care. His GAF score of 46-50 noted in September 2008 was somewhat reflective of more serious symptoms. However, as noted, the GAF score is not dispositive of the evaluation issue, but must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a) (2012). Overall, the Veteran's PTSD did not more nearly approximate the symptomatology associated with a 70 percent rating prior to October 6, 2008. In terms of symptoms, while not dispositive, the record prior to October 6, 2008 fails to show that his PTSD had been manifested by 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; or an inability to establish and maintain effective relationships. In summary, the Board finds that, from the July 16, 2007 effective date of service connection to October 6, 2008, the Veteran's PTSD had not more nearly approximated occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood. In conclusion, the Board has applied the benefit-of-the-doubt doctrine in granting a 70 percent rating for PTSD effective October 6, 2008. As the preponderance of the evidence is against an initial rating in excess of 50 percent prior to October 6, 2008, the benefit-of-the-doubt doctrine is not applicable to that aspect of the claim. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 53. Since October 6, 2008 After a careful review of the record, the Board finds that an initial disability rating in excess of 70 percent for PTSD since October 6, 2008 is not warranted. The medical and lay evidence from October 6, 2008 to November 2009 shows suicidal ideation and impaired impulse control but does not demonstrate total social and occupational impairment. While the Veteran was not working, this was not demonstrated as being solely a result of his PTSD. Also, socially, while his PTSD definitely strained his relationships and had a negative impact on how he related to others, total social impairment was not shown. A November 17, 2009 VA treatment note reflects complaints of depression. He noted intermittent thoughts of suicide over the years but no plan or intent. He denied current suicidal or homicidal ideations. He denied hallucinations. Objectively, he was appropriately groomed and dressed and oriented times three. Thoughts were organized and thought process was logical and goal-directed. Impulse and judgment were intact. The psychiatrist assigned a GAF score of 56. During a March 2011 VA examination, the Veteran stated that his medications are not too effective with respect to sleep and that, although they lower his frustration level, he still gets angry. He noted that his relationship with his wife is "ok" but they still get into arguments and that his relationship with his grown children is "ok" but that he gets angry with them and his grandchildren. He noted having one acquaintance with whom he talks once per month and going to a casino once per month. He denied suicide attempts and violence or assaultiveness to others. Objectively, the Veteran was casually dressed and oriented to person, time and place. Speech was unremarkable. There was a paucity of ideas and paranoid ideation, but no delusions or hallucinations. Although the examiner noted that the Veteran had inappropriate behavior, it was noted as being verbally hostile to his children and grandchildren. The Veteran reported general thoughts of homicide but no plan or intent. He reported suicidal thoughts but no plan or intent. The examiner noted that the Veteran was able to maintain minimum personal hygiene. Recent memory was mildly impaired but remote and immediate memory was normal. The examiner noted that the Veteran retired in 2008 when he was eligible by age or duration of work, and later noted that the Veteran had difficulty interacting with his supervisor. The examiner provided diagnoses of PTSD and depression secondary to PTSD. The examiner assigned a GAF score of 55 for the past year and stated that the Veteran's PTSD symptoms do not preclude him from obtaining or maintaining gainful employment. The examiner concluded that the Veteran does not have total occupational and social impairment due to PTSD signs and symptoms. VA treatment notes since November 17, 2009 show continued treatment for PTSD and essentially note the same symptoms and findings as the VA examination report. Given the above, the evidence fails to show that the Veteran's PTSD results in total occupational and social impairment. Although he had limited social interactions, he maintained a relationship with an acquaintance and his relationships with his wife and children were "ok." He also noted going to a casino once per month. Although he was not employed and had difficulty with his supervisor when he was working, he worked until he became eligible to retire. Lastly, the VA examiner opined that the Veteran could work and does not have total occupational and social impairment. Thus, although the Veteran may have significant occupational and social impairment, he does not have total occupational and social impairment. In terms of symptoms, while not dispositive, the record fails to show that the Veteran's PTSD has been manifested by gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting himself or others; intermittent inability to perform activities of daily living; disorientation to time or place; memory loss for names of close relatives, own occupation or own name. The GAF score of 55 is also not consistent with the next higher rating of 100 percent. In summary, the evidence fails to show that the Veteran's PTSD results in total occupational and social impairment, especially when considering his symptoms. Accordingly, the Board finds that, since October 6, 2008, his PTSD has not more nearly approximated total occupational and social impairment to warrant a 100 percent rating. The Board has taken into consideration the Veteran's and his wife's lay statements regarding the severity of his PTSD in determining the ratings assigned. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006)). However, the Veteran and his wife are not competent to provide medical determinations with respect to the severity of the PTSD and the Board has relied mostly on the medical evidence of record in this regard, particularly to the extent that their lay statements are incongruent with the medical evidence of record. Thus, to the extent that the Veteran and his wife have contended that his PTSD is more severely impaired than the ratings assigned, the preponderance of the evidence is against the claim; and the benefit of the doubt doctrine is not applicable. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extra-Schedular The Board must determine whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2012). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. Thun v. Peake, 22 Vet. App. 111 (2008). When either of those elements has been satisfied, the appeal must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1) (2012); Thun v. Peake, 22 Vet. App. 111 (2008). In this case, the schedular evaluations are adequate. Prior to October 6, 2008, the symptoms associated with the Veteran's PTSD (i.e., depression, panic attacks, and sleep impairment) are not shown to cause any impairment that is not already contemplated by the rating criteria. The 50 percent rating assigned under DC 9411 contemplates occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Effective October 6, 2008, the symptoms associated with the Veteran's PTSD (i.e., suicidal ideation, panic attacks, depression, impaired impulse control, and difficulty in adapting to stressful circumstances) are not shown to cause any impairment that is not already contemplated by the rating criteria. The 70 percent rating assigned under DC 9411 contemplates symptoms such as occupational and social impairment with deficiencies in most areas, such as work, thinking, or mood, due to such symptoms as: suicidal ideation; 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; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships, and the Board finds that these rating criteria reasonably describe the Veteran's disability. For these reasons, referral for consideration of an extraschedular rating is not warranted for this claim. Evaluations in excess of those assigned are provided for certain manifestations of the service-connected PTSD, but the medical evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's disorder. As the rating schedule is adequate to evaluate the disability, referral for extra-schedular consideration is not in order. Finally, although the Veteran has submitted evidence of a medical disability, and made a claim for the highest rating possible, he has not submitted evidence of unemployability, or claimed to be unemployable, due to his PTSD. In fact, during the March 2011 VA examination, he reported having difficulties with his supervisor but that he worked until he was eligible to retire due to his age or duration of work. Therefore, the question of entitlement to a total disability rating based on individual unemployability due to a service-connected disability has not been raised. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). ORDER Service connection for a skin disorder of the arms, back and wrist, to include as due to in-service herbicide exposure, is denied. An initial disability rating in excess of 50 percent for PTSD prior to October 6, 2008 is denied. An initial 70 percent disability rating for PTSD from October 6, 2008 to November 17, 2009 is granted, subject to the provisions governing the award of monetary benefits. An initial disability rating in excess of 70 percent for PTSD since November 17, 2009 is denied. ____________________________________________ SARAH B. RICHMOND Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs