Citation Nr: 1323583 Decision Date: 07/24/13 Archive Date: 08/01/13 DOCKET NO. 07-12 146 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Young, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from April 1966 to June 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal from a June 2005 rating decision of the Chicago, Illinois Department of Veterans Affairs (VA) Regional Office (RO), which granted service connection for PTSD, rated 50 percent, effective January 16, 2005. In September 2011 a Travel Board hearing was held before the undersigned. A transcript of the hearing is associated with the claims file. In November 2011, the Board remanded the case for additional development. In January 2013 the Board sought an advisory medical opinion from the Veterans Health Administration (VHA) regarding this matter, such opinion was received in April 2013. FINDING OF FACT From May 10, 2007 to July 2, 2012 the Veteran's PTSD is reasonably shown to have been manifested by symptoms productive of occupational and social impairment with deficiencies in most areas but symptoms productive of total occupational and social impairment were not shown; prior to May 10, 2007 and from July 2, 2012 the Veteran's PTSD was (and has been) manifested by symptoms productive of a disability picture no more severe than occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW The Veteran's PTSD warrants "staged" ratings of 50 percent prior to May 10, 2007; (an increased) 70 percent from May 10 2007 to July 2, 2012; and 50 from July 2, 2012. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.21, 4.126, 4.130, Diagnostic Code (Code) 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to the instant claim. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The rating decision on appeal granted service connection for PTSD, and assigned a disability rating and an effective date for the award, statutory notice had served its purpose, and its application was no longer required. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86(2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). An April 2007 statement of the case (SOC), and April 2008, August 2009, August 2011 and July 2012 supplemental statements of the case (SSOC) properly provided notice on the "downstream" issue of entitlement to an increased initial rating, and readjudicated the matter after the Veteran had opportunity to respond. It is not been alleged that he is prejudiced by a notice defect. See Goodwin v. Peake, 22. Vet. App. 128 (2008). The Veteran's service treatment records are associated with his claims file, and pertinent postservice treatment records have been secured. The Board has reviewed Virtual VA records, including recent VA treatment records considered by the RO in the July 2012 SSOC. Pursuant to the Board remand, records from the Social Security administration (SSA), and private treatment records have been associated with the claims file. The Veteran underwent VA examinations in May 2005, September 2006, November 2009, and August 2011. A review of the examination reports found that they cumulatively are adequate for rating purposes, as they reflect the disability picture presented by the PTSD and include clinical findings adequate for rating purposes. The Board finds that the record as it stands includes adequate competent evidence for the Board to decide this matter, and that no further development of the evidentiary record is necessary. See generally 38 C.F.R. § 3.159(c)(4). The Veteran has not identified any pertinent evidence that is outstanding; notably, he did not respond to the RO's request (in December 2011) for identifying information regarding providers of private mental health treatment he has received since 2004 (records of which are not already associated with the claims file). VA's duty to assist the Veteran' is met. Legal Criteria, Factual Background, and Analysis The Board notes that all of the evidence in the Veteran's claims file and in Virtual VA with an emphasis on the evidence relevant to this appeal, has been reviewed. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate, and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. Disability ratings are assigned in accordance with VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. As this appeal is from the initial rating assigned with the grant of service connection, "separate ratings can be assigned for separate periods of time based on facts found." Fenderson v. West, 12 Vet. App. 119, 126 (1999). PTSD is rated under 38 C.F.R. § 4.130, Code 9411 (and the General Rating Formula for Mental Disorders (General Formula)), which provides for a 50 percent rating when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. To warrant the next higher (70 percent) rating, there must be occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent rating is warranted when the evidence shows 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. 38 C.F.R. § 4.130. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). 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). The Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996). A GAF score of 21-30 is appropriate where behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all area (e.g., stays in bed all day; no job, home, or friends). A GAF score of 31-40 is appropriate where there is 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., a depressed individual avoids friends, neglects family, and is unable to work). A GAF score of 41 to 50 is appropriate where there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A score of 51 to 60 is appropriate where there are moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM-IV) 47 (4th ed. 1994). It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability there from and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran's service treatment records are silent for any complaints, history, treatment or diagnosis of a psychiatric disorder. Postservice, in the early 1980's the Veteran was admitted to a VA hospital (from October 1981 to February 1982) with Axis I diagnoses of alcohol abuse and major depression (single episode); this was his first psychiatric admission. He had presented at the hospital with suicidal ideation. He stated that he had been thinking about taking a lot of Librium and then setting fire to his car. He stated that he had been feeling poorly for roughly the last year prior to admission to the hospital, but matters became much worst after he learned that his wife was going to divorce him. He reported that his frame of mind was such that he was unable to hold a job, had difficulty concentrating, and had difficulty sleeping. He denied any significant alcohol abuse within the last year before being hospitalized. On discharge from the hospital there was a significant decrease in anxiety. His mood/affect showed no underlying preoccupations with guilt. There did not appear to be any significant depressive mood disorder. He was referred to a local mental health center for follow-up psychiatric care. An October 2004 VA mental health clinic social work assessment reveals the Veteran appeared anxious. On evaluation, he denied suicidal and homicidal ideation. He admitted to substance abuse and that he had been an inpatient in a psychiatric ward in 1985, and that he had psychiatric intervention at VA for PTSD. He reported that he was fired from his job (2 days prior) for several instances for which he perceived he had no responsibility. There was no diagnosis. On April 2005 private psychological testing for the Bureau of Disability Determination Services it was noted that the Veteran had applied for disability benefits due to PTSD, but, that he actually appeared to have more of an anxiety disorder with panic attacks and not true PTSD. He reported that he had been seeing a psychologist and a psychiatrist at the West Side VA Center since January 2004. He reported a longstanding history of alcohol dependence and consuming at least a twelve-pack of beer a day and seven shots of 100% whiskey. He now reported he had stopped drinking, cold turkey, in December 2004, after he was charged with driving under the influence and lost his driver's license. He has been divorced twice since 1996. He had one son (by his first marriage) whom he has not seen since 1981 when the ex-wife took him with her when she moved to Texas. He became depressed last fall after he was fired from his job as a security guard because he failed to report an incident. He was also evicted from his home when his apartment flooded, after he let the sink overflow onto the floor. He then began receiving VA psychiatric treatment. VA records showed that he initially denied having any mental problems or depression and refused treatment for depression. There was also no mention of PTSD in VA records. The only symptoms of PTSD he reported were some memories and dreams at times of bombings when he was in Vietnam as a marine. If he were to hear a loud thunderous sound, he would reflexively try to find low ground, recalling the bombing. The psychologist stated that the Veteran was very pleasant and cooperative during the evaluation. The diagnoses under DSM-IV Axis I were anxiety disorder, not otherwise specified, somewhat controlled with medication, severe alcohol dependence in early partial remission, and alleged PTSD, not confirmed. The psychologist commented that the Veteran had average mental potential to perform work related activities involving understanding and memory, sustained concentration and persistence, social interaction, and adaptation. He had worked as a security guard much of his life and also did factory and mechanical work. It was noted that he was capable of resuming that type of work but was having difficulty getting to a job due to not having a driver's license. He also had to move in with his sister since he became homeless. On May 2005 VA examination (for initial evaluation for PTSD), the examiner noted the claims file was reviewed. The Veteran reported that he spent a year in combat in Vietnam during 1968, and was involved in the Tet offensive. He reported that he had been depressed and anxious and had been experiencing sleep problems for many years. He stated that his sleep problems (referring to nightmares) keep him "up and down all night." There was no indication that at the time of the examination, he was involved in active psychotherapy or psychiatric care. He reported that he had worked as a security guard, but was currently not working. He stated that he tends to be isolated and alone. The examiner noted that the Veteran came on time for the interview and was dressed in a very casual manner. He was friendly, cooperative and unshaven. He was alert and oriented to time, place, and person. His affect and mood were depressed. There was no psychosis. There were no delusions or hallucinations, and no suicidal or homicidal ideations (plans or impulses). He was depressed and anxious. His memory was okay and his insight was very limited. His fund of knowledge was below average. His decision-making ability was okay. He had no impairment of thought process or post military stressors. He had normal activities of daily living. The Axis I diagnosis was chronic PTSD; the GAF score assigned was 47. On September 2006 VA psychiatric examination, the Veteran reported that he last worked in October 2004, and that he "lives" on his disability compensation benefits. He stated that he cannot work because he cannot walk ("my legs are all screwed up") and "because the doctor says I have about 2/3 of my heart working." He stated "I'm still not sleeping right," and that he was not eating right. He reported that he has a lonely feeling, even in a crowd. On mental status examination he was described as fully alert and oriented in all spheres. He was carelessly attired in soiled clothing too small for his girth. He was poorly groomed. He exuded body odor and needed a shave and a haircut. His fingers were tobacco stained and there was dirt under each fingernail. He made adequate eye contact. His speech content was grossly logical, with excessive emphasis on non-essential information. His verbal flow lacked discernible direction; he rubbed his head stereotypically and gestured awkwardly with his hands at unexpected moments. His mood was neutral; he was neither depressed nor anxious. His affect was not congruent with verbal content; his range of affect was constricted. He stated "I hate everyone." He admitted distrust for the examiner based on her gender ("because of my two divorces and the girlfriends I had after that."). He stated that he hears voices calling his name on occasion. There was no overt evidence of a psychotic process noted during the course of the examination; however, he did not seem internally preoccupied. He denied suicidal or homicidal ideation or intent. He reported an inability to concentrate effectively and had occasional memory lapses (not including episodes during which he blacked out due to excessive alcohol consumption). His intellectual capacity was within normal range of human intelligence; no formal IQ testing was performed. He lacked insight ;he did not perceive himself as engaging in excessive alcohol use and attributed his reported distress to a disorder for which he had not sought regular treatment. His judgment was highly questionable. The examiner found certain episodes described by the Veteran extremely worrisome, insofar as they placed him as well as random individuals in danger each time he gets behind the wheel of his car in an intoxicated (and sometimes barely conscious) state. Given the devastating impact of alcohol on the Veteran's health and the expense of his daily dozen beers and six shots, he would benefit from the designation of a payee for VA purposes. The examiner noted that there is little question that the Veteran's functional disabilities are attributable largely to his drinking. The diagnosis under Axis I was PTSD, by history, mild in severity, and alcohol dependence (primary). The examiner further found that there appeared to be little change in the Veteran's psychiatric status since his last examination in May 2005. He stated that the Veteran appeared to have sought minimal psychiatric care, and that which is documented makes no mention of trauma, re-experiencing, avoidance of stimuli associated with trauma, or hyperreactivity. He appeared to be no more impaired by a combat-related disorder than he might have been when last examined for compensation purposes. Rather his alcohol dependence appeared to be the source of his functional disabilities. He drank dangerous quantities of alcohol each day, which contributed to his social and occupational impairment, and is, more likely than not, a major factor in respect to his malnutrition and his precarious health. In an April 2007 Vet Center Intake Assessment, it was noted that the Veteran had been referred to the Vet Center for symptoms of PTSD and substance abuse. It was noted that he was unkempt, overweight, and unemployed. His manner was friendly and cooperative. His intelligence was below average. His speech was appropriate, he was oriented to person, place and time, and his memory function was within normal limits. His affect was appropriate, his judgment was fair and his insight was good. He had normal thought content, but his thought processing was disorganized. His perception was normal and his mood was depressed. He report that he had nightmares every night. He awoke every 2 hours, and this pattern had not changed since he reduced his alcohol intake. He stated that he thinks about Vietnam several times during the day. He stated that he "hates" women because of the betrayal by his first wife. He did not have friends other than his drinking companions; he occasionally went to a bar with his brother. He became angry easily and did not trust anyone. He stated that he gets discouraged because his health limits his activities, and that he could no longer work even a part-time job. He had had a heart attack and by-pass surgery, but continued to smoke and drink. On May 10, 2007 private evaluation to assess PTSD the Veteran reported that he had a longstanding treatment history for chronic emotional and behavioral problems (including a history of legal difficulties) directly resulting from his combat experience in Vietnam. He was dressed in casual but tattered clothing appropriate to the season. He had a rather disheveled appearance and his grooming and hygiene were poor. His intelligence appeared to be within normal to below normal limits. His mood and affect vacillated between anxious, angry, and depressed. He admitted to past and present suicidal and homicidal ideation but denied any immediate intent. He reported that he had a documented history of at least one suicide attempt, for which he was hospitalized. He denied having delusions, but acknowledged that he struggles frequently with mild auditory hallucinations and distinct flashbacks. His memory for remote information appeared relatively intact but he reportedly experienced difficulties recalling short term and recent information. His thought processes were at times irrational, which likely contributed to his homicidal ideation. His speech was clear and audible, and at times excited and loud. His insight and judgment were extremely poor. He reported experiencing numerous symptoms, including but not limited to, chronic substance abuse, flashbacks, disturbing thoughts, memory problems, changes in appetite, irritability, heart palpitations, stress, anxiety, mood swings, sexual concerns, family concerns, poor self esteem, phobias, depression, panic attacks, lack of interest, sleeping problems, social isolation, confusion, suicidal thoughts, difficulty concentrating, work difficulties (chronic), and self destructive behaviors. The examiner did not consider the symptoms to be exaggerated or feigned. The examiner noted that the frequency and severity of the Veteran's symptoms were such that he was functioning at a substandard level, with minimal attention to and follow through for the responsibilities of daily living. The examiner opined that the Veteran's PTSD, depression, and substance abuse are chronic and severe and that he was unlikely to be able to hold down even menial jobs, in part due to his disorders, and in large part due to the risk of harm he posed to himself and others. It was further noted that the Veteran was experiencing multiple psychosocial stressors which further exacerbated his symptoms. The GAF score was 30-32. A February 2008 VA mental health clinic report notes that the Veteran has a history of PTSD along with alcohol dependence, and mood disorder, not otherwise specified. His main symptoms since service have been unstable mood, depressive symptoms mixed with irritability and anxiety, along with a history of impulsivity. He reported a suicide attempt in 1981; he had been in a VA hospital for four months and after discharge took an excessive amount of the pills he was provided at discharge and also drank some beer. He denied any other suicidal attempts, but he had had chronic suicidal ideation. He denied ever harming anybody else. The provider noted that since Wellbutrin had been added to the Veteran's medications he has no taste for alcohol (he had not had any for a month). On mental status examination, it was noted that the Veteran looked physically better since he stopped drinking. He was alert, oriented, and attentive, and made good eye contact. He was less affectively blurry since he had not been using alcohol, although he had some mild anxiety during the interview. He had adequate spontaneous speech, eye movement, facial expression, and motor activity. There was no impairment of thought process or communication. He had no active ideation, but had chronic passive thoughts of not caring whether he lives or dies. There was no homicidal ideation or psychosis. His cognitive ability, insight, and judgment were adequate to make informed treatment decisions. It was felt that the Veteran was at low risk of harm to himself or anyone else. In a May 2008 letter, a readjustment counselor at a Vet Center noted that she had been seeing the Veteran since March 2007, and that he experienced intrusive thoughts, nightmares, sleep disturbance, anger, social isolation, alcohol abuse, intense anxiety, depression, suicidal thoughts, homicidal thoughts, and difficulties in his relationships. He avoided talking about his experiences in Vietnam. He was "triggered" frequently, causing a significant increase in his suicidal thoughts and depression. He has severe medical issues that make it difficult for him to be physically active, forcing him to spend most of his time alone and unable to distract himself from his thoughts. On July 2009 VA outpatient psychiatry note, it was noted that the Veteran has PTSD along with secondary mood disorder which was considered to be the result of his history of long-term alcohol dependence; however, he had not used alcohol in over a year. On mental status examination, he was alert, oriented and attentive. He made good eye contact. His mood overall was a little bit dysphoric, but not depressed. His affect was appropriate. He had good spontaneous speech, good spontaneous eye movement, facial expression and motor activity. He had full range of affect and was interactive. There was no impairment of thought process or communication. There was no suicidal or homicidal ideation. There was no psychosis, and there was adequate cognition, insight and judgment. On November 2009 VA psychiatric examination, the Veteran was fully alert and oriented in all spheres. He was generally cooperative with the interview, but somewhat detached from spontaneous conversation and awkward in his interaction. He appeared disheveled and unshaven. His hygiene was poor. Hypophonia was evident in his speech, and his articulation was poor. His speech content was generally logical, but appeared to be impulsively derived and unrelated to the topic at hand. His mood was dysphoric and irritable. He described his mood as "bad" and stated "I hate everybody." He had a guarded affect. He made sarcastic comments and laughed during the interview. He reported visual and tactile hallucinations when falling asleep. There was no evidence of a psychotic process or core. He denied any current suicidal or homicidal ideation, intent or plan. He reported that he had no short-term memory. His insight was limited and his judgment was questionable, given self care and poor hygiene. He denied any current (since July 2008) use of alcohol.. Psychological testing suggested that the Veteran was experiencing severe levels of depressed and anxious feelings and behaviors. He continued to meet the DSM-IV criteria for PTSD based on the symptoms he endorsed. He reported nightmares, flashbacks, intrusive thoughts of combat situations, avoiding thoughts and conversations regarding the traumas, sleep difficulties, irritability, concentration problems, hypervigilance, and an exaggerated startle response. The symptoms appeared to be mild to moderate in severity and chronic (as he reported they had occurred since his combat). He was following through with psychiatric appointments at a VA clinic, and reported he was seeing a psychotherapist near his home for treatment of PTSD. He reported that he had a longstanding (pre-dating his military career) history of social difficulties and personality influences. The examiner noted that there did not appear to be significant changes in his presentation from prior compensation psychiatric evaluations. The Axis I diagnoses were PTSD and alcohol dependence (in remission). A February 2010 VA outpatient psychiatry report notes that the Veteran had PTSD along with a history of secondary mood symptoms. He also had a history of alcohol dependence, but had not used alcohol for almost two years. On mental status examination, he was alert, oriented and attentive. He made good eye contact; however, as the interview progressed "he does take down into tears." It was appropriate crying, in that in late December, after Christmas, he had to put his dog "down." The rest of the mental status examination he was very cooperative. He was interactive; and able to modulate his affect. There was no psychomotor agitation or retardation. There was no impairment of thought process or communication, or suicidal or homicidal ideation. There was no psychosis. His cognition, insight and judgment were intact. The physician noted that in his estimation the Veteran was fully capable of being his own payee. He had not used alcohol in almost two years and he attended to his activities of daily living and his needs appropriately and without difficulty. An April 2011 VA outpatient psychiatry report notes that on mental status examination the Veteran was alert, oriented and attentive. He made good eye contact. His mood overall was euthymic. His affect was appropriate with good spontaneous eye movement, facial expression and speech, along with positive discussions about his dog and how much fun he had with his dog. He had a good positive outlook on life. His speech was of a normal tone and rate. There was no impairment of thought process or communication. There was no suicidal or homicidal ideation, and no psychosis; cognition, insight and judgment were intact. On August 2011 VA psychiatric examination, the Veteran reported that he was not engaged in any therapy for PTSD or any other mental health disorder. He reported past group attendance that he described as "kinda like a Vet Center Group." He denied psychiatric hospitalization or serious attempts to harm himself or others. He reported that his sleep is, "very bad." He reported frequent waking and some problems falling asleep that he attributed to "dreams". He reported frequent nightmares regarding events in Vietnam. He also reported that he experiences intrusive thoughts that serve as frequent triggers, and that he isolates himself from others, with decreased participation in activities, avoiding crowds, avoiding going out at night and feelings of detachment from others. He described frequent safety behaviors like checking locks and windows and hypervigilance. It was noted that the Veteran had many physical problems which were the most salient factors driving his decrease in enjoyable activities and isolation from others. On mental status examination the Veteran was described as fully alert and oriented in all spheres. He was dressed casual and overly dressed for very warm weather in long pants and a sweatshirt. His grooming was poor. He had stains on his clothes which were wrinkled. His speech was a normal rate, rhythm, and volume. The content was logical and goal directed. His mood was angry and sad. His affect was full range and well related. It was noted that he laughed and made jokes in a good-natured manner. He denied hallucinations and delusions. There was no evidence of a psychotic process or core. He denied suicidal or homicidal ideation or intent. There was no cognitive deficit reported, noted or detected. He described some mild forgetfulness such as forgetting where he put his glasses from time to time. His intellectual capacity was within the normal range of human intelligence. He had little insight and unimpaired judgment. The examiner noted that the Veteran did not describe his PTSD as worsened or improved. He described feelings of decreased meaning, involvement in activities and connections with others related to his medical problems. The examiner noted that it is unclear what role PTSD played in those aspects of the clinical picture as the Veteran himself did not connect those behaviors and feelings with PTSD himself. His most recent psychiatric appointment for medication management appears to note the Veteran as improved and generally with a positive view on life and euthymic in mood. All considered, the Veteran can only be said to have mild symptoms at the present although these do appear to be chronic in nature given that they have persisted for longer than three months. One could speculate that the Veteran could see further improvement and perhaps resolve should he engage himself in one of the available therapies. The diagnosis under Axis I was PTSD, chronic, mild. His GAF score was 60. At the September 2011 Travel Board hearing, the Veteran testified that he believes that his service-connected PTSD should be rated 70 or 80 percent because he was getting a lot of "flashbacks and everything." He stated that he did not have individual group therapy or treatment at VA Medical Center (VAMC), but he was going for the "group" at the VA clinic. He stated that he lost quite a few jobs because of the PTSD. He testified that his current symptoms are that he is up at least five times a night, and he hears noises that are not there. He feels something crawling on his legs and there is nothing there. He stated that he is "hyper." He has anxiety attacks. He stated that he does not get enough sleep, nor is he eating correctly. He stated that he last worked in 2004, as a security guard. His job was terminated because he could not get along with the young people where he was assigned. On July 2, 2012 the Veteran was seen for follow-up at a VA outpatient psychiatry clinic. It was noted that his mood symptoms had improved since he became sober. It was noted that Wellbutrin was initially started several years prior to help him quit smoking and had also helped him quit drinking. On mental status examination he was described as alert, oriented and attentive. He made good eye contact. His mood overall was euthymic. His affect was appropriate with good positive appropriate bright expression. His speech was of a normal tone and rate. There was no impairment of thought process or communication. There was no suicidal or homicidal ideation, and no psychosis. Cognition, insight and judgment were intact. In January 2013 the Board sought a VA medical advisory opinion regarding this matter, noting that the Veteran had been assigned psychiatric diagnoses other than PTSD (major depressive disorder, anxiety disorder, and alcohol dependence). With respect to alcohol dependence, the Board sought to ascertain whether the Veteran's alcohol abuse is a symptom of his PTSD (and if not, what, if any, symptoms may be distinguished as due solely to the alcohol abuse ). The Board sought to ascertain what, if any, symptoms and impairment were distinguishable as due solely to co-existing and nonservice-connected psychiatric diagnoses rather than to PTSD. In April 2013 a consulting VHA psychologist who reviewed the record opined that it is at least as likely as not that the Veteran's alcohol dependence/abuse was a symptom of his PTSD. He noted that the Veteran did not consume alcohol prior to service, that based on his self-report, his alcohol use began in Vietnam, and that consequently it was more likely than not, that his alcohol use was an attempt to self-medicate initial PTSD symptoms caused by the stressors of war. He stated further that it is not possible, without resorting to speculation, to attribute symptoms (e.g. depressed mood) to the Veteran's alcohol use independent of PTSD. He opined that the most accurate diagnosis for the Veteran's psychiatric disability is PTSD, and that his depression and anxiety are symptoms of PTSD and not independent diagnoses. Hence, there were no symptoms attributable to depression or anxiety that were not caused by PTSD. Based on the VHA opinion, which is accompanied by an explanation of rationale with citation to factual data, and which the Board finds no reason to reject, the Board will attribute all of the Veteran's psychiatric symptoms (to include alcohol abuse effects as required under caselaw) to his service-connected PTSD. See Mittleider v. West, 11 Vet. App. 181 (1998) (finding that when it is not possible to separate the effects of the service-connected condition from a nonservice-connected condition, 38 C.F.R. § 3.102, which requires that reasonable doubt on any issue be resolved in the Veteran's favor, clearly dictates that such signs and symptoms be attributed to the service-connected condition). The RO has not assigned "staged" ratings for the PTSD. However, as discussed below, the severity of his PTSD has varied, and periods of varying symptoms will be discussed in turn. Prior to May 10, 2007 The Veteran's PTSD symptoms shown prior to May 10, 2007 (the date of a private evaluation showing worsening of PTSD symptoms) do not show that symptoms of his PTSD produced deficiencies in most areas so as to meet or approximate the criteria for a 70 percent rating. He did not display suicidal ideation, obsessional rituals which interfere with routine activities, speech disturbances, near-continuous panic or depression, impaired impulse control, spatial disorientation, difficulty in adapting to stressful circumstances, or an inability to establish and maintain effective relationships, or any other symptoms of similar gravity. Furthermore, he did not exhibit the social and occupational impairment that is commensurate with such rating. Although the Veteran had reported a suicide attempt in 1981, he denied suicidal and homicidal ideation when he was seen at a VA mental health clinic in October 2004, in May 2005, and September 2006. Moreover, prior to May 10, 2007 there was no evidence of obsessional rituals. A September 2006 VA examiner found the Veteran's speech content grossly logical, even though he placed excessive emphasis on non-essential information and his verbal flow lacked discernible direction. While the evidence showed the Veteran experienced periods of depression/depressed mood, it has not been demonstrated that such depression/depressed mood reflects near-continuous problems or his ability to function independently. Episodes of situational depression noted were consistent with the circumstances, such as when the Veteran became depressed after being fired from his job as a security guard, and when he was evicted from his home when his apartment flooded, after he let a sink overflow. In May 2005 an examiner noted that the Veteran was capable of resuming work as a security guard, and factory and mechanical work, but was having difficulty getting to a job due to not having a driver's license. At no time was the Veteran shown to exhibit spatial disorientation; on the contrary, he was consistently described as oriented to time, person, and place. The Veteran stated that he did not have any friends but did have friends he drank with and occasionally went to the bar with his brother. While the record prior to May 10, 2007, shows some deficiencies in occupational and social functioning, including: thinking, family relations, work, personal appearance and hygiene and mood, such deficiencies (tends to be isolated and alone, depressed affect and mood, anxious, limited insight, angers easily, and inability to work) do not rise to the level required for a 70 percent rating. The Board finds significant that the Veteran, maintains some friendships (albeit with drinking buddies and a brother), and (prior to May 2007) was found capable of sustaining gainful employment. Therefore, the Board finds that for the period prior to May 10, 2007, the Veteran's overall disability picture is inconsistent with a disability picture warranting a 70 percent rating. In summary, during the period prior to May 10, 2007, the Veteran's PTSD symptoms are not shown to have been productive of impairment greater than occupational and social impairment with reduced reliability and productivity. Accordingly, a rating for PTSD in excess of 50 percent is not warranted for any period of time prior to May 10, 2007. From May 10, 2007 to July 1, 2012 The evidence summarized reflects that beginning May 10, 2007 the Veteran's PTSD symptoms were productive of occupational and social impairment with deficiencies in most areas. Of particular note is the low GAF score of 30-32 assigned in May 2007 on private clinical diagnostic evaluation. On that evaluation, the Veteran's mood and affect vacillated between anxious, angry, and depressed. He reported that he struggles frequently with mild auditory hallucinations and distinct flashbacks. His thought processes were at times irrational. His insight and judgment were extremely poor. He reported experiencing numerous symptoms, including but not limited to, chronic substance abuse, flashbacks, disturbing thoughts, memory problems, changes in appetite, irritability, heart palpitations, stress, anxiety, mood swings, sexual concerns, family concerns, poor self esteem, phobias, depression, panic attacks, lack of interest, sleeping problems, social isolation, confusion, suicidal thoughts, difficulty concentrating, work difficulties (chronic), and self destructive behaviors. The examiner did not determine the symptoms to be exaggerated or feigned. A February 2008 VA mental health clinic report notes the Veteran had chronic suicidal ideation (passive suicidal thoughts of not caring whether he lives or dies). That report also showed the Veteran's psychiatric symptoms had improved since abstaining from alcohol for a month, but a subsequent May 2008 letter by a Vet Center readjustment counselor noted he was still experiencing anger, social isolation, alcohol abuse, intense anxiety, depression, suicidal and homicidal thoughts, and difficulties with his relationships. Further, VA psychiatric examination in November 2009 revealed he presented at the examination disheveled and unshaven, and his hygiene was poor. Hypophonia was evident in his speech and articulation was poor. He was somewhat detached from spontaneous conversation and awkward in interaction. His content was generally logical but impulsively derived and not related to the topic at hand. His mood was dysphoric and irritable. He reported visual and tactile hallucinations when falling asleep. Psychological testing suggested he was experiencing severe levels of depressed and anxious feelings and behaviors. The August 2011 VA psychiatric examination findings suggest that there had been some improvement of the veteran's PTSD. Nevertheless, he presented inappropriately dressed for the weather, his grooming was poor; and his clothes were wrinkled and stained. Significantly, his alcohol abuse was in lengthy remission, and the symptoms noted and described were of lesser gravity than previously found. The GAF score of 60 was consistent with the moderate symptoms reflected by clinical findings. The Board finds, however, that the examination findings do not show that the improvement was sustained, so as to warrant a reduction based on that examination alone. The Board has considered whether the next higher (100 percent) schedular rating is warranted for any period of time from May 10, 2007 to July 2, 2012. Significantly, the Veteran is not shown to have had (nor does he allege) totally disabling psychiatric symptoms of sufficient gravity for such a rating (i.e., gross impairment in thought process or communication, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent ability to perform activities of daily living, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name, or any other symptoms of similar gravity). From July 2, 2012 The July 2, 2012 VA psychiatric treatment report reflects that the improvement found on August 2011 examination was indeed sustained , and that a rating in excess of 50 percent for PTSD was no longer warranted. Symptoms of PTSD were no longer shown to produce deficiencies in most areas. The Veteran did not display suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression; impaired impulse control; spatial disorientation; difficulty in adapting to stressful circumstances; or an inability to establish and maintain effective relationships or any other symptoms of similar gravity. Furthermore, at that time he had not exhibited the social and occupational impairment that is commensurate with a 70 percent rating. As he himself acknowledged, his physical limitations due to various other disabilities had the more significant impact on his occupational and social functioning. In summary, for the period from July 2, 2012 it is not shown that the Veteran's PTSD has been manifested by symptoms productive of deficiencies in most areas (or approximating such a level of severity). Consequently, a schedular rating in excess of 50 percent from July 2, 2012 is not warranted. 38 C.F.R. § 4.7. The Board has also considered whether referral for extraschedular consideration is necessary. The PTSD symptoms (and associated impairment) shown by the factual evidence are entirely encompassed by the criteria for the 50 and 70 percent schedular ratings assigned. Therefore, the schedular criteria are not inadequate. Consequently, referral for extraschedular consideration is not warranted. See 38 C.F.R. § 3.321(b); Thun v. Peake, 22 Vet. App. 111 (2008). Finally, the record shows that a January 2010 rating decision awarded the Veteran a total disability rating based on individual unemployability due to service-connected disabilities. He did not file a notice of disagreement with the effective date assigned. Consequently, the matter of entitlement to a total rating based on individual unemployability is moot. See Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER A "staged" increased rating of 70 percent (but no higher) is granted for the Veteran's PTSD effective from May 10, 2007 to July 2, 2012, subject to the regulations governing payment of monetary awards; ratings for PTSD in excess of 50 percent prior to May 10, 2007 and from July 2, 2012 are denied. ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs