Citation Nr: 1327424 Decision Date: 08/27/13 Archive Date: 09/05/13 DOCKET NO. 07-32 193 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Providence, Rhode Island THE ISSUE Entitlement to an initial rating in excess of 50 percent for the service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Joseph R. Moore, Esq. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. H. Nilon, Counsel INTRODUCTION The Veteran served on active duty from October 1967 to October 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an April 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Providence, Rhode Island that granted service connection for PTSD and assigned an initial rating of 30 percent effective from April 1, 2006. In May 2009 the Veteran testified before a Veterans Law Judge in a hearing at the RO ("Travel Board" hearing). A transcript of the hearing is of record. In September 2009 the Board issued a decision that granted an initial rating of 50 percent, effective from April 1, 2006. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court), which issued an Order in September 2010 that granted a Joint Motion of the Parties to vacate the Board's decision and return the case to the Board for further consideration. The Board remanded the case to the RO in October 2011 for further development, which has been accomplished. The Board advised the Veteran in June 2013 that the Veterans Law Judge who presided at the earlier Travel Board hearing is no longer active with the Board, and that he is entitled to another hearing, before a currently-active Member of the Board, if he so desires. The Veteran was advised that if he did not respond within 30 days the Board would assume he does not want another hearing and proceed accordingly. The 30 day period having passed without response, the Board will proceed with adjudication based on the evidence of record. FINDING OF FACT From April 1, 2006, the disability picture associated with the Veteran's PTSD has more closely approximated occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW The criteria for an initial rating higher than 50 percent for PTSD are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist Before addressing the merits of the claim on appeal, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The VA is required to assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. The VA is required to notify a claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, the VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, the VA will attempt to obtain on behalf of the claimant. In addition, the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant be provided "at the time" of, or "immediately after," the VA's receipt of a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The present appeal arises from the initial award of service connection. The United States Court of Appeals for Veterans Claims (Court) has held that in cases in which 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 v. Nicholson, 19 Vet. App. 473, 490-91 (2006); see also Dunlap v. Nicholson, 21 Vet. App. 112 (2007) (section 5103(a) notice is no longer required after service-connection is awarded); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Thus, VA's duty to notify in this case has been satisfied. In any event, neither the Veteran nor his representative has alleged or demonstrated any prejudice with regard to the content or timing of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009 (reversing prior cases law imposing a presumption of prejudice on any notice deficiency and clarifying that the burden of showing harmful or prejudicial error normally falls on the party attacking the agency's determination). See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The record also reflects that service treatment records (STRs), Social Security Agency (SSA) disability records and all available post-service medical evidence identified by the Veteran have been obtained. The Board previously determined the Veteran should be afforded another VA examination to address current symptoms, and remanded the case for VA examination in October 2011. The requested examination was provided to the Veteran in November 2011, with an addendum opinion in December 2011. The Board has reviewed the examination report with addendum and finds the RO substantially complied with the requirements articulated in the Board's remand. D'Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran has not asserted, and the evidence of record does not show, that his symptoms have changed significantly since the most recent VA examination. See Glover v. West, 185 F.3d 1328, 1332 (Fed. Cir. 1999) (holding that the VCAA does not require a VA medical examination unless the medical evidence of record is not adequate or sufficient for the appropriate legal action or unless there has been a material change in the disability). The Veteran has been afforded a hearing before a Veterans Law Judge (VLJ) in which he presented testimony in support of his appeal for a higher rating for his PTSD. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) (2010) requires that the VLJ who chairs a hearing explain the issues and suggest the submission of evidence that may have been overlooked. Here, the VLJ identified the issue to the Veteran, and the Veteran testified as to his symptomatology and functioning, as well as reporting his treatment history. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), to include during his appeal to the Court, nor has he identified any prejudice in the conduct of the Board hearing. The hearing focused on the elements necessary to substantiate the claim, and the Veteran provided testimony relevant to those elements. As such, the Board finds that no further action pursuant to Bryant is necessary, and the Veteran is not prejudiced by a decision at this time. The Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal, and has not argued that any error or deficiency in the accomplishment of the duty to notify and duty to assist has prejudiced her in the adjudication of this appeal. The Joint Motion for Remand (JMR) in September 2010, which resulted in the Court's action vacating the Board's decision in September 2009, asserted that VA had failed in the duty to assist because treatment records from private counselor M. Mashburn had not been obtained. The Board notes at this point that the treatment provided to the Veteran by Ms. Mashburn was prior to the period under appellate review and is accordingly not relevant, other than for historical consideration, to the evaluation to be assigned during the period on appeal. Nonetheless, such records have been obtained, reviewed, and incorporated into the Veteran's claims file. The Joint Motion did not assert any other deficiency in the duty to assist; the Board is confident that any such error would have been brought to the Court's attention in the interest of judicial economy. Based on a review of the claims file, the Board finds that there is no indication in the record that any additional evidence relevant to the issue to be decided herein is available and not part of the claims file. See Mayfield, 499 F.3d 1317. Therefore, the Board finds that duties to notify and assist have been satisfied and will proceed to the merits of the issue on appeal. Applicable Legal Principles Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Where there is a question as to which of two evaluations shall 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. It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. When evaluating a mental disorder, the rating agency shall consider the frequency, severity and duration of psychiatric symptoms, the length of remissions and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on social and occupational impairment rather than solely on the examiner's assessment of the level of disability at the moment of examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder the rating agency will consider the level of social impairment but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). PTSD is rated under the criteria of 38 C.F.R. § 4.130 (schedule of ratings - mental disorders), diagnostic code 9411 (PTSD). In relevant part, the rating criteria are as follows. A rating of 50 percent is assigned 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; difficulty in establishing and maintaining effective work and social relationships. A rating of 70 percent is assigned 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 worklike setting); inability to establish and maintain effective relationships. A rating of 100 percent is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behaviour; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. In any claim for higher ratings, the Board must consider whether "staged ratings" are warranted. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on her behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Evidence In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (2012) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disability herein decided, to include the records from Ms. Mashburn. The Board has found nothing in the historical record that would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations that would warrant an exposition of remote clinical histories and findings pertaining to the disability. Service connection was granted effective from February 11, 2006, with a temporary rating of 100 percent until April 1, 2006, and an initial rating of 30 percent from that date. The Veteran received inpatient VA treatment for PTSD during the period December 13, 2005, through March 15, 2006. The discharge diagnosis was PTSD, alcohol dependence and dysthymia. The Veteran's Global Assessment of Functioning (GAF) score at discharge was 39. The discharge note states the Veteran was considered to be competent to handle his own funds but unemployable due to his PTSD symptoms. The Veteran's spouse submitted a letter in May 2006 describing the Veteran's observable symptoms during their 20 years of marriage. She stated the recent several years had been particularly difficult. The Veteran had retired from his full-time teaching job and felt compelled to retire from his subsequent part-time teaching job; he was also struggling with alcoholism. The Veteran had recently completed a 45-day PTSD residential treatment program and was currently taking part in outpatient therapy. The Veteran appeared to be making progress in his coping mechanisms, but was still unable to work. The Veteran was examined by a private psychologist in June 2006 in support of his claim for SSA disability benefits. The Veteran was noted to have retired in June 2005 after teaching high school for 30 years; the Veteran asserted he was a "workaholic" for the first 20 years and used work to repress his memories of Vietnam, but these resurfaced in the 1990s. In terms of current functioning, the Veteran complained of very poor sleep and intermittent loss of appetite. His current PTSD symptoms included nightmares, startle response, anger/irritability and some short-term memory problems. Mental status examination showed the Veteran to have good grooming and hygiene. Speech was normal. Thought process was coherent and goal-directed with no indication of hallucinations, delusions or paranoia. Affect was agitated, irritated and somewhat labile; mood was neutral and somewhat irritable. Sensorium was clear and the Veteran was oriented times three. Attention and concentration were normal on examination; recent memory was normal but remote memory was somewhat impaired. Cognitive functioning was unremarkable and insight/judgment was fair. The Veteran needed occasional help managing money but was otherwise unimpaired in regard to activities of daily living (ADLs). The Veteran had adequate socialization and close family relationships with abundant family support. The examining psychologist in June 2006 stated the Veteran was shown to be able to follow and understand simple instructions and to perform simple tasks independently. His attention and concentration had a slight deficit. He was able to maintain a regular schedule, learn new tasks and to perform complex tasks, although he may need a longer time to process and organize. The Veteran was not always able to make appropriate decisions for himself given that he had used alcohol in the past to deal with his psychiatric problems. The Veteran related adequately to others but may have some limitations in dealing with stress. It was anticipated the Veteran's condition would improve with continued ongoing treatment. The examiner diagnosed PTSD and alcohol abuse in early remission. The examiner did not assign a current GAF. The file contains a Mental Residual Functional Capacity Assessment dated in September 2006 that was performed in support of the Veteran's application for SSA disability benefits. The assessment showed as follows. In the category of understanding and memory the Veteran had "marked" limitation in the ability to understand and remember detailed instruction, "moderate" limitation in the ability to remember locations and work-like procedures and no significant limitation in the ability to understand and remember very short and simple instructions. In the category of sustained concentration and persistence the Veteran had "marked" limitation in the ability to carry out detailed instructions; he had "moderate" limitation in the ability to maintain attention and concentration for extended periods, the ability to work in coordination with others without being distracted and the ability to complete a normal work schedule without interruptions from psychologically-based symptoms; there was no significant limitation in the other four areas assessed in this category. In the category of social interaction the Veteran had no "marked" impairment; he had "moderate" impairment in the ability to interact appropriately with the general public, the ability to accept instructions and respond appropriately to criticism from supervisors and the ability to maintain socially appropriate behavior; he had no significant limitation in the other two areas assessed in this category. In the category of adaptation the Veteran had no "marked" limitation; he had "moderate" limitation of the ability to respond appropriately to changes in the work setting and the ability to travel in unfamiliar places or use public transportation, and no significant impairment in the other two areas assessed in this category. In the remarks portion of the Functional Capacity Assessment the examiner stated the Veteran could comprehend and recall simple tasks with ease and could sustain focus on the execution of simple work tasks within an unpressured setting with limited co-worker interaction. The Veteran could work for a supportive, non-critical boss at a job involving infrequent and controlled contact with the public; he could occasionally distract co-workers and would do best in an isolative setting. In all, the Veteran's mental symptoms resulted in "mild" restriction in activities of daily living (ADLs) and "moderate" difficulties in maintaining social functioning and in maintaining concentration, persistence or pace. Limitation in regard to episodes of decompensation had not been shown, and no functional areas showed "marked" or "extreme" limitation. VA outpatient psychiatry notes dating from the period August 2006 through March 2007 show the Veteran continued to have problems relating to binge drinking. He had been on antidepressants for two years and had better mood as a result. He was currently attending Alcoholics Anonymous (AA) meetings, had volunteered for the National Park Service and was taking weekly boat trips. He felt supported by his family. Mental status examinations during the period generally showed the Veteran to be neat in appearance and unremarkable in speech or behavior. Thought process showed no evidence of thought disorder and thought content was devoid of current suicidal ideation (SI), homicidal ideation (HI), delusions, paranoia, hallucinations or perceptual disturbances. The Veteran did endorse feeling very nervous around people and he also reported occasional nightmares and flashbacks related to Vietnam. The Veteran's mood was generally euthymic and affect was appropriate to mood. Cognitive function was generally grossly intact and insight/judgment was good. GAF score during the period was 55. The Veteran had a VA examination in July 2007, performed by a psychologist who reviewed the claims file. In regard to current symptoms, the Veteran endorsed a recent flashback in which a rock struck the windshield of a car he was driving; the Veteran thought it was a bullet and took evasive action, nearly causing an accident. The Veteran had not worked since 2005 but currently performed 4-16 volunteer hours per week at the Cape Cod National Seashore in support of the National Park Service. The Veteran continued to attend weekly VA PTSD meetings and daily AA meetings. The Veteran endorsed subjective symptoms of flashbacks associated with noises, nightmares with sweating, irritability, indecisiveness, forgetfulness, social isolation, depression and hypervigilance. The Veteran stated he had an excessive need for structured environment and tended to have paranoia in large groups. Mental status examination in July 2007 showed the Veteran to be neatly dressed and groomed, oriented times four and without evidence of motor retardation or abnormalities. The Veteran was not withdrawn or agitated. The Veteran denied hallucinations and there was no evidence of altered level of consciousness. The Veteran's mood was euthymic and he denied suicidal or homicidal ideation. Memory was grossly normal, concentration was unimpaired and abstract thinking was intact. The Veteran reported having been sober since October 2005 and denied feelings of hopelessness or worthlessness. He stated he was obsessed with the number 24 and that he had a need to mirror actions of one hand or foot with the counterpart appendage. He endorsed irritability but denied mania. He endorsed panic attacks on a weekly basis which could last 1-3 hours, even with medication, and were associated with sweating, hyperventilation, palpitations and chest pain, sense of dread, fear of dying, and fear of losing control. The Veteran reported having a good relationship with his spouse and having 10 good friends. He denied problems with authority figures. He reported being able to sleep six hours per night with the help of medication. He characterized his energy level as "good overall" and endorsed a number of interests and hobbies. The Veteran reported no problems with task persistence in performing everyday household chores. The examiner in July 2007 diagnosed chronic PTSD, obsessive-compulsive disorder, alcohol dependence in sustained full remission, and panic disorder with agoraphobia. The examiner assigned a current GAF score of 60 and stated the Veteran was able to manage his own funds. The examiner stated the Veteran's alcohol abuse and his diagnosed anxiety disorders (obsessive compulsive disorder (OCD) and panic disorder) were secondary to PTSD and that it was impossible to separate the specific impairments caused by each individual diagnosis. The examiner stated the Veteran's PTSD symptoms had a moderately negative impact on his ability to obtain and maintain physical or sedentary employment but caused significant interference with his social functioning. A VA mental health clinic (MHC) note dated in October 2007, by a psychiatrist, documents that the Veteran was disappointed and upset at having been denied an increased rating (in excess of 30 percent) for PTSD. He reported weekly panic attacks, fear of dying in his sleep and worry about his spouse. Despite medications he continued to have residual anxiety and symptoms of reexperiencing. He complained of continued major problems with concentration and memory and stated he had been in a "funk" for the past few days. He admitted being easily startled by loud noises and susceptible to triggering if exposed to the news. Mental status examination in October 2007 showed the Veteran to be neatly dressed but with restricted affect. Speech was normal and there was no evidence of thought disorder. Mood was mildly anxious and depressed. He had a good range of affect and cognitive function was grossly intact. Insight/judgment was good. He endorsed intrusive thoughts and memories. He reported better sleep. He denied recent public panic attacks but endorsed anticipatory anxiety. He endorsed compulsivity about punctuality, difficulties in traffic and waiting in lines and intolerance and avoidance of crowds. He denied current suicidal or homicidal ideation and also denied hallucinations. The psychiatrist diagnosed chronic PTSD with residual hyperarousal and avoidance, major depression in remission, history of panic disorder and history of alcohol dependence in remission, rule out OCD. The psychiatrist assigned a current GAF score of 50. In his substantive appeal, received in October 2007, the Veteran reported a severe problem of forgetting to complete tasks and short-term memory. A VA psychiatry note in October 2007 shows the Veteran reported continued symptoms of irritability, hyperarousal, intrusive thoughts and nightmares. He had been sober for the past two years but continued to worry about reverting to alcoholism. His main symptom currently was irritability, which expressed itself in his relationship to his spouse and while driving; the Veteran had no patience and lost his temper easily. He continued to attend AA meetings and to perform volunteer service for the National Park Service. The Veteran had been on antidepressant medications for the past two years and reported improvement in mood; since starting medication he was able to resume activities he formerly enjoyed. Mental status examination showed the Veteran to be well-groomed and calm. Mood was euthymic ("I feel pretty good today") and affect was congruent with mood. Speech was unremarkable. The Veteran denied SI, HI or hallucinations. Cognition and memory were intact, and the Veteran was fully oriented. Judgment, insight and reliability were all good. The psychiatrist diagnosed chronic PTSD and substance-induced mood disorder and assigned a current GAF score of 42. Subsequent VA psychiatry notes from October 2007 through June 2008 showed some fluctuation in reported symptoms, especially irritability. Mental status examinations during the period were grossly consistent with observations in October 2007 as detailed above. On one occasion the Veteran had a GAF score of 50, but otherwise the GAF score during the period was consistently 42. The Veteran's attending VA psychologist submitted a letter in June 2008 essentially endorsing the Veteran's sincerity in applying for increased disability rating. The psychologist stated the Veteran was challenged every day by persistent and sometimes severe PTSD symptoms that affected his functioning. Through PTSD treatment and his own abilities the Veteran had learned some ways to cope with his PTSD symptoms, but it continued to be a challenge for him to manage his PTSD symptoms so that he could function well in his marriage, maintain his health and develop satisfying social experiences. The Veteran's attending VA psychiatrist submitted a letter dated in July 2008 stating that as long as the Veteran was working he had been able to avoid thinking about Vietnam-related trauma. However, he had continued disturbances of mood, irritability, nightmares and hypervigilance that caused him to take early retirement due to his difficulty establishing and maintaining effective work and social relationships; he also had trouble keeping up with changes in the workplace. The Veteran also could not keep up with complex commands at work and had recently started to experience long-term memory problems and forgetting to complete certain [unspecified] ADLs. The Veteran was unable to maintain a large group of friends because he could not tolerate crowds, although he did have pastimes and hobbies that did not involve crowds or loud noises. The Veteran continued to attend daily AA meetings and weekly PTSD counseling. The psychiatrist stated he truly believed the Veteran qualified for a higher percent of service connection [which at that time was 30 percent]. VA psychiatric outpatient treatment records in July 2008 incorporate the comments in the letter cited above. Mental status examination was grossly consistent with observations detailed previously, and GAF score was continued at 42. A VA psychologist made an entry into the file in August 2008 at the Veteran's request, regarding the Veteran's employability. The psychologist stated the Veteran had retired from teaching at 56 years of age due to his PTSD symptoms. This early retirement did not ease the Veteran's PTSD symptoms, and he continued to have symptoms such as weekly nightmares and panic attacks 1-2 times per week. He reported intrusive memories daily, triggered by sounds such as helicopters overhead. The Veteran stated he could not concentrate, and his spouse stated he would withdraw. The psychiatrist stated the Veteran's marriage was severely impacted and he had serious occupational impairment in his capacity to work. The psychologist assigned a current GAF score of 50. The Veteran testified before the Board in May 2009 that his volunteer work at the National Park should not be considered as "gainful employment" because it was essentially therapeutic for him to get away from crowds by taking visitors on canoe trips into the salt marshes, an activity he performed on a weekly basis. He attended individual and group therapy sessions and took daily medications. The Veteran testified he had diminished attention span of approximately 20 minutes ("like a little kid") and almost no short-term memory. He reported nightmares of Vietnam and hypervigilance toward people standing behind him. The Veteran avoided large gatherings but was reasonably comfortable in small groups such as his PTSD counseling sessions because the participants had all gone through similar situations. VA psychiatry notes during the period August 2008 through February 2010 show fluctuations in reported mood, episodes of irritability and nightmares, but mental status examinations were grossly consistent with previous observations. The attending psychiatrist characterized the Veteran as being well-maintained on his present regimen of psychotherapy and psychopharmacotherapy, with no acute exacerbations of his chronic mental or emotional problems. The attending psychiatrist continued GAF score of 42 during the period, although the Veteran's attending psychologist in the Substance Abuse Treatment Program (SATP) consistently assigned a GAF score of 65 during the same period. The Veteran presented for VA psychiatric outpatient therapy in March 2010 reporting improvement in his social functioning and activity level in general. He had just returned from a skiing vacation, was contemplating buying a vacation home, was considering taking flying lessons and was looking forward to taking out his newly-purchased leisure boat during the summer. The Veteran commented on a recent suicide in his neighborhood, but denied SI himself because he had so much to live for and so much to enjoy. Mental status examination was consistent with previous observations; current GAF score was 55. A VA cardiology note in April 2010 states the Veteran was currently very physically active (skiing, sailing, swimming, walking and golfing) and was also teaching courses in kayak and water safety at the National Seashore. During the period April 2010 through May 2011the Veteran reported fluctuations in mood, episodes of irritability and sleep disturbance with nightmares. However, mental status examinations were essentially consistent with previous observations and GAF score of 55 was continued through the period. Of note, these clinical observations were made by a number of different VA psychiatrists but are extremely consistent. A VA psychiatric treatment report in June 2011 states the Veteran was still struggling with traumatic nightmares and existential angst. Mental status examination showed the Veteran to have appropriate grooming and no abnormalities in speech or motor activity. Mood was "okay" with congruent affect. Though process was linear and goal-directed and though process was without reported ruminations, suicidal or homicidal ideation. There was no indication of delusions or hallucinations, and sensorium was grossly intact. Judgment and insight were both good. The psychiatrist assigned a current GAF score of 45. The file contains a report dated in August 2011 by Barbara Center, a private psychiatrist who reviewed the Veteran's psychiatric history and also interviewed the Veteran. Dr. Center discussed the Veteran's symptoms over time in detail and noted that the Veteran's alcoholism was in remission and that medication had been of some benefit in decreasing the frequency of nightmares and flashbacks, but other symptoms such as intense startle response and interpersonal difficulties secondary to irritability had not improved despite individual and couples counseling. She noted on interview that the Veteran's volunteer work at the National Park was not indicative of any ability to work full-time but rather an effort to isolate himself from the rest of society and engage only a handful of people in a secluded environment. Dr. Center stated the Veteran was suffering a severe and totally disabling PTSD with symptoms controlled to a limited extent by strict compliance with his treatment regimen, but only due to the fact he was able to isolate himself and avoid the stress of full-time employment. She stated the Veteran's PTSD was clearly manifested by occupational and social impairment with deficiencies in most areas including work, family relations, judgment, thinking and mood and that he had been totally disabled since 2005. She diagnosed chronic PTSD, panic disorder with agoraphobia (secondary) and alcohol dependence in full sustained remission, and assigned a current GAF score of 25. A VA PTSD clinic group counseling note in August 2011 states the Veteran returned from a three-week family vacation in Yellowstone Park reporting having had a "fabulous time." However, a VA psychiatric treatment report in September 2011 states the Veteran continued to have marital problems. Mental status examination was consistent with observations in June 2011, and the psychiatrist again assigned a current GAF score of 45. The Veteran had a VA psychiatric examination in November 2011, performed by a VA neuropsychiatrist who reviewed the claims file and confirmed present diagnosis of PTSD. The examiner also recorded Axis I diagnoses of depressed mood not otherwise specified, panic attacks and alcohol dependence in full sustained remission (the Veteran reported having been sober since 2005). The examiner noted that review of the file showed previous diagnosis of bipolar disorder, apparently made while the Veteran was actively drinking, but stated that such diagnosis could not be currently rendered. The Veteran reported PTSD symptoms of intrusive recollections once per week, nightmares 2-3 times per week, nervousness to certain sounds and smells, physical symptoms of anxiety (sweating and racing heart), flashbacks (described by the examiner as intrusive thoughts rather than true flashbacks), avoidance of others and emotional distancing from friends and family. He described difficulty falling or staying asleep, irritability including "road rage," hypervigilance, hyperstartle and difficulty concentrating. The Veteran stated he would like to return to work but does not consider himself able to do so. The Veteran reported depressive symptoms of fluctuation of appetite and occasional thoughts of death, but denied actual suicide ideation. The Veteran also endorsed survivor guilt related to decision he had made in Vietnam. The Veteran reported such attacks approximately once per week, lasting one hour each and accompanied by chest pain, occasional stomach distress, fear of dying, feeling of unreality, numbness, fear of losing control and fear of "going crazy." The Veteran reported he would sometimes yell or punch the wall during these attacks. Panic attacks could be prompted by Vietnam triggers, interpersonal disagreements or simply occur spontaneously. The examiner noted the symptoms that were, and were not, represented by the Veteran's diagnoses. The examiner stated the Veteran had demonstrated depressed mood; anxiety; panic attacks weekly or less often; and, chronic sleep impairment, all of which are symptoms associated with a 30 percent schedular rating. The Veteran had also demonstrated disturbances of motivation and mood, which is a symptom associated with the currently-assigned 50 percent rating; and, suicidal ideation, a symptoms associated with the 70 percent rating. The Veteran had not demonstrated any of the other symptoms associated with the 70 percent rating and had demonstrated none of the symptoms associated with the 100 percent rating. The examiner stated that most of the Veteran's depressive symptoms appeared to be driven by his PTSD, and stated that the Veteran's PTSD symptoms caused clinically significant distress or impairment in social, occupational or other important areas of functioning. However, the examiner stated an opinion that the Veteran's level of social and occupational impairment was best characterized as occupational and social impairment due to mild or transient symptoms that decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication (i.e., the schedular criteria for a 10 percent disability rating). The examiner stated the Veteran's PTSD had contributed to his subjective sense of poor concentration and lack of ambition, to which he attributed his choice to remain in retirement rather than return to his teaching career. The examiner stated the Veteran was capable of managing his own financial affairs, and assigned a current GAF score of 60, representing a mild degree of impairment in marital and occupational functioning. The examiner also indicated mild interference with career preferences in that the Veteran wanted to return to teaching but felt he could not due to a combination of his emotional and physical difficulties. The VA examiner who performed the examination in November 2011 issued an addendum opinion in December 2011 addressing employability. The examiner stated that the Veteran was currently retired, which made it difficult to ascertain the degree to which his symptoms undermined his ability to function in the setting of paid employment. However, it was notable that the Veteran was able to maintain full and gainful employment for 32 years until his retirement in June 2005. Per results of his most recent compensation and pension examination, his symptoms were no worse in severity than they were when the Veteran was gainfully employed. This suggests that on the basis of PTSD symptoms alone the Veteran continues to maintain the capacity to secure and maintain gainful employment, whether physical or sedentary, although his PTSD symptoms put him at risk for decreased efficiency in the workplace. It is also notable that the Veteran had reported having significant medical problems that may have undermined his ability to work, but the examiner was unable to formally assess that question since it was out of his scope of practice. VA psychiatric treatment notes during the period November 2011 to May 2012 generally show the Veteran to have been sober and attending PTSD counseling regularly. His psychological stressors were chiefly existential and related to issues of guilt, mortality, loneliness and control. His interests included sailing, canoeing, kayaking, reading, downhill skiing and golfing. Mental status examination generally showed him to be appropriately groomed and dressed. Motor activity generally showed no abnormalities and speech was generally normal in rate, tone, volume and cadence. Mood/affect was generally "okay" and superficially congruent with some underlying tension. Thought process was generally linear and goal-oriented and thought content was generally topical and future-oriented. The Veteran voiced no SI/HI or assaultive intent during the period. There was no indication during the period of delusions, hallucinations or ideas of reference. Sensorium was grossly intact during the period and judgment/insight was good. GAF score during the period was 45. Of note, in addition to the previously-diagnosed PTSD and depression the attending psychiatrist added a diagnosis of obsessive-compulsive disorder (touching, counting). The Veteran had a VA audiological evaluation in May 2012 in which the audiologist noted the Veteran had asserted unemployability due to tinnitus because the disorder kept him awake and night and was associated with nightmares. The audiologist stated that severe tinnitus is rare and would usually be accompanied by other symptoms such as insomnia, depression, anxiety, hopelessness, cognitive distortions and sometimes suicidal ideation. The audiologist stated such considerations were outside the scope of her practice and deferred to a mental health professional. The Veteran also had a VA general medical examination in May 2012. As a result of this examination, the RO issued a rating decision in June 2012 that increased the disability rating for service-connected coronary artery disease (CAD) to 60 percent effective from August 3, 2011, and also granted a TDIU effective from that date. The same rating decision continued the current 50 percent rate for PTSD. A VA psychiatric treatment note in January 2013 shows mental status examination and observations consistent with previous recent notes described above. GAF score continued at 45. Dr. Barbara Center, who had submitted an earlier letter in August 2011, submitted a follow-up letter in March 2013. She stated that she continued her previous opinion that the Veteran had been totally disabled by his PTSD since he stopped working in 2005. Dr. Center observed that the clinically-assigned GAF score of 45 appeared to be consistent with the Veteran's degree of impairment and represented serious symptoms such as suicidal ideation, anxiety and extreme isolation. The GAF score was also representative of serious impairment of functioning including inability to work and lack of friend relationships outside his treatment. The VA evaluator's assignment of GAF score of 60 in November 2011 was not consistent with her own evaluation of the Veteran's symptoms or the opinions of the Veteran's clinical providers. It was clear that the Veteran could not function in an employment situation and that his symptoms would rapidly worsen and prevent him from sustaining any employment if he were to attempt to return to work. The Veteran's PTSD had clearly been manifested by occupational and social impairment with deficiencies in all areas including work, family relations, judgment, thinking and mood. In summary, the Veteran suffered from severe, chronic and totally disabling PTSD that left him totally disabled since 2005. Dr. Center diagnosed chronic PTSD, depressive disorder NOS (secondary), panic disorder with agoraphobia (secondary), and alcohol dependence in full remission. Dr. Center assigned a current GAF score of 45. Analysis The Board finds on review of the evidence above that the Veteran's service-connected psychiatric disorder most closely approximates the criteria for the currently-assigned 50 percent rating. In that regard, the Veteran has demonstrated only two of the symptoms associated with the higher 70 percent rating; i.e., suicidal ideation and difficulty in adapting to stressful circumstances including work or a worklike setting. All the other symptoms cited for the higher rating (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; and, inability to establish and maintain effective relationships) are disproved by the record. Id. The examinations of record reflect significant disagreement in regard to the level of the Veteran's disability. The VA examiners in July 2007 and November 2011, and the SSA examiner in September 2006, essentially found the Veteran's impairment to be just mild-to-moderate; in contrast, Dr. Center reported in August 2011 and again in March 2013 that in her opinion the Veteran was totally disabled by PTSD throughout the period under review. It is the Board's duty to assess the credibility and probative value of evidence, and, provided that it offers an adequate statement of reasons or bases, the Board may favor one medical opinion over another. Owens v. Brown, 7 Vet. App. 429, 433 (1995). As true with any piece of evidence, the credibility and weight to be assigned to these opinions are within the province of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). The Board finds at the outset that the VA examiners cited, as well as Dr. Center, were fully informed of the factual premises and provided opinions supported by clinical rationale. However, ratings for a mental disability must be based on all the evidence of record that bears on social and occupational impairment rather than solely on an examiner's assessment of the disability at the moment of examination. 38 C.F.R. § 4.126(a). Accordingly, in resolving the conflicting opinions of Dr. Center versus the other examiners cited above, the Board places great probative value on the VA clinical psychiatric treatment records, which demonstrate the Veteran's subjective and objective symptoms over time as recorded by a number of different psychiatrists and psychologists. The Board acknowledges the opinion of Dr. Center that the Veteran's disability picture has approximated deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood, but finds Dr. Center's opinion to be less probative than the VA clinical notes, and especially the mental status examinations therein. These clinical records clearly demonstrate that the Veteran has had a supportive family relationship and has had intact judgment and thinking (thought process and thought content). Disturbance of mood has been intermittently noted, but "disturbances of motivation and mood" are symptoms associated with the currently-assigned 50 percent rating; the mental status examinations of record do not demonstrate mood impairment of such severity as to approximate the higher disability picture. The mental status examinations affirmatively demonstrate that the Veteran remained essentially alert and oriented throughout the period and without impairment of speech, judgment or insight. Although the Veteran has complained of impairment in concentration and memory, these functions were largely intact in mental status examinations. While Dr. Center cites family discord and social isolation, clinical records show the Veteran had a supportive family life and enjoyed a number of outdoor activities. In that regard, "difficulty establishing and maintaining effective work and social relationships" is a characteristic of the currently-assigned 50 percent rating; inability to establish and maintain effective relationships, as characteristic of the 70 percent evaluation, is not shown. The Veteran has reported anger/irritability with episodes of "road rage" but there is no indication that his anger actually resulted in verbally or physically assaultive behavior toward another person; thus, his anger/irritability does not equate to "unprovoked irritability with periods of violence" as characteristic of the 70 percent evaluation. In sum, given the degree of functional ability that is consistently demonstrated by the VA psychiatric treatment notes, the Board finds the Veteran's disability does not more nearly approximate a 70 percent rating. Indeed, the Veteran's reported activities, to include volunteering by taking small groups of people on canoe trips into the salt marshes on a weekly basis, teaching courses in kayak and water safety, and taking a skiing trip and a three week family vacation, do not reflect a disability picture of someone with deficiencies in most areas such as such as work, school, family relations, judgment, thinking, or mood. In considering the severity of the Veteran's symptoms during the period under review the Board has also considered the GAF scores that were assigned. The GAF score reflects the clinician's judgment of the individual's overall level of functioning, with 100 representing a high level of functioning and no psychiatric symptoms. Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM IV), page 32. While the GAF score is not the sole basis for assigning a disability rating, it provides a clinical indicator of the patient's functional ability. There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). Like the opinions expressed in the examinations during the period, the GAF scores assigned during the period have fluctuated significantly. The VA examiners in July 2007 and November 2011 both assigned a GAF score of 60, which represents the highest values of record. Dr. Center assigned a GAF score of 25 in August 2011, which represents the lowest value. GAF scores assigned during VA outpatient psychiatric treatment had a narrower range: 55 during the period August 2006-March 2007; 42 during the period October 2007-February 2010; 55 during the period March 2010-July 2011; and, 45 since then. The Board finds at this time that the isolated high GAF scores of 60 and low GAF score of 25 are not representative of the Veteran's symptoms as demonstrated in numerous mental status examinations, to include the very examinations in which those GAF scores were assigned. Indeed, a GAF score of 21 to 30 indicates that behavior is considerably influenced by delusions or hallucinations, or serious impairment in communication or judgment (e.g., sometimes incoherent, acting grossly inappropriately, suicidal preoccupation), or an inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM IV), page 32. However, there is no indication of delusions, hallucinations, or serious impairment in communication or judgment. Moreover, his various vacations and volunteer work with small groups of the public belies a finding that he has an inability to function in almost all areas. Accordingly, the Board finds that the GAF scores of 25 and 60 have a lower probative value, and that the GAF score range of 42-55 more accurately portrays the Veteran's functional capacity. GAF scores of 51-60 represent moderate symptoms or moderate difficulty with social, occupational or school functioning, while scores of 41-50 represent serious symptoms or any serious impairment in social, occupational or school functioning. See DSM-IV. While GAF scores of 41-50 are arguably supportive of a 70 percent rating, the contemporaneous mental status examinations did not reflect a dramatic change in the Veteran's underlying symptoms. Thus, the GAF scores alone do not demonstrate a disability picture approximating the criteria for a 70 percent rating. 38 C.F.R. § 4.126(a). The Board has found no discrete time period during the period under review in which the criteria for evaluation higher than 50 percent were met. Accordingly, "staged" initial rating is not warranted. Fenderson, 12 Vet. App. 119. VA must consider all favorable lay evidence of record. 38 USCA § 5107(b); Caluza v. Brown, 7 Vet. App. 498 (1995). Accordingly, in addition to the medical evidence cited above the Board has carefully considered the lay evidence provided by the Veteran in the form of his testimony before the Board, his correspondence to VA and his statements to various medical providers and examiners. The Board must consider the purpose for which lay evidence is offered. Washington v. Nicholson, 19 Vet. App. 362 (2005). In this case, the Veteran's lay evidence is offered to show the severity of his symptoms; a layperson is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995). However, even affording the Veteran with full competence and credibility in reporting his symptoms (nightmares, sleep disturbance, anger/irritability, etc.), his reported symptoms do not approximate the schedular criteria for a rating higher than 50 percent. The Board has relied heavily on VA psychiatric treatment notes, which duly considered the Veteran's subjective symptoms and accepted those symptoms as credible but nonetheless recorded mental status examinations showing only a relatively moderate limitation of function. Accordingly, the Veteran's lay evidence does not support a rating higher than 50 percent. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board finds that the rating criteria for PTSD contemplate the Veteran's disability on appeal. The focus in evaluating psychiatric disabilities is the overall impact a veteran's specific psychiatric symptoms have upon his level of occupational and social functioning, not just on symptoms listed in the rating criteria. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). For the reasons stated above, the Board has concluded that the Veteran's level of such occupational and social impairment is adequately reflected by the current schedular rating. As such, the Board finds that the manifestations of the Veteran's PTSD are contemplated in the rating criteria. There is no indication of any exceptional or unusual disability picture. The rating criteria are therefore adequate to evaluate the Veteran's service-connected PTSD and referral for consideration of extraschedular rating is not warranted. A request for a total disability rating based on individual unemployability (TDIU), whether expressly raised by a claimant or reasonably raised by the record, is an attempt to obtain an appropriate rating for disability or disabilities, and is part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009); see also Roberson v. Principi, 251 F. 3d 1378, 1384 (Fed. Cir. 2001) (holding that once a veteran submits evidence of a medical disability and makes a claim for the highest rating possible, and additionally submits evidence of unemployability, the 'identify the benefit sought' requirement of 38 C.F.R. § 3.155(a) is met and the VA must consider TDIU). A rating decision in June 2012 granted TDIU effective from August 3, 2011, the date the Veteran's service-connected CAD was increased to 60 percent (resulting in combined evaluation of 80 percent). However, during the course of the appeal, the Veteran's PTSD has been evaluated as 50 percent disabling and does not meet the criteria for TDIU under 38 C.F.R. § 4.16(a). It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated as totally disabled. Therefore, rating boards should submit to the Director, Compensation and Pension Services, for extra-schedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). See 38 C.F.R. § 4.16(b). The effect of a service-connected disability appears to be measured differently for purposes of extraschedular evaluation under 38 CFR § 3.321(b)(1), as discussed above, and for purposes of a TDIU claim under 38 CFR § 4.16. Kellar v. Brown, 6 Vet. App. 157, 162 (1994). As noted above, the Board must address referral under 38 CFR § 3.321(b)(1) only in cases where the issue is expressly raised by the claimant, or the record before the Board contains evidence of "exceptional or unusual circumstances" indicating the rating schedule may be inadequate to compensate for average impairment of earning capacity due to the disability. In contrast, 38 C.F.R. § 4.16 does not require a finding that the schedular ratings are inadequate to compensate for the average impairments in earning capacity caused by particular disabilities, but requires only a finding that the service-connected disabilities render a particular veteran unemployable. See VAOPGCPREC 6-96 (August 16, 1996). The medical opinions regarding unemployability are contradictory. Dr. Center has stated a medical opinion that the Veteran was unemployable from the date of his retirement in 2005. However, this opinion is contradicted by the September 2006 SSA Mental Residual Functional Capacity Assessment (stating the Veteran was currently able to work for a supportive, non-critical boss at a job involving infrequent and controlled contact with the public) and the VA examiners in July 2007 (finding only "moderately negative impact the ability to obtain and maintain physical or sedentary employment") and November 2011 (finding only "mild interference with career preferences"). The VA psychiatric treatment notes during the period are silent in regard to employability, presumably because the Veteran had been unemployed/retired since 2005, but the mental status examinations do not record functional impairment indicative of unemployability. While the Veteran has emphasized that his volunteer work is unpaid, and Dr. Center has addressed the Veteran's ability to return to full time work, the question is whether the Veteran is capable of performing acts required by employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The opinions on the September 2006 SSA report, July 2007 VA examination and November 2011 VA examination, are consistent with the facts of the record suggesting the Veteran is able to interact with the public in small groups and to teach courses in water safety and kayaking, both of which are consistent with paid employment, even though his may be volunteer rather than paid. In other words, such activities indicate he is able to perform the actions required of similar kinds of employment. Thus, referral for consideration of entitlement to a TDIU due to PTSD on an extraschedular basis pursuant to 38 C.F.R. § 4.16(b) is not warranted. Based on the evidence and analysis above, the Board finds the criteria for an initial rating higher than 50 percent for PTSD are not met. Accordingly, the claim must be denied. Because the preponderance of the evidence is against the claim the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54. ORDER An initial rating higher than 50 percent for PTSD is denied. ____________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs