Citation Nr: 1318975 Decision Date: 06/11/13 Archive Date: 06/21/13 DOCKET NO. 07-03 251 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for service-connected posttraumatic stress disorder (PTSD) prior to January 30, 2008, and since May 1, 2008. 2. Entitlement to service connection for a throat disorder, claimed as a thyroid condition. 3. Entitlement to a total disability rating based on individual unemployability (TDIU) for the period prior to January 30, 2008, and since May 1, 2008. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Donna D. Ebaugh, Counsel INTRODUCTION The Veteran served on active duty from January 1960 to August 1969. This case comes before the Board of Veterans' Appeals (Board) on appeal from decisions by the Department of Veterans Affairs (VA) Regional Offices (RO) in April 2005 and November 2005. These claims were previously remanded by the Board in September 2012 and are now ready for further disposition. The July 2011 VA examination report raised the issue that the Veteran may be unable to work due to his PTSD. The Board is aware that under Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009), the issue of an entitlement to total disability based upon individual unemployability due to service-connected disabilities (TDIU) would be raised in such a situation. However, the Board notes that the Veteran is in receipt of a 100 percent evaluation for his service-connected ischemic heart disease disability and such rating has been effective since August 2002, which is prior to the initial rating period for his PTSD. (Service connection for PTSD has been in effect since November 2004). A TDIU is provided where the combined schedular evaluation for service-connected diseases and disabilities is less than total, or 100 percent. 38 C.F.R. § 4.16(a) (2012). A 100-percent rating under the Schedule for Rating Disabilities means that a veteran is totally disabled. Holland v. Brown, 6 Vet. App. 443, 446 (1994), citing Swan v. Derwinski, 1 Vet. App. 20, 22 (1990). Thus, if VA has found a veteran to be totally disabled as a result of a particular service-connected disability or combination of disabilities pursuant to the rating schedule, there is typically no need, and no authority, to otherwise rate that veteran totally disabled on any other basis. See Herlehy v. Principi, 15 Vet. App. 33, 35 (2001) (finding request for TDIU moot where 100 percent schedular rating was awarded for the same period). It previously was concluded in VAOPGCPREC 06-99 that a TDIU may not be considered when a 100 percent schedular evaluation already is in effect for one or more service-connected disabilities. See also Green v. West, 11 Vet. App. 472 (1998); Vettese v. Brown, 7 Vet. App. 31 (1994); Holland v. Brown, 6 Vet. App. 443 (1994). However, the opposite conclusion was reached in Bradley v. Peake, 22 Vet. App. 280 (2008). Recognized therein was that no additional disability compensation may be paid when a total schedular evaluation for a particular service-connected disability is in effect. Yet also recognized was that consideration of a TDIU for another service-connected disability or other service-connected disabilities may still be necessary so that a determination can be made regarding special monthly compensation (SMC). VAOPGCPREC 6-99 was withdrawn in light of Bradley. In this case, SMC was awarded for the period from January 30, 2008 to April 30, 2008 under 38 C.F.R. § 3.350(i). However, SMC has not been awarded for the periods currently on appeal. As such, the inferred claim for TDIU is not moot simply because the Veteran has been awarded a 100 percent disability rating for another service-connected disability. The Board notes that pertinent VA outpatient treatment records are located in Virtual VA. Instead of paper, Virtual VA is a highly secured electronic repository used to store and review every document involved in the claims process. Any future consideration of this appellant's case should take into consideration the existence of this electronic record. The issue of entitlement to a TDIU for the period prior to January 30, 2008 and from May 1, 2008 is addressed in the Remand portion of the decision below and is Remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. For the periods prior to January 30, 2008 and from May 1, 2008, the evidence demonstrates that the Veteran's acquired psychiatric disorder resulted in occupational and social impairment with reduced reliability and productivity; however, the evidence does not demonstrate occupational and social impairment in most areas such as work, school, judgment, thinking or mood. 2. The evidence of record is against a finding that the Veteran's has a throat disorder, claimed as a thyroid disorder, related to his active duty service. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 50 percent, but no higher, for the periods prior to January 30, 2008 and from May 1, 2008, for an acquired psychiatric disorder are met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 3.326, 4.130, Diagnostic Code (DC) 9411 (2012). 2. The criteria for the establishment of service connection for a throat disorder, claimed as a thyroid disorder, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and assist the claimant in substantiating this claim for VA benefits, as provided by the Veterans Claims Assistance Act of 2000 (VCAA). 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record that is necessary to substantiate the claim. Proper notice will inform the Veteran of what evidence VA will seek to provide, and of what evidence the claimant is expected to provide, in accordance with 38 C.F.R. § 3.159(b)(1) (2011). Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information regarding the disability rating and effective date for the award of benefits if service connection is awarded. Id. at 486. The U.S. Court of Appeals for the Federal Circuit previously held that any errors in notice required under the VCAA should be presumed to be prejudicial to the claimant unless VA shows that the error did not affect the essential fairness of the adjudication. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). Under Sanders, VA bore the burden of proving that such an error did not cause harm. Id. In the case Shinseki v. Sanders, 129 S.Ct. 1696 (2009), however, the U.S. Supreme Court held that the Federal Circuit's blanket presumption of prejudicial error in all cases imposed an unreasonable evidentiary burden upon VA. Rather, in Shinseki v. Sanders, the Supreme Court suggested that determinations concerning prejudicial error and harmless error should be made on a case-by-case basis. Id. As such, in conformance with the precedents set forth above, on appellate review the Board must consider, on a case-by-case basis, whether any potential VCAA notice errors are prejudicial to the claimant. Regarding the initial rating for PTSD, the Veteran's claim arises from an appeal of the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA. Regarding the claim for service connection, VA satisfied the VCAA duty to notify by way of a letter sent to the Veteran in August 2005 that fully addressed all of the notice elements and was sent prior to the initial RO decision in this matter. Through the letter, VA informed him of what evidence was required to substantiate the claim and of his and VA's respective duties for obtaining evidence. VA also informed him that his service connection claim must be supported by evidence indicating a current disability, evidence that the injury or disease was incurred or aggravated during service, and medical evidence of a nexus between the current disability and the in-service injury or disease. VA informed him that VA would seek to provide federal records and that it was his responsibility to support his claim with appropriate evidence, though VA would help him obtain records from any non-federal sources. With respect to the Dingess requirements, letters dated in May 2008 (regarding PTSD) and September 2009 (regarding PTSD and throat disorder) included notice of what type of information and evidence was needed to establish a disability rating, as well as notice of the type of evidence necessary to establish an effective date. As the rating decision at issue here was issued prior to the Dingess decision, the Dingess notice was necessarily issued after the rating decision. Thus, there was a timing defect with respect to the Dingess notice. However, after issuance of the letters, and opportunity for the Veteran to respond, the April 2012 SSOC and February 2013 SSOC reflect readjudication of the claims. Hence, the Veteran is not shown to be prejudiced by the timing of the notice. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in an SOC or SSOC, is sufficient to cure a timing defect). Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board and VA has complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in obtaining any outstanding records of identified VA or private medical treatment relevant to his claim, and affording him an examination when appropriate. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. With regard to records, VA has associated with the claims folder the Veteran's service treatment records, private medical records and pertinent VA medical records. The Veteran has not indicated that there exist any records of VA or private VA medical treatment relative to this claim that are not already in the claims file. The RO/AMC also accomplished the development directed by the Board in the prior remands, obtaining a VA examination for the PTSD disorder claim in March 2012 as well as obtaining outstanding VA outpatient treatment records as directed by the October 2010 and September 2012 Remands, and offering the Veteran another opportunity to have VA obtain private treatment records on his behalf. Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Further, regarding the claim for an initial rating in excess of 30 percent for PTSD, the Veteran has been afforded several VA examinations, in January 2005, October 2005, June 2008, July 2011, and March 2012. The Board finds that the examination reports are adequate as the VA examiners conducted thorough interviews with the Veteran, and assessed the Veteran's functioning. Further, the January 2005, July 2011, and March 2012 VA examiners reviewed the claims file. The Board acknowledges that it is unclear whether the October 2005 VA examiner reviewed the claims file and that the June 2008 VA examiner did not review the claims file. Nevertheless, the fact that the claims file was unavailable to the examiners is not a fatal flaw. The Court has held probative value of a medical opinion comes from when it is factually accurate, fully articulated, and has sound reasoning for the conclusion, not the mere fact that the claims file was reviewed. Nieves- Rodriguez v. Peake, 22 Vet App 295 (2008); see also Gardin v. Shinseki, 613 F.3d 1374 (2010) (noting that neither statute nor regulation requires that a physician review a veteran's medical service record before his or her opinion may qualify as competent medical evidence). Here, both the October 2005 and June 2008 VA examiners discussed the Veteran's PTSD treatment. Moreover, the June 2008 VA examiner indicated that the Veteran's medical records had been reviewed. The discussion of the Veteran's symptoms, medical history, and current physical findings mirrors those found in the claims file and support the conclusions made in the reports. Additionally, the Board acknowledges the Veteran's contention that the March 2012 VA examination is inadequate as it addressed service connection rather than an increased rating. However, the Board has reviewed the report and finds that it is adequate in light of the fact that the report contains an inventory of the Veteran's PTSD symptoms and addresses his current functioning. With respect to the claim for service connection of a throat disorder claimed as a thyroid disorder, the Board acknowledges that the Veteran has not been provided with a VA examination. As outlined in 38 C.F.R. § 3.159(c)(4), a VA examination to address the question of etiology as related to service is required when the Veteran presents a claim for service connection in which there was a pertinent event, injury, or disease in service; there is evidence of current disability; the medical evidence of record does not contain sufficient competent medical evidence to decide the claim; and the Veteran indicates that the claimed disability or symptoms may be associated with service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran provided testimony in August 2010 regarding his claimed throat and/or thyroid disorder informing of no diagnosis of such a disorder since he had his tonsils removed in 1979. In the absence of any reasonable indication of a diagnosis of a current disorder, and no indication that any acute throat disorder diagnosed in the late 1970's or early 1980's has current residuals or was ever related to service, a VA examination to address the Veteran's throat and/or thyroid claim is not warranted. 38 C.F.R. § 3.159(c)(4). The Board notes in this regard that "[t]he duty to assist is not always a one-way street. If a Veteran wishes help, he cannot passively wait for it in those circumstances [where his input is crucial for obtaining that assistance]." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). See also Olson v. Principi, 3 Vet. App. 480, 483 (1992). Here, the Veteran only testified vaguely to the possibility that he had a throat/thyroid disorder, without indicating that any such diagnosis was based on any medical evidence or any specific knowledge. Thus, by not articulating a basis of claim supported by any evidence, the Veteran has failed to put forth the minimal basis of claim which would give rise to the necessity of an examination for his throat/thyroid claim. McLendon, 20 Vet. App. 79. Additionally, in August 2010, the Veteran was provided an opportunity to set forth his contentions during the hearing before the undersigned Veterans Law Judge. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the U.S. Court of Appeals for Veterans Claims recently held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the August 2010 hearing, the undersigned Veterans Law Judge enumerated the issues on appeal. See Hearing Transcript (T.) at p. 2. Also, information was solicited regarding the nature of his throat/thyroid disorder (T. at p 9-10) as well as the severity of his PTSD symptoms (T. at p. 11-13) and whether there were any outstanding medical records available regarding either claim. See T. at p. 18. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim" were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, the hearing discussion did not reveal any evidence that might be available that had not been submitted. Under these circumstances, nothing gave rise to the possibility that evidence had been overlooked with regard to the appellant's claim for an increased initial rating for PTSD or for service connection for a throat and/or thyroid disorder. As such, the Board finds that, consistent with Bryant, the undersigned Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Initial Rating In this case, the Veteran claims higher ratings for his service-connected PTSD for the period prior to January 30, 2008 and from May 1, 2008. Notably, he was assigned a temporary total rating for the period from January 30, 2008 to April 30, 2008. a. Laws and Regulations Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Separate diagnostic codes (DCs) identify the various disabilities. 38 U.S.C.A. §1155 (West 2002); 38 C.F.R. § Part 4 (2012). When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. See Fenderson v. West, 12 Vet. App. 119 (1999). Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). In this case, the Veteran was granted service connection for PTSD in April 2005, effective in November 2004. Throughout the rating periods on appeal, the Veteran has been assigned a 30 percent rating for PTSD. As discussed above, he was assigned a temporary total rating from January 30, 2008 to April 30, 2008. He contends that his symptoms are of such severity as to warrant higher ratings for both periods on appeal. PTSD is evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, DC 9411. Under DC 9411 and the General Rating Formula for Mental Disorders, ratings may be assigned ranging between 0 and 100 percent. A 30 percent disability rating is appropriate when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. The next higher rating of 50 percent requires 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; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating requires 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 work like setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating requires 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. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. When evaluating a mental disorder, the evaluation must be 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). Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Reports of psychiatric examination and treatment frequently include a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a GAF scale includes scores ranging between zero and 100 which represent the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health illness. The GAF score and the interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, an assigned GAF score, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a). In this regard, GAF scores of 41 to 50 indicates 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 51 to 60 indicates 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). A GAF score of 61 to 70 indicates 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 with some meaningful interpersonal relationships. b. Factual Background The Board notes that a June 1998 Social Security Administration (SSA) decision indicated that one of the Veteran's severe impairments was depression. By rating decision of April 2005, service connection was granted for PTSD, and a 30 percent evaluation was granted effective November 30, 2004. The Veteran underwent a VA examination in January 2005 regarding his PTSD. At that time, he reported that he had been sleeping poorly. He reported that he woke up at least two to three times in a month and would see a helicopter flying. He also reported that he "sees people getting injured," wakes up and cannot fall back asleep. He also reported recurrent thoughts about Vietnam. He reported that at times, he heard voices but could not understand them. He also reported that he felt sad and depressed but he denied any thoughts to hurt himself or other people. He denied any paranoid symptoms. The examiner diagnosed PTSD and assigned a GAF of 70. In a March 2005 statement, the Veteran reported that there were times when he wanted to commit suicide. He also reported waking up in a cold sweat from visions of Vietnam. He also reported a battle with alcohol as well as overeating. The Veteran underwent another VA examination in October 2005. At that time, he reported he was taking prescription medication that helped with his depression and sleep; however, he reported that he still had nightmares at least once a month. He also reported that he would sleep for five to six hours and wake in the middle of the night with sweats. He reported that he usually dreamed about the Vietnam War and usually saw himself getting lost. He reported that at times, he had difficulty concentrating. He also reported that he felt mildly depressed at times but that his energy level was okay. The examiner also noted that the Veteran was dressed appropriately. The examiner noted that the Veteran was mildly depressed and anxious but that he communicated well with the examiner. The examiner noted that there was no evidence of delusional thinking and that the Veteran was not considered paranoid, was free from any suicidal or homicidal ideas or intent. The examiner also noted that the Veteran was alert and oriented to time, place and person. The examiner noted that the Veteran's memory for recent and remote events was fair. The examiner assigned a GAF of 65. A December 2007 VA outpatient treatment record noted that the Veteran denied any anxiety and reported that he was depressed off and on, but was not depressed at the time of the evaluation. The Veteran reported that he had nightmares. The VA psychiatrist noted that he was calm, interacted appropriately; his mood was euthymic and his affect was constricted; his speech was coherent, relevant, and spontaneous; his sleep and appetite were fair; his memory and cognition were intact; and his insight and judgment were adequate. The VA psychiatrist assigned a GAF of 65. An April 2008 VA discharge note indicated that the Veteran's PTSD symptoms included depression, anxiety, tendency to isolate himself, intolerance of crowds, exaggerated startle response, and anger. At that time, the Veteran also reported that he experienced insomnia (slept four hours per night), nightmares three times per week, night sweats three times per week, and flashbacks three times per month. A May 2008 VA outpatient treatment record noted that the Veteran was concerned about not having his anger under control. In another May 2008 VA outpatient treatment record, the Veteran reported that he rated his depression as a 6 on a scale from 0 to 10. He reported that he felt bad and had no energy. He denied any suicidal or homicidal ideations as well as auditory or visual hallucinations or delusional thinking. He reported that his judgment was fair. The VA medical professional noted that the Veteran's insight was limited. The VA medical professional also noted that the Veteran may feel tired and worn out when his glucose level is low. (The Veteran has diabetes). The VA medical professional also indicated that the Veteran might feel tired if his thyroid level was low. The Veteran underwent another VA examination in June 2008. At that time, he reported that he was tired, had difficulty sleeping and only got about three hours of sleep per night. He also reported having nightmares twice per week. He also reported that he was married in 2006 and divorced in January 2008. He reported that he had no children and currently lived alone. He reported that he does not like to be around people and is isolated. Although, he also reported that he enjoyed getting together with a group of his cousins and grilling, watching sports, etc. He reported that he likes to listen to music and watch baseball on television. He also reported that he dined out most day and listed the restaurants that he frequented. The Veteran denied having any hallucinations. He denied any obsessive or ritualistic behavior. He also denied panic attacks, homicidal thoughts, and suicidal thoughts. He denied episodes of violence. The examiner noted that the Veteran was clean, casually dressed, cooperative, attentive. The examiner noted that his affect was appropriate. The examiner noted that the Veteran's attention was intact. The examiner also noted that the Veteran was oriented to person, time, and place. The examiner noted that the Veteran's thought process and content were unremarkable. The examiner noted that regarding judgment, the Veteran understood the outcome of his behavior. The examiner also noted that the Veteran had good impulse control and an ability to maintain minimal personal hygiene. The examiner noted that the Veteran's remote, recent, and immediate memories were all normal. Despite the examiner's note that impulse control was good and that the Veteran had no episodes of violence, the examiner also noted that the Veteran had persistent symptoms of irritability or outbursts of anger. The June 2008 VA examiner also noted several conflicts between the Veteran's reports and the examiner's observations and that the pattern of conflict was noted in the progress notes from his in-patient treatment. First, the examiner noted the Veteran's report that he was "at rock bottom" and that "everything is falling apart." The examiner also noted that the Veteran stated he was isolated and does not socialize yet, the examiner pointed out that the Veteran eats out almost daily and has a group of friends with whom he socializes frequently. The examiner also noted that the Veteran reported that he "can't get no help" but that the record indicated that the in-patient treatment was helpful. The examiner also noted that the Veteran reported that he had no memory but that he did well on several questions addressing memory. The June 2008 VA examiner assigned a GAF of 65 and commented that the Veteran continued to have problems sleeping and is depressed at times and possibly anxious. The examiner also noted that the Veteran's condition appeared to have improved slightly or at least stabilized. The examiner noted that the Veteran's PTSD was not to the point of not being able to maintain gainful employment but that the Veteran's other medical problems would likely result in him not being able to work. A September 2008 VA outpatient treatment record noted that the Veteran reported nightmares, intrusive thoughts, avoidance, irritability, exaggerated startle response, hypervigilance, insomnia and poor concentration. The Veteran also complained of being depressed but denied suicidal or homicidal ideation. The VA psychiatrist assigned a GAF of 46. An October 2008 VA outpatient treatment record noted the Veteran's report that he was tired and did not sleep at night but that he slept during the day. The Veteran also reported that he was not active and spent a lot of time at home. He reported that he was estranged from his family. He denied suicidal or homicidal ideation. The VA psychiatrist assigned a GAF of 46. Another October 2008 VA outpatient treatment record authored by the same VA psychiatrist, Dr. G., noted the Veteran's report that he was sleeping better but that he continued to experience nightmares, intrusive thoughts, avoidance, irritability, exaggerated startle response, and hypervigilance. He denied suicidal and homicidal ideations. Dr. G. noted that the Veteran's mood was up and down. Dr. G. assigned a GAF of 47. A December 2008 VA outpatient treatment record authored by the same VA psychiatrist, Dr. G., noted similar reports as the October 2008 records and assigned a GAF of 47. In February 2009, another VA outpatient treatment record by Dr. G., again noted the Veteran's report that he continues to experience nightmares, intrusive thoughts, avoidance, irritability, exaggerated startle response, hypervigilance, and insomnia. The Veteran reported that he cannot sleep at night because he is "waiting for something to happen." He reported that the closer it gets to sunrise, the better he sleeps. He also reported that he spends a lot of time alone. He denied suicidal or homicidal ideation. Dr. G. assigned a GAF of 47. In March 2009, the Veteran was treated by Dr. G. again and reported the same symptoms. Dr. G. assigned a GAF of 45. In April 2009, the Veteran was treated by Dr. G. again and reported that he was in a lot of pain and was not sleeping. He denied suicidal or homicidal ideations. Dr. G. assigned a GAF of 47. In May 2009, he was treated again by Dr. G. and reported that he continues to experience nightmares, intrusive thoughts, avoidance, irritability, exaggerated startle response, and hypervigilance. Dr. G. assigned a GAF of 45. A July 2009 VA outpatient treatment record authored by a VA psychology intern indicated that the Veteran was alert and oriented times four. The author noted that the Veteran's thoughts and speech were scattered, his mood was dysthymic and affect was congruent with moderate range. The Veteran denied homicidal thoughts and hallucination, endorsing occasional escapist thoughts with no plan for self-harm. The Veteran scored a 32 on the Beck Depression Inventory, which was in the severe range, and scored 58 on the State Trait Anxiety Inventory, which was in the moderate range. In March 2010, the Veteran was treated by Dr. G. again and reported the same symptoms - nightmares, intrusive thoughts, avoidance, irritability, exaggerated startle response, and hypervigilance. He denied suicidal or homicidal ideations. Dr. G. assigned a GAF of 46. In June 2010, Dr. G. treated him again and assigned a GAF of 48. At that time, the Veteran reported nightmares, intrusive thoughts, avoidance, irritability, exaggerated startle response, and hypervigilance. The Veteran also reported that he had no energy and was withdrawn socially. He reported that he was more comfortable alone and that the news and events of the day caused him to become anxious. He reported that he had poor concentration and wondered if individual therapy might help. He denied suicidal or homicidal ideations. A June 2010 VA psychiatric consult by a different VA psychiatrist, Dr. B., noted that the Veteran had fair concentration and appetite; he had anxiety due to PTSD; his energy was low; he had loud snoring at night; he was alert, oriented times three. Dr. B. noted that his cognition was intact, he was cooperative, his speech was productive and goal-directed, his mood was depressed. Dr. B. also noted that his affect was appropriate to his mood, his insight was good, judgment was good, impulse control was good. The Veteran reported that he thinks of suicide because he hurts so badly all of the time, although he reported that he had no plan for suicide and wanted help for his pain. Dr. B. indicated that the Veteran was unstable due to his chronic pain. Dr. B. noted that the Veteran's "level of functioning" was 55. Another June 2010 VA group therapy record authored by a VA psychologist, Dr. T., indicated that the Beck Depression Inventory II was administered and that the Veteran scored a 40, indicating severe depressive symptoms. An August 2010 VA psychiatric note by Dr. G. noted the Veteran's reports of nightmares, intrusive thoughts, avoidance, irritability, exaggerated startle response, hypervigilance, and poor concentration. He denied suicidal or homicidal ideations. He reported that his relationship with his family was poor and that he was most comfortable alone. Dr. G. assigned a GAF of 47. Another August 2010 VA outpatient treatment record noted that the Veteran reported having passive suicidal thoughts a few times per week. An October 2010 VA outpatient treatment record regarding medical complaints indicated that the Veteran should follow up with Dr. G. because the Veteran appeared to be having anxiety attacks. An October 2010 record authored by Dr. G. indicated the Veteran's complaints of nightmares, intrusive thoughts, avoidance, irritability, exaggerated startle response, hypervigilance, and poor concentration. He denied suicidal or homicidal ideations. Dr. G. assigned a GAF of 47. An October 2010 VA outpatient treatment record regarding physical problems noted that the Veteran should follow up with Dr. G. as he appeared to be having anxiety attacks. Another October 2010 note from Dr. G. indicated that the Veteran called in complaining of anxiety attacks and that Dr. G. added another medication to the Veteran's regimen. A November 2010 VA discharge summary indicates that the Veteran was an inpatient in a VA facility for approximately 17 days. He was diagnosed with a psychotic disorder not otherwise specified, rule out adjustment disorder, and PTSD. He reported symptoms including homicidal ideation toward a woman who broke into his house and stole his medications. He also reported suicidal ideation as well as that he was not sleeping much, had increased depression, low energy, loss of interest, chronic need to isolate, and hurting all over. He also described feelings of clairvoyance and auditory hallucinations. He also reported a history of violence, indicating that he cut a man who owed him money. He reported that he had anxious feelings and felt hopeless. On mental status examination, he was noted to be well-nourished and well kept, appropriate in appearance and demeanor. He was noted to be alert, congruent and fairly logical except in his ideation to take the law into his own hands. His thought process seemed fairly organized and linear. His affect was restricted and his mood was depressed and anxious. The VA physician noted that he reported poor sleep and fair appetite. The initial diagnosis was transient situational disturbance superimposed on chronic PTSD. The physician also noted that he also had schizoaffective disorder and was felt to be psychotic on admission. The physician also noted that the Veteran was having an adjustment disorder with mixed anxiety and depressed mood related to medical conditions and chronic pain. By the time of discharge, he denied hallucinations, homicidal ideations. The physician noted that he was alert and oriented, congruent but still with some cognitive inefficiency. He continued to have a mildly idiosyncratic presentation but it had improved with medication. He was sleeping adequately and he had a brighter affect. He reported a good mood and requested discharge. He was assessed to pose no acute risk of harm to himself or others. VA outpatient treatment records authored by Dr. G. and dated in January 2011, April 2011, June 2011 and November 2011 are consistent with the other VA outpatient treatment records. During these treatments, Dr. G. assigned GAF scores ranging from 45 to 48. The Veteran reported the same symptoms of nightmares, intrusive thoughts, avoidance, irritability, exaggerated startle response, hypervigilance, and poor concentration and he denied suicidal or homicidal ideations. In another February 2011 VA outpatient treatment record, the Veteran reported anxiety attacks. In November 2011, the Veteran reported that he was sleeping better but continued to have the symptoms listed above. In July 2011 the Veteran underwent another VA examination. At that time, the Veteran reported the following symptoms that were attributed to his PTSD diagnosis: depressed mood, anxiety, suspiciousness, weekly panic attacks, chronic sleep impairment, impairment of short and long term memory, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationship, difficulty in adapting to stressful circumstances, inability to establish and maintain effective relationships, and neglect of personal appearance and hygiene. The examiner assigned a GAF of 48 and opined that the Veteran's level of social and occupational impairment was total social and occupational impairment. The examiner explained that all symptoms including anxiety, sleep disturbance, poor social interactions, isolation, nightmares, flashbacks, hypervigilance, an exaggerated startle response, angry outbursts and avoidance behaviors could be attributed to PTSD. Notably, the Veteran had previously been diagnosed with a schizoaffective disorder in addition to PTSD; however, the July 2011 VA examiner opined that the Veteran only had one Axis I diagnosis - PTSD. In March 2012, the Veteran underwent another VA examination. At that time, the Veteran reported that he had been married for three years but chose to divorce his wife because she was hoarding and collecting lots of things that he did not like. When specifically asked whether his Vietnam experience affected his marriage, he answered "no." He also reported that he is usually able to socialize well. He reported that he goes to the senior citizen center and plays Bingo and domino games five days a week. He also reported that he has been sleeping six to seven hours a night. He reported that he hardly has dreams, maybe once per week, and it does not bother him. He reported that he usually sees people getting hurt. He reported that he has a good appetite. He reported that he sometimes feels depressed but not because of being in Vietnam but rather because of his medical condition, including heart disease. The examiner noted that there was no evidence of any psychotic symptoms in the form of hearing voices or seeing things. He denied any panic attacks or anxiety symptoms at the time of the examination. The examiner also noted that the Veteran had good eye contact; that his affect was appropriate; he did not have any looseness of association; did not have any thought disorder; did not have any hypervigilance, and was not considered suicidal or assaultive. The examiner noted that the Veteran's judgment and insight were fair and that he was alert and oriented to time, place and person. The examiner noted that the Veteran's mood was mildly depressed. The Veteran's GAF score was 60. The examiner noted that PTSD symptomatology was not contributing to the Veteran's work impairment. c. Analysis For the reasons explained below, the Board affords the Veteran the benefit of the doubt and finds that the Veteran's psychiatric disability warrants a 50 percent disability rating, but no higher, for the both periods on appeal. Regarding the period prior to January 30, 2008, the Board emphasizes that the Veteran experienced auditory hallucinations on at least one occasion. See January 2005 VA examination in which the Veteran reported hearing voices. On another occasion prior to January 30, 2008, the Veteran reported that there were times when he wanted to commit suicide. See March 2005 VA outpatient treatment record. Another VA outpatient treatment record indicated that his mood was euthymic and he had a constricted affect, which demonstrates the criteria for disturbance of motivation and mood as well as flattened affect. See December 2007 VA outpatient treatment record. The Board acknowledges that VA examination reports and VA outpatient records during the period prior to January 30, 2008 assigned GAF scores of 65-70, indicating only mild PTSD symptoms. Further, the Board acknowledges that the VA examination reports and outpatient treatment records do not support findings of all of the elements of the 50 percent rating criteria. For example, the evidence does not demonstrate symptoms like circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once per week; difficulty understanding complex commands; or impaired abstract thinking. However, as noted above, the symptoms recited in the criteria in the rating schedule for evaluating mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms. Mauerhan, 16 Vet. App. 436, 442 (2002). In accordance with Mauerhan, the Board has considered all symptoms of the Veteran's service-connected mental condition that affect the level of occupational or social impairment. Giving the Veteran the benefit of the doubt, the Board finds that during the period prior to January 30, 2008, the Veteran's disability more nearly approximates a finding of occupational and social impairment with reduced reliability and productivity. Thus, the 50 percent disability rating is warranted for the period prior to January 30, 2008. Regarding the period from May 1, 2008, in reaching the conclusion that a 50 percent disability rating is warranted, the Board places a high probative value on the VA outpatient treatment records authored by the Veteran's regularly-treating psychiatrist. The VA psychiatrist consistently assigned GAF scores in the 40's indicating serious psychiatric symptoms. The Board also emphasizes the June 2010 VA group therapy record that noted serious PTSD symptoms and that the Veteran was hospitalized in November 2010 for his PTSD. Further, the Veteran has reported symptoms consistent with the 50 percent disability rating at the VA examinations in July 2011 and March 2012. The Board acknowledges that some of the criteria that warranted the 50 percent disability rating for the period prior to January 30, 2008 (auditory hallucinations and suicidal ideations) appear to have resolved during the period from May 1, 2008, the Board emphasizes that other criteria appeared during the period from May 1, 2008. For example, the Veteran consistently reported symptoms of nightmares, intrusive thoughts, avoidance, irritability, exaggerated startle response, hypervigilance, insomnia and poor concentration during the period from May 1, 2008. See September 2008 VA outpatient treatment record. Further, his regularly treating VA psychiatrist consistently assigned GAF scores in the 40's, indicating serious psychiatric symptoms, during the period from May 1, 2008. An October 2010 VA outpatient treatment record regarding physical problems noted that the Veteran should follow up with Dr. G. as he appeared to be having anxiety attacks. Moreover, the Veteran was treated as an inpatient for approximately 17 days during the period, in November 2010 when he sought admission on his own and reported homicidal ideations toward someone who broke into his home and stole his prescription medication. The Board acknowledges that VA examination reports dated in June 2008 and March 2012 noted GAF scores in the mild to moderate range. Further, the Board acknowledges that the June 2008 VA examiner found conflicting responses to questions at the examination. However, the totality of the evidence supports a finding of occupational and social impairment with reduced reliability and productivity. Thus, the Board finds that the Veteran's disability warrants a 50 percent disability rating during the period from May 1, 2008. Having determined that the Veteran is entitled to a 50 percent disability rating during the periods on appeal, the Board will consider whether he is entitled to a higher evaluation for either period under the criteria for evaluating mental disorders under 38 C.F.R. § 4.130 (2012). As noted above, in order to be assigned the next-higher 70 percent rating, the evidence must show that the Veteran's PTSD causes 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); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, DC 9411. In this case, the Board finds that the evidence does not support assignment of the 70 percent rating during either period on appeal. In this regard, the Board notes that VA examination reports dated in June 2005, October 2005, June 2008, and March 2012, as well as VA outpatient treatment records dated throughout both periods, do not support a finding of the following criteria found in the 70 percent disability rating: 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); or an inability to establish and maintain effective relationships. The Board acknowledges that in March 2005, the Veteran experienced suicidal ideations. The Board has already afforded the Veteran the benefit of the doubt with respect to the period prior to January 30, 2008 by increasing the initial rating to 50 percent. The Board also acknowledges that the July 2011 VA examination report indicated total occupational and social impairment, however the examiner's explanation for the opinion listed the criteria that support a 50 percent disability rating. Moreover, the Veteran has offered sworn testimony that his unemployment is due to his physical disabilities, in particular his inability to lift. T. at p. 13. Further, the Board acknowledges that the Veteran was treated as an inpatient for approximately 17 days during the period, in November 2010. He sought admission on his own and reported homicidal ideations toward someone who broke into his home and stole his prescription medication, including pain medication among others. Notably, he did not report any impaired impulse control associated with the event. Rather, he was in control of his impulses and checked himself into the hospital when he felt the homicidal ideation. The evidence does not indicate that he displayed any other criteria found in the general rating formula to support a 70 percent disability rating. The Board emphasizes that the Veteran was consistently found to have intact orientation to person, time and place. He consistently denied obsessive rituals or panic attacks. With the exception of the March 2005 and November 2010 statements, he denied homicidal or suicidal thoughts. The evidence does not support a finding of impaired impulse control or episodes of violence. He was consistently found to maintain a minimum level of personal hygiene. Additionally, with the exception of the July 2011 VA examination report, the evidence does not even demonstrate difficulty in establishing and maintaining effective work and social relationships. For example, in June 2008, despite his complaints that he did not like to be around people, he reported socializing with his cousins regularly and going out to eat on a daily basis. Similarly, in March 2012, he reported that he socialized regularly at the senior citizen center. Further, despite his complaints of depression, it does not appear to have affected his ability to function. For example, the March 2012 VA examiner noted that the Veteran had been doing fairly well living by himself and that his PTSD was stable. As noted above, the VA outpatient treatment records as well as the July 2011 VA examination report consistently showed that the Veteran had GAF scores in the 40's during the period from May 1, 2008. While the Board acknowledges that a score from 41-50 demonstrates serious symptoms, the Board notes the January 2005 VA examiner's assignment of a GAF of 70, the October 2005 VA examiner's assignment of a GAF of 65, the December 2007 VA medical professional's assignment of a GAF of 65, June 2008 VA examiner's finding of a GAF of 65, and the March 2012 VA examiner's finding of a GAF of 60, all indicating mild to moderate symptoms. The June 2008 and March 2012 VA examiners also opined that the Veteran's work and social impairments were due to his medical conditions and not PTSD. Based on an evaluation of all the evidence of record, and irrespective of whether the individual criteria for a 70 percent disability rating have been met, the Board finds that the Veteran's psychiatric symptoms during the period prior to January 30, 2008 and from May 1, 2008, are consistent with reduced reliability and productivity due to his PTSD symptoms but not deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. As discussed above, the Board has also considered the Veteran's representative's July 2012 statement that the March 2012 VA examination report was inadequate as it did not use a Disability Benefits Questionnaire (DBQ) for an increased rating claim. However the Board notes that the VA examiner addressed the Veteran's current symptoms, the criteria found in the Diagnostic Code 9411, and assigned a GAF score. As such, the Board finds that the March 2012 VA examination was adequate and that another VA examination was not necessary. Further, the Board acknowledges that under 38 C.F.R. § 4.29, the Veteran may have an avenue to a temporary 100 percent disability rating for a period of hospitalization over 21 days. Here, the Veteran was hospitalized in November 2010 for less than the 21 days as required by the regulation for such a rating, and a temporary 100 percent rating is not warranted. Regarding both periods on appeal, the Board has considered the Veteran's written statements, as well as sworn statements, regarding the severity of his disability. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this case, the Veteran is competent to report symptoms of his PTSD because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. However, the Veteran is not competent to identify a specific level of disability of this disorder-according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's psychiatric disabilities has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and VA outpatient treatment records) directly address the criteria under which this disability is evaluated. Based on the evidence, the Board finds that a rating of 50 percent, but no higher, is warranted for the periods prior to January 30, 2008 and from May 1, 2008. Further, the disability does not warrant referral for extraschedular consideration. In exceptional cases where schedular ratings are found to be inadequate, consideration of an extraschedular rating is made. 38 C.F.R. § 3.321(b)(1) (2012). There is a three-step analysis for determining whether an extraschedular rating is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as governing norms. Id.; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are present, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. In this case, there has been no showing that the Veteran's disability picture for his acquired psychiatric disorder could not be contemplated adequately by the applicable schedular rating criteria discussed above. His psychiatric symptoms are addressed in the rating criteria. The criteria provide for higher ratings, but as has been explained thoroughly herein, the currently assigned rating adequately describes the severity of the Veteran's symptoms for this disability during the period of appeal. Given that the applicable schedular rating criteria are adequate, the Board need not consider whether the Veteran's disability picture includes such exceptional factors as periods of hospitalization and interference with employment. Nevertheless, the Board emphasizes the June 2005, October 2005, June 2008, and March 2012 VA examiners' opinions that the Veteran's work impairment is due to his medical conditions, not PTSD. The Board emphasizes the Veteran's sworn testimony that his inability to lift, and not his PTSD, prevents employment. T. at p. 13. The Board acknowledges the July 2011 VA examiner's opinion that his work impairment is due to PTSD but notes that the subsequent, March 2012 VA examination report specifically noted that the Veteran's medical disabilities, and not PTSD, prevented him from working. Further, the Board notes that despite the Veteran's voluntary hospitalization in November 2010, he has not reported frequent hospitalizations for his PTSD. Referral for consideration of the assignment of a disability rating on an extraschedular basis is not warranted. See Thun, 22 Vet. App. at 111. II. Service Connection The Veteran contends that he currently has a throat disorder, claimed as a thyroid disorder that developed in service. At the hearing before the Board, the Veteran testified that he believes he has a thyroid disability because he has aches all the time and he is very depressed. T. p. 9. He also testified that he had lots of sore throats in service. T. p. 10. The record reflects that he had his tonsils removed in 1979. The Veteran testified that he has had problems with his throat since the tonsil removal as well. T. p. 10. Under applicable law, service connection is granted if the evidence establishes that coincident with his service, the Veteran incurred a chronic disease or injury, or had a preexisting injury permanently aggravated, in the line of duty of his active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for certain chronic diseases, when such disease is manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. If there is no showing of a chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). However, recently, the Court clarified that the demonstration of continuity of symptomatology, applied to specific chronic diseases only. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The specific chronic diseases to which 38 C.F.R. § 3.303(b) applies, are listed at 38 C.F.R. § 3.309(a). Id. at 1338. Service connection can also be found for any disease diagnosed after discharge, if the evidence establishes it was incurred in service. 38 C.F.R. § 3.303(d). Service connection requires: (1) medical evidence of a current disability, (2) medical evidence, or lay testimony in some cases, that the injury or disease was incurred or aggravated during service, and (3) medical evidence of a nexus between the current disability and the in-service injury or disease. Pond v. West, 12 Vet. App. 341 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection. See 38 U.S.C.A. § 1110 (West 2002); Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). "In the absence of proof of a present disability there can be no valid claim." See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The current disability requirement for a service connection claim is satisfied if the claimant has a disability at the time the claim is filed or during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 319 (2007). In this case, the claim was filed in August 2005; a clinical diagnosis of a chronic throat and/or thyroid disorder was not of record at that time (resolved or unresolved) nor at any time subsequently since the claim has been pending. Here, the Veteran's service treatment records indicate complaints of sore throat and swollen glands. See treatment records dated in March 1963, January 1964 and February 1964. Following service, the Veteran had his tonsils removed in 1979. T. at p. 5. He offered sworn testimony that the first time he went to a doctor after service was in 1975 or 1976, approximately six years or more after service discharge. Id. The Veteran also testified that he was treated at the Alameda Hospital in the late 1970's regarding his throat disorder. Those treatment records are in the file. A January 1981 operative report noted a diagnosis of infectious epiglottitis. Another January 1981 private treatment record indicated that the Veteran reported a history of sore throats for many years and that he had a tonsillectomy the prior year. Another January 1981 private treatment record contained a "final diagnosis" of acute epiglottitos, with an undetermined etiology. An April 1984 private record also noted a diagnosis of "pharyngitis ?" strep." At that time, the Veteran reported that he had been sick for two years. The Veteran filed his claim for service connection of a thyroid disorder in August 2005. VA treatment records do not contain any diagnosis of a chronic throat disorder or thyroid disorder during the pendency of the claim. The Board acknowledges that there is one diagnosis of an upper respiratory infection in March 2009, in response to a complaint regarding a sore throat; however, the treatment record did not indicate that Veteran had a throat disorder or that his upper respiratory infection was anything other than an acute illness. VA outpatient treatment records dated in February 2011 indicate that the Veteran complained that his throat was bothering him, along with seasonal allergies. The VA physician diagnosed allergic rhinitis, noted no swollen glands, and prescribed antibiotics as well as a nasal spray. No chronic throat or thyroid disorder was diagnosed. Additionally, other VA outpatient treatment records dated throughout 2011 and 2012 indicate that the Veteran consistently reported that he had no problems with his throat that make it difficult to chew or swallow. Similarly, treatment records dated during this period also noted that the Veteran had no sore throat and that his thyroid was not enlarged. Moreover, in a VA treatment record, dated in July 2012, the VA physician noted that the Veteran had "no thyroid problem," and "no problems with ears, eyes, nose or throat." Regarding the possibility of a thyroid disorder, a June 2012 VA outpatient treatment record noted that the Veteran's thyroid was not enlarged. Further, June 2012 VA record of bloodwork results indicates that the Veteran's thyroid studies (TSH and Free T4) were within normal limits. See August 2012 VA treatment record regarding review of June 2012 bloodwork. In the present case, the claim fails because the Veteran does not have a current disability of a chronic throat disorder or thyroid disorder. Even though the Veteran had diagnoses of acute disorders over 20 years before filing his claim for service connection, there is no indication that the Veteran's diagnoses in 1981 and 1984 were related to service, or that the acute diagnoses had any residual effect. As discussed, there is no indication that the Veteran's diagnoses of an upper respiratory infection in March 2009, or allergic rhinitis in February 2011 are diagnoses of throat and/or thyroid disorders. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997) (holding that the VA's and the Court's interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary and therefore the decision based on that interpretation must be affirmed); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). The Board has considered the Veteran's statements that he had sore throats in service, that he has had sore throats for many years since service, and that he has a current thyroid disorder. The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir.1996) (table); Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (although interest may affect the credibility of testimony, it does not affect competency to testify). Lay testimony is competent to establish the presence of observable symptomatology and may provide sufficient support for a claim of service connection. Barr v. Nicholson, 21 Vet.App. 303, 307 (2007). The Board acknowledges that lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (The Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence.). In this case, the Veteran is competent to report symptoms such as sore throat pain as well as a low energy level as this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, the Board finds that the Veteran is not competent to provide a diagnosis for his sore throat and/or alleged thyroid disorder. The only evidence of record supportive of the Veteran's claim is the Veteran's own contention that he has had a throat disorder, or thyroid disorder, since service. As a lay person, the Veteran is not competent to offer such diagnoses as he does not possess the requisite specialized knowledge. In this regard, such diagnoses require the administration and interpretation of specialized test results, to include diagnostic studies. Therefore, making such a diagnosis is a complex medical question and the Veteran is not competent to offer such a diagnosis for either a throat disorder or thyroid disorder. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). The Board acknowledges that lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), throat disorders and thyroid disorders fall outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). "Competent medical evidence" is evidence that is provided by a person qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a). For entitlement to compensation, the evidence must show the existence of a current disability, and one that has resulted from a disease or injury that occurred in the line of duty. In the absence of an identified disease or injury, service connection may not be granted. See Sanchez-Benitez v. West, 25 F.3d 1356 (Fed. Cir. 2001). At this time, there is no competent evidence that the Veteran has a throat or thyroid disorder, nor that he had any such disorder at any time while the claim has been on appeal. Based on the foregoing, the weight of the evidence is against the claim for service connection of a throat and/or thyroid disorder. As the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply. Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). The Veteran's claim for service connection for a throat disorder or thyroid disorder is denied. ORDER A disability rating of 50 percent but no higher, for PTSD, for the periods prior to January 30, 2008 and from May 1, 2008 is granted subject to the laws and regulations governing the award of monetary benefits. Service connection for a throat disorder, claimed as a thyroid disorder, is denied. REMAND As detailed in the Introduction, the contention that the Veteran is unable to work due, at least in part, to his service-connected PTSD, is raised by the record. In this regard, the Board notes that the 1998 SSA award decision indicated that the Veteran's depression was one of his severe impairments. Additionally, the July 2011 VA examination report indicated that he has total occupational and social impairment due to PTSD. Based on the foregoing, the question of entitlement to a total disability rating based on individual unemployability due to service-connected PTSD has been raised. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). The Court has held that the duty to assist requires that VA obtain an examination which includes an opinion on what effect the appellant's service connected disabilities have on his ability to work. Friscia v. Brown, 7 Vet. App. 294, 297 (1994); see 38 C.F.R. §§ 3.103(a), 3.326, 3.327, 4.16(a). In the present case, there are conflicting opinions regarding the affect of the Veteran's psychiatric disability on his employability. For example, despite the July 2011 VA examiner's opinion, the Board notes that the symptoms cited in the July 2011 VA examination report are found in the rating criteria as support for occupational and social impairment of reduced reliability and productivity, not total social and occupational impairment. Further, other VA examination reports of record have specifically noted that the Veteran's medical disabilities, and not his PTSD, cause him to be unemployable. See June 2008 and March 2012 VA examination reports. Further, the Veteran offered sworn testimony that his inability to lift prevented him from working. T. p. 13. As the opinions of record are in conflict and the Veteran has not been afforded an examination specifically for the purpose of establishing TDIU, such an opinion is required to adjudicate this inferred claim. The Board also acknowledges that the Veteran has already been granted a 100 percent disability rating for another service connected disability during the periods on appeal. However, as discussed in the introduction above, it previously was concluded in VAOPGCPREC 06-99 that a TDIU may not be considered when a 100 percent schedular evaluation already is in effect for one or more service-connected disabilities. See Green v. West, 11 Vet. App. 472 (1998); Vettese v. Brown, 7 Vet. App. 31 (1994); Holland v. Brown, 6 Vet. App. 443 (1994). However, the opposite conclusion was reached in Bradley v. Peake, 22 Vet. App. 280 (2008). Recognized therein was that no additional disability compensation may be paid when a total schedular evaluation for a particular service-connected disability is in effect. Yet also recognized was that consideration of a TDIU for another service-connected disability or other service-connected disabilities may still be necessary so that a determination can be made regarding special monthly compensation (SMC). VAOPGCPREC 6-99 was withdrawn in light of Bradley. VA indeed has a "well-established" duty to maximize a claimant's benefits. Buie v. Shinseki, 24 Vet. App. 242 (2011); AB v. Brown, 6 Vet. App. 35 (1993). In conformity with this duty, SMC "benefits are to be accorded when a Veteran becomes eligible without need for a separate claim." Bradley, 22 Vet. App. at 280. SMC is payable where there is a single service-connected disability evaluated as 100 percent and additional service-connected disability or disabilities independently evaluated at 60 percent or more. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i). Bradley thus suggests that a TDIU for a service-connected disability or for service-connected disabilities not evaluated at 60 percent or more must be considered notwithstanding the fact that a 100 percent schedular evaluation is in place for another service-connected disability because, if granted, SMC also would be granted. In this case, SMC has been granted but only for the period from January 30, 2008 to April 30, 2008. Thus, during the periods currently on appeal, the Veteran has not been assigned SMC. Under Bradley, the inferred TDIU claim for these periods has not been rendered moot simply because the Veteran has been granted a 100 percent disability rating for another service-connected disability. Accordingly, the case is REMANDED for the following action: 1. After updating the file with the most recent VA medical records after May 2009, afford the Veteran the appropriate VA examination so as to determine the impact of his service-connected PTSD on his employability. The claims file, to include a copy of this Remand, must be made available to and be reviewed by the examiner. Any indicated evaluations, studies, and tests should be conducted. The examiner must evaluate and discuss the effect all of the Veteran's service-connected disabilities, singularly and jointly, have on his employability. In this regard, the examiner should opine as to whether it is at least as likely as not that the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities, i.e., PTSD, ischemic heart disease, diabetes mellitus, type II, and scar, either singularly or jointly, taking into consideration his level of education, special training, and previous work experience, but not his age or any impairment caused by nonservice-connected disabilities. The rationale for any opinion offered must be provided. 2. If any benefit sought on appeal remains denied, the RO/AMC should issue a supplemental statement of the case, before the claims file is returned to the Board, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs