Citation Nr: 1319647 Decision Date: 06/18/13 Archive Date: 06/27/13 DOCKET NO. 05-03 522A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) with alcohol abuse, from July 31, 2003 through April 9, 2007. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities. REPRESENTATION Appellant represented by: Joseph Moore, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD S.J. Janec, Counsel INTRODUCTION The Veteran served on active duty from November 1966 to October 1968. This matter comes to the Board of Veterans' Appeals (Board) on from a September 2003 rating action that granted service connection for PTSD and assigned an initial rating of 10 percent from July 2003; and a May 2008 rating action that denied entitlement to a total disability rating based on individual unemployability due to service-connected disabilities. In February 2005, the RO granted a 30 percent rating for PTSD from July 2003. In August 2007, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge at the RO. In October 2010, the RO granted a 100 percent evaluation for PTSD with alcohol abuse effective from April 10, 2007. In a November 2011 decision, the Board denied a rating in excess of 30 percent for PTSD with alcohol abuse, from July 31, 2003 through April 9, 2007. The Veteran appealed the determination to the United States Court of Appeals for Veterans Claims (Court). In a January 2013 Order, the Court granted a Joint Motion for Remand, vacated the Board's November 2011 decision, and returned the case to the Board for further review. The issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities had been remanded to the Board in November 2011 for the issuance of a statement of the case. A statement of the case was mailed to the Veteran in January 2012 and he perfected an appeal that same month. Hence, the issue remains before the Board. The issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities is addressed in the REMAND portion of the decision below and is REMANDED to the Department of Veterans Affairs Regional Office. FINDING OF FACT For the period from July 31, 2003 through April 9, 2007, the most probative evidence shows that the Veteran's PTSD with alcohol abuse was manifested by no more than persistent, chronic, mild symptoms, which reflect no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. CONCLUSION OF LAW The criteria for an initial rating in excess of 30 percent for PTSD with alcohol abuse for the period from July 31, 2003 through April 9, 2007, were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 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 that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice errors are presumed prejudicial unless VA shows that the error did not affect the essential fairness of the adjudication. To overcome the burden of prejudicial error, VA must show (1) that any defect was cured by actual knowledge on the part of the claimant; (2) that a reasonable person could be expected to understand from the notice what was needed; or, (3) that a benefit could not have been awarded as a matter of law. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). The Veteran's claim arises from his disagreement with 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. As to VA's duty to assist, the RO associated the Veteran's VA outpatient treatment records, as well as private medical records, and he was afforded VA examinations. The Board finds that no additional assistance is required to fulfill VA's duty to assist. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Significantly, neither the Veteran nor his attorney has identified, and the record does not otherwise indicate, any existing, pertinent evidence, in addition to that noted above, that has not been obtained (including in the recent Joint Motion for Remand). The record thus also presents no basis for further development to create any additional evidence to be considered in connection with the matter currently under consideration. Under these circumstances, the Board finds that the Veteran is not prejudiced by appellate consideration of the claim on appeal at this juncture, without directing or accomplishing any additional notice or development action. Increased Initial Evaluation for PTSD Prior to April 2007 Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7 (2012). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1 (2012); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. See Fenderson, 12 Vet. App. at 126. It is the responsibility of the Board to determine the probative weight to be ascribed as among multiple medical opinions in a case, and to state reasons or bases for favoring one opinion over another. Winsett v. West, 11 Vet. App. 420, 424-25 (1998). The probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999). If all the evidence is in relative equipoise, the benefit of the doubt should be resolved in the claimant's favor, and the claim should be granted. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2012). However, if the preponderance of the evidence is against the claim, the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran's PTSD has been initially rated as 30 percent disabling under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411 for the period of July 2003 to April 2007. Under that Diagnostic Code, a 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation), 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). A 50 percent rating 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. A 70 percent rating requires occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 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. A 100 percent rating requires total occupational and social impairment, due to such symptoms as: grossly inappropriate behavior; persistent danger of hurting oneself or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives or one's own occupation or name. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social and occupational functioning on a hypothetical continuum of mental health- illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM IV), page 32]. A GAF score of 31 to 40 reflects some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood, (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF score 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 the examiner's assessment of moderate symptoms (e.g., a 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 the examiner's assessment of mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well and having some meaningful interpersonal relationships. While the Rating Schedule does indicate that the rating agency must be familiar with the DSM IV, it does not assign disability percentages based solely on GAF Scores. See 38 C.F.R. § 4.130 (2012). Rather, GAF scores are but one factor to be considered in conjunction with all the other evidence of record. Words such as "mild", "slight", "moderate" and "serious" are not defined in VA's Schedule for Rating Disabilities [or in the DSM-IV]. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just". 38 C.F.R. § 4.6 (2012). It should also be noted that use of such terminology by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. See 38 C.F.R. §§ 4.2, 4.6 (2012). The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant's social and work situation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). 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. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b) (2012). Factual Background As there is a specific time frame for the consideration of this claim, (July 2003 to April 2007) the Board will only address the evidence pertinent to the issue before it. The Board has reviewed all the evidence in the Veteran's claims file. The Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Upon July 2003 VA psychiatric examination, the Veteran was noted to have been married for 34 years, and employed for 27 years with an airline company, most recently loading and unloading airplanes. He reported that he thought of Vietnam a couple of times a day and he got distracted from work. However, he never lost a job. He denied a short temper or irritability, but he did not like anyone standing behind him. He also denied illicit substance abuse. He used alcohol and used to drink heavy alcohol. However, currently he only drank six to eight beers a day which he believed helped to relax him. The examiner discussed that if he quit using alcohol, his hyperarousal symptoms would come out. Mental status examination revealed that he was alert, oriented, and attentive, nicely groomed, with good eye contact. Overall mood was anxious, and he became tearful and tangential when speaking about Vietnam. There was otherwise no impairment of thought process or communication. Mood was not severely depressed, and there was no retardation of motor activity, suicidal or homicidal ideation, or evidence of psychosis. Cognition and judgment were adequate, and he had some insight. The assessment was mild, chronic PTSD, for which the Veteran had treated himself with long-term alcohol use, and the examiner felt that the Veteran did not need medications. A Global Assessment of Functioning (GAF) score of 65 was assigned on the basis of mild symptoms which were partially treated with his use of alcohol. On August 2003 VA psychological examination, the Veteran was attentive, cooperative, and well oriented in all spheres, and he denied hallucinations and delusions. There was no evidence of any psychotic process. He appeared somewhat mildly depressed, and was notably anxious. Speech was articulate but halting and awkward in character, with short, chopped sentences. He appeared to function well within the normal range of intelligence. Insight was somewhat limited, but judgment was sound. The examiner concluded that the Veteran had chronic, combat-related PTSD that was mild in intensity, and noted that he used alcohol to avert more severe symptoms. The Veteran had been successful in his personal and vocational life, having avoided vocational difficulties and inability to forge significant relationships often seen in people who suffered from PTSD; the examiner noted that this might be attributable to the substantial social support he received from family and friends. On the basis of this and mild symptoms, the examiner concluded that the Veteran's PTSD was not currently clinically disabling, and a GAF score of 77 was assigned. On January 2004 VA outpatient evaluation, the Veteran was alert and oriented in three spheres. Personal hygiene was good, and there was no sign of emotional distress. Affect was mildly blunted, and mood was appropriate. When seen for psychiatric evaluation in February, the Veteran was noted to be using alcohol to treat himself for the hyperarousal symptoms of PTSD. On mental status examination, he was alert, oriented, and attentive, with good eye contact. Overall mood was anxious, and affect was mildly labile. There was no impairment of thought process or communication, no suicidal or homicidal ideation, and no evidence of psychosis. Cognition, insight, and judgment were adequate. On February 2004 VA outpatient evaluation, the Veteran was alert and oriented in three spheres. He made good eye contact about half the time. His mood was anxious and his hand shook a bit when he drank water. His affect was mildly labile. There was no impairment of thought process or communication. There was no suicidal or homicidal ideation. There was no psychosis. There was adequate cognition, insight and judgment. The examiner noted that there was an alcohol abuse problem, which the Veteran used to treat himself for the hyperarousal symptoms. In April 2004, the Veteran underwent a VA Agent Orange examination. At that time, he was well oriented in all spheres and denied hallucinations or delusions. He denied suicidal ideation. His insight was limited, but his judgment was sound. In early May, the Veteran was alert, oriented, and attentive, with good eye contact. He was still anxious, with a depressed mood and blunted affect. Speech was adequate, and there was no impairment of thought process or communication, no suicidal or homicidal ideation, and no evidence of psychosis. Cognition, insight, and judgment were intact. In a late May 2004 evaluation, A.B., M.S ., of Cornerstone Care, P.C., noted that the Veteran reported feeling significantly depressed at least once per month, but that this seldom lasted for more than four hours. The examiner stated that the Veteran reported being depressed and that sometimes he thought about suicide. When asked if he had a plan, he reported that he thought about driving into a wall. It was noted that he Veteran had intrusive thoughts of Vietnam, survival guilt, and was startled by loud noises. On June 2004 VA outpatient psychiatric evaluation, the Veteran reported that recently-prescribed medication had helped him sleep better and made him calmer. On mental status examination, he was alert, oriented, and attentive, with good eye contact. Overall mood remained anxious, but there was no impairment of thought process or communication, no suicidal or homicidal ideation, and no evidence of psychosis. Cognition, insight, and judgment were adequate. When seen again in August, he was alert, oriented, and attentive, with good eye contact. Mood was a bit irritable and anxious. Speech was normal, and there was no impairment of thought process or communication, no suicidal or homicidal ideation, and no evidence of psychosis. Cognition, insight, and judgment were adequate. In September, he was alert, oriented, and attentive, with good eye contact, but still a little bit anxious. Speech was normal, and there was no impairment of thought process or communication, no suicidal or homicidal ideation, and no evidence of psychosis. Cognition, insight, and judgment were intact. In November, the Veteran was alert, oriented, and attentive, with good eye contact. Mood remained a little bit dysphoric, but not as anxious as it had been. Speech was normal, and there was no psychomotor retardation, no impairment of thought process or communication, no suicidal or homicidal ideation, and no evidence of psychosis. Cognition, insight, and judgment were adequate. On August 2004 VA outpatient evaluation, the Veteran was alert, oriented and attentive. He made good eye contact. His mood was a bit irritable and anxious. He had normal tone and rate of speech. There was no impairment of thought process or communication. There was no suicidal or homicidal ideation. There was no psychosis. There was adequate cognition, insight and judgment. On September 2004 VA outpatient evaluation, the Veteran was alert, oriented and attentive. He made good eye contact but sat tensely in his chair. His mood was still a bit anxious. He had normal tone and rate of speech. There was no impairment of thought process or communication. There was no suicidal or homicidal ideation. There was no psychosis. There cognition, insight and judgment were intact. On November 2004 VA outpatient psychiatric evaluation, the Veteran was alert, oriented and attentive. He made good eye contact. His mood remained a little bit dysphoric but not as anxious as it had been in the past. He had good spontaneous facial expression and good spontaneous eye movement. There was no psychomotor retardation. Speech was of normal tone and rate. There was no impairment of thought process or communication. There was no suicidal or homicidal ideation. There was no psychosis. Cognition, insight and judgment were adequate. On January 2005 VA outpatient psychiatric evaluation, the Veteran was alert, oriented, and attentive, with good eye contact. Overall mood was just a little bit anxious, but more euthymic, and not as anxious and labile as it had been in the past. Speech was normal, and there was no impairment of thought process or communication, no suicidal or homicidal ideation, and no evidence of psychosis. Cognition, insight, and judgment were intact. The Veteran was evaluated by the Vet Center in March 2005. He was noted to be neat and oriented to person place and time, with above average intelligence. He appeared anxious, had an inappropriate affect, was agitated, and had impaired memory function. His judgment was impaired. There were no delusions or hallucinations and no disorganized thinking. His appetite was average and his sex life okay. It was noted that he has friends. He noted that he had not thought about suicide for a couple of years and had no homicidal thoughts. When seen on VA treatment in March 2005, the Veteran was alert, oriented, and attentive, with good eye contact. Overall mood remained anxious, and there was mild affective lability, but affect was appropriate. There was no impairment of thought process or communication, no suicidal or homicidal ideation, and no evidence of psychosis. Cognition, insight, and judgment were adequate. A GAF score between 60 and 65 was assigned on the basis of persistent, chronic, mild symptoms. In mid-May, he was sleeping better and was alert, oriented, and attentive, with good eye contact. Overall mood remained a bit anxious but was more euthymic, and affect was less labile. Speech was normal, and there was no impairment of thought process or communication, no suicidal or homicidal ideation, and no evidence of psychosis. Cognition, insight, and judgment were adequate. In late May, the Veteran's personal hygiene was good. Mood was appropriate, there were no signs of emotional distress, and he did not appear to be depressed. On May 2005 VA outpatient psychiatric evaluation, the Veteran was alert, oriented and attentive. He made good eye contact but he was anxious. His affect was less labile and his mood was more euthymic. There was no impairment of thought process or communication. There was no suicidal or homicidal ideation. There was a normal tone and rate of speech. There was no psychosis. Cognition, insight and judgment were adequate. On September 2005 VA outpatient psychiatric evaluation, the Veteran reported that medication helped to relax him, and sleep was good. On mental status examination, he was alert, oriented, and attentive, with good eye contact. Overall mood was a bit more euthymic, and he was calmer, more relaxed, and less anxious and irritable. Affect was appropriate, and there was no impairment of thought process or communication, no suicidal or homicidal ideation, and no evidence of psychosis. Cognition, insight, and judgment were intact. When seen again in December, the Veteran was alert, oriented, and attentive, with good eye contact. He was a bit more anxious, but mood was appropriate. There was no impairment of thought process or communication, no suicidal or homicidal ideation, and no evidence of psychosis. Cognition, insight, and judgment were adequate. On December 2005 VA outpatient psychiatric evaluation, the Veteran was alert, oriented and attentive. He made good eye contact but he was anxious. He was appropriate. There was no impairment of thought process or communication. There was no suicidal or homicidal ideation. There was no psychosis. Cognition, insight and judgment were adequate. On March 2006 VA outpatient psychiatric evaluation, the Veteran was noted to have recently retired from work. On mental status examination, he was alert, oriented, and attentive, with good eye contact. Overall mood remained anxious, but he did not have depression. Speech was normal, and there was no impairment of thought process or communication, no suicidal or homicidal ideation, and no evidence of psychosis. Cognition, insight, and judgment were adequate. When seen again in May, the Veteran reported doing better with the use of prescribed medication, and he felt calmer. On mental status examination, he was alert, oriented, and attentive, with good eye contact. Overall mood was less anxious, a bit calmer and a bit more euthymic. Speech was normal, and there was no impairment of thought process or communication, no suicidal or homicidal ideation, and no evidence of psychosis. Cognition, insight, and judgment were intact. On May 2006 VA outpatient psychiatric evaluation, the Veteran was alert, oriented and attentive. It was noted that overall, he believed he was doing better on the medications. He felt calmer and his wife noticed this as well. He made good eye contact. He was described as more euthymic and less anxious. There was a normal tone and rate of speech. There was no impairment of thought process or communication. There was no suicidal or homicidal ideation. There was no psychosis. Cognition, insight and judgment were intact. In a June 2007 statement, the Veteran's spouse reported that the Veteran's behavior deteriorated after his return from Vietnam and she believed that he was getting worse as he got older. He had difficulty working because he could not stay focused, he had difficulty sleeping, and he disliked crowds. In an August 2007 statement, A. B., M.S ., of Cornerstone Care, P.C., reported that since retiring in April 2007, the Veteran returned to therapy because he has experienced "increasing problems." He indicated that the Veteran's anxiety and depression significantly increased and impacted his alcohol consumption. It was concluded that the lack of employment exacerbated the Veteran's PTSD. His GAF was estimated to be 45. In an August 2007 statement, J.E., CADC, and B.E.T. Ph.D., reported that the Veteran described daily intrusive thoughts, weekly nightmares, and flashbacks from Vietnam. He had to stop working at a part-time job due to intrusive thoughts. He isolated and drank more than a case of beer daily to stop the thoughts and flashbacks. A private clinician, M.L.C., M.D., offered a statement in support of the Veteran's claim in July 2009. He stated that the Veteran had a diagnosis of alcohol dependence that was secondary to PTSD. He remarked that it was "clear from the medical record" that the Veteran's alcohol usage was a direct response to his symptoms of PTSD. He also remarked that the Veteran's PTSD has been "completely disabling to him for an extended period of time, beginning approximately in 2003 and becoming profoundly disabling by his end of employment with Northwest Airlines in January of 2006. By May of 2007 [the Veteran] had totally stopped working and was completely unemployable due to his PTSD." He also noted that it was clear that the Veteran was "nonfunctional in many aspects of his life including the ability to engage in appropriate relationships and even some social situations, let alone within a workplace." He concluded that the Veteran's PTSD alone "had made him unable to sustain gainful employment since at least 2007." He estimated the Veteran's GAF to be 35. Upon VA examination in September 2009, the Veteran's GAF was reported to be 49. The examiner stated that he had serious impairment in social and occupational functioning due to PTSD. A private clinician, M.L.C., M.D., offered a follow-up statement in support of the Veteran's claim in October 2011. The examiner stated that the Veteran has displayed since 2003, if not earlier, severe and profound symptoms of social isolation, occupational dysfunction, and the incapacity to manage basic personal relationships. It was stated that the Veteran seemed less psychiatrically ill during the time frame in question since he was using alcohol. The clinician noted that although the Veteran was able to maintain employment until January 2006, his decline began before this. It was reported that his symptoms worsened in 2003 and were pervasive and severe in 2003. The examiner stated that in the early 2000s the Veteran had hyperarousal, sleep difficulty, anger, severe violence potential, suicide ideation, hypervigilance and difficulty concentrating and functioning. He opined that the Veteran is clearly and profoundly disabled due to PTSD. Lay statements from family members and friends describe the Veteran's social impairments, short temper, Vietnam discussions and drinking. Analysis Considering the evidence in light of the criteria noted above, the Board finds that the most probative evidence of record - the private and VA clinical records and examinations dated in the relevant time period - demonstrates that the Veteran's reported psychiatric symptoms from PTSD with alcohol abuse (anxiety, depression, suspiciousness, hyperarousal, intrusive thoughts/memories, and sleep impairment, and alcohol use) are indicative of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, thus meeting the criteria for no more than a 30 percent rating for the period from July 2003 to April 2007. See Winsett, supra. The medical evidence in the relevant time period detailed above demonstrates persistent mild symptoms because the Veteran was generally able to function satisfactorily. For example, he remained gainfully employed with the same company that employed him for more than 27 years, he was able to maintain his self care, his conversation was normal, and thinking and judgment were intact. In other words, his grooming and hygiene have been consistently normal, he has described functioning satisfactorily in his family social relationships, and his psychiatric impairment never significantly impaired his ability to work for more than two and a half decades. The Board finds that the symptoms associated with the Veteran's PTSD with alcohol abuse simply do not meet the criteria for at least the next higher 50 percent rating at any time during the relevant time period. The delineated symptoms at that level were not reported in the contemporaneous mental status reports detailed above. Specifically, he has not been shown to have a flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships. In fact, there was no mention of panic attacks; his speech was predominantly of normal rate; and his judgment and thinking were consistently described as intact. Again, notably, the Board observes that the Veteran remained employed with the same company that he had been employed with for more than 27 years. Although the Veteran reported that he continued to experience thoughts about Vietnam while he was working, he was clearly able to maintain his employment and stated that he had never lost a job. The records do show that the Veteran used alcohol to self-medicate and that this resulted in a lessening of his hyperarousal symptoms. However, even with his use of alcohol, the examiners reported symptoms in the mild range. As such, the Board finds that the objective evidence dated during this time period does not support the conclusion that the Veteran's psychiatric impairment resulted in occupational and social impairment with reduced reliability and productivity as required for the 50 percent rating due to either symptoms outlined in that part of Diagnostic Code 9411 or other reported manifestations of the disability demonstrated upon clinical evaluation. See Mauerhan, supra. The Board also notes that the Veteran has been assigned GAF scores ranging from 60 to 77 (during the period at issue), as reflected in VA clinic records and examination reports. According to the 4th Edition of the American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF scores between 51 and 60 are indicative of moderate symptoms (e.g., a flat affect and circumstantial speech, occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., having few friends, having conflicts with peers or co-workers). GAF scores between 61 and 70 are indicative of some mild symptoms (e.g., a depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but indicate that the subject generally functions well, and has some meaningful interpersonal relationships. GAF scores between 71 and 80 are indicative of symptoms, if present, that are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument), or no more than slight impairment in social, occupational, or school environment (e.g., temporarily falling behind in schoolwork). GAF scores assigned in a case, like an examiner's assessment of the severity of a condition, are not dispositive of the percentage disability rating issue; rather, a GAF score must be considered in light of the actual symptoms of the Veteran's disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a) (2012). Here, the clinical records in the relevant time period outlined above consistently state that the Veteran's symptoms were mild, even when noting his alcohol abuse. The Board also finds that the evidence does not support a finding that the Veteran's PTSD with alcohol abuse symptoms warranted either a 70 percent or 100 percent rating during this time frame. There is no indication of occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting 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. In fact, virtually none of these symptoms were reported in the medical records for the relevant time period. His speech was consistently described as normal, there were no reports of near-continuous panic or depression that prevented the Veteran from functioning independently, there were no reports of unprovoked irritability with periods of violation, no spatial disorientation, and no neglect of personal appearance and hygiene. Again, notably, the Veteran remained employed and married during this time period; he had friends. The majority of evidence in the contemporaneous clinical reports does not demonstrate that the Veteran's occupational and social functioning was reduced by his use of alcohol during this time period. In fact, it was shown to ameliorate his symptoms of hyperarousal - a fact that was communicated to him by a clinician. As detailed in the Joint Motion for Remand, a private clinician noted in a May 2004 report that the Veteran discussed feelings of guilt and thoughts of suicide, including a thought to drive into a wall. However, that is the only notation of suicidal thoughts in the medical reports and the corresponding VA clinical reports consistently show that the Veteran denied suicidal and homicidal ideation. The Veteran stated during his hearing before the undersigned in August 2007 that he had thought of killing himself many times, but did not tell his doctor. Here, the Board gives greater weight to the findings documented during his treatment rather than to statements made in support of the claim for a higher rating. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) (a pecuniary interest may affect the credibility of a claimant's testimony). In sum, the Board finds that one documented notation of suicidal ideation in and of itself does not support a finding that a 70 percent rating is warranted, particularly in the absence of any other of the delineated symptoms contemplated for such a rating. Moreover, although the Veteran continued to use alcohol to self-medicate, it does not appear that his use of alcohol caused an exacerbation of his symptoms such that he was unable to function appropriately and effectively in both social and occupational roles as detailed in the extensive clinical files. The Board has accorded the lay statements less probative value because they were not made contemporaneous to the Veteran's treatment and were not made to any of his treatment providers at the time he sought treatment, but rather made in conjunction with a claim for monetary benefits. See Cartwright, supra. A 100 percent rating requires total occupational and social impairment, due to such symptoms as: grossly inappropriate behavior; persistent danger of hurting oneself or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives or one's own occupation or name. None of these criteria is shown on the clinical evaluations during this time frame. The Veteran retired from employment in April 2007, and he began a program for his sobriety; and it was at this time, but not earlier, that his PTSD symptoms were exacerbated such that he met the criteria for a total rating. See for example, the August 2007 statement from A.B., M.S., with a reported GAF score of 45. The Joint Motion for Remand specifically directed the Board to address more fully the statements of M.L.C., M.D., completed in July 2009 and October 2011. Dr. C. concluded based on his review of the record that the Veteran underreported his symptoms during the relevant time period, and he was ,in fact, "completely," "totally," and "profoundly" impaired during the entire time period. The Board has accorded these statements little probative value. See Winsett, supra. First, these statements are retrospective in nature and not contemporaneous. See Bloom, supra. The Board finds that the contemporaneous reports are more probative because they were rendered in conjunction with the Veteran's actual treatment and with the intention of providing him the level of medical and pharmaceutical care required to help him with his disability. The statements of Dr. C. were rendered solely to support a claim for higher monetary benefits. See Cartwright, supra. There is no indication that the Veteran sought treatment with Dr. C. at the time in question because he believed that the care he was receiving from other treatment providers was inadequate or improper. Second, there is no explanation for how Dr. C. could more accurately assess the Veteran's symptoms two to five years later than the actual clinicians who provided the treatment; and he has not sought to explain how the treatment providers underestimated the Veteran's symptoms. See Bloom, supra. In fact, in the clinical VA treatment records it was specifically noted that the Veteran's use of alcohol served to reduce his hyperarousal - a symptom contemplated in the 30 percent rating. A rating is assigned based on the objective symptoms displayed during clinical evaluations - not on conjecture about whether the symptoms were masked, underreported, or underestimated by other treatment providers. Notably, the contemporaneous clinical records demonstrate that in August 2003, the Veteran reported substantial social support from family and friends. In March 2005, he reported that he has friends. When he testified before the undersigned he noted being married for 38 years and that he got along with his wife and two daughters. He stated that he sees his children and his grandchild. He stated that he had some friends other than Vietnam Veterans. Such findings and statements are contrary to a finding of complete or profound disability from PTSD with alcohol abuse. Finally, Dr. C.'s statement contains incorrect factual information. For example, he states that the Veteran's PTSD "has been completely disabling to him" beginning immediately after his active duty service even though the Veteran remained gainfully employed for more than 27 years at the same company. As clearly outlined by the rating criteria, if the Veteran were completely disabled due to his psychiatric impairment, he would not have been able to work or maintain the social relationships noted above. Dr. C.'s conclusion that the Veteran was totally disabled from his discharge until his retirement is not supported by the record and completely lacking merit. See Black v. Brown, 5 Vet. App. 177 (1993); Swann v. Brown, 5 Vet. App. 229 (1993); Reonal v. Brown, 5 Vet. App. 458 (1993) (medical opinions have no probative value when they are based on an inaccurate factual predicate, such as a self-reported and inaccurate history); see also Miller v. West, 11 Vet. App. 345 (1998). In reaching its decision, the Board has considered the Veteran's statements and other lay statements regarding his symptoms and functional impairment, as well as the medical evidence in his file. The Board finds that the Veteran and his family and friends are competent to report any functional limitations. However, here, the contemporaneous clinical evidence pertaining to the Veteran's psychiatric disability is more probative for the purposes of assigning a current rating in conjunction with the relevant rating criteria - and the Board finds that the Veteran's social and functional impairment has been appropriately considered in assigning the current rating consistent with the documented symptoms. To the extent that he (or others) may argue or suggest that the clinical data supports an increased initial disability rating or satisfies the rating criteria for a higher rating, such assertions fall outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Ordinarily, VA's Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three- step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. The rating criteria reasonably describe the Veteran's disability level and symptomatology due to his service-connected disability. The Veteran has not exhibited symptoms of a psychiatric disability that are not contemplated in the rating criteria. Therefore, a further analysis under Thun is not warranted. Finally, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, the Veteran's claim for entitlement to an initial rating in excess of 30 percent, for his service-connected PTSD with alcohol abuse from July 31, 2003 through April 9, 2007, is denied. ORDER An initial rating in excess of 30 percent for PTSD with alcohol abuse, from July 31, 2003 through April 9, 2007, is denied. REMAND It is unclear from the record whether the Veteran is in receipt of Social Security Administration (SSA) disability benefits. Since any such records are potentially relevant to the Veteran's claim for entitlement to a total disability rating based on individual unemployability due to service-connected disability, VA should attempt to obtain and consider such records. 38 U.S.C.A. § 5103A(c)(3); 38 C.F.R. § 3.159(c)(2); see also Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010); Moore v. Shinseki, 555 F.3d 1369 (Fed. Cir. 2009). Additionally, in his statement in support of the claim, the Veteran's attorney asserted that the Veteran's employment as a bus driver for the period from February 27, 2006 through April 9, 2007 was marginal employment as defined by VA regulation. See 38 C.F.R. § 4.16(a) (2012) (". . . marginal employment shall be deemed to exist when a veteran's earned annual income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person."). A copy of the Veteran's Social Security Income Statement was included; however, the Board finds that in order to properly make this determination, additional development is necessary. Accordingly, the case is REMANDED for the following action: 1. Request, directly from the SSA, complete copies of any determination on a claim for disability benefits from that agency, together with the agency's own medical records that served as the basis for any such determination (duplicate records should not be placed in the file). All attempts to fulfill this development should be documented in the claims file. If the search for these records is negative, that should be noted and the Veteran must be informed in writing. If the Veteran is in receipt of SSA benefits based upon age, and not disability, documentation thereof must be added to the claims file. 2. Ask the Veteran to submit copies of all of his earnings summaries (W-2 Forms) for the years 2005, 2006, and 2007, so there is objective evidence to ascertain whether his work as a bus driver for the period from February 27, 2006 through April 9, 2007 constituted gainful or marginal employment. 3. After the development requested above and any other development deemed necessary have been completed to the extent possible, the RO should review the record and readjudicate the claim for entitlement to a total disability rating based on individual unemployability due to service-connected disability. The RO must specifically consider whether the Veteran's employment as a bus driver for the period from February 27, 2006 through April 9, 2007 constitutes gainful or marginal employment, as defined by VA regulation. If the benefit sought on appeal remains denied, the appellant and representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. The appellant has the right to submit additional evidence and argument on the matter 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). ______________________________________________ FRANK J. FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs