Citation Nr: 1323107 Decision Date: 07/19/13 Archive Date: 07/24/13 DOCKET NO. 09-46 131 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD), prior to December 1, 2009. 2. Entitlement to a rating in excess of 70 percent for PTSD, from December 1, 2009. 3. Entitlement to a total rating based on individual unemployability (TDIU) due to service-connected disabilities, prior to December 1, 2009. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD John Francis, Counsel INTRODUCTION The Veteran served on active duty from October 1968 to April 1984. This appeal to the Board of Veterans' Appeals (Board) arose from a May 2009 rating decision in which the RO, denied a rating in excess of 50 percent for PTSD, and a TDIU, as well as denied service connection for hypertension. In June 2009, the Veteran filed a notice of disagreement (NOD). A statement of the case (SOC) was issued in October 2009, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in November 2009. In July 2010, the RO granted an increased rating of 70 percent for PTSD, and a TDIU, effective December 1, 2009, the date of a VA examination. Although the RO granted a higher, 70 percent rating from December 1, 2009, inasmuch as higher ratings for this disability are available both before and after that date, and the Veteran is presumed to seek the maximum available benefit for a disability, the Board has characterized the appeal as to rating for service-connected PTSD as now encompassing the first and second matters set forth on the title page. Id.; AB v. Brown, 6 Vet. App. 35, 38 (1993). As explained below, in evaluating the Veteran's PTSD from December 1, 2009, the period for which the RO assigned a temporary total rating for hospitalization-from February 21, 2012 through April 30, 2012-is excluded. The 70 percent rating was continued as of May 1, 2012. Also in the July 2010 rating decision, the RO granted a TDIU, effective December 1, 2009. However, as December 1, 2009 is not the date of the claim for increased rating, the Board finds this does not represent a full grant of the benefit sought with respect to a TDIU, and that remaining on appeal is the matter of the Veteran's entitlement to a TDIU prior to December 1, 2009 (as reflected on the title page). Id. Further, the Board notes that, in the July 2010 rating decision, the RO granted service connection for hypertension, effective February 23, 2009. The Virtual VA paperless claims processing system contains additional VA outpatient treatment records that have been considered by the RO in the most recent March 2013 supplemental statement of the case (SSOC). As a final preliminary matter, the Board points out that, in an October 2012 brief, the Veteran's representative contended that a 2002 rating decision in which the RO decision that denied service connection for a nervous disorder was clearly and unmistakably erroneous because the Veteran had received treatment for alcohol abuse in service. The representative argued that the Board may remand this issue but cited a precedential decision by the United States Court of Appeals for Veteran's Claims that does not address this jurisdictional issue. This argument appears to raise a question as to the Veteran's entitlement to an earlier effective date for the award of service connection for PTSD, a matter that has not been raised before, or adjudicated by, the RO. As such, this matter is not properly before the Board, and is referred to the RO for appropriate action (to include advising the Veteran to submit a well articulated claim to the RO, if desired). FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate each claim on appeal have been accomplished. 2. Prior to December 1, 2009, the Veteran's PTSD was manifested by such symptoms as intrusive thoughts of his combat experiences, night terrors, hypervigilance, exaggerated startle response, avoidance activities, irritability, lack of concentration, sleep disturbance, and some social isolation; overall, these symptoms are indicative of no more than occupational and social impairment with reduced reliability and productivity. 3. Since December 1,2009, the Veteran's PTSD has been manifested by such symptoms as continuation of the combat-related and avoidance symptoms but with additional and more severe symptoms of neglected hygiene, persistent thoughts of suicide, panic attacks not associated with detoxification, degraded concentration and attention deficits, and episodes of syncope or seizures; overall, these symptoms are indicative of no more than occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, mood, with suicidal ideation, and difficulty in adapting to stressful circumstances. 4. The applicable rating criteria are adequate to rate the Veteran's PTSD at all points pertinent to this appeal. 5. Prior to December 1, 2009, service connection was in effect for PTSD (rated as 50 percent disabling), diabetes mellitus (rated as 20 percent disabling), and, as of February 23, 2009, hypertension (rated as noncompensable). 6. For the period prior to December 1, 2009, the Veteran's service-connected disabilities did not meet the minimum percentage requirements for award of a TDIU, and these disabilities were not shown to prevent him from obtaining or retaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent for PTSD, prior to December 1, 2009, are 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, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for a rating in excess of 70 percent for PTSD, from December 1, 2009, are 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, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2012). 3. The criteria for a TDIU, prior to December 1, 2009, are not met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.18, 4.19 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In a March 2009 pre-rating letter, the RO provided notice to the Veteran explaining what information and evidence was needed to substantiate the claim for an increased rating for service-connected PTSD, what information and evidence must be submitted by the appellant, and what information and evidence would be obtained by VA. The letter also provided the Veteran with information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations. The May 2009 rating decision reflects the initial adjudication of the claim after issuance of this letter. Hence, the March 2009 letter-which meets the content of notice requirements described in Dingess/Hartman and Pelegrini-also meets the VCAA's timing of notice requirement. The Board further notes that the October 2009 SOC set forth the criteria for higher ratings for PTSD (the timing and form of which suffices, in part, for Dingess/Hartman). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter on appeal. Pertinent medical evidence associated with the claims file consists of service, VA and private treatment records, and the reports of March 2009 and April 2010 VA examinations. An additional VA examination was scheduled in December 2012. A VA Medical Center representative documented that the Veteran cancelled the examination. [Parenthetically, the Board notes that the stated reason for cancellation of the examination was that the Veteran did not wish to pursue a claim for an increased rating at the time. In correspondence in March 2013, the RO advised the Veteran of the procedure to withdraw an appeal in writing, but, as no response from the Veteran was received, his appeal was deemed to continue.]. Also of record and considered in connection with the appeal are various written statements provided by the Veteran. The Board finds that no additional RO action to further develop the record in connection with any of these matters, prior to appellate consideration, is required. The Veteran reported that he was receiving disability benefits from the Social Security Administration. In response to a request by the RO for records of medical examination associated with the award, SSA reported in April 2010 that no medical records were held. Hence, no further RO action in this regard, is warranted. In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO, the Veteran has been notified and made aware of the evidence needed to substantiate the claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with any claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matters on appeal, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Increased Ratings for PTSD A. Background The Veteran served in the U.S. Army as a helicopter crewman and repair technician, as an armored vehicle crewmember, and as a recruiter. He had combat service in the Republic of Vietnam from April 1969 to April 1970 and retired at the rank of Master Sergeant. He contends that his PTSD is more severe than is contemplated in the current ratings. In April 2006, the Veteran sought VA treatment for alcohol dependence. A staff psychologist noted that the Veteran had undergone two courses of inpatient alcohol abuse rehabilitation treatment while on active duty and was successful in avoiding alcohol abuse for 15 years until experiencing a relapse two years earlier. Service treatment records showed that the attending clinicians in service attributed the Veteran's symptoms at that time to family discord and the stress of work as a recruiter. There was no mention of the impact of combat experiences. However, long after service, VA clinicians noted some symptoms of PTSD. The Veteran received VA outpatient care from April 2006 to November 2006 when he was hospitalized for several days for seizures associated with alcohol abuse. He was hospitalized again in March 2007 for detoxification. The attending physician also diagnosed PTSD associated with traumatic combat experiences described by the Veteran that occurred during his service as a helicopter crew chief and door gunner. The same month, the RO granted service connection and a 30 percent rating for PTSD, effective July 24. 2006, the date of receipt of the claim for service connection. In August 2007, a VA staff psychiatrist examined the Veteran, noted continued heavy alcohol abuse, additionally diagnosed PTSD with significant depression, and assigned a GAF score of 50. In September 2007, the RO awarded a 50 percent rating for PTSD, effective August 20, 2007, the date of the VA examination. It was noted that the Veteran participated in group and individual therapy primarily as a patient in a drug and alcohol aftercare program. In November 2007, the RO awarded the 50 percent rating for PTSD from the July 24, 2006 effective date of the award of service connection. The RO received the Veteran's claim for a rating in excess of 50 percent for PTSD and for a TDIU in February 2009. From June 2008 to January 2009, an attending VA therapist noted the Veteran's reports of some improvement in PTSD symptoms and a reduced desire to self-medicate with alcohol. The therapist assigned a GAF score of 55. In February 2009, the Veteran was again admitted to a VA inpatient alcohol detoxification and rehabilitation management program. The Veteran reported intrusive thoughts of his combat experiences as a door gunner. He also reported night terrors, hypervigilance, exaggerated startle response, avoidance activities, irritability, and lack of anger control. The attending psychiatrists noted the Veteran's reports of social isolation, reduced energy, lack of concentration, and "cloudy thinking." There were no homicidal or suicidal ideations, obsessive compulsive behaviors, panic attacks, or psychotic symptoms associated with PTSD, although the latter did manifest during alcohol withdrawal. The Veteran was unemployed, having been fired by a retail business in 2004 for unspecified reasons. The Veteran was in a third marriage and had a good relationship with an adult daughter. On examination, the Veteran displayed a depressed mood and affect but thought content was clear and directed. Speech was fluent but mildly slowed. Attention, concentration, judgment, and insight were good with no gross sensory deficits. The psychiatrists diagnosed alcohol dependence, rule out alcohol induced mood, and assigned a GAF of 37 without further explanation. In March 2009, a VA clinical psychologist performed a compensation and pension examination. He did not have access to the complete claims file but noted a review of the VA medical records. The Veteran reported regular participation in group therapy, individual counseling, and periodic psychiatric follow-up, and felt that his coping skills had improved. The Veteran reported limited contact with a daughter and grandchild but a very close relationship with his wife. He reported that he spent most of his time at home. He reported that he no longer pursued interests in sports and dancing but was looking forward to traveling with his wife when she retired in a few months. The Veteran described certain combat-related symptoms as more severe including anxious arousal, weekly nightmares, and other re-experiencing symptoms. The Veteran also described mood and strong feelings of loss associated with the functional impact of his numerous physical problems and his wife's recent cancer diagnosis. The Veteran denied homicidal or suicidal ideations, obsessive or inappropriate behavior, episodes of violence, and hallucinations and delusions but did report occasional panic attacks without explaining the circumstances or effects on functioning. On examination, the psychologist noted an anxious and depressed mood and soft or whispered speech. However, there were no thought process or orientation deficits. The Veteran understood his problem and the outcome of his behaviors. The Veteran did display difficulty in concentration but was able to maintain his hygiene and accomplish all activities of daily living. The psychologist concluded that PTSD and the related alcohol dependence and mood disorder imposed a major impact on the Veteran social and occupational functioning with deficiencies in thinking, family relations, and mood but not that the social and occupational impairment was total. He assigned a GAF score of 55. In May 2009, the Veteran underwent another VA inpatient course of treatment for alcohol detoxification. On the first day of June 2009, the Veteran's attending mental health therapist noted the Veteran's report of staring to feel better emotionally. The Veteran spent a holiday with family including grandchildren at a barbeque and visited a local Vietnam Memorial. He reported more energy, more motivation, and enjoyment of life while not using alcohol. The therapist assigned a GAF score of 50. Eight days later in June 2009, the Veteran's attending psychologist noted that the Veteran's irritability increased, that his concentration was very poor, and that he was not able to engage in goal directed behavior. The Veteran did nothing all day, isolated himself from others, and abused alcohol as a coping strategy. He experienced panic attacks when he stopped drinking. The psychologist also noted that the Veteran has a very depressed mood and episodic suicidal thoughts. He no longer maintained relationships with his children including the daughter and grandchild. He expressed no interest in sexual relations, although primary care records show regular prescriptions for treatment for erectile dysfunction. On examination, the psychologist noted coherent thoughts and relevant goal directed speech. However, mood was depressed and anxious, concentration was very poor, and grooming and hygiene were marginal. The psychologist concluded that the Veteran was unemployable and required a very low stress environment to control mood and behavior. One week later, the Veteran's attending psychiatrist also examined the Veteran and noted the same general symptoms. However, the psychiatrist noted that the Veteran was an active participant in group therapy sessions and desired to get involved in volunteer work. The Veteran denied any suicidal ideations and his thoughts were linear and goal directed without hallucinations or delusions. The Veteran was well-groomed. The psychiatrist assigned a GAF score of 55. In July and August 2009, the psychiatrist noted that the Veteran had travelled to a vacation location and had resumed alcohol abuse with a concurrent increase in anxiety, nightmares, and depressed mood. The Veteran expressed thoughts of violence at the offices of the RO for failing to grant his claims. However, he did not want to undergo detoxification treatment because he had another weekend trip planned. On December 1, 2009, the VA psychologist who examined the Veteran in March 2009 again noted a review of the medical records and the results of testing and questionnaires. He noted a disheveled appearance and he odor of alcohol. The Veteran reported maintaining a close relationship with his wife and remaining in contact with a daughter. The Veteran reported experiencing persistent suicidal ideations, violent thoughts directed at the RO for failing to grant claims, and hostile confrontations with others, although there is no evidence in the file to date of any actual violent behavior. On examination, the Veteran's mood was angry and his affect constricted. The psychologist noted severe attention, concentration, and immediate memory deficits. The Veteran understood that he had a problem and needed emergency treatment and psychiatric hospitalization but did not understand the outcome of his behavior. The Veteran neglected his hygiene, experienced sleep interruptions, nightmares, and daytime fatigue. He continued to experience the combat-related and avoidance symptoms of PTSD. Psychological testing was consistent with PTSD, anxiety, mood disorder, severe alcohol use and somatic distress. Notwithstanding these severe symptoms, the psychologist noted that the Veteran understood and could manage his personal and financial affairs. The psychologist did not comment directly on employability but assigned a GAF score of 41 and recommended hospitalization to treat severe symptoms and impairment of functioning. The same day, an attending clinician noted that the clinic would seek involuntary commitment if the Veteran did not cooperate with inpatient treatment. The Veteran did receive three days of inpatient detoxification. Ten days later, the clinician noted that the Veteran had ceased alcohol use and now displayed a stable mood with no thoughts of suicide or homicide. Thought processes and memory were not clinically impaired although insight and judgment remained limited. In April 2010, the VA psychologist who had conducted the compensation and pension examination again examined the Veteran. The psychologist noted the Veteran's reports of some easing of symptoms with medication although he reported continued frequent panic symptoms and combat related PTSD symptoms. This examination report contained some differences from that reported in December 2009. The Veteran's hygiene appeared to be normal. The Veteran reported conflict rather than closeness in his marital and family relationships. The psychologist noted that the Veteran did understand his problems and the outcome of his behaviors and had no suicidal or homicidal thoughts. The psychologist noted significant short term memory deficits but psychological testing was invalid because of significant symptom over reporting. The psychologist assigned a GAF score of 50 and recommended long term care but not hospitalization. VA outpatient treatment records document that the Veteran was able to accomplish all activities of daily living except that he did not drive an automobile because of recurrent episodes of syncope which some clinicians attributed to hypotension or hypoglycemia and others to alcohol abuse. The Veteran was hospitalized for short periods in April and May 2010 for treatment following an episode. In June 2010, the Veteran reported that he was "feeling great" after returning from a vacation trip where he refrained from alcohol use. In July 2010, the RO granted an increased rating of 70 percent for PTSD and a total rating based on individual unemployability, effective December 1, 2009 (the date of the VA examination). In January 2011, it was noted that the Veteran was on a vacation cruise when he experienced a seizure and received treatment at the VA Medical Center in San Juan, Puerto Rico. Clinicians noted a history of seizures following alcohol withdrawal. The Veteran did not remain in the VAMC for further evaluation. The Veteran received VA inpatient treatment for 21 days in December-January 2012 and for 58 days from February to April 2012 for PTSD and alcohol dependence. The attending clinicians assigned arrival and discharge GAF scores of 37-49 and 43-48 respectively. Although the inpatient clinicians noted suicidal ideations at the time of admission, none were present upon discharge. Between the two periods of hospitalization, the Veteran's primary care physician advised the Veteran that he could go on another Caribbean cruise. In January 2012, a VA social worker noted the Veteran's report that he could no longer perform his duties as the president of a retired men's club because of his alcohol abuse. However, he continued to participate in group vacations such as an upcoming cruise with therapy sessions aboard the ship. The social worker noted that some of the Veteran's strengths were great leader and great with people as indicated by his management of a 1000 member club. The Veteran acknowledged that he needed to work on his use of leisure and recreational time. In May 2012, the RO granted a temporary total rating for hospitalization over 21 days from February 21, 2012 to through April 30, 2012, and continued the 70 percent rating for PTSD from May 1, 2012 forward. The RO scheduled the Veteran for another compensation and pension examination in December 2012. The VA Medical Center reported that the Veteran cancelled the examination because he no longer wished to pursue a claim for an increased rating at the time. The Veteran did not respond to a March 2013 request from the RO to confirm his intention in writing. B. Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). As the RO has already assigned staged ratings for the Veteran's PTSD, the Board must consider the propriety of the rating assigned for each period, as well as whether any further staged rating is warranted. The ratings for the Veteran's PTSD have been assigned pursuant to Diagnostic Code 9411. However, the actual criteria for rating the Veteran's disability are set forth in a General Rating Formula for evaluating psychiatric disabilities other than eating disorders. See 38 C.F.R. § 4.130. A 50 percent rating is warranted for 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-term and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating may be assigned where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessed 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. A 100 percent rating is warranted where there is total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. The symptoms and manifestations listed under the above rating formula are not requirements for a particular evaluation, but are examples providing guidance as to the type and degree of severity of these symptoms. Consideration also must be given to factors outside the rating criteria in determining the level of occupational and social impairment. The Board will not require the presence of a specified quantity of symptoms in the rating schedule to warrant the assigned rating for PTSD. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). VA must give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The evaluation of evidence generally involves a three step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. Then, the Board must determine whether the evidence is credible. The Board must make an express credibility finding regarding lay evidence. Dalton v. Nicholson, 21 Vet. App. 23 (2007). Finally, the Board must weigh the probative value of the proffered evidence in light of the entirety of the record. Considering the pertinent evidence in light of the above, the Board finds that a rating in excess of 50 percent for PTSD, prior to December 1, 2009, is not warranted. During this period, the severity of the Veteran's symptoms and the associated social and occupational impairment varied significantly depending on the intensity of his alcohol abuse and frequency of inpatient detoxification treatment. The Board acknowledges that clinicians considered the abuse as a form of self-medication or coping with his PTSD and physical medical problems. Collectively, the pertinent medical evidence reflects that prior to December 1, 2009, the Veteran's PTSD was manifested by such symptoms as intrusive thoughts of his combat experiences, night terrors, hypervigilance, exaggerated startle response, avoidance activities, irritability, and lack of concentration. This level of occupational and social impairment manifesting as reduced reliability and productivity not greater than that contemplated by a 50 percent rating. There were no homicidal or suicidal ideations or obsessive compulsive behaviors. Panic attacks or psychotic symptoms manifested only during alcohol withdrawal. The Veteran displayed a depressed mood and affect but thought content was clear and directed. The depressed mood was also attributed by examiners to physical problems of the Veteran and his wife. Speech was fluent but mildly slowed. Attention, concentration, judgment, and insight were good with no gross sensory deficits. The Veteran expressed thoughts of violence and suicide on some occasions but denied these thoughts on other occasions. There is no evidence that the Veteran had firm plans or actually engaged in any violent acts. Although the Veteran reported that he spent much time alone at home with few friends, the record also shows some relationship with wife and family, membership in a social organization, and regular travel for recreation. The medical evidence simply does not show that, at any point during the period in question, the Veteran had symptoms characteristic of the next higher, 70 percent rating, such as obsessed 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); or spatial disorientation. Neglect of personal appearance and hygiene was noted only on the occasion of admission for detoxification for severe alcohol abuse. The Veteran did maintain effective relationships, and his work as a member or officer of a club demonstrates some level of occupational capacity. The Board notes that the Veteran is competent to report his own symptoms, perceptions, and behaviors that are observable by a lay person. Here, the Board finds that his description of his PTSD symptoms are deemed credible primarily because they have not been challenged as imaginary or manipulative by clinicians. The Veteran's report of no employment since 2004 is credible, as it is consistent with the award of benefits by SSA, as well as his multiple hospitalizations. The Board places less probative weight on his reported degree of social isolation, the medical records document that he generally maintained relationships with his wife and daughter-albeit, strained, at times-as well as with his grandchildren; and that he participated actively in group therapy, engaged in vacation travel including ocean cruises, and was a participant and officer of a large men's social organization. The Board further finds that none of the GAF scores assigned prior to December 1, 2009-generally from 50 to 55, and, on a single occasion, 37-alone, provides, a basis for higher rating. According to DSM-IV, GAF scores from 51 to 60 are indicative of moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks), OR moderate difficulty in social, occupation, or school functioning (e.g., few finds, conflict with peers or co-workers). Scores from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), OR serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). GAF scores from 31 to 40 reflect 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). In this case, the majority of the assigned GAFs from 50 to 55 are indicative of moderate symptoms or moderate difficulty in social, occupational, or school functioning; clearly support no more than the 50 percent rating assigned for the period in question. Indeed, as these scores actually suggest less impairment than that contemplated in the 50 percent rating, these scores provide no basis for assignment of an even higher rating. While the single score of 37 conceivably suggests greater impairment that that contemplated in the 50 percent rating, this score is not representative of the Veteran's overall level of impairment during the period in question. As noted, the score was assigned at the time of admission for detoxification in February 2009, and the psychologists did not provide an explanation for the score. The short-lived score also is not consistent with several other scores noted in the remainder of the year prior to December 1, 2009-to include the GAF of 55 assigned by the VA psychologist evaluating the Veteran for compensation and pension purposes approximately one month later, in March 2009. In any event, as noted above, the Board reiterates that the symptoms shown, and not an examiner's assessment of the disability or assigned GAF, provide the primary basis for evaluation of psychiatric disability. See 38 C.F.R. § 4.126. Here, for reasons discussed above, the symptoms shown prior to December 1, 2009 are consistent with no more than the 50 percent rating assigned for that period. The Board also finds that a rating in excess of 70 percent for PTSD, from the date of the December 1, 2009 documenting increased impairment, is not warranted. Since that date, the Veteran's PTSD has been manifested by a continuation of the combat-related and avoidance symptoms but with additional symptoms of neglected hygiene, more persistent thoughts of suicide, panic attacks not associated with detoxification, and episodes of syncope or seizures that precluded driving an automobile and required hospitalization. The Veteran's attention and concentration deficits degraded to a degree such that clinicians insisted on the Veteran's participation in immediate crisis care. The Veteran's recurrent alcohol abuse relapses represent a degradation of the Veteran's judgment, insight, and ability to function independently, appropriately and effectively. However, at no point pertinent to this appeal has the Veteran's overall PTSD symptomatology met the criteria for the maximum, schedular 100 percent rating. The credible lay and medical evidence does not show the Veteran to have symptoms such as gross impairment of thought and communications, delusions or hallucinations, disorientation, or severe memory deficits to the extent of an inability to remember names, or other symptoms that are characteristic of a 100 percent rating. Other than an inability to safely operate an automobile, the Veteran has been able to perform most activities of daily living including participation in vacation travel. Although the frequent hospitalization for alcohol abuse treatment would likely preclude forms of gainful employment in a business-addressed in connection with the TDIU claim, below-the Veteran's psychiatric symptoms, alone, have not been shown to result in total occupational and social impairment. The Board further notes that GAF scores assigned starting in December 2009 have generally been from 40-50, indicating a deterioration to serious symptoms and impairment in social and occupational functioning largely consistent with the major deficiencies in most areas for which the 70 percent rating was assigned. Based on the foregoing, the Board concludes that the Veteran's psychiatric symptomatology more nearly approximated the criteria for the 50 percent schedular rating prior to December 1, 2009 and the 70 percent schedular rating thereafter. See 38 C.F.R. § 4.7. The above-noted determinations are based on consideration of pertinent provisions of VA's rating schedule. Additionally, the Board finds that at no pertinent point has the disability under consideration been shown to be so exceptional or unusual as to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). There is a three-step analysis for determining whether an extra-schedular rating is appropriate. Thun v. Peake, 22 Vet. App. 111, 115 (2008). The threshold factor for extra-schedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). See also 38 C.F.R. § 3.321(b)(1); VA Adjudication Procedure Manual, Pt. III, Subpart iv, Ch. 6, Sec. B(5)(c). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996). See also Thun, supra. In this case, the applicable rating criteria are adequate to rate the Veteran's PTSD at all pertinent points, as they reasonably contemplate the Veteran's particular symptoms and the resulting degree of occupational and social impairment. Although the rating criteria does not specifically address the frequency of alcohol abuse, detoxification, and episodes of syncope, the criteria does recognize the associated psychiatric symptoms such as reduced concentration and attention, irritability, and degraded judgment and insight. As clinicians have associated the alcohol abuse as a coping mechanism for the symptoms of PTSD, the Board has considered the impact of this component illness on the degree of disability. Nevertheless, the rating criteria do encompass the constellation of symptoms presented in this case, and authorize (a) higher rating(s)when warranted by the symptomatology and impairment shown. Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). For all the foregoing reasons, the Board concludes that there is no basis for further staged rating of the Veteran's PTSD, pursuant to Hart, and that ratings for PTSD greater than 50 percent prior to December 1, 2009, and greater than 70 percent thereafter must be denied. In reaching these conclusion, the Board has considered the applicability of the benefit-of-the doubt doctrine; however, as the preponderance of the evidence is against assignment of any higher rating at any pertinent point, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). III. TDIU Under the applicable criteria, total disability ratings for compensation based upon individual unemployability may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. See 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In exceptional circumstances, where the veteran does not meet the aforementioned percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to obtain or retain substantially gainful employment. 38 C.F.R. § 4.16(b). In this case, the Veteran does not meet the objective, minimum percentage requirements, set forth in 38 C.F.R. § 4.16(a), for award of a schedular TDIU. Prior to December 1, 2009, service connection was in effect for PTSD (rated as 50 percent disabling), diabetes mellitus (rated as 20 percent disabling), and, as of February 23, 2009, hypertension (rated as noncompensable). Although there was one disability rated at greater than 40 percent, the combined rating with the additional two disabilities was 60 percent. However, a total rating, on an extra-schedular basis, may nonetheless be granted, in exceptional cases (and pursuant to specifically prescribed procedures), when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities (per 38 C.F.R. §§ 3.321(b) and 4.16(b)). Hence, consideration of whether the Veteran is, in fact, unemployable, is still necessary in this case. The central inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's education, special training, and previous work experience, but not to his age or to the impairment caused by non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2009); see also Van Hoose v. Brown, 4 Vet. App. 361 (1993). Prior to December 1, 2009, the Veteran did maintain some effective relationships, and his work as a member or officer of a club demonstrates some level of occupational capacity. Although he was terminated from his last job in 2004 for unspecified reasons, there is no indication that this was due to service-connected disabilities, or that he attempted any form of employment in another venue or occupation. The Veteran's military experience including 10 years as a senior recruiter and as the owner of a small business demonstrates significant administrative, management, and leadership skills. His ability to lead a large club is representative of a capacity to put these skills to productive activities and shows at least some level of occupational capability. There is no medical or vocational evidence to show that the Veteran's diabetes or hypertension or the associated prescription medications contribute to an inability to engage in substantially gainful employment prior to December 1, 2009. Furthermore, to whatever extent the Veteran and/or his representative attempt(s) to establish the Veteran's entitlement to a TDIU prior to December 1, 2009, on the basis of lay assertions. alone, such attempt(s) must fail. In this regard, the Board emphasizes that, neither the Veteran nor his representative has not been shown to possess expertise in medical or vocational matters. See 38 C.F.R. § 3.159 (a)(1) (competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). See also, e.g., Bostain v. West, 11 Vet. App. 124, 127 (1998); Routen v. Brown, 10 Vet. App. 183, 186 (1997) (a layperson is generally not capable of opining on matters requiring medical knowledge). As such, neither is competent to render an opinion as when the Veteran was, in fact, rendered unemployable as a result of his service-connected disabilities, the lay assertions in this regard have no probative value. For the foregoing reasons, the Board concludes that there is simply no competent, credible and persuasive evidence to support a finding that, as a result of service-connected disabilities, the Veteran was unable to procure or sustain all forms of substantially gainful employment prior to December 1, 2009. Accordingly, the benefit-of-the-doubt doctrine is not for application (see 38 U.S.C.A. § 5107(b) and 38 C.F.R. § 3.102 and Gilbert, 1 Vet. App. at 53-56), and the matter of the Veteran's entitlement to a TDIU prior to December 1, 2009 must be denied. (CONTINUED ON NEXT PAGE) ORDER A rating in excess of 50 percent for PTSD, prior to December 1, 2009, is denied. A rating in excess of 70 percent for PTSD, from December 1, 2009 , is denied. A TDIU, prior to December 1, 2009, is denied. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs