Citation Nr: 1324436 Decision Date: 08/01/13 Archive Date: 08/13/13 DOCKET NO. 09-48 227 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial rating higher than 30 percent prior to October 29, 2008, for post-traumatic stress disorder (PTSD). 2. Entitlement to a total disability rating for individual unemployablity due to service-connected disabilities (TDIU) prior to October 29, 2008. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Andrew Mack, Counsel INTRODUCTION The Veteran served on active duty from August 1968 to March 1970. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In that decision, the RO granted service connection for PTSD and assigned an initial rating of 30 percent, effective the May 11, 2005, date of his claim for service connection. On October 29, 2008, the Veteran's representative submitted a statement indicating that the Veteran requested an increased rating for PTSD, which the RO construed as new claim for an increased rating. In a February 2009 rating decision, the RO granted a rating of 70 percent for PTSD, effective October 29, 2008, primarily based on the information contained in a January 2009 VA examination report. In May 2009 statements, the Veteran requested an effective date of May 11, 2005, for the 70 percent rating, and explained that he had not intended to file a new claim in his October 2008 communication, but rather to challenge the initial 30 percent rating for PTSD. As the January 2009 VA examination report was received prior to the expiration of the appeal period of the May 11, 2005, claim for service connection, it is considered evidence filed in connection with that claim. See 38 C.F.R. § 3.156(b). Therefore, the propriety of the initial, 30 percent rating for PTSD prior to October 29, 2008, is considered to be on appeal, and the Board has identified this issue as listed on the cover page. See AB v. Brown, 6 Vet. App. 35 (1993); Fenderson v. West, 12 Vet. App. 119 (1999). While the Veteran expressed disagreement with the initial rating of 30 percent for his PTSD prior to October 29, 2008, and argued that it should be increased to 70 percent, he has not expressed disagreement with his 70 percent rating beginning October 29, 2008. Therefore, the issue of a rating higher then 70 percent for PTSD is not on appeal. Also, in a May 2009 statement, the Veteran requested a TDIU beginning May 11, 2005. In a June 2009 rating decision, the RO granted a TDIU, effective October 29, 2008. While the issue of a TDIU has not been separately perfected, when a request for a TDIU is made during the pendency of a claim, whether expressly raised by a veteran or reasonably raised by the record, it is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability as part of the initial adjudication of the claim. Rice v. Shinseki, 22 Vet. App. 447, 453-454 (2009). Thus, the issue of entitlement to a TDIU prior to October 29, 2008, is before the Board. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. FINDINGS OF FACT 1. From the time of the May 11, 2005, date of service connection, the Veteran's PTSD has been productive of occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking, and mood, due to such symptoms as frequent crying spells, anger with outbursts, obsessive behaviors, mistrust of others, and social isolation. 2. From May 11, 2005, the Veteran has been unable to secure or follow a substantially gainful occupation as a result of his service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 70 percent for PTSD beginning May 11, 2005, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for TDIU beginning May 11, 2005, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. A disability rating may require re-evaluation in accordance with changes in a veteran's condition. Thus, it is essential that the disability be considered in the context of the entire recorded history when determining the level of current impairment. See 38 C.F.R. § 4.1. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Nevertheless, where the veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson, 12 Vet. App. 119. Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. The Board notes that staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). In this case, as reflected in statements such as that submitted in May 2009, the Veteran seeks both a 70 percent rating for his service-connected PTSD and a TDIU beginning the May 11, 2005, effective date of service connection for PTSD. PTSD is evaluated under Diagnostic Code (DC) 9411, 38 C.F.R. § 4.130. Under DC 9411, the following applies: A 30 percent evaluation is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is warranted 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 frequently than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 evaluation is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and an inability to establish and maintain effective relationships. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities; provided that, if there is only one such disability, this disability shall be ratable as 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a); see also 38 C.F.R. §§ 3.340, 3.341. For purposes of one 60 percent disability or one 40 percent disability in combination, disabilities of a common etiology or from a single accident are considered to be one disability. 38 C.F.R. § 4.16(a). Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b). Factors such as employment history, as well as educational and vocational attainments, should be considered. Id. For VA purposes, the term unemployability is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). The word substantially suggests intent to impart flexibility into a determination of a veteran's overall employability, as opposed to requiring the appellant to prove that he is 100 percent unemployable. Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). In this case, the Veteran's only service-connected disability is PTSD. An April 2005 VA treatment note reflects that the Veteran stated that every since he came home from Vietnam he had had emotional problems, and decided to come in for an assessment. He reported that at a recent cancer support group meeting, the speaker was a nurse who had been stationed in Vietnam during the war, and that his interaction with her had triggered a worsening of his PTSD symptoms and increased ruminations. He reported that his mood was depressed and anxious, described falling into pits of despair, and admitted to moderate anhedonia. He described survivor's guilt related to Vietnam War experiences, and stated at his energy was low, and concentration was impaired. He denied audiovisual hallucinations, but reported chronic insomnia. He reported multiple symptoms of PTSD, but denied suicidal or homicidal ideation or any history of either manic episodes or mental health treatment. The Veteran reported being married to his wife since 1981 and having two children, and having a Master's level education in business, working 29 years as an insurance adjuster but being terminated a few months prior secondary to his long-term chemotherapy and radiation treatment, which was a significant source of stress for the Veteran. He admitted to having few close friends and described a limited support system, but stated that he and his wife had become more emotionally connected since his diagnosis of cancer. On PTSD screening, the Veteran described feelings of terror in connection with his war experiences and admitted to daytime and nighttime ruminations regarding them. He avoided crowds and close relationships with most individuals, and reported that Vietnam War movies and reading material increased ruminations. He admitted to hypervigilance and reported keeping a gun in close possession, and sitting with his back to the wall when in public. He also reported that his yard was fenced and had strands of barbed wire at the top of the fencing, and that he patrolled the perimeter of the fence, checking for safety on a daily basis. He reported a history of being jumpy, awakening with a start, being mistrustful to others, and socially isolating. On mental status examination, the Veteran was unremarkably dressed and groomed, cooperative, and easily engageable, with no psychomotor abnormalities or abnormal involuntary movements, and he was not noted to have been responding to internal stimuli. His speech was normal in rate, volume, tone and rhythm. His mood was anxious and depressed, his affect was frequently tearful when discussing Vietnam War experiences, and his eye contact was appropriate. His thoughts were coherent and goal directed, no audiovisual hallucinations were noted, and he was not delusional, suicidal, or homicidal. He was alert and oriented, and his memory and concentration were intact. His diagnoses were PTSD, and major depression, recurrent, severe, and his assigned Global Assessment of Functioning (GAF) score was 30. VA treatment records reflect mental health treatment for PTSD from June 2005 to November 2007. In June 2005, the Veteran reported that there had been no change in his mood, and that he was emotional and depressed and moved easily into tears frequently. He voiced strong guilt feelings and recurrent intrusive thoughts, memories of his service in Vietnam, nightmares and frequent dreams about Vietnam, and sleeping problems. The treating physician noted that overall the Veteran remained depressed and had significant PTSD symptoms. In July 2006, he was noted to have become tearful several times during an interview when talking about his experiences in Vietnam. Subsequent treatment notes reflect that the Veteran continued to experience recurrent intrusive thoughts about Vietnam, insomnia, crying spells triggered by Vietnam memoires, and guilt feelings, and that he remained depressed and anxious. In an August 2006 statement, the Veteran reported having constant nightmares, which he often did not remember. He reported that although he was a top producer in his office in 28 years as a property insurance adjuster, he never got along with his boss, got into screaming arguments with him, was threatened with being fired, and many times thought about how easy it would be to kill him. He further stated that over the past two years his emotional problems had returned in full force and he often could not control his emotions, that he would start crying uncontrollably, and that he had episodes of feeling a crushing pressure in his head and not able to stop crying, which was why he sought treatment in early 2005. He stated that he was unable to function normally in society or in private family life, and unable to function in a work environment. A letter dated in December 2007 from a private physician, Dr. A.R., reflects the opinion that the Veteran suffered from Vietnam war-related late onset PTSD, and that the Veteran was unable to work due to emotional/withdrawals, avoidant behavior, severe anxiety, episodes of uncontrollable crying, depression, and severe sleep deprivation. During a hearing before a Decision Review Officer (DRO) at the RO in January 2008, the Veteran testified that he began seeking psychiatric treatment in April 2005 after all of his emotional problems came back more severely when he was trying to recover from radiation and chemotherapy and decided that he needed help. The report of a January 2008 VA examination reflects that the Veteran reported being married for 26 years and being unemployed since 2004 when he had been diagnosed with throat cancer. The Veteran reported that he had avoided mental health treatment until around 2004, when he was treated for cancer, which re-triggered PTSD issues. He reported avoiding thinking about Vietnam, and avoiding triggers, but still having frequent intrusive thoughts and nightmares averaging a couple of times a month. He reported being married and arguing a great deal with his wife, and getting along with his daughter but butting heads with his son and losing his temper with him a lot. He also reported having a couple of Vietnam buddies he drank with twice a week and a cancer support group. It was noted that the Veteran had not been able to go to work since he began treatment for cancer. The examiner stated the Veteran's PTSD did not significantly impact the Veteran's activities of daily living, that he stayed at home mostly but did pick up his son from school sometimes, ran errands, read, got on his computer, and watched movies. He reported patrolling the perimeter of his property and being obsessed with war issues and spending time researching them. On mental status examination, the Veteran was groomed, articulate, verbal, and generally cooperative with fair social skills. Thought process was logical, coherent, and relevant, affect was depressed and he was tearful at times. He was well-oriented with fair reasoning and judgment, and fund of general information and verbal comprehension were average. He reported some difficulty with concentration and short term memory since 2004. The Veteran reported anger and irritability with occasional tantrums and outbursts. He yelled and screamed at his family, but denied any physical aggression. He indicated depressed mood and crying spells secondary to Vietnam, but also some secondary to his cancer. He reported anhedonia, fatigue, middle insomnia, of feelings of guilt and worthlessness, primarily focused on his inability to work. He denied psychotic symptoms and sucidality but indicated previous homicidal thoughts such as thinking of ways to kill his boss, but did not report a history of physical aggression or combativeness. The Veteran's PTSD was estimated by the examiner to have had mild impact on occupational functioning when the Veteran was working and clearly the most significant factor impacting the Veteran's work was his cancer. The examiner noted that the Veteran was able to function quite well in his job and was actually a top performer until the cancer diagnosis. The examiner also stated that, socially, the Veteran reported anger outbursts and interpersonal problems that related to the PTSD diagnosis, which had had moderate impact on social functioning, although he did maintain a long-term marriage and had some meaningful relationships. It was noted that the Veteran reported persistent re-experiencing symptoms related to Vietnam including intrusive thoughts, nightmares, flashbacks, and distressing reactions to similar symbols. He reported that he avoided thinking about these issues, interpersonal detachment, and heightened arousal symptoms including sleep disturbance and anger problems, as well as hypervigilance. He indicated that he had a lot of guns and had actually set up a fence perimeter around his house including barbed wire and would patrol the perimeter regularly. The Veteran was administered the Minnesota Multiphasic Personality Inventory II, and results to the test were valid and reflective of an individual who was in a great deal of distress and was experiencing primarily depressive symptoms with some explosive outbursts and possible decompensation at times. Such testing showed that he was socially withdrawn, lacked energy, and was highly identified with overtly masculine traits and was more likely to act out on emotions than internalize. He produced a significant elevation on the PK scale, which was developed on veterans with PTSD. The diagnoses were chronic PTSD and mood disorder secondary to a general medical condition with depressive features. The Veteran's assigned GAF score, excluding the direct effects of physical health, was 50. The report of a January 2009 VA examination reflects that the Veteran reported that his family could not stand to be around him because of his constant anger and tendencies toward flying off the handle, hollering, and screaming. He stated that his wife had left him within the past year, and that he was unable to control his emotions, cried frequently, was obsessed with Vietnam, and felt depressed. He described himself as having a sleep disorder, outbursts, and feeling suspicious of other people. It was noted that he was obsessed with firearms and with security on his property, had intrusive thoughts about Vietnam, including two types of recurring distressing dreams, and flashbacks with military-related specials or shows on television. He reported sleep disturbance every night, crying spells and intrusive thoughts every day, distressing dreams two times per month, constant anger, depression, suspiciousness, obsessiveness, and daily volatility. He reported moderate to severe depression and volatility, and severe sleep disturbance, crying spells, intrusive thoughts, flashbacks, anger, suspiciousness, and obsessiveness. The Veteran reported at the time that he was currently separated from his wife of 27 years over conflicts from cultural differences, problems with communication, and personal issues related to his war experiences. He reported being told that he was controlling and angry, and he stated that he felt he had a more positive relationship with his daughter until she revealed to him recently that she was tired of tolerating his anger, and that he had a long-term conflictual relationship with his son. He reported having three close male friends, two of whom were Vietnam veterans, and stated that he was unable to connect with anyone else. He reported attending a shooting camp two times per year with his friends, spending time on his computer editing his digital photographs, and watching military or police related shows, documentaries, and films. On mental status examination, it was noted that the Veteran assumed that people he did not know could not be trusted and were lying all the time to a significant degree, which had not impacted his ability to work but significantly restricted his ability to establish and maintain relationships. He had no delusions or hallucinations, but reported that he was quick to anger even when situations did not warrant it, was too depressed, had explosive outbursts, and was difficult to be around. The Veteran reported difficulty remembering the day of the week and date, and forgetting appointments and conversations unless he wrote about them on paper, which had become severe in the last couple of years. It was noted that the Veteran was obsessed with information related to the Vietnam war and other wars and about security on his property and not throwing things out, and was ritualistic about his daily schedule since being out of work and became irate if something disrupted it; it was noted that this was moderate when he worked but currently was severe, and caused him to have arguments with his wife and son. The Veteran had no irrelevant, illogical or obscure speech patterns or panic attacks. He had depression all the time from a moderate to severe degree, anxiety to a moderate degree, and problems with anger and volatility from a modern to a severe degree on a daily basis. The diagnosis was PTSD with current GAF score of 50. The VA examiner stated that the Veteran's functional status with respect to schooling and employment did not change significantly after the war, the he was able to earn a Master's degree, and that he worked for several years as a senior adjuster for a company. The examiner stated that, on the surface, the Veteran's marriage appeared functional because it was long lasting, but that his wife leaving him this year signified that they had had years of conflict that culminated over time, and that he had an argumentative relationship with his son. The examiner further stated that the Veteran's inability to deal with his war-related traumatic experiences had led to his PTSD and his problems in functioning, and that his substance abuse problems manifested as a means of coping with PTSD. The examiner concluded that the Veteran's PTSD was productive of reduced reliability and productivity due to PTSD signs and symptoms, and that the Veteran reported significant problems with short-term memory which he stated would interfere with his returning to work, but that it was unclear if this was due to his cancer and related treatments or to his PTSD. It was clear that the Veteran had impaired judgment due to PTSD, for example obsession with security in placing fences with barbed wire around his property and patrolling it every day, which represented distorted thinking, and his feeling that everyone he did not know could not be trusted and was lying. The Veteran's mood had clearly been disturbed since the war as evidenced by his anger and volatility among family members and coworkers, and his relationships appeared intact on the surface but were significantly strained in reality, likely because of his lack of emotional control. The examiner stated that the Veteran's PTSD symptoms required continuous medication and were severe enough to interfere with occupational and social functioning. The examiner further stated that the Veteran's prognosis was poor because of the aspects is his lifestyle that helped him maintain his preoccupation with Vietnam, war, and his PTSD. In a January 2009 statement, the Veteran asserted that his problems resulting from PTSD had worsened significantly since his January 2008 VA examination. He stated that he continued to have very frequent episodes in which he experienced an immense pressure in his head followed by uncontrolled crying for 10 or 15 minutes, that the episodes were almost daily, and that the frequency had significantly increased. He stated that since June 2008 his wife had been separated from him because she was tired of trying to deal with his moodiness, depression, and anger from PTSD. He stated that he stayed very depressed and numb, that his children had revealed to him last year that they were tired of his anger outbursts, that he continued to have dreams about Vietnam twice a month and thought about Vietnam every day, that he was more antisocial than ever and only had two close friends who were Vietnam veterans, and that he continued to be hyper-surveillant and patrolled the perimeter of his property daily. He also stated that he had been drinking more in the past seven months. In a May 2009 statement, the Veteran asserted that the effective date for his 70 percent rating for PTSD should be the May 11, 2005, effective date of service connection. He argued that his symptoms had been severe when he first sought VA treatment in April 2005. The report of a May 2009 VA examination reflects that, regarding the Veteran's employability, he quit work because of the effects of radiation from cancer treatment, and since that time his PTSD symptoms were exacerbated. The Veteran reported that due to his sleep deprivation, daytime naps, depression, and anxiety, he could not be in structured environment at a job. He reported that he would not be able to get along in the work environment as he could not relate to strangers, and that he did not have control of his temper and had memory issues and uncontrolled crying at times. The Veteran's assigned GAF score on that examination was 45, and the examiner stated that the Veteran had symptoms of experiencing trauma, avoidance of triggers that reminded him of war, numbing, and increased arousal. The examiner stated that the Veteran's PTSD symptoms created tension within his marriage and family due to his temper outbursts, irritability, and being withdrawn emotionally, and that he was withdrawn from socializing and interpersonal relationships except for a few military buddies. The examiner also concluded that the Veteran also met the criteria for major depression, which was more than likely a result of his combat experiences and secondary to his medical condition of having throat cancer. The examiner stated that the Veteran's lack of emotional control, including crying spells and temper problems, would be detrimental to his job performance, and also that the Veteran's reported memory problems would interfere with him going back to work. The examiner also stated that the Veteran had impaired judgment due to PTSD symptoms, demonstrated by his six-foot barbed wire fence, patrolling the perimeter, and his suspiciousness of others, and it appeared more likely than not that the Veteran qualified for unemployablity based on deficits in social interaction, sleep disturbance, irritability, temper outbursts, impaired judgment, suspiciousness, and intolerance of others that was directly related to PTSD. Considering the pertinent evidence in light of the governing legal authority, resolving all reasonable doubt in the Veteran's favor, his claims for a rating of 70 percent for PTSD and a TDIU beginning May 11, 2005, must be granted. While the Veteran has been granted a 30 percent rating for PTSD beginning the May 11, 2005, date of service connection, and a 70 percent rating for PTSD and a TDIU beginning October 29, 2008, the record reflects that the Veteran's PTSD symptoms have been essentially consistent in nature and severity from the date of service connection. Consistently, the Veteran's PTSD has been manifested by severe depression, survivor guilt, low energy, some impairment in concentration and memory, ruminations of his war experiences, intrusive thoughts, occasional nightmares, sleeping problems, avoidance of crowds and close relationships, mistrust of others, suspiciousness, social isolation, hypervigilance, frequent crying spells, emotional withdrawal, being argumentative with his family, anger, irritability, occasional outbursts including screaming and yelling, anhedonia, feelings of worthlessness, and obsessive behavior. Moreover, significantly, the record reflects essentially the same symptoms and manifestations of PTSD that led the January 2009 and May 2009 VA examiners to conclude that the Veteran's PTSD was productive of reduced reliability and productivity due to PTSD signs and symptoms and rendered the Veteran unemployable from the time of service connection on May 11, 2005. The January 2009 VA examiner, in determining that the Veteran's PTSD was productive of reduced reliability and productivity due to PTSD signs and symptoms, explained that it was clear that the Veteran had impaired judgment due to PTSD, for example obsession with security in placing fences with barbed wire around his property and patrolling it every day, which represented distorted thinking, and his feeling that everyone he did not know could not be trusted and was lying, and that the Veteran's mood had clearly been disturbed since the war as evidenced by his anger and volatility among family members and coworkers, and his relationships appeared intact on the surface but were significantly strained in reality, likely because of his lack of emotional control. Such symptomatology, including the obsessional behavior of using barbed wire fences and patrolling his property every day, has been repeatedly reported by the Veteran since he first sought mental health treatment in April 2005. Also, the May 2009 VA examiner, in determining that the Veteran was unemployable due to PTSD, pointed to his Veteran's lack of emotional control including crying spells and temper problems that would be detrimental to his job performance, his reported memory problems that would interfere with him going back to work, his impaired judgment due to PTSD symptoms demonstrated by his six-foot barbed wire fence, patrolling the perimeter and his property, and suspiciousness of others, as well as his deficits in social interaction, sleep disturbance, irritability, temper outbursts, impaired judgment, suspiciousness, and intolerance of others directly related to PTSD. Likewise, such symptoms, including his uncontrolled and frequent crying spells, temper problems, impaired judgment, and difficulty interacting with others have consistently been noted in the medical record since April 2005; in this regard, the Veteran has frequently been noted to become tearful during PTSD examinations, and it has been noted that his temper and social problems have significantly affected his marriage, family, and social relationships. The Board notes that, during the January 2008 VA examination, the Veteran's PTSD was estimated by the examiner to have had mild impact on occupational functioning when the Veteran was working and that, socially, the Veteran's reported anger outbursts and interpersonal problems related to PTSD had had moderate impact on social functioning, although he did maintain a long-term marriage and have some meaningful relationships. If read alone, such examination report might not reflect PTSD symptoms severe enough to warrant a 70 percent rating or a TDIU. However, when read in connection with the later examination findings in January 2009 and May 2009, the January 2008 VA examination report does not reflect less severe symptomatology. The January 2008 VA examiner noted that the Veteran maintained a long-term marriage and had some meaningful relationships, noting that the Veteran had been married for 26 years and got along with his daughter. However, as explained in the January 2009 VA examination report, while on the surface the Veteran's marriage appeared functional because it was long lasting, his wife leaving him that year signified that they had had years of conflict that culminated over time, and his relationships appeared intact on the surface but were significantly strained in reality, likely because of his lack of emotional control. Also, while the January 2008 VA examiner opined that the Veteran's PTSD had a mild impact on occupational functioning when the Veteran was working, and that the Veteran was able to function quite well in his job and was actually a top performer until his cancer diagnosis, such opinion focuses on the Veteran's level of occupational impairment up to the time his cancer treatment in 2004, when he stopped working. The Veteran has consistently asserted that his PTSD symptoms became much more severe following his 2004 cancer treatment, after leaving employment; he asserted this during VA treatment in April 2005, in an August 2006 statement, during the January 2008 DRO hearing, and on January 2008 VA examination. The January 2008 VA examiner did not make any distinction between the effect of the Veteran's PTSD on his previous employment that ended in 2004, and his current employability, given his increased level of psychiatric symptomatology. Furthermore, the January 2008 VA examination findings, as well as the medical record generally prior to October 29, 2008, are consistent with the later examination findings on January 2009 and May 2009 VA examinations, on which the Veteran's increased 70 percent disability rating was based. The Veteran's GAF scores on both the January 2008 and January 2009 VA examinations was 50; GAF scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). See 38 C.F.R. § 4.130; see also the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV). Also, on psychological testing in January 2008, Minnesota Multiphasic Personality Inventory II results, which were valid, were reflective of a great deal of distress and experiencing primarily depressive symptoms with some explosive outbursts and possible decompensation at times, social withdrawal, and lack of energy, and the Veteran produced a significant elevation on the PK scale, which was developed on veterans with PTSD. VA treatment records reflect that, at the time of his initial evaluation for PTSD in April 2005, the Veteran was assigned a GAF score of 30. A score from 21 to 30 is indicative of behavior which is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. Id. While the weight of the evidence does not reveal symptoms as severe as delusions, hallucinations, serious impairment in communication, or inability to function at that time, such a low GAF score indicates an assessment of significant psychiatric symptomatology. Also, in June 2005, a VA physician determined that the Veteran had "significant" PTSD symptoms. Moreover, the December 2007 opinion of Dr. A.R. indicates that the Veteran was unable to work due to emotional withdrawals, avoidant behavior, severe anxiety, episodes of uncontrollable crying, depression, and severe sleep deprivation from his PTSD. This description of symptomatology that prevented the Veteran from working is consistent with that given by the May 2009 VA examiner, and such symptoms are reasonably consistent with those noted from the May 5, 2005, date of service connection for PTSD. The Board notes that, in his January 2009 statement, the Veteran asserted that his problems resulting from PTSD had worsened significantly since his January 2008 VA examination. The Veteran may have felt at that time that some symptoms, such as the frequency of his crying spells, had increased. However, as described above, the record reflects that, substantially, there was little difference in the nature and severity of the Veteran's PTSD symptomatology and resulting functional impairment prior to or after January 2009, overall, as it relates to the pertinent rating criteria. The symptoms described by the Veteran such as the pressure in his head followed by uncontrolled crying, depression, anger, outbursts, social withdrawal, and obsessive behavior such as patrolling the perimeter of his properly daily had been previously and consistently described by the Veteran from the time he began mental health treatment in April 2005, with approximately the same level of severity. Also, as noted above, some results of the Veteran's PTSD, such as his wife separating from him, which occurred in 2008, were noted in the medical evidence to be the result of longstanding PTSD problems. Furthermore, in statements beginning in May 2009, the Veteran asserted that his severe symptoms, present at the time of his January 2009 VA examination, were present since he first sought treatment for PTSD in 2005. Thus, resolving reasonable doubt in the Veteran's favor, the Board finds that, from the time of the May 11, 2005, date of service connection, the Veteran's PTSD has been productive of occupational and social impairment with deficiencies in most areas such as work, family relations, judgment, thinking, and mood, due to such symptoms as frequent crying spells, anger with outbursts, obsessive behaviors, mistrust of others, and social isolation. Finally, the Board notes that, as an initial rating of 70 percent for PTSD is being granted beginning May 11, 2005, the Veteran meets the schedular criteria for a TDIU as of that date. As discussed above, the evidence reflects that the Veteran has been unable to secure or follow a substantially gainful occupation as a result of his service-connected PTSD since that time. Given the above, the Board finds that, overall, the evidence pertaining to whether the Veteran met the criteria for a 70 percent rating for PTSD and for a TDIU beginning the May 11, 2005, effective date of service connection is at least in relative equipoise. Accordingly, resolving reasonable doubt in the Veteran's favor, an initial rating 70 percent rating for PTSD and a TDIU beginning the May 11, 2005 must be granted. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3 (2012); Gilbert, 1 Vet. App. at 53-56. Finally, as provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). In this case, the Board is granting in full the benefits sought on appeal. Accordingly, assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and will not be further discussed. ORDER An initial rating of 70 percent for PTSD beginning May 11, 2005, is granted. A TDIU beginning May 11, 2005, is granted. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs