Citation Nr: 1325477 Decision Date: 08/12/13 Archive Date: 08/16/13 DOCKET NO. 07-27 289 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUE Entitlement to an initial evaluation higher than 70 percent for posttraumatic stress disorder (PTSD) from July 1, 2003 to November 13, 2012. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Russell P. Veldenz, Counsel INTRODUCTION The Veteran served on active duty from July 1975 to October 1977. This matter initially came to the Board of Veterans' Appeals (Board) on appeal from an April 2005 rating decision of the Department of Veterans Affairs (VA) Regional Offices (RO) in Denver, Colorado, that granted service connection for PTSD and awarded an initial 50 percent disability evaluation, effective from May 6, 2003. The Veteran submitted a timely notice of disagreement (NOD) in May 2005. An April 2006 rating decision awarded a 70 percent rating for PTSD and major depressive disorder, effective from May 6, 2003, to which the Veteran submitted another NOD in September 2006, and then perfected his appeal. In a rating decision dated in June 2007, the Sioux Falls, South Dakota, RO granted a temporary total disability rating of 100 percent, effective from May 5, 2003 and effectuated the 70 percent rating from July 1, 2003. In June 2009, the Veteran testified during a hearing at the Sioux Falls RO before the undersigned. A transcript of this hearing is associated with the claims folder. Jurisdiction of the Veteran's case is currently with the VA RO in St. Paul, Minnesota. In July 2010 and November 2012, the Board remanded this case to the RO via the Appeals Management Center (AMC) in Washington, D.C. for further development. As the requested development has been completed, no further action is necessary to comply with the Board's remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). In a February 2013 rating decision February 2013, the AMC granted a 100 percent rating for PTSD, effective November 14, 2012. As such, the Board is of the opinion that the issue as characterized on the title page most accurately represents the current status of the Veteran's claim. FINDING OF FACT Resolving all doubt in the Veteran's favor, from July 1, 2003 to November 13, 2012, PTSD has precluded the Veteran from obtaining and maintaining full-time employment, effectively resulting in total social and occupational impairment, and manifested by withdrawal/social isolation, depression, angry outbursts, and limited ability to perform a variety of duties due to problems with anxiety, communication, lack of concentration, memory, and attention. CONCLUSION OF LAW Resolving all reasonable doubt in the Veteran's favor, from July 1, 2003 to November 13, 2012, the criteria for an initial evaluation of 100 percent for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist The Veterans Claims Assistance Act (VCAA) substantially amended the provisions of Chapter 51 of Title 38 of the United States Code, concerning the notice and assistance to be afforded to claimants in substantiating their claims. VCAA § 3(a), 114 Stat. 2096, 2096-97 (2000) (now codified as amended at 38 U.S.C.A. § 5103 (West 2002 & Supp. 2012)). In view of the favorable disposition of this appeal, discussed below, the Board finds that VA has satisfied its duty to notify and assist the Veteran in apprising him as to the evidence needed, and in obtaining evidence pertaining to his claim for an increased rating for PTSD under the VCAA. As set forth herein, no additional notice or development is indicated in the Veteran's claim for an increased rating. II. Factual Background and Legal Analysis The present appeal involves the Veteran's claim that the severity of his service-connected PTSD warrants a higher disability rating. Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) held that a veteran need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). See also 38 C.F.R. §§ 4.1, 4.2. Additionally, although regulations require that a disability be viewed in relation to its recorded history, 38 C.F.R. §§ 4.1, 4.2, when assigning a disability rating, it is the present level of disability which is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Board observes that the words "slight," "moderate," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just". 38 C.F.R. § 4.6 (2012). It should also be noted that use of descriptive terminology such as "mild" by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 U.S.C.A. § 7104(a) (2012); 38 C.F.R. §§ 4.2, 4.6. Regulations require that where there is a question as to which of two evaluations is to be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in 38 C.F.R. § 3.321 an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2012). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). The Veteran's statements describing the symptoms of his service-connected PTSD are deemed competent evidence. However, these statements must be considered with the clinical evidence of record and in conjunction with the pertinent rating criteria. The Veteran contends that he is entitled to a higher rating for his service-connected PTSD. After careful consideration of all the evidence of record, the Board concludes that the Veteran's service-connected PTSD has effectively rendered him unable to work since he filed his current claim for VA benefits and, thus, that a 100 percent rating is warranted. As noted, service connection for PTSD was granted in the April 2005 rating decision that assigned an initial 50 percent disability rating effective from May 6, 2003, to which the Veteran submitted a timely NOD. The April 2006 rating decision granted a 70 percent rating effective from May 6, 2003. Then, the July 2007 rating decision assigned a temporary total disability rating of 100 percent effective from May 5, 2003 and effectuated the 70 percent rating from July 1, 2003. The February 2013 rating decision granted a 100 percent rating for PTSD from November 14, 2012. Thus, the question now before the Board is whether the Veteran is entitled to a 100 percent rating for PTSD from July 1, 2003 to November 13, 2012. Under the current schedular criteria, Diagnostic Code 9411 (PTSD), is evaluated under the general rating formula used to rate psychiatric disabilities other than eating disorders. 38 C.F.R. § 4.130. A 70 percent rating contemplates 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); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 100 percent rating contemplates 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 ability 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. Id. Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social and occupational functioning on a hypothetical continuum of mental health- illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the DSM IV, page 32). A GAF score ranging from 31 to 40 represents some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF score of 41 to 50 indicates serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score from 51 to 60 represents 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). While the Rating Schedule does indicate that the rating agency must be familiar with the DSM IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. Rather, GAF scores are but one factor to be considered in conjunction with all the other evidence of record. When it is not possible to separate the effects of a nonservice-connected condition from those of a service- connected disorder, reasonable doubt should be resolved in the claimant's favor with regard to the question of whether certain signs and symptoms can be attributed to the service- connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998); see also 38 C.F.R. § 3.102. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders 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, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. Facts VA medical records and examination reports, dated from 2003 to 2012, reflect that the Veteran's PTSD was treated with in and out patient individual and group psychotherapy and prescribed medication. According to VA medical records, in April 2003, the Veteran was diagnosed with PTSD along with major depressive disorder. He was also a recovered alcoholic. His symptoms included nightmares, intrusive thoughts, avoidance of anything reminding him of his stressors, emotional numbing, detachment, difficulty with authority, and anger. He had symptoms of depression. A GAF score of 45 was assigned. In May 2003, the Veteran entered an in-patient VA program for PTSD. He believed he needed help controlling anger, resentment, and frustration, detachment, and low self esteem. The Veteran reported feeling anxious and depressed but his appetite and sleep was good. He had no current thoughts about suicide. The GAF score was 60. In June 2004, it was noted that the Veteran lived with a girlfriend, her son, and his teenage daughter. The Veteran reported his depression and PTSD symptoms continue. He also reported relationship problems with his girlfriend. The GAF score was 45. In January 2005, VA received a statement from the Veteran's mother describing how he had no problems before service but, afterwards, he was moody, distant, extremely negative/pessimistic, and fearful about life. The Veteran has an agitated, angry, unhappy and fearful attitude about everything. When seen in March 2005, the Veteran's chief complaints were intrusive memories, nightmares, depressed mood, low self-esteem, and suicidal ideation. By now, he was raising both of his teenage daughters. He had increased chronic pain from neck surgery and could no longer work as a helicopter mechanic. The VA clinic psychologist stated the Veteran was not employed and he was not really able to function in a work setting at all. This resulted in financial stressors. Failing health and increasing life stressors exacerbated his PTSD symptoms. On the other hand, the Veteran remained sober. Sobriety resulted in increasing frequency of nightmares and particularly intrusive thoughts. The Veteran had a somber effect and dysphoric underlying mood. A GAF score of 33 was assigned. In March 2005, the Veteran underwent VA examination. He reported that, post-service, he studied aviation maintenance management and held 3-5 jobs between 1977 and 1998 in construction and as a helicopter mechanic. He was last employed in June 1998 and was disabled. The Veteran stated, however, that he left prior jobs for not being treated right - from his prospective, although he was fired on many occasions. He was divorced but lived with his girlfriend in what he reported as a generally good relationship although the examiner noted it appeared strained. The Veteran was also raising two teenage daughters and had a good relationship with them. His relationship with other family members was poor. The Veteran reported not having many friends and believed he had run them off. The examiner believed overall, the Veteran had limited social support. The Veteran reported sleep disturbance, excessive anger with rage and temper outbursts, depression, anxiety attacks, nightmares, intrusive thoughts, restlessness, sweating episodes, significant anxiety low self esteem, guilt, crying episodes, and avoidance behavior such as crowds. He avoided being emotionally close to others and it was evident he had authority issues. Other symptoms included exaggerated startle response, hypervigilance, and the need to control his surroundings. Upon examination, it was noted the Veteran had fair grooming and good hygiene. He had good posture and eye contact. He cooperated and had normal psychomotor activity. The Veteran described his mood as depressed and reported poor sleep, anhedonia, significant guilt, poor energy, poor concentration and attention, poor appetite and poor sexual drive. He reported hopelessness, helplessness, and worthlessness. He had a full range affect. His speech was normal and goal directed. The Veteran reported suicidal ideation but would not act on it because of his family. He had no illusions, delusions, or hallucinations. The Veteran was oriented but demonstrated some limited attention and concentration. He demonstrated the ability to think abstractly and memory was within normal limits. The difficulty he had during testing was attributed to attention/concentration rather than a memory deficit. Judgment and insight was fair. The VA examiner diagnosed chronic PTSD, and noted a concern of employment and relationship problems. The Veteran also had symptoms consistent with major depressive disorder with a focus on self- image issues, as he tends to feel quite worthless, helpless, and hopeless. Thus, the VA examiner also diagnosed severe recurrent major depressive disorder. He assigned a GAF score of 42, which covered both diagnoses and the examiner could not separate the effects of the two diagnoses in the Veteran's ability to function. In May 2005, the Veteran's treating VA clinic psychologist assigned a GAF score of 33, but another clinician assigned a GAF score of 60. In June 2005, the Veteran's GAF score was 33 and remained at that level as his daughters planned to move out and his girlfriend left him. This resulted in feelings of abandonment. In July 2005, the Veteran recognized that his daughters were moving out, that was appropriate for the situation, and he was trying hard not to take it as a personal rejection. He also reported his girlfriend had returned, but he decided to end his relationship with her as she had a negative impact on his self- esteem. The Veteran's assigned GAF score remained at 33. In November 2005, the Veteran reported that back pain caused him to be less active and more depressed. He was also lonely as his youngest daughter would not be at home as often and provide the emotional support he needed. He was looking for employment to give him something to do and help supplement his limited income. His assigned GAF score remained at 33. In December 2005, the Veteran's chief complaints were depression and low self- esteem. He focused on coping skills and prepared a budget. Again, his GAF score was 33, as it was when he was seen in January 2006. In May 2006, the Veteran reported that his depression reached the point that, the previous week, he seriously considered suicide. But he subsequently learned he was awarded a 70 percent disability rating for his PTSD and received a retro-active disability benefits check. His assigned GAF score was still 33. In a letter dated in May 2007, the Veteran's youngest daughter, B.O., stated it was clear to her that her father tried his hardest to be a good parent but struggled with life issues including long term unemployment, divorce, recovery from alcohol abuse and his involvement with dysfunctional relationships with other women. According to B.O., his problems resulted from low self- esteem. The Veteran lost his house to foreclosure and B. O. and her older sister now attended college. The Veteran presently lived alone and rarely left his new house outside of town. He told her and her sister that there were days that he did not speak with anyone. He had no hobbies or friends. Also in May 2007, the Veteran underwent another VA examination. According to the examination report, the VA examiner reviewed the Veteran's medical records including the recent statement provided by the Veteran's daughter. The examiner noted the Veteran received periodic psychiatric therapy at VA and was consistently given a GAF score of 33. There was no record of successful treatment of symptoms with medication. (The Board notes, parenthetically, that other notes indicate that the Veteran did not like taking medication to treat his PTSD symptoms.) The Veteran reported constant fatigue, no memory, and no concentration. He had significant pain which caused depression. He described lying around the house because of severe pain that increased his depression. The Veteran had daily intrusive thoughts related to his in-service stressors. He also had severe headaches 3 to 4 times a week. He spent 4 to 6 days with no contact with another person and rarely left his home. The Veteran was still unemployed and had not attempted any educational endeavors. The Veteran had one romantic relationship, which he described as chaotic. He did maintain quality relationships and tried to see his youngest daughter up to two times a month. He was in weekly contact with his children, which was the only thing he cared about. He had two friends but reported only sporadic contact with them. He had very few leisure pursuits. The Veteran enjoyed motorcycles and guns but rarely went out to shoot and fount he was incapable of rebuilding his three motorcycles. This was attributed to having no concentration to put the motorcycles back together. The Veteran maintained complete abstinence from alcohol. He had no episodes with assaultiveness or violence or suicide attempts. He reported, however, that he had minimal ability to take care of himself. He may go days without showering or brushing his teeth. He did not take good care of his home and had no social or interpersonal relationships. The Veteran reported difficulty controlling anger with frequent outbursts and impaired sleep. The Veteran was clean and dressed in casual attire. The VA examiner stated the Veteran's hygiene was appropriate on the day of the examination despite the reports of difficulty maintaining personal hygiene. The examiner noted a mild level of motor agitation and pressured speech. The Veteran tended to ramble, talk over the examiner, and had difficulty slowing himself when speaking. He maintained eye contact and had no homicidal or suicidal ideation. There was no significant memory loss but the Veteran had some difficulty with concentration and demonstrated poor organization. Thought process was circumstantial but there were no distortions in his thought content. The Veteran reported occasional panic attacks and had a depressed, sad mood. His affect was incongruent. As to the PTSD, the examiner noted intrusive memories, but also amnesia for parts of the in-service trauma. The Veteran had diminished interest and emotional detachment. He demonstrated symptoms consistent with a foreshortened future and hypervigilance. The PTSD significantly affected his concentration, and limited his social and occupational endeavors. It resulted in conflict and angry impulses and occasional panic attacks. There was more social and industrial impairment for the depression but the chronic pain was responsible for the more severe impairment in these areas. The VA examiner noted that, in August 2006, the Veteran's life became disrupted when both his daughters moved out and went to college. This appeared to exacerbate his symptoms. Since then, he had more social isolation and depressive features, and less leisure and recreational pursuits. The VA examiner described the severity of the symptoms as moderate and assigned a GAF score of 51 for the symptoms attributable to PTSD. If the Veteran's depressive features were added, the GAF score dropped significantly. The examiner noted that the Veteran's PTSD "significantly" affected his concentration and limited his social and occupational endeavors. It also resulted in conflict and angry impulses. The examiner stated that it was difficult to determine to what degree depression was related to PTSD and what degree was due to pain. The Veteran described difficulty with interpersonal trust and angry outbursts affecting interpersonal relationships. His unemployment was not fully explained by PTSD, that affected his ability to maintain employment but may not completely rule it out. The examiner said it appeared that PTSD was partially related to the Veteran's unemployability. In August 2007, the Veteran moved and was treated at a different VA medical center (VAMC), where he was noted to have minimal hygiene and grooming. His mood was quite anxious with a congruent affect. Speech was pressured. He was alert and oriented and there was no evidence of a thought disorder. He remained concerned about his isolation, limited social support system, increased anxiety, inability to concentrate, long/short term memory problems, sleep disturbance, chronic pain, and an inability to relax. He believed he suffered from panic attacks. In October 2007, the Veteran reported being irritable with a somewhat depressed mood and fragmented sleep. He lived 10 miles outside of town, stated this was too lonely, and planned to move the following May. He was aggravated, resentful, and angry all the time with constant negative thoughts. He attended AA meetings two to three times a week, sponsoring people and talking to other AA members. He was tense but with good hygiene and casual dress. He was rather vocal, interrupted, and had pressured speech. Insight and judgment was fair. He had no suicidal or homicidal ideation. Another evaluation in October 2007 indicated that the Veteran wanted help so he could live to see his grandchildren and find love. He still had intrusive thoughts, and psychological and physiological response to re- exposure to trauma and trauma related material. He isolated for long periods (4 to 6 days). He remained emotionally distant from relatives with his children thinking he is angry when he is really "just behind his glass wall." He reported fragmented sleep and hypervigilance awakened him with the slightest noise. Concentration was still difficult for him. The VA clinic physician noted that the Veteran had hygiene that was less than adequate. The Veteran was somewhat animated with a steady stream of speech that was difficult to interrupt as he derails and is over inclusive and circumstantial. Eye contact and concentration was good. He was moderately depressed with an anxious mood. His insight and judgment was fair and memory was intact. The VA clinician diagnosed moderate PTSD and assigned a GAF score of 42. In May 2008, the Veteran moved to Minneapolis, Minnesota, and started treatment with the Minneapolis VMAC. He lived in his mother's basement and felt more isolated than anxious. He felt that his friends deserted him but recognized his behavior brought about these changes. The Veteran denied any current suicidal thoughts but reported having passive suicidal thoughts in the past. He was looking forward to his son's wedding in June. A GAF score of 55 was assigned by a social worker. A May 2008 intake evaluation, prepared by a VA clinic psychologist, noted the Veteran's PTSD symptoms had not abated much over the past 10 years since he injured his back and could not work as a helicopter mechanic. The Veteran wanted his life to be more active but was still close to his children and wanted to remain emotionally close to them and also have a social circle and more activities to fill his days. He denied suicidal or homicidal ideation. The Veteran was well-groomed and on time for the interview and appeared fully oriented and cooperative. His mood was anxious and the affect was full. Motor activity was normal but his speech was rapid. His thought content was appropriate and though process was clear. Judgment and insight was good. The Veteran had sleep problems, depressed mood, and a lack of energy. He acknowledged he was overly self- critical, irritable, and pessimistic. He walked away when he got angry. At this time, the VA clinician determined the Veteran had a depressed mood, anhedonia, loss of energy, sleep difficulty, being overly self- critical and feeling hopeless, and increased irritability and pessimism. These symptoms were attributed to his major depressive disorder. As to PTSD, the Veteran's symptoms included intrusive memories, becoming emotionally upset upon reminders of the stressor, physical reactions to triggers, anhedonia, emotional numbing, and feelings of detachment, peritraumatic amnesia, foreshortened future, sleep difficulties, increased irritability, and hypervigilance. A GAF score of 45 was assigned. In June 2008, the Veteran expressed frustration regarding getting a VA primary care provider. His mental health provider noted it really appeared that the Veteran needed help in following through. He also reported frustration with his management of pain and that he was thought to be engaging in drug seeking behavior when he has been sober for years. The Veteran felt very connected to his daughters but frustrated he was living at his mother's house. He attended AA every week multiple times and was very social but felt disconnected. The VA provider concluded the Veteran was trying to accept his pain and not try so hard to get rid of his pain and negative emotions. A GAF score of 50 was assigned. A fuller evaluation occurred later in June 2008 during which the Veteran reported that he struggled with increased anxiety and depression, but had no suicidal ideation. When he lived in South Dakota, he was quite housebound and isolated, which he believed substantially increased his depression and decompensation. His relationship with his mother was strained. He had a depressed mood, hopeless feeling, little energy, and did not enjoy areas of his life. Concentration was poor. The Veteran felt anxious about everything and had difficulties with anger and irritability. He had tried antidepressant medication, but the medication was ineffective. He had used individual therapy and group therapy, which he was interested in utilizing again. Upon examination, the Veteran was pleasant, cooperative and forthcoming. His speech was mildly pressured and eye contact was good. His mood was depressed and his affect was anxious. The Veteran would rapidly disclose history without prompting and was over-inclusive. He needed to be interrupted multiple times but could be redirected. His thought content did not demonstrate loosening of associations, suicidal ideation, homicidal ideation, or psychosis. Cognition and memory were intact and insight and judgment were good. The GAF score was 50. In June 2008, the Veteran attended his son's wedding and reported that it went well. He felt living in his mother's house was driving him crazy and he saw his daughters every two to three weeks. Anger was still an issue for him as far as living the life he wanted. He had an anxious mood, restricted affect, and very rapid speech. His thought process was clear and goal directed. Thought content was appropriate and his judgment and insight was good. The GAF score was 50. In July 2008, the Veteran reported attending 3 to 7 AA meetings a week and expressed some interest in returning to work, although he had concerns about his physical limitations and his anxiety and concentration. He reported struggles with depression, hopelessness, becoming overly emotional, and recurring anxiety. A care provider recommended medication, which the Veteran strongly resisted as few medications had worked for him and wondered why the medical provider had not looked at his records. The provider found he had sleep disturbance, anxiety, and mild depression. Other than engaging with AA groups, he otherwise was largely isolated, stressed by his move, and had little daily structure. The GAF score was 50. According to an August 2008 VA mental health treatment plan, the Veteran's GAF score was 45. In September 2008, the Veteran reported support from friends, his AA sponsor, and his children. He enjoyed working on his motorcycle and was in the process of building one. He rode his motorcycle when possible. An October 2008 VA outpatient record shows that the Veteran went to Arizona to work with a friend but left after the friend was intoxicated most of the time. As this was the only person the Veteran considered a friend, he felt socially isolated and overwhelmed but then backed off that assessment as the session continued. The GAF score was 55. On October 22, 2008, in discussion as to entering a VA program for treatment of his PTSD, the Veteran demonstrated feeling overwhelmed and frustrated and the therapist tried to explain that he was being offered a skill building therapy that took time to understand. The Veteran presented as demanding and somewhat threatening, and complained that he was being underserved. The therapist acknowledged this could be the Veteran's way of expressing distress and wanted help. The Veteran expressed willingness and motivation to identify and work on his problems. A GAF score of 50 was assigned. In November 2008, the Veteran still expressed reservations about the VA program recommended by the VA psychologist, who tried to reassure him that PTSD symptoms can improve, which he interpreted as PTSD can be cured. He was irritable and agitated. The Veteran appeared fixated upon his PTSD symptoms, although he was genuinely trying to clarify his concerns. The GAF score was 50. By February 2009, the Veteran expressed dissatisfaction with his mental health care providers according to a mental health progress note. Attempts were made by the mental health staff to contact the Veteran but were unsuccessful. When contacted by telephone, the Veteran believed he was uncared for, or provided incompetent care, and treated like a number at the Minneapolis VAMC. He wanted help and his PTSD symptoms had intensified over recent months and weeks. The VAMC provider offered to transfer the Veteran to another provider but the conversation became difficult as the Veteran was dysregulated and sounded unable to process information. The Veteran hung up and stated he wanted to be left alone. VA tried to assign a new provider but could not contact the Veteran. During his June 2009 Board hearing, the Veteran testified he had not much, if any, of a life. He did nothing except attend AA meetings and did not date. He moved to Minnesota to be near his daughters but, before that, lived in South Dakota, isolated in a farmhouse out of the nearest town. The Veteran got lonesome and suicidal. He made the move to Minnesota and currently lived with his mother. His daughters told him he was too negative and depressed. He felt himself isolating again but attended AA meetings. Otherwise, he stayed home and watched television. Further, the Veteran said that he also had trust issues with people. He testified that in his jobs, he got into big fights with everyone. The helicopter maintenance job allowed him to travel to remote areas and work by himself, but he still had conflicts with that employer. He left because of his anger symptoms. He stated he had no patience and had a low tolerance of other people in public. He described having conflicts with the mental health provider at the Minneapolis VAMC and stopped going for therapy. He admitted he was confrontational with his provider and needed to trust him which took a long time. He had anxiety attacks twice a week. The Veteran also testified that he did not care about his personal hygiene and took a shower every third day because he did not care. He had not seen a dentist in years and he did not take care of himself as he should. He had problems with appointments because of forgetfulness including dropping a daughter off at school and when it was time to pick her up, he would be 45 minutes away. He needed to use calendars and notes. The Veteran also submitted evidence of his hypervigilance wherein, a couple years back, he discovered his daughter's boyfriend visiting in the middle of the night after hearing something and grabbed his gun. He submitted a letter his daughter wrote at the time to her boyfriend about how vigilant the Veteran was and how the Veteran found evidence that the boyfriend came to see her. In January 2010, on a return visit to the Cheyenne VAMC, the Veteran stated that his daughters no longer lived with him as they were adults in college and reached the point where they were ready to stand on their own. The Veteran reported depression continued to be a problem for him. He still attended AA meetings but not psychotherapy. The GAF score assigned was 33. The Veteran underwent VA examination in November 2012. At that time, the Veteran was still involved with AA, but sleep disturbance resulted in fatigue and anxiety in attending although he was still in contact with his sponsor and some others that he sponsored. He had no other interaction. He had contact with his children but contact was sporadic and often conflicted. The Veteran reported staying in his apartment for 3 to 4 days without contact with anyone. As he could not even attend AA reliably, he did not feel he could sustain a job. He reported difficulties with anxiety, extreme response to stress, periodic sleep problems with exhaustion the next day, impatience and angry outbursts in what should be minor disagreements (including his mother and children) and impaired concentration and retention of instructions. He stopped therapy at the Minneapolis VA after feeling distrustful, but did inquire about re-involvement in counseling. He also read self-help books. The Veteran displayed a flattened affect and circumstantial speech. The examiner found the Veteran had impaired impulse control and an intermittent inability to perform activities of daily living including maintenance of minimal personal hygiene. Speech was responsive but reduced in spontaneity, increased in rate and productivity, and often circumstantial and one topic reminds him of another. The affect was tense, restricted, guarded, and tearful. He reported mood as tense, worried, anxious, irritable, sad, and at times hopeless with suicidal ideation but without intent or plan. He was without libido and was anhedonic except to read or watch videos. The examiner noted worsening symptoms since the last VA examination in 2007. The Veteran was now more socially isolated, struggled even more with interpersonal relationships, and could not even reliably attend AA meetings. He had marked difficulty with anger, anxiety, severe stress responsiveness, impaired concentration, and focus, with circumstantiality due to anxiety, making the examination long and difficult. The examiner concluded the Veteran's PTSD alone more likely than not by itself precluded the Veteran from securing and following employment. The diagnoses were PTSD, panic disorder without agoraphobia, secondary to PTSD and recurrent, moderate symptoms of major depressive disorder. The examiner attributed sleep problems, concentration difficulties, anger, irritability, stress responsiveness, constant worry and anxiety, social isolation, loss of hope for the future, and distrust of people to PTSD. The panic disorder with panic attacks was secondary to the PTSD. The depression produced periods of hopelessness, suicidal ideation without intent or plan, and reduced energy and initiative. Problems with anger, concentration, sleep problems that made daytime activity unreliable, stress responsiveness, worry and anxiety, and difficulty in establishing and maintaining social work relationships are all consequent to PTSD symptoms. Overall, the Veteran's GAF score was 42, but the GAF score from PTSD symptoms alone was 57 and was still in the serious range. Analysis Giving the Veteran the benefit of the doubt, and after considering all of the objective medical and other credible evidence of record, it is the judgment of the Board that the schedular criteria for a 100 percent rating are met, as the Veteran's psychiatric disability has effectively resulted in total occupational and social impairment. The Board finds that the medical evidence shows the Veteran is unemployable due to the disability at issue. See Mittleider v. West, supra. In fact, in March 2005, the VA examiner diagnosed the Veteran with chronic PTSD and noted a concern of employment and relationship problems. The Veteran was also diagnosed with a severe recurrent major depressive disorder at that time. Moreover, in May 2007, a VA examiner noted the Veteran's difficulty with interpersonal trust and angry outbursts that affected interpersonal relationships. The examiner observed that the Veteran's unemployment was not fully explained by PTSD that affected his ability to maintain employment, but may not completely rule it out and also stated that it appeared that PTSD was partially related to the Veteran's unemployability. Clinicians since 2003 particularly noted the Veteran's combat-related sleep difficulty, poor impulse control, anxiety, social isolation, anhedonia, and history of poor interpersonal relations. The medical evidence demonstrates the fluctuating arc of the Veteran's psychiatric disability during the course of his appeal. Notably, in April and June 2003, VA medical providers assigned GAF scores of 45, and the March 2005 VA examiner assigned a GAF score of 42, reflective of serious symtoms or serious impairment in social and occupational functioning. The VA examiner said that score covered both diagnoses and he could not separate the effects of the two diagnoses in the Veteran's ability to function. See Mittleider, supra. However, from May through December 2005, VA clinicians assigned a GAF score of 33, denoting some impairment in reality testing or major impairment in several areas such as work, family relations, judgment, thinking, or mood. The Board notes that the May 2007 VA examiner evidently considered the Veteran less impaired, as shown by the assigned GAF score of 51, representative of moderate to severe social and occupational impairment. But, in October 2007, a VA clinician assigned a GAF score of 42, commensurate with serious impairment. Although, from June to November 2008, GAF scores of 50 and 55 were assigned, denoting moderate impairment. But, in January 2010, a VA clinician assigned a GAF score of 33, again denoting some impairment in reality testing or major impairment in several areas, such as work, family relations, judgment, thinking, or mood. In view of the foregoing, the Board concludes that the evidence is at least in relative equipoise as to the level of psychiatric disability, and as to whether it is reasonable to conclude that the disability picture is comparable to a 100 percent evaluation. Overall, the current level of disability arguably, but not clearly, approximates the criteria for a 100 percent evaluation. Thus, the Board concludes, with favorable resolution of reasonable doubt, that a 100 percent rating under Diagnostic Code 9411 is warranted, under the regulations currently in effect. 38 C.F.R. § 4.7. It is significant, however, that the Veteran's psychiatric symptomatology does not precisely mirror the symptoms illustrative of a 100 percent evaluation under Diagnostic Code 9411. For example, there is little or no evidence in the record of gross of impairment in communication; gross inappropriate behavior, disorientation to time or place; memory loss for names of close relatives, own occupation or own name. However, it is apparent that the Veteran's symptoms, especially his sleep difficulty, anxiety, depression, social isolation, hypervigilance, and irritability, have essentially totally impaired his social and occupational functioning by severely reducing his reliability and productivity. In these circumstances, therefore, the Board finds that a 100 percent evaluation is warranted for the service-connected PTSD. See 38 C.F.R. § 4.21 (2012) (not all cases will show all findings specified in the rating criteria, but the rating must in all cases be coordinated with actual functional impairment). The March 2005 VA examiner assigned a GAF score of 42, that denotes serious impairment in communications or judgment or an inability to function in almost all areas but, in May 2007, the VA examiner reported moderately severe PTSD symtoms and assigned a GAF score of 51. However, the examiner explained that if the Veteran's depressive features were added, the GAF score dropped significantly. The examiner also stated that it was difficult to determine to what degree depression was related to PTSD and what degree was due to pain. Other treating VA clinicians have assigned GAF scores that ranged from 33 to 55, reflective of some impairment in reality testing or major impairment in several areas, such as work, family relations, judgment, thinking, or mood to moderate symtoms. See Carpenter v. Brown, supra; see also Mittleider. Further, the Veteran's psychiatric symptomatology has included hypervigilance, severe anxiety, social isolation, depression, concentration difficulty, anger outbursts, and recurrent combat-related nightmares and intrusive recollections of service-related events. In reaching this decision, the Board recognizes that the Veteran's capability to work was at times attributed to nonservice-connected disorders. Nevertheless, the record also establishes that he has been treated for chronic, debilitating symptoms non-dissociable from the service-connected psychiatric disability that included nightmares and sleep difficulty, severe anxiety, social isolation, hypervigilance, depression, irritability, and concentration difficulty, that, for all intents and purposes, precluded him from gainful employment. See e.g., Mauerhan v. Principi, supra (factors listed in the rating formula are examples of conditions that warrant a particular rating and are used to help differentiate between the different evaluation levels.). From the objective and competent medical evidence of record, it is not unreasonable to conclude that since he filed his claim in May 2003, the Veteran's service-connected PTSD disorder essentially rendered him unable to work. Resolving reasonable doubt in the Veteran's favor, the Board concludes that since July 1, 2003, the criteria for the assignment of a 100 percent rating for PTSD have been satisfied. In view of the above, the Board finds that the application of the benefit-of-the-doubt doctrine contemplated by 38 U.S.C.A. § 5107(b) is appropriate in this case. As stated, the level of disability, when the benefit of the doubt is given to the Veteran, is approximately commensurate with the 100 percent rating under Diagnostic Code 9411 under current rating criteria. 38 U.S.C.A. §§1155, 5107; 38 C.F.R. §§ 4.7, 4.132, Diagnostic Code 9411. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a total rating based upon individual unemployability due to service-connected disability (TDIU) claim is part of an increased rating claim when such claim is raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. However, the RO considered the extent that the Veteran's service-connected PTSD affects his ability to obtain and maintain substantially gainful employment in its December 2007 unappealed decision that denied the Veteran's claim for entitlement to a TDIU. Furthermore, the Board considered the extent that his service-connected PTSD affects his ability to obtain and maintain substantially gainful employment in its decision herein that grants a 100 percent rating for PTSD from July 1, 2003. Finally, in view of the holding in Fenderson, the Board has considered whether the Veteran is entitled to a "staged" rating for his service-connected PTSD disability, as the Court indicated can be done in this type of case. Based upon the record, we find that at no time since the Veteran filed his original claim for service connection has the disability on appeal been more disabling than as currently rated under the present decision ORDER A 100 percent rating for PTSD is granted from July 1, 2003 to November 13, 2012 subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ D. J. DRUCKER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs