Citation Nr: 1318956 Decision Date: 06/11/13 Archive Date: 06/21/13 DOCKET NO. 08-07 043 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to a disability evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Chisholm Chisholm & Kilpatrick LTD WITNESSES AT HEARING ON APPEAL Appellant and a friend ATTORNEY FOR THE BOARD Patrick J. Costello, Counsel INTRODUCTION The appellant served on active duty in the United States Navy from August 1966 to March 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The appellant, along with a witness, testified in August 2009 before the Board at the RO. A transcript of that hearing has been included in the claims folder for review. This appeal was previously before the Board in October 2009, at which time it was remanded to obtain Social Security Administration records and to afford the appellant another VA examination. Such records were obtained in March 2010, and the appellant was afforded a VA examination in May 2010. Given the foregoing, the Board finds that VA has substantially complied with the Board's prior remand with regard to this appeal. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where there was substantial compliance with Board's remand instructions). After the claim was returned to the Board for review, the Board subsequently issued a Decision/Remand in July 2011. In that action, the Board determined that the evidence did not support the assignment of a disability evaluation in excess of 50 percent for PTSD. As such, the appellant's claim on this issue was denied. The Board further found that the issue of entitlement to a total disability evaluation based on individual unemployability due to the appellant's service-connected disabilities (TDIU) had been raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). That issue was remanded to the RO via the Appeals Management Center (AMC), in Washington, DC, for additional development and action. The appellant appealed the denial of his claim to the United States Court of Appeals for Veterans Claims (Court). After the claim was appealed to the Court, the parties of the appeal submitted to the Court a Joint Motion for Partial Remand, which was granted in an Order issued in August 2012. In that Joint Motion for Partial Remand, the parties concluded that the Board failed to fully discuss pieces of evidence in the claims folder (produced by the Social Security Administration) and that the portion of the Decision/Remand that denied the appellant's claim for benefits should be vacated and remanded to the Board for additional action. The Court, as noted, agreed, and the claim has since been returned to the Board for review. With respect to the Board hearing that occurred in August of 2009, the Board notes that in Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. 3.103(c)(2) requires that the Veterans Law Judge (VLJ) who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ noted that basis of the prior determination and noted the elements of the claim that were lacking to substantiate the claim for benefits. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim. Moreover, the appellant has not asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) or identified any prejudice in the conduct of the Board hearing. Indeed, the hearing focused on the elements necessary to substantiate the claim for benefits and the appellant, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board can adjudicate the claim based on the current record. FINDINGS OF FACT The appellant's service-connected PTSD is manifested by such symptoms as depression, poor sleep, nervousness, hypervigilance, nightmares, and flashbacks resulting in reduced reliability in social and occupational functioning CONCLUSION OF LAW The criteria for a disability rating in excess of 50 percent rating for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b), 5121 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 2.159, 3.321(b)(1), 3.1000, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. The Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating a claim for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2012). For the reasons to be discussed below, the Board finds that VA has satisfied its duties to the appellant under the VCAA. A VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim (1) veteran status; (2) existence of disability; (3) connection between service and the disability; (4) degree of disability; and (5) effective date of benefits where a claim is granted. Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006). VA has made all reasonable efforts to assist the appellant in the development of his claim, has notified him of the information and evidence necessary to substantiate the claim, and has fully disclosed VA's duties to assist him. In September 2006 and June 2008, the appellant was notified of the information and evidence needed to substantiate and complete the claim on appeal. Additionally, the September 2006 letter provided him with the general criteria for the assignment of effective dates and initial ratings. Id. Furthermore, as a claim for an increased initial rating is a downstream issue from that of service connection, he bears the burden of demonstrating prejudice resulting from defective VCAA notice. See Goodwin v. Peake, 22 Vet. App. 128 (2008) (holding that "where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream issues"). The Court further held, in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), that to satisfy the first Quartuccio element for increased ratings claims, that section 5103(a) compliant notice must meet a four part test. The US Court of Appeals for the Federal Circuit (Federal Circuit), however, overruled Vazquez-Flores in part, striking the claimant tailored and "daily life" notice elements. Vazquez-Flores v. Shinseki, 580 F. 3d 1270 (Fed. Cir. 2009). Thus modified, VA must notify the claimant that (1) to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability; (2) 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, and their impact upon employment; and (3) provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation. Vazquez-Flores, 22 Vet. App. at 43, overruled in part sub. nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). In any event, though not required, the appellant was provided with the specific language of the diagnostic criteria in post-adjudicatory documents. The Board further finds that VA has complied with the duty to assist by aiding the appellant in obtaining evidence. It appears that all known and available records relevant to the issues on appeal have been obtained and are associated with the appellant's claims files. The RO has obtained the appellant's service treatment records, as well as VA medical records. Pertinent medical records have also been obtained from the Social Security Administration (SSA). See Baker v. West, 11 Vet. App. 163, 169 (1998); Murincsak v. Derwinski, 2 Vet. App. 363, 370-72 (1992). He was also afforded VA medical examinations in January 2007, June 2008, and May 2010. The Board notes that the VA examination reports contain sufficiently specific clinical findings and informed discussion of the pertinent history and clinical features of the disability on appeal and are adequate for purposes of this appeal. Additionally, in August 2009, the appellant was afforded the opportunity to testify before the Board. During that hearing, the appellant described the symptoms and manifestations he was experiencing as a result of his service-connected psychiatric disorder. He further noted how the symptoms and manifestations affected his daily activities. The Board is not aware, and the appellant (or his accredited representatives) has not suggested the existence of, any additional pertinent evidence not yet received. Based on the foregoing, the Board finds that the appellant has not been prejudiced by any failure of VA in its duties to notify and assist him, and that any such violations could be no more than harmless error. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the appellant has neither alleged nor demonstrated any prejudice with regard to the content or timing of VA's notices or other development. See Shinseki v. Sanders, 129 U.S. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). Thus, adjudication of his claim at this time is warranted. II. Laws and Regulations The appellant seeks a disability rating in excess of 50 percent for PTSD. Disability evaluations are based upon the average impairment of earning capacity as contemplated by the schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the appellant's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (West 2002). In cases in which a reasonable doubt arises as to the appropriate degree of disability to be assigned, such doubt shall be resolved in favor of the appellant. 38 C.F.R. § 4.3 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7 (2012). PTSD is rated under Diagnostic Code 9411, for PTSD, which provides a 50 percent rating where 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 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. 38 C.F.R. Part 4 (2012). A 70 percent rating is warranted where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted where there is total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. In evaluating psychiatric disorders, the Board is mindful that the use of the term "such symptoms as" in 38 C.F.R. § 4.130 (2012) demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve only as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In addition, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a) (2012). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. When, however, 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 on the basis of social impairment. 38 C.F.R. § 4.126(b) (2012). III. Facts and Discussion In October 2006, the appellant described having problems sleeping, complicated by nightmares. He also reported that he constantly felt depressed, had flashbacks, and felt fatigued. He wrote that the medicine that was prescribed to him made him feel paranoid, so he quit taking it. In January 2007, the appellant was afforded a VA examination for PTSD. The appellant reported feeling depressed for approximately one hour per day. He denied experiencing anhedonia, and there were no signs or symptoms of mania. In describing his marital and family relationships, the appellant explained that he divorced in 1984, but was currently dating and the relationship was going well. He had a daughter but reported that they were not close because he did not get along with her mother and family. He estimated that he had approximately six friends, and described leisure activities of socializing at Veterans of Foreign Wars locations once or twice a week, playing computer games, watching movies, and tending to plants. He denied a history of suicide attempts, violence or assaultiveness. The appellant reported previous alcohol abuse, and arrest for driving under the influence of alcohol. The appellant indicated that he had one beer the night prior to the interview, and sometimes consumed up to three drinks. He reported that he did not use other substances. On physical examination his appearance was clean, neatly groomed, and appropriately and casually dressed. His psychomotor activity was unremarkable. His speech was unremarkable, spontaneous, clear and coherent. His attitude toward the examiner was cooperative, friendly, and attentive. His affect was constricted and the appellant reported his mood as a little nervous. The appellant was unable to perform serial sevens or to spell a word forwards and backwards; however, the examiner noted that the appellant's difficulties might be due to limited education. The appellant was oriented to person and place; however, he was not oriented to time, and missed the correct date by five days. His thought process was unremarkable, and he did not exhibit delusions. As far as his judgment, he understood the outcome of his behavior. He was of average intelligence, and with respect to insight, he partially understood that he had a problem. The appellant experienced sleep impairment, which he described as a sleep schedule of five to six hours at night, followed by one to three hour naps. The appellant did not have hallucinations, inappropriate behavior, obsessive or ritualistic behavior, panic attacks, homicidal or suicidal thoughts, or episodes of violence. The appellant had good impulse control, and was able to maintain minimum personal hygiene. There were no problems with daily living. The appellant had normal remote and immediate memory; however, his recent memory was moderately impaired. The appellant could recall three of three items immediately, but only one of three items after a several minute delay. The appellant acknowledged recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions, recurrent distressing dreams of the event, and acting or feeling as if the traumatic event were recurring. The appellant persistently avoided stimuli associated with the trauma and numbing of general responsiveness in an effort to avoid thoughts, feelings, or conversations associated with the trauma, and activities, places or people that aroused recollections of the trauma. The appellant felt detached or estranged from others, and had a restricted range of affect. The appellant had persistent symptoms of increased arousal such as difficulty concentrating, hypervigilance, and an exaggerated startle response. His symptoms were described as chronic. The appellant reported that during the previous week he had four intrusive memories, two nightmares, and three flashbacks. In addition, he reported feeling detached, having a restricted range of affect, difficulty concentrating, and being hypervigilant most of the time, and stated that he had three to four experiences with an exaggerated startle response. The appellant described avoiding war movies because they brought about upsetting reminders. The appellant knew the amount of his benefit payment and monthly bills. He prudently handled payments, personally handled money and paying bills, and was capable of managing financial affairs. The appellant explained that he had been a maintenance worker, but had been unemployed for two to five years and was in receipt of Social Security disability payments for his arthritis. The appellant did not contend his unemployment was due to the mental disorder's effects. The appellant at that time had chronic PTSD, and alcohol dependence in reported partial remission. He was assigned as having a Global Assessment of Functioning (GAF) score of 60. In summary, the appellant had not worked since 2001 reportedly due to arthritis. He had a positive relationship with his girlfriend, and had a number of social friends. The appellant was not considered to be unemployable due to PTSD. The appellant's prognosis was fair to good, and it was noted that he was not currently in treatment. There was not total occupational and social impairment due to PTSD, and there were not deficiencies in judgment, thinking, family relations, work, mood or school. There was not reduced reliability and productivity due to PTSD. There was, however, an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to PTSD, but with generally satisfactory functioning (routine behavior, self-care, and normal conversation). Pertinent symptoms included some social detachment and depression. VA treatment records show that in October 2007 the appellant was given a standard depression screening, and on review of the results, wherein he reported that he had not felt down, depressed or hopeless, or experienced little interest or pleasure in doing things over the previous two weeks, it was determined that no counsel or referral was necessary. Then, in June 2008, the appellant was afforded another VA examination. The information elicited was much the same as in 2007, with exceptions discussed below. This examiner reviewed the appellant's 2000 and 2001 history of outpatient treatment for PTSD and alcohol dependence. The appellant reported experiencing depression on a daily basis for the previous two weeks. He described the duration as from a few minutes to several hours at a time. He denied experiencing anhedonia, and there were no signs or symptoms of mania. The appellant described his three-year relationship with his now live-in girlfriend in very positive terms. The appellant described his relationship with his daughter as positive. He reported having two to three friends, and six acquaintances. The appellant had consumed two beers one day during the previous week, and reported drinking one to two days a week, consuming as many as six beers in the previous month. On examination, the findings were similar to those in 2007, with differences discussed below. His affect was constricted. He reported his mood was a little depressed, but not too bad. His attention was intact in that he could spell a word forwards and backwards. He was intact to person, time and place. His thought content revealed some suicidal ideation and obsessions, although the examiner indicated that he did not have obsessive ritualistic behaviors or suicidal thoughts. He described sleep impairment in the form of only five hours of sleep a night, with one to two hour naps during the day. His impulse control was fair. His remote, recent and immediate memory were normal, and the appellant was able to recall three of three items immediately and after a several minute delay. He reported intrusive memories, nightmares, and flashbacks, each occurring once in the previous week. He had not had any recent experiences with upsetting memories. He affirmed that he had physical reactions triggered by cues of trauma, to include sweating and getting cold. He described attempting to avoid thinking or talking about trauma as marked avoidance, and an attempt to avoid war movies that triggered upsetting memories of trauma. The appellant denied experiencing difficulty recalling important details from traumatic events, anhedonia, or a sense of a foreshortened future. The appellant reported having a mild restricted range of affect and detachment. He indicated that he had not been irritable or angry recently. He had mild to moderate problems with concentration, and described feeling hypervigilant when he was around someone that he did not know. He also explained that he had experienced an exaggerated startle response once in the previous week. Behavioral, cognitive, social, affective, or somatic changes that the appellant attributed to stress exposure were intrusive memories, nightmares, flashbacks, restricted range of affect, poor concentration, hypervigilance, and startle response. The appellant was again assigned as having a GAF score of 60. Since the previous examination the appellant's social interpersonal relationships were affected by a restricted range of affect experienced in his friendships, with the exception of his relationship with his girlfriend, and he was not as close to his friends. The PTSD, which was again considered not severe enough to cause the appellant to be unemployable, resulted in mild social impairment. The appellant's alcohol dependence exacerbated his restricted range of affect, and its relationship to the PTSD in causing such restricted range could not be separated without speculation. VA treatment records show that in March 2008 the appellant's significant other called with concerns that the appellant was having significant night sweats for the previous month or longer, and it seemed to be worse on the nights that he did not drink alcohol. At his August 2009 hearing, the appellant indicated that he sought occasional treatment amounting to about six months, and for a short time took medication that he perceived as causing paranoia so he discontinued its use. The appellant expressed that he experienced depression and anxiety, and had considered hurting himself. Ms. W., his girlfriend, explained that the appellant slept a lot, both during the day and at night, and perspired in his sleep, such that he would wrap himself in a towel. The appellant reported having night sweats and nightmares occasionally. The appellant responded in the affirmative regarding questioning about phobias, giving an example of a preference to sit facing the door, so that he was aware of what happened behind him. The appellant reportedly was not around others often, and had few interests. The appellant indicated that he had periodic flashbacks, and that his symptoms were triggered in response to loud noises, or periodically, television. He indicated that he sometimes had an exaggerated startle response, described as freezing up for a little while, and he testified that he had some memory loss. Ms. W. testified that the appellant's sense of direction was poor, possibly related to his difficulty paying attention. Ms. W. indicated that she drove the appellant to his appointments, and kept track of his schedule. The appellant testified that he had not worked since 2002 because of his PTSD symptomatology, particularly because he did not want to be around others. The appellant and Ms. W. indicated that the appellant socialized very little. Most recently, the appellant was afforded a VA examination in May 2010. At that time the appellant reported experiencing a chronic depressed mood, daily, and of moderate severity, present for as long as he could remember. He denied anhedonia. The appellant indicated that he lived with his girlfriend, with whom he had a good relationship. He indicated that many of his friends were deceased, and that he had not acquired many new friendships. He described his activities and leisure pursuits as gardening and playing computer games. He denied a past legal history or history of suicide attempts. He also denied a history of violence or assaultiveness. He indicated that he did not use alcohol. On examination he appeared clean, neatly groomed, and casually dressed. His psychomotor activity was unremarkable. His speech was unremarkable, clear, and coherent. His attitude was cooperative, affect normal, and mood tired. He was easily distracted. Although he was able to perform serial sevens, he was unable to spell a word both forwards and backwards. He was oriented to time, person and place. His thought process and content were unremarkable. He was without delusions. As far as his judgment, he understood the outcome of his behavior. He was of average intelligence, and had insight such that he could understand that he had a problem. The appellant experienced sleep impairment, as he reported waking up nightly between three and four in the morning, such that he would be tired the following day and require an afternoon nap. He was without hallucinations or inappropriate behavior. The examiner noted that the appellant simply could not interpret proverbs. The appellant denied experiencing obsessive or ritualistic behavior, panic attacks, or the presence of homicidal thoughts. He reported suicidal thoughts; however, he denied intent. The extent of his impulse control was fair. His remote, recent, and immediate memory were normal, and was able to recall two of three words, and following a prompt even the third word after several minutes. He acknowledged experiencing recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions, recurrent distressing dreams of the event, acting or feeling as if the traumatic event were recurring, intense psychological distress and physiological reactivity at exposure to internal or external cues that symbolized or resembled an aspect of the traumatic event. In addition, the appellant reported efforts to avoid thoughts, feelings, or conversations associated with the trauma, and activities, places, or people that aroused recollections of the trauma. He exhibited an inability to recall an important aspect of the trauma, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, restricted range of affect, and a sense of a foreshortened future. The appellant described persistent symptoms of increased arousal, such as difficulty falling or staying asleep, irritability or outbursts of anger, and difficulty concentrating. He described his symptoms as chronic, occurring daily to weekly, of moderate severity and present since service. The appellant denied any period of remission. Following testing, the appellant was assigned as having a GAF score of 60, indicative that he had moderate symptoms, or moderate difficulty in social, occupational, or school functioning. In considering his mental competency, the examiner noted that the appellant did not know the amount of his benefit payment and monthly bills, and he did not personally handle money, pay bills or prudently handle payments. Instead, the appellant's girlfriend handled the money, and the appellant was uncertain if he could handle payments. The appellant indicated that he was a cabinet maker, but had been unemployed since 2000 for physical reasons, including arthritis and its interference with his ability to operate power tools. The appellant did not contend that his unemployment was due to his mental disorder. The examiner noted that the appellant's service-connected PTSD should not preclude physical or sedentary employment. The appellant's combat experience was his primary PTSD stressor. The appellant was in sustained full remission of his alcohol dependence. The appellant's PTSD interfered with his social functioning. Although he had a meaningful, sustained relationship with his girlfriend, he otherwise avoided socializing and denied having friends. The appellant was noted to be able to maintain activities of daily living. Upon reviewing the complete record, the Board would note that over the course of this appeal, when the appellant has undergone VA Psychiatric Examinations, GAF scores of 60 have been assigned. Such a designation is significant in that it is based on a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995), citing the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington, DC, American Psychiatric Association, 1994 (DSM-IV) (which has been adopted by the VA in 38 C.F.R. §§ 4.125, 4.130). See also Richard v. Brown, 9 Vet. App. 266 (1996). Under DSM-IV, GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Id. GAF scores ranging between 41 and 50 are assigned when there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Id. GAF scores from 31 to 40 indicate some impairment in reality testing or communication 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 was unable to work). In evaluating the appellant's disability, the Board is mindful that when it is not possible to separate the effects of the service-connected condition from a non-service connected condition, 38 C.F.R. § 3.102 (2012), which requires that reasonable doubt be resolved in the appellant's favor, dictates that such signs and symptoms be attributed to the service-connected condition. See Mittleider v. West, 11 Vet. App. 181 (1998). In Mittleider, the appellant had been diagnosed with PTSD and various personality disorders and there was no medical evidence in the record separating the effects of the service-connected disability from the nonservice-connected disorders. Id. at 182. The Board finds this case distinguishable from Mittleider in that there is no medical evidence of record that the appellant's psychiatric manifestations and symptoms are associated with another disorder and cannot be separated out from that separate condition. Upon reviewing the record, it is the conclusion of the Board that the evidence does support an evaluation of 50 percent for PTSD, but no higher. The examinations accomplished have noted depression, isolation, anger-management problems, sleep deprivation, nightmares, and irritability. The evidence of record does not indicate a higher rating of 70 percent is warranted. The appellant was repeatedly assigned a GAF score of 60, 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 peers or co-workers). See American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994). Although the appellant acknowledged suicidal thoughts, he also denied intent, and although he reported obsessions he did not engage in obsessive ritualistic behaviors. His speech was not intermittently illogical, obscure, or irrelevant; at all times of record, he was able to converse with others in a clear, coherent manner, even if his affect was at times constricted. Although he experienced a depressed mood, he did not exhibit near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, as he was considered able to maintain his personal hygiene and activities of daily living. The appellant at his most recent examination indicated that he did not handle his finances, and was unemployed reportedly due to arthritis and a related inability to handle power tools. The appellant testified at his hearing that he has been unable to work since 2002 because of his PTSD. The Board does not find the appellant's testimony in this regard to be credible. He specifically reported that he was receiving Social Security disability due to his arthritis. His contention that he was unemployed because of his PTSD is not credible. The Board would further note that although the appellant has been granted Social Security Administration (SSA) benefits, these benefits have not been solely for his service-connected PTSD. That is, in the SSA Decision of October 10, 2003, the Administrative Law Judge (ALJ) noted that the appellant's impairments that would be considered for SSA purposes severe to be: dysthymic disorder, PTSD, amnesic disorder, left sided hearing loss, moderate lumbosacral osteoarthritis, and a left femoral hernia. The ALJ further wrote that the above-named disabilities were not, in and of themselves, solely responsible for the appellant's unemployment. The ALJ also concluded that the appellant did not have any type of residual functional capacity to perform the type of work that would be consistent with an individual of his age group, education, and past work experience. The ALJ acknowledged that the appellant was only service-connected by the VA for PTSD and that he had a long history of treatment for mental health problems not involving PTSD but his other psychiatric disorders and his severe alcohol abuse. It was further reported by the ALJ that a severe limiting factor in the appellant's ability to work was not the acquired psychiatric disorder (PTSD), but his more recently diagnosed severe unnamed neurotic/psychotic disorder. It is noted that the SSA benefits award was based upon private and government medical information that is now nearly ten years old. There is no indication that the appellant has been re-examined since that time by SSA to see whether there has been any improvement of the appellant's situation. Even though the appellant has been granted SSA benefits, the Board believes that the more recent examination reports, because they contain more current notations as to the appellant's actual limitations and restrictions, along with the type of manifestations he is suffering therefrom, are given precedence over more remote SSA records where, as here, the current reports are adequate and relevant to the rating issue. The Board has not ignored the SSA determination but it has not accepted the SSA conclusions, and does not find them determinative in this case. See Murincsak v. Derwinski, 2 Vet. App. 363, 372 (1992) (citing Collier v. Derwinski, 1 Vet. App. 413, 417 (1991)). Additionally, over the course of this appeal, the appellant has not displayed impaired impulse control, such as unprovoked irritability with periods of violence. VA examination reports and treatment records indicate he was fully alert and oriented at most times of record during the pendency of this appeal, with the exception that he was not oriented to time in January 2007. Overall, the appellant does not experience occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, rather his symptomatology most nearly approximates the criteria for a 50 percent rating for occupational and social impairment with reduced reliability and productivity. Thus, the Board concludes an initial rating in excess of 50 percent is not warranted. Furthermore, the Board concludes that, as the appellant has displayed an essentially similar level of impairment since the initiation of this appeal, staged ratings in excess of that already awarded are not warranted for any period during the pendency of this appeal. See Fenderson, 12 Vet. App. at 119. The Board is cognizant of the appellant's earnest contentions that his PTSD results in a level of impairment which warrants an increased disability rating. Despite being a layperson, the appellant is certainly competent to report such observable symptomatology as his psychiatric symptoms. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The appellant's contentions regarding his PTSD symptomatology are also considered credible by the Board. Nevertheless, the Board finds the appellant's written and testimonial statements to be of lesser probative value as compared to the VA examination reports, rendered by objective examiners with expertise in assessing psychiatric impairment. In conclusion, the Board thus denies the appellant's claim for the assignment of a disability evaluation in excess of 50 percent for PTSD. As a preponderance of the evidence is against the award of disability ratings in excess of those already assigned, the benefit-of-the-doubt doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2002 & Supp. 2012); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). IV. Extraschedular Evaluation In accordance with Thun v. Peake, 22 Vet. App. 111 (2008), there is a sequential three-step analysis to determine whether a case should be referred for extraschedular consideration. Step one, is to determine whether the schedular rating adequately contemplates a claimant's disability picture. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate, then no referral to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for consideration of an extraschedular rating is required. If the schedular criteria do not contemplate the claimant's level of disability and symptomatology and the schedular criteria are therefore found to be inadequate, then step two is to determine whether the claimant's disability picture is exceptional with such related factors such as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular criteria. If the disability picture meets the second step, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. Regarding the first step of Thun, the Board finds that the rating criteria reasonably describe the appellant's disabilities and symptomatology. In other words, the appellant has described symptomatology regarding PTSD that includes anxiety, intrusive thoughts, nightmares and sleep disturbance, irritability, depression, social isolation, and difficulty handling finances. The Board is cognizant that the appellant is unemployed and has been unemployed since approximately 2000, reportedly partially related to his arthritis and corresponding difficulty handling power tools. The appellant, however, does not experience symptomatology not already contemplated by the Rating Schedule. As the rating criteria reasonably describe the disability and symptomatology, the threshold factor for extraschedular consideration under step one of Thun has not been met, and the Board need not reach the second step of the Thun analysis, that is, whether the disability picture is exceptional. In short, there is nothing in the record to indicate that this service-connected PTSD on appeal causes impairment with employment over and above that which is contemplated in the assigned schedular rating. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) [noting that the disability rating itself is recognition that industrial capabilities are impaired]. The Board therefore has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) (2012) is not warranted. ORDER Entitlement to an increased evaluation for PTSD, currently rated as 50 percent disabling, is denied. ____________________________________________ JAMES L. MARCH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs