Citation Nr: 1317967 Decision Date: 06/03/13 Archive Date: 06/11/13 DOCKET NO. 98-19 854A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to a rating in excess of 30 percent for an anxiety disorder. 2. Entitlement to service connection for posttraumatic stress disorder (PTSD). 3. Entitlement to service connection for tinnitus. REPRESENTATION Appellant represented by: Kathy A. Lieberman, Attorney at Law ATTORNEY FOR THE BOARD L. Barstow, Counsel INTRODUCTION The Veteran had active military service from April 1968 to January 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 1998 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico. A Board decision in November 2006 denied a rating in excess of 30 percent for anxiety disorder; denied service connection for PTSD, arteriosclerotic heart disease and tinnitus; and denied entitlement to a total rating based on individual employability due to service-connected disabilities (TDIU). The Veteran thereafter appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In an Order dated in April 2008, the Court granted a Joint Motion for Remand (JMR) by the Veteran and VA General Counsel, which was incorporated by reference, to vacate the Board's decision as to those issues and remand the case for readjudication in accordance with the JMR. In September 2009, the case was remanded to provide the Veteran with proper notice regarding his claims and to afford him new VA examinations. Review of the record indicates substantial compliance. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Following the September 2009 remand, the RO granted service connection for coronary artery disease, claimed as arteriosclerotic heart disease, and also awarded a TDIU in an October 2011 rating decision. The effective date for both issues was May 13, 1997, the date of the Veteran's original claim. As the Veteran has not disagreed with the effective dates for both issues and/or the disability rating assigned to the coronary artery disease, the Board concludes that those issues are no longer before the Board. FINDINGS OF FACT 1. The evidence does not demonstrate that the anxiety disorder results in 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; and impaired abstract thinking. 2. The Veteran has PTSD which is as likely as not related to his active duty. 3. Tinnitus was not present during service and did not develop as a result of any incident during service. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for anxiety disorder have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9400 (2012). 2. The criteria for service connection for PTSD are met. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304(f) (2012). 3. Tinnitus was not incurred or aggravated in service. 38 U.S.C.A. §§ 1101, 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). With regard to claims for increased disability ratings for service-connected conditions, the law requires VA to notify the claimant that, to substantiate a claim, the claimant was must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. Finally, the notice must provide examples of the types of medical and lay evidence that the Veteran may submit (or ask the VA to obtain) that are relevant to establishing his or her entitlement to increased compensation. However, the notice required by section 5103(a) need not be specific to the particular Veteran's circumstances; that is, VA need not notify a Veteran of the specific diagnostic codes that may be considered or notify of any need for evidence demonstrating the effect that the worsening of the disability has on the particular Veteran's daily life. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In this case, the Board is granting in full the issue of service connection for PTSD. Consequently, the Board finds that any lack of notice and/or development, which may have existed under the VCAA, cannot be considered prejudicial to the Veteran, and remand for such notice and/or development would be an unnecessary use of VA time and resources. As for the Veteran's increased rating and service connection for tinnitus claims, both pre-existed the VCAA. The Veteran was notified in letters dated in October 2003 and May 2011 regarding the type of evidence necessary to establish his claims. He was instructed that to show entitlement to an increased evaluation for his service-connected disability, the evidence must show that the disability has gotten worse. He was also instructed how to establish service connection. The Veteran was notified of what evidence and/or information was already in the RO's possession, what additional evidence and/or information was needed from the Veteran, what evidence VA was responsible for getting, and what information VA would assist in obtaining on the Veteran's behalf. A May 2006 letter as well as the May 2011 letter also notified the Veteran of the criteria for assigning a disability rating and an effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In addition, the May 2006 and May 2011 letters informed the Veteran that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. Regarding VA's duty to assist, the RO obtained the Veteran's service treatment records (STRs), personnel records, Social Security Administration (SSA) records, post-service medical records and also secured examinations in furtherance of his claims. Pertinent VA examinations were obtained in July 1997, January 1998, October 1999, July 2004, June 2005, and August 2011 for the Veteran's anxiety disorder; audiological examinations were obtained in July 2004 and August 2011. 38 C.F.R. § 3.159(c)(4). The VA examinations obtained in this case are sufficient, as the examiners conducted complete examinations, recorded all findings considered relevant under the applicable law and regulations, and offered well supported opinions based on consideration of the full history of the disorders. The Board finds that VA's duty to assist the Veteran with respect to obtaining a VA examination concerning the issues adjudicated herein has been met. 38 C.F.R. § 3.159(c)(4). The Veteran has not identified any additional pertinent medical records that have not been obtained and associated with the claims folder. VA has no duty to inform or assist that was unmet. II. Analysis A. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7. Vet. App. 55, 58 (1994). Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Id. Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Court has held that staged ratings are appropriate for initial rating and increased rating claims when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App 505 (2007). As discussed in detail below, the Board concludes that a staged rating is not warranted. The Veteran contends that he is entitled to a rating in excess of 30 percent for the service-connected anxiety disorder due to the severity of his symptomatology. This service-connected disability is rated as 30 percent disabling under 38 C.F.R. § 4.130, DC 9400, which evaluates impairment from generalized anxiety disorder. Specifically, pursuant to DC 9400, a 30 percent evaluation is warranted if the evidence establishes that 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). 38 C.F.R. § 4.130, DC 9400 (2012). A 50 percent evaluation is warranted if the evidence establishes 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 maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted if the evidence establishes 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. Id. A 100 percent evaluation is warranted if the evidence establishes 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 oneself or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The list of symptoms in the rating formula is not intended to constitute an exhaustive list, but rather shows examples of the types and degrees of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (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 disability that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). 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. 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. 38 C.F.R. § 4.126(a) (2012). When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The Global Assessment of Functioning (GAF) is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV). A GAF score of 71 to 80 is indicative of, if symptoms are present, they are transient and expectable reactions to psychological 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). A GAF score of 61 to 70 is indicative of 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, has some meaningful interpersonal relationships. A GAF score of 51 to 60 is indicative of 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 co-workers). A GAF score of 41 to 50 is indicative of 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). A GAF score of 31 to 40 is indicative of some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). Based on the evidence of record, the Board concludes that a rating in excess of 30 percent is not warranted at any time during the pendency of this appeal. Throughout this appeal, the pertinent evidence record has not shown 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; impaired judgment; or impaired abstract thinking. Although the evidence does show symptoms such as disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships, the totality of the symptomatology shown throughout this appeal does not equate to occupational and social impairment with reduced reliability and productivity. In reviewing the evidence, as discussed in detail below, the Board is granting service connection for PTSD and both disorders are rated under the same criteria. Additionally, the pertinent evidence of record does not differentiate between what symptoms are attributable to PTSD versus anxiety disorder. Therefore, the Board will rate the Veteran's service-connected anxiety disorder on the symptoms shown in the pertinent treatment records and examinations, regardless of whether the diagnosis is anxiety disorder or PTSD. Prior to the Veteran's May 1997 claim, but within the relevant time period for increased rating claims, a September 1996 private evaluation does not indicate that the Veteran's anxiety disorder resulted in occupational and social impairment with reduced reliability and productivity. At that examination, he reported being anxious and having persistent war related nightmares. He had poor relations with his peers at work and could not tolerate pressures at work. Examination revealed that he was alert and cooperative. His facial expression was one of preoccupation and sadness. Personal hygiene was adequate; psychomotor activity was slowed; and speech was logical, relevant and connected. The Veteran was not hallucinating and had no delusions, ideas of reference or phobias. He had strong ideas of invalidism and worthlessness. He wanted to work, but his cardiologist said no. His mood was depressed and anxious; affect was appropriate; orientation to person was preserved; and he was well oriented to place and time. Immediate memory testing showed that he could recall two of five digits repeated forward and backwards; short term memory testing showed that he could recall one of five words after five minutes; recent memory testing showed that he was partially impaired; and remote memory testing showed that he reported being born a long time ago. He paid attention all the time; could not recite the months backwards; could not subtract in series of threes and sevens; could perform simple calculations and name the president and governor; judgment was partially impaired as the understanding of situations was restricted in some areas; and insight was partially impaired. Restrictions of activities of daily living were due to severe physical impairment and he had no desire to do things because he had lost interest in all activities. He had no interest in making new social contacts and could not attend baseball games anymore because he was extremely anxious. The Veteran was afraid and fearful. He reacted to stress with anxiety, restlessness and with pain and oppression to his chest. The Veteran was able to pay attention. He could not stay or tolerate stressful situations. He had panic attacks; how often was not noted. A GAF score of 70 was assigned. This evaluation does not reveal the symptoms akin to those supporting a 50 percent evaluation. Occupational and social impairment with reduced reliability and productivity was not shown. The Veteran was not working due to his cardiologist telling him not to as opposed to his psychiatric disorder causing impairment. Although he reported that he could not tolerate stress at work and had poor relations with his peers, evidence showing that had reduced reliability and productivity at work was not presented. Social impairment seemed to be affected by both physical impairment as well as a lack of desire. This evaluation does not show that the Veteran was less reliable or productive with his social relationships, however few such relationships might be. Accordingly, a 50 percent evaluation based on this record is not warranted. A VA examination in July 1997 fails to show that the Veteran's anxiety disorder causes occupational and social impairment with reduced reliability and productivity. The Veteran was married with two adult children and had been retired since 1996. He was very shaky with a very strong voluntary component and making gestures of nervousness, anxiety, etc. Examination revealed that his shakiness and trembling had a voluntary component and were not involuntary. His responses were very vague, superficial and not elaborated with a marked evasiveness and superficiality. There was no thought disorder and no perceptive disorder. He mentioned Vietnam nightmares. The Veteran was very alert, making hysterical gestures. He was well oriented in the three spheres and memories were preserved. Recall, retention, intellect and the entire sensorium were clear. There were no depressive signs; no suicidal ruminations; judgment was well preserved; and he was able to differentiate well between right and wrong. A GAF score of 75-80 was assigned. This examination fails to show that the Veteran has occupational and social impairment with reduced reliability and productivity due to his anxiety disorder. As the Veteran was not currently employed, this examination does not indicate occupational impairment with reduced reliability and productivity. Furthermore, to the extent that the Veteran has occupational impairment, as noted in the Introduction, the Veteran is in receipt of a TDIU effective May 1997. The Veteran was still married, but no other social relationships were discussed. Although the total effect that his disability had on his social impairment was not discussed, the symptoms shown on this examination are not akin to those listed in the rating criteria as indicative of occupational and social impairment with reduced reliability and productivity. Therefore, this examination does not support a 50 percent rating. A private evaluation dated in August 1997 also does not show that the Veteran's anxiety disorder warrants a rating in excess of 30 percent. He reported losing interest in baseball and boxing. His mental condition had significantly impaired his social areas of functioning. He reported that he forgot everything, and had lost interest in everything, including making social contacts. He was fearful when faced with critical situations and reacted with anxiety, restlessness, and pain and oppression to his chest. He had no interest in personal care or in relating to other people. Examination revealed adequate personal hygiene. He was agitated and talked about having flashbacks. He moved his extremities frequently. The Veteran's face expressed anxiety, preoccupation and anger. Production of thought was logical; answers were relevant and connected; ideas flowed in a rapid fashion; there was no blocking of ideas; and associations were not loosened. The Veteran showed great concern about his frequent flashbacks. Strong ideas of worthlessness were elicited; ideas of physical and mental impotence were present; affect was appropriate; mood was one of anger, anxiety and depression; and he was partially disoriented as to time. His memory was fairly preserved for all events. He paid attention at all times; capacity for concentration was variable; fund of information was adequate; and insight and judgment were impaired. A GAF score of 50-55 was assigned. This examination fails to show that the Veteran has occupational and social impairment with reduced reliability and productivity. Although this evaluation indicates that the Veteran was fearful when faced with critical situations, it does not show that such fear caused reduced reliability and productivity. Even though this examination indicates that the Veteran had lost interest in social contacts, it does not reveal impairment in relationships that the Veteran did have such as with his wife. Furthermore, the overall symptomatology shown on this examination is not akin to those listed in the rating criteria as indicative of occupational and social impairment with reduced reliability and productivity. Although impaired judgment was shown and this evaluation suggests disturbances of motivation and mood as well as difficulty in establishing and maintaining effective work and social relationships, other symptoms indicative of a 50 percent rating were not shown. Furthermore, this examination was only one month after the VA examination. The overall symptoms shown in both examinations for this time period does not show that the Veteran's anxiety disorder warrants a 50 percent rating. The Veteran was afforded another VA examination in January 1998, which again indicates that a rating in excess of 30 percent is not warranted. He lived with his wife and daughter. He reported that he suffered from nightmares and needed to be isolated. Examination revealed that he was clean and neatly dressed. He was alert and oriented times three. He purposely shook his right leg and avoided eye contact. Mood was anxious; affect was constricted; attention was fair; concentration and memory were good; and speech was clear and coherent. He was unable to describe any stressor in detail. The Veteran was not hallucinating, suicidal or homicidal; insight and judgment were fair; and he exhibited fair impulse control. A GAF score of 70 was assigned. This examination also does not indicate that the Veteran has occupational and social impairment with reduced reliability and productivity. None of the symptoms associated with a 50 percent rating were demonstrated on examination. Although this examination does not reveal the affect that the Veteran's anxiety had on his occupational and social functioning, considering the actual symptomatology shown on examination, the Board finds that it does not support a rating in excess of 30 percent. A July 1999 private evaluation reflects that the Veteran had a GAF score of 41. Although this evaluation report shows the symptoms reported by the Veteran supporting a diagnosis of PTSD, a mental status examination was not included. It also does not discuss the effect that the Veteran's psychiatric disorder had on his occupation and social functioning. Therefore, this evaluation does not contain sufficient information to determine whether a rating in excess of 30 percent is warranted. An October 1999 VA examination does not reveal that a rating in excess of 30 percent is warranted. He continued to live with his wife. The Veteran slept very poorly and did nothing at all. Examination revealed that he was clean, adequately dressed and groomed. He presented with exaggerated body shakes. He was alert and oriented times three; mood was anxious; affect was blunted; attention was good; concentration and memory were fair; speech was clear and coherent; he was not hallucinating, suicidal or homicidal; insight and judgment were fair; and he exhibited good impulse control. A GAF score of 60 was assigned. As with previous VA examinations, this examination fails to show the symptoms contemplated for by a 50 percent rating. This examination also does not reveal the full effect that the Veteran's disorder had on his occupational and social functioning, but the Board reiterates that the symptoms shown are not indicative of a 50 percent rating. A private evaluation dated in March 2004 shows that the Veteran reported being unable to do activities at home because he was afraid to do physical efforts. He visited church once a week. He had lost interest in pleasurable activities. The Veteran was afraid and fearful; under stressful conditions, he reacted with extreme anxiety, restlessness, palpitations, sudoration and oppression to his chest. Examination revealed that he was alert, cooperative and spontaneous. He had a sad facial expression; personal hygiene was adequate; psychomotor activity was below normal; he was logical, relevant and connected; there was some blocking of ideas, ideas of worthlessness and ideas of invalidism. Mood was anxious and depressed; affect was inappropriate; and he was well oriented as to time, person and place. The Veteran had memory problems; recent memory was partially impaired and memory for remote events was poorly preserved. The Veteran did not recite the months backwards and did not subtract in series of seven. He had difficulty understanding some situations; and judgment and insight were partially impaired. He had a GAF score of 45. It was noted that the Veteran had panic attacks very frequently. A 50 percent rating is not warranted based on this evaluation. Although impaired judgment and very frequent panic attacks were shown, other symptoms indicative of occupational and social impairment with reduced reliability and productivity were not shown. This examination did not contain opinions as to whether the Veteran's psychiatric disorder caused reduced reliability and productivity. While the Veteran reported visiting church weekly, this examination does not show whether the Veteran had social relationships at church; and, if so, the extent that his psychiatric disorder caused impairment in such relationships. Overall, the results of this examination fail to show that the Veteran meets the criteria for a 50 percent rating. The report of a July 2004 VA examination does not indicate that the Veteran's psychiatric disability results in occupational and social impairment with reduced reliability and productivity. The Veteran still lived with his wife and also with a nephew. He complained of poor sleep and being restless. Examination revealed that he was clean, adequately dressed and groomed. He was alert and oriented times three. Mood was anxious; affect was constricted; attention, concentration and memory were good; speech was clear and coherent; he was not hallucinating, suicidal or homicidal; insight and judgment were fair; and he exhibited good impulse control. The examiner noted that no impairment of thought processes or communication were reported; no delusions or hallucinations were described; no inappropriate behavior had been claimed; he kept his personal hygiene and did other activities; and he attended church. The Veteran was oriented and no memory loss or impairment was reported. He complained of anxiety, headaches, gastric problems and sleeping problems. He received a GAF score of 60. The results of this examination do not show occupational and social impairment with reduced reliability and productivity. The Veteran continued to have a relationship with his wife and also attended church. None of the symptoms identified in the rating criteria as supporting a 50 percent rating were shown. In this case, the actual impairment shown on this examination does not indicate that a rating in excess of 30 percent is warranted. A June 2005 VA examination also does not show that a rating in excess of 30 percent is warranted. The Veteran was not working; he had stopped working due to cardiac problems. He still lived with his wife. The Veteran reported anxiety, restlessness, tension, an inability to concentrate, insomnia and irritability. He was excessively anxious and worried about all kinds of things. No psychotic and no cognitive symptoms were reported. Examination revealed that he was appropriately dressed with adequate hygiene and cooperative. He was spontaneous and established eye contact with the examiner. The Veteran was alert and in contact with reality. There was no evidence of psychomotor retardation or agitation. There were no tics, tremors or abnormal involuntary movements. Thought process was coherent and logical; there was no looseness of association; and no evidence of disorganized speech, delusions or hallucinations. He had no phobias, obsessions, panic attacks or suicidal ideas. Mood was anxious; affect was broad and appropriate; he was oriented in person, place and time; memory for recent, remote and immediate events was intact; abstraction capacity was normal; judgment was good; and insight was fair. The examiner opined that the Veteran's signs and symptoms were moderately interfering with employment functioning and moderately interfering with social functioning. There was no impairment of thought process or communication and no evidence of inappropriate behavior. The Veteran was able to maintain basic activities of daily living. A GAF score of 60 was assigned. The results of this examination do not show occupational and social impairment with reduced reliability and productivity. The examiner opined that the Veteran's disability moderately interfered with his function, but did not indicate reduced reliability and productivity. The Veteran continued to live with his wife; details about other social relationships were not provided. The symptoms shown on this examination are not akin to those contemplated for by a 50 percent rating. While the Veteran had stopped working due to cardiac problems, there is no indication that his psychiatric disorder had caused reduced occupational impairment with reliability and productivity. The Board notes that the currently assigned 30 percent rating adequately reflects his impairment as the rating already contemplates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Therefore, the Board concludes that a rating in excess of 30 percent based on this examination is not warranted. A May 2011 letter from R.F., M.D. indicates that the Veteran's symptoms of anxiety, palpitations, agitation, pain to chest, sensation of imminent danger, flashbacks, war related nightmares, gastrointestinal symptoms and headaches had increased in severity and frequency. The Veteran's ability to display a healthy social interaction had diminished. This letter does not contain a mental status examination and is not indicative of the actual impairment the Veteran's psychiatric disorder caused him. As such, a 50 percent rating based on this letter is not warranted. A VA examination in August 2011 does not support a rating in excess of 30 percent. The Veteran reported insomnia and anxiety. He had been married for 39 years; a good relationship with his family was reported. The Veteran belonged to a fraternity. There was no history of suicide attempts or violence/assaultiveness. Examination revealed that he was appropriately dressed and restless. Speech was rapid, coherent and pressured; he was cooperative; affect was constricted; and mood was anxious and depressed. He had difficulties with serial sevens and spelling a word forward and backward. The Veteran was oriented to person, time and place. Thought process was tangentiality; thought content was preoccupation with one or two topics; there were no delusions; he understood the outcome of his behavior; and partially understood that he had a problem. Sleep impairment caused him to only sleep about five hours a night. He had persistent auditory hallucinations. He had no inappropriate behavior; interpreted proverbs appropriately; had no obsessive/ritualistic behavior; no panic attacks; and homicidal and suicidal thoughts were not present. The Veteran had fair impulse control with no episodes of violence. He became irritable if he felt pressure from others. He was able to maintain minimum personal hygiene. His disability had no effect on toileting, grooming, self-feeding, bathing, and dressing/undressing; a slight effect on household chores, shopping and traveling; a moderate effect on driving; and a severe effect on engaging in sports/exercise and recreation. The Veteran was isolated. He had a heart condition that he referred prevented him participating in sports or exercise and in most recreational activities. His remote and recent memory was normal, but immediate memory was impaired. A GAF score of 55 was assigned. The examiner opined that the Veteran did not have reduced reliability and productivity. Rather, he had occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks but with generally satisfactory functioning. Examples and pertinent symptoms included no perceptual disturbances, being isolated, and avoiding conversations that recalled the war as well as watching movies about war. He had frequent nightmares about combat experience and about situations that he experienced at his previous job at the postal office. This examination does not indicate that a higher rating of 50 percent is warranted. Indeed, the examiner specifically indicated that the Veteran did not have reduced reliability and productivity such that a 50 percent rating is warranted. This examination shows that the Veteran had good relationships with his family as well as belonging to a fraternity. As with previous examinations, this examination indicates that the Veteran's heart condition caused occupational impairment. This examination does not indicate that the Veteran has symptomatology resulting in occupational and social impairment with reduced reliability and productivity. In addition to all of the above discussed examinations, pertinent treatment records, including psychiatric evaluations from Dr. R.F. throughout this appeal dated from September 1996 through May 2011 have not shown consistent symptoms of 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; impaired judgment; or impaired abstract thinking. Although some records do show panic attacks, the frequency they occurred was not shown. The totality of these records does indicate disturbances of motivation and mood as well as a difficulty in establishing and maintaining effective work and social relationships. However, these records do not include opinions indicating that the Veteran has occupational and social impairment with reduced reliability and productivity. The totality of the evidence shows that the Veteran's service-connected anxiety disorder does not cause 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; impaired judgment; or impaired abstract thinking. Although disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and some memory impairment has been reflected, the overall evidence fails to show that such symptoms, in connection with the other symptoms shown during this appeal, equates to reduced reliability and productivity. In reaching the conclusion that a rating in excess of 30 percent is not warranted, the Board notes that the reported GAF scores of 60 are indicative of moderate symptoms, which are consistent with the currently assigned 30 percent rating. The Veteran has also been shown to have scores as high as 80, indicative of no more than slight impairment in social, occupational, or school functioning, which is not consistent with a rating of 30 percent. The Veteran has also been shown to have scores as low as 41 and 50, indicative of serious symptoms, which is also not consistent with a rating of 30 percent. However, the Board also notes that, while important, the GAF scores assigned in a case are not dispositive of the evaluation and must be considered in light of the actual symptoms of the Veteran's disorder. See 38 C.F.R. § 4.126(a). In this case, the extent and severity of the Veteran's actual anxiety disorder reported and/or shown are suggestive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events); i.e., the level of impairment contemplated in the assigned 30 percent rating for psychiatric disabilities. For these reasons, the Board finds that the criteria for a rating in excess of 30 percent for anxiety disorder have not been met. Furthermore, the rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the disability. 38 C.F.R. § 4.1. The Board notes that in exceptional cases where evaluations provided by the rating schedule are found to be inadequate, an extraschedular evaluation may be assigned which is commensurate with the veteran's average earning capacity impairment due to the service-connected disorder. 38 C.F.R. § 3.321(b). However, the Board believes that the regular schedular standards applied in the current case adequately describe and provide for the Veteran's anxiety disorder symptoms and disability level. Marked interference with employment beyond that contemplated by the schedular criteria has not been shown. The record does not reflect a disability picture that is so exceptional or unusual that the normal provisions of the rating schedule would not adequately compensate the Veteran for his service-connected disability. The evidence does not show that the Veteran's anxiety disorder has resulted in interference with employment or activities of daily life which would warrant a rating in excess of 30 percent. Moreover, the Veteran has been in receipt of as a total disability rating based on individual unemployability since May 1997. Accordingly, the Board need not consider whether such claim has been raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). B. Service Connection Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C.A. § 1110. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Certain chronic diseases (e.g., psychoses) may be presumptively service connected if they become manifest to a degree of 10 percent or more within one year of leaving qualifying military service. 38 C.F.R. §§ 3.307(a)(3); 3.309(a) (2012). Lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). 1. PTSD The Veteran contends that he has PTSD that is related to in-service mortar and rocket attacks. See, e.g., May 1997 claim. Entitlement to service connection for PTSD in particular requires medical evidence diagnosing PTSD in accordance with the DSM-IV; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. §§ 3.304(f); 4.125(a). Where the claimed stressor is not related to combat, the veteran's lay testimony, by itself, will not be enough to establish the occurrence of the alleged stressor. Instead, the record must contain evidence that corroborates the veteran's account as to the occurrence of the claimed stressor. See 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d), (f) (2012); Cohen v. Brown, 10 Vet. App. 128 (1997). Evidence denoting participation in combat includes award of decorations such as the Combat Action Ribbon, Combat Infantryman Badge (CIB), Purple Heart Medal, and decorations such as the Bronze Star Medal that have been awarded with a Combat "V" device. After reviewing the evidence of record, the Board concludes that service connection for PTSD is warranted. The evidence supports of a finding of confirmed in-service stressors and a current diagnosis of PTSD related to the Veteran's stressors. Initially, the Board finds that the Veteran does have confirmed in-service stressors. The Board observes that the Veteran's records do not confirm the receipt of any decorations or medals denoting participation in combat. Where VA determines that the veteran did not engage in combat with the enemy, or that the veteran did engage in combat with the enemy but the claimed stressor is not related to such combat, the veteran's lay testimony, by itself, will not be enough to establish the occurrence of the alleged stressor. Instead, the record must contain evidence that corroborates the veteran's account as to the occurrence of the claimed stressor. See 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d), (f); Cohen v. Brown, 10 Vet. App. 128 (1997). With regards to the corroboration of stressors, the Board observes the recent amendment to 38 C.F.R. § 3.304 concerning stressors based on a veteran's "fear of hostile military or terrorist activity." Specifically, the amendment provides that, if a stressor claimed by a veteran is related to the veteran's "fear of hostile military or terrorist activity" and if a VA or VA-contracted psychiatrist or psychologist confirms that the claimed stressor is adequate to support a diagnosis of PTSD, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor so long as there is not clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service. Stressor Determinations for Posttraumatic Stress Disorder, 75 Fed. Reg. 39,843, 39,852 (July 13, 2010) (to be codified at 38 C.F.R. § 3.304(f)(3)); 75 Fed. Reg. 41,092 (July 14, 2010) (correcting the effective date of the rule published on July 13, 2010). For purposes of this section, "fear of hostile military or terrorist activity" means that "a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, . . . , and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror." 75 Fed. Reg. at 39,852. In this case, a February 1987 letter from the Department of the Army confirms that the Veteran's unit was subjected to mortar and rocket attacks in Vietnam in 1969. Therefore, the Veteran has confirmed in-service stressors. When affording the Veteran the benefit-of-the-doubt, the evidence also supports a finding of a current diagnosis of PTSD related to the Veteran's stressors. The earliest diagnosis of PTSD is an October 1984 VA examination for an increased rating claim for his service-connected anxiety neurosis. Previous examinations diagnosed the Veteran with anxiety neurosis. At the October 1984 VA examination, the Veteran reported frequent nightmares about his Vietnam experiences, in addition to other symptoms. Following examination, the examiner diagnosed the Veteran with PTSD with psychophysiological components. The examiner opined that the Veteran was suffering a PTSD condition secondary to Vietnam war experiences. The examiner reported that at the time of service connection, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III) was not in use and anxiety neurosis was the service-connected diagnosis best represented today by the aforementioned diagnosis of PTSD. A November 1985 VA opinion confirmed that the definitive diagnosis should be PTSD and that the clinical evidence supported that diagnosis. Following the October 1984 VA examination and November 1985 opinion, the pertinent medical evidence of record reflects both diagnoses of PTSD based on the Veteran's in-service stressors as well as generalized anxiety disorder. VA examiners in August 1988, November 1991, July 1997, January 1998, October 1999, July 2004, June 2005 and August 2011 all indicate that the Veteran did not meet the criteria for PTSD and the more appropriate diagnosis was generalized anxiety disorder. These opinions were all premised upon an interview and examination of the Veteran. Compared to the VA examiners, the Veteran's fee-based treatment provider, Dr. R.F., has indicated in numerous evaluations that the Veteran has PTSD. Evaluations from Dr. R.F. dated in September 1996, April 1997, August 1997, March 2004 and May 2011 all reveal diagnoses of PTSD due to the Veteran's Vietnam experiences. Some of Dr. R.F.'s opinions were supported by rationales identifying how the Veteran met the criteria for a diagnosis of PTSD. Additionally, a private evaluation from J.C., M.D. dated in July 1999 indicates that the Veteran had PTSD due to his military service. As with the October 1984 VA examiner's opinion, this evaluation indicates that PTSD was not a diagnostic category until the publication of the DSM-III in 1980. This opinion also indicates that according to the DSM-IV, anxiety disorder was a diagnostic category, which contains a group of various diagnoses in which PTSD was one of them. Also, a private evaluation from a psychologist dated in June 2009 indicates that based on a review of the Veteran's claims file, a diagnosis of PTSD was supported by the evidence. The examiner agreed with Dr. J.C.'s July 1999 evaluation. In this case, the medical evidence of record is conflicted as to whether the Veteran has PTSD or anxiety disorder. VA examiners overwhelmingly opine that the Veteran does not have PTSD, while private examiners opine that he does have PTSD. While not all of them, various opinions of record include rationales and are premised upon the Veteran's reported history in addition to an examination of the Veteran. After reviewing all of the opinions and treatment records, the Board concludes that the records showing a diagnosis of PTSD have equal evidentiary weight as those records showing that he does not meet the criteria for a diagnosis of PTSD. Therefore, the Board concludes that the there is an approximate balance of evidence both for and against a finding that the Veteran has PTSD. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Since the evidence as to whether the Veteran has PTSD is in relative equipoise to the evidence that he does not have PTSD, the Veteran prevails. As such, the Board concludes a finding that the Veteran has PTSD is warranted. Therefore, in considering the Veteran's verified stressors, the positive nexus opinions, as well as the pertinent medical evidence of record, and in affording the Veteran the benefit-of-the-doubt, the Board finds that it is at least as likely as not that the Veteran has PTSD that was incurred in service. The evidence is in favor of the grant of service connection for PTSD. Service connection for PTSD is granted. 38 U.S.C.A §5107 (West 2002 & Supp. 2012). In granting service connection for PTSD, as noted in the Board's November 2006 decision, PTSD and generalized anxiety disorder are rated under the same criteria. When assigning the rating for the anxiety disorder, the Board took into consideration all psychiatric symptomatology. Thus, the Veteran is not eligible for additional compensation for this now service-connected disability. 2. Tinnitus The Veteran contends that he has tinnitus that is related to in-service acoustic trauma. As discussed above, the Veteran has verified stressors of mortar and rocket attacks. Accordingly, in-service acoustic trauma is conceded. The Board has conducted a careful review of the record, and concludes that the record is without sufficient evidence supportive of a finding that the Veteran's current tinnitus became manifest or otherwise originated during his period of service or is otherwise related to his military service. There is no finding that tinnitus was treated or diagnosed during service. The Veteran's pre-induction examination in February 1968 and separation examination in January 1970 both revealed clinically normal ears. The Veteran also denied having ear, nose or throat trouble in his examinations. There is no indication in any of his STRs that he complained of, or was treated for, tinnitus. The Veteran's contemporaneous service records fail to show that the onset of any tinnitus occurred during service. The totality of the evidence fails to show that the onset of any current tinnitus occurred during the Veteran's service. The Veteran's statements during this appeal have not indicated that the onset of his tinnitus began during his military service. None of the Veteran's post-service treatment records contain complaints of, or treatment for, tinnitus. No medical professional has reported that the onset of any current tinnitus began during the Veteran's military service. The pertinent medical evidence that has been presented shows a current diagnosis of tinnitus; however, the evidence does not contain medical opinions relating any currently diagnosed tinnitus to the Veteran's military service. A July 2004 VA examination is silent as to whether the Veteran had tinnitus; and if so, whether it was related to his military service. At an August 2011 VA examination, the Veteran was unable to specify the date or circumstance of the onset of his tinnitus. The examiner opined that the Veteran's tinnitus was as likely as not a symptom associated with his hearing loss. The examiner noted that the Veteran had normal hearing bilaterally at entrance and separation from service; mild hearing loss was first identified 15 years after release of active service; and there was no evidence in the claims file of complaints of tinnitus while in active service and of treatment for tinnitus post-service. Therefore, the examiner concluded that the Veteran's tinnitus was less likely than not that initially manifested during service. This opinion is uncontradicted. The probative medical evidence simply fails to adequately establish any nexus between current tinnitus and the Veteran's period of service. No medical professional has provided any opinion indicating that any currently diagnosed tinnitus is related to the Veteran's military service. Without competent evidence of an association between tinnitus and his active duty, service connection for tinnitus is not warranted. The Board observes that, in some instances, lay evidence may be sufficient to establish a nexus. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (rejecting view lay person is not competent to provide testimony regarding nexus). However, the Veteran has not provided any reports of having tinnitus since in-service acoustic trauma. No reported onset date was provided in his initial claim in May 1997. As discussed above, the Veteran was unable to specify the date or circumstance of the onset of his tinnitus at the August 2011 VA examination. None of his statements throughout this appeal have indicated that his tinnitus began in service. Therefore, although lay evidence in some instances may be sufficient to establish a nexus, the Veteran's statements in this appeal have not established a nexus. Without evidence of the onset of tinnitus in service or competent evidence of an association between tinnitus and the Veteran's active duty, service connection for tinnitus is not warranted. Based on this evidentiary posture, the Board concludes that the preponderance of the evidence is against the Veteran's claim for service connection for tinnitus. As the preponderance of the evidence is against this issue, the benefit-of-the-doubt rule does not apply, and the Veteran's claim of entitlement to service connection for tinnitus is denied. See 38 U.S.C.A §5107. ORDER Entitlement to a rating in excess of 30 percent for anxiety disorder is denied. Entitlement to service connection for PTSD is granted. Entitlement to service connection for tinnitus is denied. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs