Citation Nr: 1325456 Decision Date: 08/12/13 Archive Date: 08/16/13 DOCKET NO. 06-00 400 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to an initial rating greater than 30 percent from June 18, 2003, to March 3, 2008, for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD R. Dodd, Associate Counsel INTRODUCTION The Veteran had active service from June 1961 to November 1967. The appeal comes before the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. A videoconference Board hearing was held at the RO in May 2008 before the undersigned Acting Veterans Law Judge and a copy of the hearing transcript has been added to the record. In a July 2010 rating decision, the RO assigned a higher initial 70 percent rating effective March 3, 2008, for the Veteran's service-connected PTSD. In a February 2011 rating decision, the RO assigned a 100 percent rating for PTSD effective March 3, 2008. Given the RO's actions since July 2010, the Board has recharacterized the issue on appeal as stated on the title page of this decision. In July 2008, July 2009, and August 2011, the Board remanded this matter to the RO via the Appeals Management Center (AMC) in Washington, DC, for additional development. A review of the claims file shows that there has been substantial compliance with the Board's remand directives. The Board directed the RO/AMC send the Veteran a letter requesting information concerning his employment. This letter was sent to the Veteran in August 2011. The Board also directed that the RO/AMC schedule the Veteran for a social and industrial survey. This survey occurred in July 2012. See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). A review of the Virtual VA paperless claims processing system revealed no relevant records. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a total rating based on individual unemployability (TDIU) claim is part of an increased rating claim when such claim is raised by the record. As of this writing, this issue has not been raised by the record and will not be addressed in this decision. FINDINGS OF FACT 1. From June 18, 2003 to June 29, 2005, the Veteran's service-connected PTSD was manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as chronic sleep disturbance, nightmares, anxiety, depression, decreased concentration, anger problems, panic attacks more than once a week, impairment in short term memory, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships, including social conflicts due to anxiety and irritability at work. 2. From June 30, 2005, the Veteran's service-connected PTSD was manifested by total occupational and social impairment, due to such symptoms as depressed mood, anxiety, sleep disturbance, nightmares, anger, irritability, panic attacks, and suicidal ideations, with an inability to maintain gainful employment and an inability to establish and maintain effective relationships. CONCLUSIONS OF LAW 1. From June 18, 2003 to June 29, 2005, the criteria for a 50 percent rating, and no higher, for service-connected PTSD have been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.130, Diagnostic Code (DC) 9411 (2012). 2. Effective June 30, 2005, the criteria for a 100 percent rating for service-connected PTSD have been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.130, DC 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Under 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 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002). This notice must be provided prior to an initial RO decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). VCAA notice requirements apply to all five elements of a service connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). Defective timing or content of VCAA notice is not prejudicial to a claimant if the error does not affect the essential fairness of the adjudication, such as where (1) the claimant demonstrates actual knowledge of the content of the required notice; (2) a reasonable person could be expected to understand from the notice what was needed; or (3) a benefit could not have been awarded as a matter of law. Sanders v. Nicholson, 487 F.3d 881, 889 (Fed. Cir. 2007), rev'd on other grounds, Shinseki v. Sanders/Simmons, 556 U.S. 369 (2009). Defective timing may be cured by a fully compliant notice letter followed by a readjudication of the claim. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). But "[i]n cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated-it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled." Dingess/Hartman, 19 Vet. App. at 490; Dunlap v. Nicholson, 21 Vet. App. 112, 116-17 (2007) (noting that once an initial VA decision awarding service connection and assigning a disability evaluation and effective date has been made, section 5103(a) notice is no longer required). Additionally, where service connection has been granted, the claimant bears the burden of demonstrating prejudice from defective notice with respect to downstream elements such as effective dates or disability ratings. Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). The Veteran has made no such assertions here. Accordingly, the Board finds that VA's duty to notify has been satisfied. The Board also finds that VA's duty to assist the Veteran has been satisfied. 38 U.S.C.A. § 5103A(b), (c); 38 C.F.R. § 3.159(c)(1)-(3). The Veteran's service treatment records, private treatment records, and VA outpatient treatment records have been obtained and associated with the claims file. The duty to assist also includes making as many requests as are necessary to obtain relevant records from a Federal department or agency, including, but not limited to, VA medical records and relevant Social Security Administration (SSA) records. 38 C.F.R. § 3.159(c)(2); Golz v. Shinseki, 590 F.3d 1317, 1321-23 (Fed. Cir. 2010). VA provided the Veteran with examinations in August 2003, September 2004, May 2007, and March 2010, as well as Social and Industrial Surveys in November 2008, September 2010, October 2010, and July 2012. The Board concludes that these examinations were adequate because they contained a history obtained from the Veteran and thorough examinations relevant to the applicable rating criteria. They also addressed the functional effects caused by the Veteran's disability, including its effects on his occupation. There is no indication in the record that additional evidence is available which is relevant to the currently appealed claim. See Pelegrini, 18 Vet. App. at 121-22. Legal Criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2012). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1(2012). In resolving this factual issue, only the specific factors as enumerated in the applicable rating criteria may be considered. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41(2012). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Board notes that where, as in this case, the current appeal is based on the assignment of an initial rating for a disability following an initial award of service connection, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, 'staged' ratings may be assigned for separate periods of time. Id. When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev'd on other grounds, Moore v. Shinseki, 555 F.3d 1369 (2009). The Veteran's service-connected PTSD for the period of June 18, 2003, to March 3, 2008 is rated as 30 percent disabling in accordance with the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, DC 9411. A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with 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). Id. 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- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks), impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for 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 an inability to establish and maintain effective relationships. A 100 percent rating is warranted for 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, an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. Id. Factual Background The Veteran contends that his service-connected PTSD is more disabling than currently evaluated. Because the Veteran is in receipt of a maximum 100 percent disability rating for service-connected PTSD effective March 3, 2008, his appeal for a higher initial rating is limited to the period of time between June 18, 2003, when service connection was granted for PTSD, and March 3, 2008. On an August 2003 VA examination to address the Veteran's claimed PTSD, the Veteran provided a history of having recurring nightmares and anxiety attacks in 1966 and 1968 that interrupted his sleep, associated with his combat experience from August 1965 through July 1966. He complained that he had a lot of difficulties concentrating as well as difficulties with coping skills. The Veteran provided a history since service of working four years as a police officer, when he had a good relationship with co-workers, followed by 29 years working as a supervisor, when his relationship with his supervisor and with co-workers also was good. The Veteran reported that his family relationships were good, with very good relationships with his six siblings, a good relationship with his spouse of 39 years, and good relationships with his two children. He denied major changes in daily activities since onset of his mental illness. He also denied major changes in social functioning since onset of his mental condition. At the August 2003 examination, the Veteran described having nightmares initially after a combat battle involving a firefight and several soldiers dying, but reported that he had been able to put those combat experiences in the back of his head for 27 years, until he attend a reunion with fellow survivors of the battle when they watched "We Were Soldiers," a movie based on combat including that battle he had experienced. He reported that this reunion 'crushed him,' and he began to have symptoms again. He reported having depressive symptoms as well as persistent, recurring recollections of the combat events, persistent, recurring distressing dreams and nightmares, intense distress and anxiousness when seeing pictures related to war, and persistent psychological reactivity to symbolic cues with his reactions including a cold sweat and his heart pounding. Other anxiety, irritability, and reactivity symptoms were noted. Panic attacks reportedly occurred as often as once per month, with each attack lasting an hour, when he would feel as if he could not breathe. At the August 2003 evaluation, the Veteran was oriented with good hygiene and appearance and appropriate behavior with communication and speech within normal limits. The Veteran's affect showed disturbances of motivation and mood. He denied delusions, hallucinations, or obsessional rituals. Thought processes, judgment, and abstract thinking appeared unimpaired or normal, although memory was mildly impaired. There was no suicidal ideation or homicidal ideation. The examiner diagnosed the Veteran as having PTSD and assigned a global assessment of functioning (GAF) score of 70. The examiner determined that the Veteran did not have impairments in activities of daily living and that he could establish and maintain effective work and social relationships. The examiner noted that the Veteran had impairments which included the above-noted symptoms as well as symptoms of irritability or anger outbursts, hypervigilance and exaggerated startle response, and resulting disturbance of social or occupational functioning. In VA outpatient treatment records, from June 2004, the Veteran stated that his condition had affected his relationship with his wife, as she was afraid to sleep in the same bed with him. The Veteran was still averaging between four to five hours of sleep per night. He reported nightmares were lessening, but still present. The Veteran also reported that his mood was down at times, feeling guilt, claustrophobia, startling easy, and avoiding crowds. He also reported being nervous, anxious, and edgy at times. The examiner noted that the Veteran was anxious and sad with a labile and tearful affect. The diagnosis of PTSD was confirmed and the Veteran was provided with medication to treat. At a follow-up appointment later that month, the Veteran reported gradual changes in mood and that he was doing better at night with no nightmares. The Veteran's only reported stressor was that he was trying to obtain a retirement offer from his job at Dow Chemical. The examiner noted that the Veteran appeared more relaxed and that his mood was less anxious and dysphoric. The examiner rendered a GAF score of 60. In an August 2004 psychosocial assessment, the Veteran reported anxiety attacks precipitated by a feeling of being closed in, becoming more severe over the past three years. This has caused problems with going to the dentist, as the Veteran has to leave during procedures. The Veteran also reported that he has a very short fuse and impulsive reactions that impair relationships with family and friends. He reported depressive symptoms, including crying spells, weight gain, fatigue, excessive sleeping during the day, poor concentration, rumination, and problems with short term memory. The Veteran has constant dreams about incidents from Vietnam. The Veteran was diagnosed with PTSD and depression. A treatment note in later August 2004, shows that the Veteran complained of anxiety attacks twice per week. He also reported depression, lack of concentration, and claustrophobia. The Veteran was diagnosed with PTSD and depression and given a GAF score of 55. At an August 2004 VA examination to address his claimed PTSD, the Veteran reported mental symptoms of PTSD for the past 38 years and having trouble sleeping for the past 10 years, including difficulty falling asleep and staying asleep. He reported that he had been to more Veterans' reunions since 1993 and, since that time, he had more nightmares and inability to sleep. He was seeing a VA psychological counselor every Friday, which he found helpful. He reported some sleep improvement with medications. He complained of an inability to control his emotions, not liking to talk about his war experiences, and having reservations about taking medications. The Veteran's history of difficulties since his mental illness were noted to include a short temper, anxiousness, being depressed, and not taking proper care. He also reported having difficulty both with crowds and hearing crying babies. He reported further that he had worked at Dow Chemical for 30 years and had a good relationship with his supervisor and his co-workers. He denied missing any time from work. The examiner diagnosed the Veteran as having PTSD and assigned a GAF score of 65/70. In a September 2004 treatment note, the Veteran reported anxiety attacks occurring less than weekly. He also reported controlling his temper better and getting along with family. The Veteran was sleeping better, but still waking up two to three times per night due to nightmares. He reported not feeling depressed for the past month. The examiner provided a GAF score of 55. In a December 2004 treatment note, the Veteran reported lessening anxiety and depression. His mood was euthymic and he was given a GAF score of 60. In a March 2005 treatment note, the Veteran reported continuing nightmares and waking his wife at night. He was taking part in smoking cessation therapy and couples counseling with his wife with good results. He was given a GAF score of 60. In a May 2005 treatment summary from the Vet Center, it was reported that the Veteran had received treatment since May 2004. The Veteran was reported as feeling intense guilt and breaking down at reunions. He suffers from continual nightmares and has wrestled and struck his wife in his sleep. The Veteran averages no more than four to five hours of sleep. He has reported extreme bouts of anxiety and depression. He also avoids crowds and has claustrophobia. The Veteran is often anxious and tearful. His panic attacks, nightmares, and hypervigilance became so severe that he finally sought treatment in 2004. The Veteran was assessed with chronic and severe PTSD that interferes with interpersonal relationships and the ability to maintain and continue stable employment. It was reported that the reason that the Veteran was able to maintain employment with Dow Chemical for 30 years was due to the fact that job did not require a great deal of interaction. However, over the past few years, the Veteran's level of functioning has deteriorated and his job has become more interactive, making it difficult in terms of concentration and completing necessary tasks. It was reported that the Veteran is often forgetful, disorganized, and struggles severely with depressed and anxious moods secondary to PTSD. It was opined that the Veteran will not be able to continue work due to the worsening of his PTSD symptoms. In a July 2005 treatment note, the Veteran reported retiring from his job the day prior, June 30, 2005, because he was burned out, lost interest, and needed to get away. He reported an occasion when he went to a reunion and left his medication behind. The Veteran endorsed dizziness, headache, and ringing in ears while drinking. The next day, the Veteran started crying and could not stop. The examiner noted that his mood was euthymic and that his GAF score was 60. In an August 2005 treatment note, the Veteran was shown to have a constricted affect and a depressed and teary mood. His medication was increased and his GAF score was 55. In an October 2005 treatment note, it was reported that his mood had improved and the medications appeared to be working. His GAF score was 60. In a January 2006 treatment note, the Veteran reported continuing sleep problems, such as not being able to sleep for more than three to four hours. He still has nightmares and punches and kicks his wife in his sleep. His mood was euthymic and medication seemed to be working, with the exception of nightmares. The examiner rendered an opinion that due to the PTSD symptoms as well as other medical problems, the Veteran was unable to gain and maintain employment on the competitive market. His GAF score was 60. In an April 2006 treatment note, it was reported that the Veteran was not doing well and was having difficulty concentrating. His mood was depressed and his GAF score was 50. In a May 2006 treatment note, the Veteran reported that he did not trust people and could not be around people and tends to isolate. Sleep disturbance continued to be a problem and his mood was euthymic. His GAF score was 50. In a September 2006 treatment note, the Veteran reported continued difficulty with sleep and staying sober. His mood was depressed and GAF score was 50. In a February 2007 treatment note, the Veteran reported feeling better and drinking less. He has continued to isolate. The Veteran reported nightmares from two to four nights per week and swinging in his sleep. His mood was euthymic and GAF score was 50. The Veteran contended at a May 2007 VA examination that he had retired two years earlier after having worked for 30 years for Dow Chemical. He also contended that his retirement was based in part on his temper flare-ups which precluded his continued work with his co-workers and supervisors. The Veteran continued to report sleep disturbance and nightmares fairly regularly. He gets violent in his sleep at night and his wife has to leave the bed. The Veteran endorses feeling depressed and claustrophobia. The Veteran also endorsed suicidal ideation in the past. He feels on edge constantly and loses his temper easily. The examiner found that the Veteran had an anxious and dysphoric mood. Recent memory function was also found to be decreased. He was diagnosed with PTSD and alcohol abuse and given a GAF score of 50, which reflects serious symptoms with impairment in interpersonal relationships. The examiner stated that the Veteran reported frequent symptoms of PTSD, which are of a moderate to serious intensity level. His symptoms began to interfere with interactions with others, so that he had to quit working before he was financially ready to do so. In a June 2007 VA outpatient treatment note, the Veteran reported trying to take things one day at a time and staying sober. His mood was euthymic and GAF score was 50. His medication was changed. In a March 2008 treatment note, it was shown that the Veteran changed psychiatric providers. He was reporting continued sleep disturbances, nightmares, hitting wife in sleep, concentration problems, irritability, being nervous around people, feeling depressed most of the time, and suicidal ideation. His affect was blunted and mood was dull. He was diagnosed with PTSD, major depressive disorder, anxiety disorder not otherwise specified, and alcohol dependence. His GAF score was 41. In a May 2008 treatment note, the Veteran was continuing to report disturbing dreams. He had a blunted-sad affect and dull mood. His GAF score was 41. In a May 2008 lay statement from the Veteran's son, it was stated that the Veteran has flashbacks, nightmares, panic attacks and depression that will not go away without help. In a May 2008 lay statement from the Veteran's daughter, it was stated that, in the past few years, the Veteran has suffered from flashbacks, horrible nightmares, anxiety, panic attacks, mood swings, and depression due to his memories and trying to deal with the horrors of Vietnam. She also stated that these things still occur today. In a May 2008 lay statement from the Veteran's friend, it was stated that, since 1997 or 1998, the Veteran has grown more moody, easily agitated, and sometimes depressed. It was also reported that the Veteran goes into a depression and experiences anxiety for several days before and after November 14 each year. In a May 2008 statement from the Veteran's dentist, it was reported that he has observed several anxiety attacks since 2002 that occur when dental procedures are performed. This is an ongoing problem on which the Veteran and his dentist have had to work together. In a May 2008 treatment summary from the Vet Center, it was reported that the Veteran has exhibited significant regression in his efforts to manage irritability, resulting in anger dysfunction that has affected both occupational functioning and interpersonal relationships since his discharge from the military. He suffers from depression with intense bouts of anxiety, substance abuse, nightmares, intrusive thoughts, tendency to isolate, feelings of worthlessness and guilt, and intermittent suicidal ideation. The Veteran's ability to function appropriately and effectively is impaired due to anger dyscontrol, anxiety, and disabling periods of depression. It was opined that, due to the severity of his symptoms, it is highly unlikely that the Veteran will ever be able to return to competitive employment. At his May 2008 Board hearing, the Veteran averred that he currently suffered from symptoms of PTSD inclusive of suicidal ideation at least weekly and anxiety attacks at least twice a week and every day for the past few months. In a November 2008 Social and Industrial Survey, it was reported that the Veteran began to have problems with his employment in 2002. The Veteran reported that, at that time, he began missing more and more days from work, arguing with supervisors, having weekly confrontations with coworkers, and losing interest in a job that he had held since 1974. The Veteran reported receiving several reprimands, but received no demotions. He described getting complaints about him by his coworkers and that this behavior was unlike him. Prior to this time, the Veteran reported excellent work performance, never missing meetings, and being motivated. In May 2005, the Veteran reported retiring from Dow Chemical after 31 years. He stated that, despite receiving help for his PTSD, his symptoms were still significantly interfering with his work. Since 2005, the Veteran stated that his social functioning has changed and that he mostly stays home and engages in solitary activities. He reported spending less time with his wife, no friends, and only remaining close to his siblings. The examiner found that the Veteran's condition worsened after his retirement in May 2005. In a September 2010 Social and Industrial Survey, it was noted that there was evidence that the Veteran retired due to increasing distress at work. His last three to four years were very stressful and there were many changes in how his job was conducted. The examiner opined that his ability to function normally in daily life activities is severely limited and he would be unable to function in competitive employment. Even volunteer work is infeasible due to his high level of anxiety. The examiner recommended that the Veteran be declared permanently and totally disabled. Analysis The Board finds that the evidence supports granting a 50 percent rating, and no higher, from June 18, 2003 to June 29, 2005, for the Veteran's service-connected PTSD. The level of occupational and social impairment due to a psychiatric disorder is the primary consideration in determining the severity of a psychiatric disorder for VA purposes and not all the symptoms listed in the rating criteria must be present in order for a rating to be warranted. See Mauerhan v. Principi, 16 Vet. App. 436, 443-44 (2002) (finding that the psychiatric symptoms listed in the rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings). First, the Veteran's GAF scores must be assessed. The GAF is a scale reflecting the 'psychological, social, and occupational functioning on a hypothetical continuum of mental health - illness.' Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quotation omitted). A GAF score is highly probative, as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey, 7 Vet. App. at 207. Here, the Veteran's GAF scores from June 18, 2003 to June 29, 2005 were predominantly in the range of 55 to 60, indicating evidence of moderate symptoms or moderate impairment in social and occupational functioning. The scores that were not in this range were higher, thus not demonstrating any worse impairment. Thus, the Veteran's GAF scores alone reflect PTSD that was of an overall moderate nature. These scores do not merit the assignment of a 70 percent rating for the Veteran's service-connected PTSD as a 70 percent rating requires deficiencies in most areas. The Veteran's GAF scores alone cannot serve as the sole basis for evaluating his higher initial rating claim for PTSD. All pertinent evidence of record must be considered and the Board's decision must be based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. The Board notes in this regard the Veteran's statements regarding his symptoms beginning in 2002, difficulties at work and in social situations due to such symptoms, and his retirement from Dow Chemical on June 30, 2005. The Veteran is competent to testify as to the severity of the symptomatology associated with his service-connected PTSD during the time period in question and his reasons for and date of retirement. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran's statements are presumed credible because his complaints of symptoms have been consistent in both his lay testimony and in what he reported to his treating providers in the medical evidence of record. Further, the Veteran's description of the events leading to his retirement and the date of his retirement also have been consistent throughout the pendency of this appeal. The Veteran's statements as well as lay statements from his friends and family provide competent and credible evidence of the Veteran's disturbances in mood, near-continuous depression, anxiety, irritability, difficulty sleeping, nightmares, social isolation, and panic attacks. Further, as per the May 2005 Vet Center statement, the Veteran had been experiencing increased difficulties at work over the past couple of years due to the progression of his service-connected PTSD symptoms. In the November 2008 Social and Industrial Survey, it was noted that the Veteran began to have problems with his employment in 2002 and this eventually led to his departure in June 2005. These reported problems at work between 2002 and his retirement in 2005 included missing more and more days from work, arguing with supervisors, having weekly confrontations with coworkers, and losing interest in a job that he had held since 1974. These symptoms were present throughout the period from June 2003 to June 2005. All of this evidence persuasively suggests that the Veteran's service-connected PTSD was manifested by more than just occupational and social impairments with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks because his PTSD symptoms were not just occasional and intermittent. Rather, the Veteran's disability picture due to his service-connected PTSD reflected occupational and social impairment with reduced reliability and productivity. Additionally, the Veteran's medical records from the time period in question contained reports of panic attacks more than once a week, impairment of short term memory, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. All of these symptoms are included in the list suggested by the Rating Schedule in assigning a 50 percent rating for PTSD. The evidence also indicates that the Veteran's PTSD during this time period more closely approximates a 50 percent rating because he has experienced more of those symptoms. 38 C.F.R. § 4.130, DC 9411. Thus, and after resolving all reasonable doubt in favor of the Veteran, the Board finds that the evidence more nearly approximates the criteria for a 50 percent rating effective from June 18, 2003, to June 29, 2005. 38 C.F.R. § 4.7; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board also finds that the Veteran's service-connected PTSD does not meet the criteria for a disability rating greater than 50 percent from June 18, 2003 to June 29, 2005. In order to warrant the next higher 70 percent rating, the evidence must show that he has occupational and social impairment with deficiencies in most areas or total occupational and social impairment. The record evidence during this time period reflects the Veteran's overall symptoms, to include chronic sleep disturbance, nightmares, anxiety, depression, decreased concentration, anger problems panic attacks more than once a week, impairment in short term memory, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The record evidence also shows GAF scores ranging from 55 to 70. The Veteran's retirement from his previous employment on June 30, 2005, due to his service-connected PTSD and his subsequent isolation from social relationships serves as the dividing line for his subsequent increased rating for TPSD after that date. The record evidence has not shown either impairment in most areas or total occupational and social impairment at any time during the period in question. Prior to June 29, 2005, the Veteran still was working, maintaining a good relationship with his wife, family, and friends, and attempting to engage in social situations. In summary, the Board finds that the Veteran is not entitled to a disability rating greater than 50 percent from June 18, 2003 to June 29, 2005, for his service-connected PTSD. Consideration also has been given as to whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. 38 C.F.R. § 3.321(b)(1); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008). In this regard, the Board finds that the schedular evaluations in this case are not inadequate. Ratings in excess of those assigned are provided for certain manifestations of the service-connected PTSD. The record evidence shows that those manifestations (occupational and social impairment with deficiencies in most areas or total occupational and social impairment) are not present from June 18, 2003 to June 29, 2005. The diagnostic criteria also adequately describe the severity and symptomatology of the Veteran's service-connected PTSD. Therefore, the Veteran's current rating appropriately contemplates the scope of his PTSD symptoms and referral for extraschedular consideration is not warranted. The Board further finds that the evidence supports assigning a 100 percent rating effective June 30, 2005, for the Veteran's service-connected PTSD. Here, the Veteran's GAF scores from June 30, 2005 to March 3, 2008 were predominantly in the range of 50 to 60. This indicated moderate symptoms or moderate impairment in social and occupational functioning to serious symptoms with impairment in interpersonal relationships. From January 2006, the Veteran's highest GAF score was 50 after fluctuating for the previous 6 months. Thus, the Veteran's GAF scores alone reflects PTSD of an overall moderate nature shortly after he retired. It appears that the Veteran's service-connected PTSD quickly progressed after January 2006 and remained at a more serious level. Although these scores alone do not mandate a 100 percent disability rating, they reflect worsening of the Veteran's service-connected PTSD after his early retirement due to this disability. As noted previously, all of the pertinent evidence must be considered and the Board's decision must be based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. Here, the Veteran's own statements as well lay statements from his friends and family provide competent and credible evidence of his disturbances in mood, near-continuous depression, anxiety, irritability, difficulty sleeping, nightmares, social isolation, panic attacks, suicidal ideation, and an inability to work since June 30, 2005. Further, the May 2005 statement from the Vet Center showed that the Veteran had been contemplating early retirement due to his service-connected PTSD symptoms and opined that he would not be able to continue work due to his worsening symptoms. In a January 2006 VA outpatient treatment note it was reported that due to the PTSD symptoms as well as other medical problems, the Veteran was unable to gain and maintain employment on the competitive market. Treatment notes in May 2006 and February 2007 showed that the Veteran could no longer be around people and increasingly was isolating himself. Further, a November 2008 Social and Industrial Survey indicated that the Veteran's condition began to worsen after his retirement from Dow Chemical in 2005 and he was increasingly isolated from his wife and others, only maintaining contact with his siblings. The Veteran also was found to be totally occupationally and socially impaired in a September 2010 Social and Industrial Survey. The Board notes that it appears that this finding was the basis for the RO's granting a 100 percent rating effective March 3, 2008, for the Veteran's service-connected PTSD in a February 2011 rating decision. Most of the Veteran's service-connected PTSD symptoms have remained constant throughout the entire appeals period with the exception of his unemployment, increased social isolation, lower GAF scores, and suicidal ideation, all of which occurred after his retirement on June 30, 2005. The Board finds that the Veteran should be afforded reasonable doubt in characterizing his retirement date as the point at which his service-connected PTSD became permanently and totally disabling. The Board also finds that the difference in the Veteran's disability picture due to his service-connected PTSD on March 3, 2008, versus June 30, 2005, is insignificant. The same symptoms and relative severity existed at both dates. And it appears that the Veteran's unemployment and social isolation really began at his retirement on June 30, 2005. Although the Board notes that documentation showing the Veteran's actual date of retirement was not included in the claims file, the Veteran's competent and credible statements regarding this date have been considered. In summary, and after resolving all reasonable doubt in favor of the Veteran, the Board finds that the evidence more nearly approximates a 100 percent rating effective June 30, 2005, for the Veteran's service-connected PTSD. 38 C.F.R. § 4.7; Gilbert, 1 Vet. App. at 49. The evidence of record does not warrant ratings in excess of those assigned for the Veteran's PTSD at any time during the appeal period. 38 U.S.C.A. § 5110 (West 2002 & Supp. 2012). See also Fenderson v. West, 12 Vet. App. at 119. ORDER Entitlement to an initial 50 percent rating, and no higher, from June 18, 2003 to June 29, 2005, for PTSD is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a 100 percent rating effective June 30, 2005, for PTSD is granted, subject to the laws and regulations governing the payment of monetary benefits. ____________________________________________ MICHAEL T. OSBORNE Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs