Citation Nr: 1327630 Decision Date: 08/28/13 Archive Date: 09/05/13 DOCKET NO. 08-34 620 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUE Entitlement to an initial rating in excess of 70 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs ATTORNEY FOR THE BOARD R. Dodd, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1966 to June 1968. This appeal comes before the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs' (VA) Regional Office (RO) in Portland, Oregon. The Board notes that a request for a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is part and parcel of a claim for an initial rating for a disability. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009); Mayhue v. Shinseki, 24 Vet. App. 273, 281-82 (2011). In this case, the Veteran was awarded entitlement to TDIU effective February 24, 2005. Subsequent to this date and given the disposition reached below on October 1, 2005, further discussion of this issue is not warranted. In March 2010 and October 2011, the Board remanded the matter for additional development, including obtaining current VA examination findings, additional treatment reports and the Veteran's Social Security Administration (SSA) reports. That development having been completed, the mandates of the remand were substantially complied with. For these reasons and additional reasons discussed below, the appeal is now ripe for adjudication. A review of the Virtual VA paperless claims processing system does not reveal additional evidence or information pertinent to the present appeal. FINDINGS OF FACT 1. From December 28, 1993 to February 26, 2004, the Veteran's service-connected PTSD was manifested by considerable impairment in the ability to establish or maintain effective or favorable relationships as well as considerable industrial impairment due to reduced reliability, flexibility, and efficiency. Alternatively, under the new rating criteria, his disability was manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as chronic sleep disturbance, nightmares, anxiety, depression, decreased concentration, anger problems, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships, including social conflicts due to anxiety and irritability at work. 2. From February 27, 2004 to September 30, 2005, the Veteran's service-connected PTSD was manifested by no more than occupational and social impairment with deficiencies in most areas due to such symptoms as chronic sleep disturbance, suicidal ideation, nightmares, anxiety, depression affecting the ability to function independently, appropriately and effectively, decreased concentration, anger problems, disturbances of motivation and mood, impaired impulse control, anger, irritability, difficulty in adapting to stressful circumstances (including work or a work-like setting), an inability to establish and maintain effective relationships. 3. From October 1, 2005, the Veteran's service-connected PTSD was manifested by total occupational and social impairment, due to such symptoms as depressed mood, anxiety, sleep disturbance, nightmares, anger, irritability, social isolation, and suicidal ideations, with an inability to maintain gainful employment and an inability to establish and maintain effective relationships. CONCLUSIONS OF LAW 1. From December 28, 1993 to February 26, 2004, the criteria for an initial evaluation in excess of 50 percent for service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.130, Diagnostic Code 9411 (1996 & 2012). 2. From February 27, 2004 to September 30, 2005, the criteria for an evaluation in excess of 70 percent for service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.130, Diagnostic Code 9411 (1996 & 2012). 3. Effective October 1, 2005, the criteria for a 100 percent rating for service-connected PTSD have been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA Under the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002). This notice must be provided prior to an initial RO decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). VCAA notice requirements apply to all five elements of a service connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). Defective timing or content of VCAA notice is not prejudicial to a claimant if the error does not affect the essential fairness of the adjudication, such as where (1) the claimant demonstrates actual knowledge of the content of the required notice; (2) a reasonable person could be expected to understand from the notice what was needed; or (3) a benefit could not have been awarded as a matter of law. Sanders v. Nicholson, 487 F.3d 881, 889 (Fed. Cir. 2007), rev'd on other grounds, Shinseki v. Sanders/Simmons, 556 U.S. 369 (2009). Defective timing may be cured by a fully compliant notice letter followed by a readjudication of the claim. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). But "[i]n cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated-it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled." Dingess/Hartman, 19 Vet. App. at 490; Dunlap v. Nicholson, 21 Vet. App. 112, 116-17 (2007) (noting that once an initial VA decision awarding service connection and assigning a disability evaluation and effective date has been made, section 5103(a) notice is no longer required). Additionally, where service connection has been granted, the claimant bears the burden of demonstrating prejudice from defective notice with respect to downstream elements such as effective dates or disability ratings. Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). The Veteran has made no such assertions here. Accordingly, the Board finds that VA's duty to notify has been satisfied. The Board also finds that VA's duty to assist the Veteran has been satisfied. 38 U.S.C.A. § 5103A(b), (c); 38 C.F.R. § 3.159(c)(1)-(3). The Veteran's service treatment records and VA outpatient treatment records have been obtained and associated with the claims file. The duty to assist also includes making as many requests as are necessary to obtain relevant records from a Federal department or agency, including, but not limited to, VA medical records and relevant Social Security Administration (SSA) records. 38 C.F.R. § 3.159(c)(2); Golz v. Shinseki, 590 F.3d 1317, 1321-23 (Fed. Cir. 2010). The Veteran's SSA records have been obtained and associated with the claims file. VA provided the Veteran with examinations in April 1994, October 2005, and October 2010, as well as a Social and Industrial Survey in April 1994. The Board concludes that these examinations were adequate because they contained a history obtained from the Veteran and thorough examinations relevant to the applicable rating criteria. They also addressed the functional effects caused by the Veteran's disability, including its effects on his occupation. There is no indication in the record that additional evidence is available which is relevant to the currently appealed claim. See Pelegrini, 18 Vet. App. at 121-22. Legal Criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2012). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). In resolving this factual issue, only the specific factors as enumerated in the applicable rating criteria may be considered. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41(2012). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). As noted, the Veteran disagreed with the evaluation assigned in connection with the original grant of service connection. Accordingly, the possibility of the assignment of separate, or "staged" ratings for separate periods of time, based on the facts found, must be considered. Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's service-connected PTSD for the period of December 28, 1993 to February 26, 2004 is rated as 50 percent disabling. 38 C.F.R. § 4.130, DC 9411. The Veteran's service-connected PTSD for the period of February 27, 2004 to present is rated as 70 percent disabling. Id. The Board notes that, during the pendency of the Veteran's appeal, the rating schedule criteria for determining the disability evaluations to be assigned for PTSD was changed effective November 7, 1996. Where a law or regulation changes during the pendency of a claim for increased rating, the Board should first determine whether application of the revised version would produce retroactive results. In particular, a new rule may not extinguish any rights or benefits the Veteran had prior to enactment of the new rule. See VAOPGCPREC 7-2003 (Nov. 19, 2003). However, if the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C.A. § 5110(g), can be no earlier than the effective date of that change. VA can apply only the earlier version of the regulation for the period prior to the effective date of the change. Prior to the amendments effective November 7, 1996, 38 C.F.R. § 4.132, Diagnostic Code 9411, pertaining to posttraumatic stress neurosis, provided that an evaluation of 50 percent is granted if the ability to establish or maintain effective or favorable relationships with people is considerably impaired. By reason of psychoneurotic symptoms the reliability, flexibility, and efficiency levels are so reduced as to result in considerable industrial impairment. Id. An evaluation of 70 percent is assigned whenever there is evidence of severe inability to establish and maintain effective or favorable relationships with people. Id. The psychoneurotic symptoms are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. Id. An evaluation of 100 percent is assigned if the attitudes of all contacts except the most intimate are so adversely affected as to result in virtual isolation in the community. Id. Totally incapacitating psychoneurotic symptoms such as fantasy, confusion, panic, and explosions of aggressive energy with disturbed thought or behavioral processes border on gross repudiation of reality resulting in profound retreat from mature behavior. Id. An evaluation of 100 percent is also assigned for inability to secure or follow a substantially gainful occupation. Id. Effective November 7, 1996, 38 C.F.R. § 4.130 , Diagnostic Code 9411, pertaining to posttraumatic stress disorder, provided that an evaluation of 50 percent is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect, circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week, difficulty in understanding complex commands, impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks), impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation, obsessional rituals which interfere with routine activities, speech intermittently illogical, obscure, or irrelevant, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, impaired impulse control (such as unprovoked irritability with periods of violence), spatial disorientation, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances (including work or a work like setting), and an inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. Id. The symptoms cited above for the 50 percent, 70 percent, and 100 percent ratings follow the phrase "such symptoms as" which indicates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Accordingly, the Board is not required to find the presence of all, most, or even some, of the enumerated symptoms for any particular rating. The list of symptoms merely provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. The Board must consider all symptoms of the veteran's condition which affect the level of occupational and social impairment. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436, 441-443 (2002). 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 occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). More recently, in Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013), the Federal Circuit held that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. In the context of a 70 percent rating, § 4.130 contemplates initial assessment of the symptoms displayed by the veteran, and if they are of the kind enumerated in the regulation, an assessment of whether those symptoms result in occupational and social impairment with deficiencies in most areas. The Global Assessment of Function (GAF) is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." American Psychiatric Association: DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM), 32 (4th ed.) (1994) (DSM IV); 38 C.F.R. §§ 4.125, 4.130 (2012). GAF scores between 71 to 80 are indicative that, if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more that slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in school work). Id. Scores ranging between 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Id. Scores ranging from 51 to 60 reflect 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). Id. Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Id. A GAF score of between 31 and 40 contemplates some impairment in reality testing or communication (e.g., speech 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). Id. GAF scores and interpretations of the scores are important considerations in rating a psychiatric disability, but they are not dispositive. Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3 (2012). Factual Background The Veteran asserts that the severity of his PTSD is worse than the current ratings. In a statement in December 1993, the Veteran complained of symptoms to include mood swings, paranoid feelings, nightmares, flashbacks, and withdrawal from people. In a November 1997 statement, the Veteran complained of symptoms to include depression, flashbacks, nightmares, bad dreams, sleep disorder, and anger problems. He further stated that he had to stay away from people and that he could only work part-time due to his condition. The Veteran has been unable to maintain steady employment since leaving the service. A review of the Veteran's VA outpatient treatment records reveals that he has been treated for his PTSD since June 1991. In a November 1993 treatment note, the Veteran reported feeling emotional, hyper, and restless at times. He also reported problems with drug use, in which he almost died, and sleep problems. In an additional November 1993 note, it was reported that the Veteran was taking medication, but was not yet feeling the effects. Further, it was noted that he was tearful when talking about Vietnam. In December 1993, the Veteran reported continued sleep disturbance, although he reported no emotional upheavals in two weeks. In January 1994, it was noted that the Veteran had been diagnosed with depression and reported having trouble sleeping on occasion, but that his mood had stabilized. In February 1994, it was reported that the Veteran was feeling better and sleeping better. In March 1994, it was reported that the Veteran's depression had lifted, but that he was to continue his medication. In April 1994 it was noted that the Veteran's condition was stable and that he was continuing to take medication. A Social and Industrial Survey was conducted in April 1994. It was noted that the Veteran has an unusually large amount of survivor's guilt. He has had trouble with sleep, but medication was helping to alleviate symptoms as well as lessening frequency and severity of nightmares. Medication was also noted as helping with flashbacks, which were typically brought on by stress. The Veteran reported difficulty handling stress since Vietnam. He harbors feelings of anger and is afraid of losing his temper and hurting someone. The Veteran had previously abused illegal substances, but had not used anything other than marijuana in the past four and a half years. The Veteran had numerous previous part-time jobs, but was currently in school and doing well. His marriage was reported as stable and that his wife supported him. The Veteran reported having acquaintances, but very few friends, due to difficulties with trust. He considered himself a loner and could only be in public for limited amounts of time. The examiner found that, although medication appears to have helped with the Veteran's sleep, nightmares, and flashbacks, it has not helped with his depression and he still has a great deal of difficulty in social situations. The examiner further determined that, if the Veteran were given the right type of job or solitary employment, he could hold a steady job. It was further noted that he had stability in his family. On VA examination in April 1994, the Veteran reported an instance in which he almost died taking mushrooms approximately four years earlier, but that it was not a suicide attempt. He also stated that he continued to lack motivation, trouble falling and staying asleep, dreams, night sweats, and a varying appetite with weight fluctuations. The examiner noted that the Veteran's speech was matter-of-fact. The examiner diagnosed substance abuse, now in remission, and PTSD, chronic and improving moderately. His GAF score was 60. In a December 1999 VA outpatient treatment note it was indicated that the Veteran had been treated for an anxiety state that was well-controlled. In a March 2004 treatment note, it was indicated that the Veteran had been treated for prolonged PTSD and anxiety state. In May 2004, the Veteran initiated new treatment for his PTSD. The Veteran reported symptoms of irritability, anger, nightmares, feelings of isolation, and mood swings, to include depression. The examiner noted exaggerated startle response, avoidance behaviors, paranoid ideation, and some thoughts of suicide. The Veteran was diagnosed with severe PTSD with anxiety and depression. The Veteran was given a GAF score of 45. In May 2004, the Veteran's spouse submitted a lay statement discussing her husband's PTSD. She stated that he changed after returning from service in Vietnam and that he has never been able to hold onto a steady job. She further stated that she has observed his problems with depression and a "rollercoaster" of emotions. It was also stated that the Veteran has problems relating to others and that he spends most of his time in a state of anger and frustration. The Veteran has experimented with and abused drugs. The PTSD also affected the Veteran's relationship with his children. As a result, the Veteran's spouse had to be the financial and emotional center for the family. In June 2004, the Veteran complained of sleep trouble and was found to have no pathology in thought, mood, or cognition. In August 2004, the Veteran continued to complain of sleep disturbance, as well as low frustration tolerance, increased irritability, depressed mood, okay self-esteem, poor concentration, racing thoughts, and anxiety. He was assessed with a mood disorder not otherwise specified, PTSD, and cannabis abuse. Medication and therapy were continued. In October 2004, the Veteran was reported as doing well on his medication. In November 2004, the Veteran was seen for a psychotherapy appointment and appeared very anxious and agitated. He was assessed with a generalized anxiety disorder and PTSD. The examiner continued medication and therapy. In December 2004, the Veteran reported no difficulties or side-effects with the medications. In February 2005, it was noted that the Veteran reported to the Mental Health Clinic due to being upset after an argument with co-workers. In March 2005, the Veteran presented as being agitated at his work supervisor and increased anxiety. Sleep continued to be fair. He was assessed with PTSD and generalized anxiety disorder and prescribed new medication. In June 2005, the Veteran reported quitting his old job and starting a new one. It was noted that there was no depressed mood and that the Veteran's condition had improved. He was continued on medication. In an August 2005 notice of disagreement, the Veteran complained of symptoms of anxiety, depression, hyper vigilance, increased startle reaction, social isolation, low tolerance for stress, difficulty sleeping, nightmares, night sweats, substance abuse, gastrointestinal conditions, hypertension, and chest pains. The Veteran was administered another VA examination on October 1, 2005. At this examination, the Veteran evidenced great difficulty in articulating his concerns to others due to the extent of his PTSD and depression. There was some circumscribed evidence of memory impairment and other gross indicators of decompensation. The summary of psychological functioning was described as impaired. The Veteran was diagnosed with PTSD and bipolar disorder type II. He was given a GAF score of 42. The examiner opined that the Veteran was unemployable based upon the severity and chronicity of his PTSD. His bipolar disorder type II was also most likely cause by or a result of military combat trauma. The Veteran has had significant changes in psychosocial functional status and quality of life. Performance in employment has been compromised. Routine responsibilities of self care have also been compromised. Family role functioning has been adversely affected as evidenced by difficulty with interpersonal relationships. The Veteran was reported as having limited social/interpersonal relationships, affected by PTSD symptoms. The Veteran's SSA records were obtained. These records revealed that, in March 2007, the Veteran was complaining of nightmares, sexual dysfunction, having to recheck money, problems with memory and concentration, anxiety attacks, and being easily irritated. He also reported that he only socializes with his wife and that his pets are his only friends. The Veteran suffers from anxiety and depression and has had to quit numerous jobs. The Veteran was granted SSA disability based upon peripheral neuropathy and diabetes. The Veteran's work history includes college attendance from January 1993 to June 1996, fast-food worker for Carls Jr. from July 1996 to November 1996, fast-food worker for Taco Time from November 1996 to May 1997, fast-food worker for Burger King from June 1997 to July 1997, newspaper delivery for News Review from August 1997 to June 2005, and food service at the VA Medical Center from October 2003 to February 2005. In an August 2009 VA outpatient treatment note, the Veteran demonstrated a restricted affect and endorsed anxiety and depression. It was noted that the Veteran occasionally thinks about suicide. Medication and treatment were recommended. A March 2010 treatment note showed that the Veteran was having increased problems with dysphoria, hypersomnia by choice to avoid people, relationship difficulties, periods of paranoia, mood swings every few weeks, anxiety, pain, hyper vigilance, and hyperarousal mitigated by forty years of cannabis use. The Veteran reported suicidal thoughts. His mood and affect were found to be blunted/restricted/constricted, anxious, and dysphoric. He had limited insight. The Veteran was diagnosed with chronic PTSD, depressive disorder not otherwise specified, and addictive disorder. His GAF score was 40. The examiner continued to prescribe medication to treat. In May 2010, the Veteran reported depression and a fluctuating mood. He appeared unkempt, with wild hair. His affect was blunted. The Veteran was assessed with PTSD, depressive disorder not otherwise specified, and cannabis dependence. The examiner increased the Veteran's medications. In August 2010, the Veteran reported no difficulties or side-effects with his medications. The Veteran was administered an additional VA examination in October 2010. At this examination, the Veteran appeared disheveled. He displayed anxiety and a tearful affect. He did not initiate or respond to humor. The Veteran did report suicidal thoughts since Vietnam that come and go. The Veteran lives with his wife, his grandson, and his granddaughter. He has arguments with his wife, but gets along well with his grandson. The Veteran does not like to leave his property or be around large crowds. He does not report having any friends. He has not worked since 2005. The examiner noted that the Veteran does not seem employable as he has a high degree of anxiety that can turn into anger and aggression towards others. Sedentary employment would be difficult because the Veteran's PTSD presents problems with concentration. The Veteran is a light sleeper and reports awakening from Vietnam-related nightmares as well as night sweats. He has at least two nightmares per week and night sweats at least two to three times per week. The examiner found that the Veteran still meets the criteria for PTSD and that his symptoms have gotten worse over the past six years. The examiner concluded that the Veteran isolates, has poor interpersonal relationships, and experiences depression secondary to PTSD. This condition renders the Veteran unable to secure or maintain substantially gainful employment. He was given a GAF score of 41. Analysis December 28, 1993 to February 26, 2004 The Board finds that the evidence does not support granting an initial evaluation in excess of 50 percent for the Veteran's PTSD for the time period from December 28, 1993 to February 26, 2004. In order to warrant the next higher 70 percent rating, the evidence must show that he has occupational and social impairment with deficiencies in most areas or total occupational and social impairment. Further, during the time period from December 28, 1993 to November 7, 1996, the date the rating criteria changed, consideration was given as to whether the old criteria may provide a more favorable evaluation, which, for a 70 percent evaluation, would require evidence of severe inability to establish and maintain effective or favorable relationships with people, as well as psychoneurotic symptoms that are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. The record of evidence during this time period reflects the Veteran's overall symptoms, to include chronic sleep disturbance, nightmares, anxiety, depression, decreased concentration, anger problems, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships, including social conflicts due to anxiety and irritability at work. The record also shows the only recorded GAF score in April 1994 as 60. During this time period, the medical evidence of record appears to indicate that the Veteran's symptoms were well-controlled, as he was taking medication, and some records, such as from December 1993 to April 1994, indicated that his symptoms of sleep disturbance and depression were actually improving. Although both he and his spouse provided statements that he was unable to work anything other than part-time jobs for short periods, as also evidenced in his SSA records, the Board notes that the Veteran was still actively engaged in both school and work during this time period. Further, in the 1994 Social and Industrial Survey, the Veteran reported doing well in school and also reported having acquaintances and a few friends. Further, the Veteran's marriage was found to be stable. Overall, his condition was determined to be moderately improving in his 1994 VA examination and in a 1999 VA treatment record, his anxiety was noted as well-controlled. The evidence during this period has not shown either impairment in most areas or total occupational and social impairment, nor has it shown severe inability to establish and maintain effective or favorable relationships with people, as well as psychoneurotic symptoms that are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. Rather, it has shown that, despite considerable impairment from the Veteran's symptoms, the Veteran had still managed to remain in school, attempts at long-term work, and maintain at least some semblance of social relationships and a stable marriage. Further, with medication and therapy, the Veteran's symptoms even appeared to be moderately improving. In summary, the Board finds that the Veteran is not entitled to a PTSD disability rating greater than 50 percent from December 28, 1993 to February 26, 2004, under either the old or new rating criteria. Consideration also has been given as to whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. 38 C.F.R. § 3.321(b)(1); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008). In this regard, the Board finds that the schedular evaluations for this period are not inadequate. Ratings in excess of those assigned are provided for certain manifestations of the service-connected PTSD. The evidence shows that manifestations more nearly approximating the criteria for the assignment of a higher rating are not present. The Veteran's disability is not productive of occupational and social impairment with deficiencies in most areas or total occupational and social impairment or severe inability to establish and maintain effective or favorable relationships with people, as well as psychoneurotic symptoms that are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. From December 28, 1993 to February 26, 2004, the diagnostic criteria also adequately describe the severity and symptomatology of the Veteran's service-connected PTSD. Therefore, the Veteran's current rating appropriately contemplates the scope of his PTSD symptoms and referral for extraschedular consideration is not warranted. The Veteran was enrolled in school during this time period and the evidence does not show that his disabilities rendered him unable to obtain or retain employment. Thus, entitlement to a TDIU has not been raised by the record during this period. February 27, 2004 to September 30, 2005 As noted, the Veteran's PTSD has been rated as 70 percent disabling since February 27, 2004. The evidence does not support a grant of an evaluation in excess of 70 percent for the Veteran's PTSD for the time period from February 27, 2004 to September 30, 2005. In order to warrant the next higher 100 percent rating, the evidence must show that he has total occupational and social impairment. The evidence during this time period reflects the Veteran's overall symptoms, to include chronic sleep disturbance, suicidal ideation, nightmares, anxiety, depression affecting the ability to function independently, appropriately and effectively, decreased concentration, anger problems, disturbances of motivation and mood, impaired impulse control, anger, irritability, difficulty in adapting to stressful circumstances (including work or a work-like setting), an inability to establish and maintain effective relationships. The record also shows the only recorded GAF score in May 2004 as 45. During this time period, the medical evidence of record appears to show that the Veteran's PTSD took a large decline, as he began seeking treatment again in May 2004. The record indicated that prior to that time he had been treated for prolonged PTSD and anxiety state, but did not discuss the severity of these conditions. The Veteran's drop in GAF score from 60 to 45 displayed a shift from what were considered moderate symptoms to serious symptoms. Although the Veteran was still complaining of sleep disturbance, nightmares, and depression generally, he also began expressing complaints of symptoms of anxiety, passive suicidal ideation, more avoidance behaviors, and paranoid ideation. Beginning in February 2005, although still working, the evidence showed signs of the Veteran's worsening problems with being in a work environment and increased anxiety. Although the Veteran ultimately quit his job in June 2005, he indicated that he had taken another one and his increased anxiety symptoms appeared to be lessening. The evidence has not shown total occupational and social impairment at any time during the period in question. Rather, it has shown that, despite evidence impairment in most areas from the Veteran's symptoms, such as his increasing problems with work, increasing problems with social situations due to avoidance behaviors, anger, irritability, and paranoid ideation, as well as problems at home with his chronic sleep disturbance, nightmares, anxiety, and depression, the Veteran had still managed to make attempts at continuing to work. Further, with medication and therapy, the Veteran's symptoms even appeared to be stabilizing towards the end of this period. However, because the Veteran was still at least able to continue working during this time period, albeit with great difficulty, he would not be considered totally occupationally impaired. In summary, the Board finds that the Veteran is not entitled to a disability rating greater than 70 percent from December 28, 1993 to February 26, 2004. Consideration also has been given as to whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. 38 C.F.R. § 3.321(b)(1); Barringer, 22 Vet. App. 243-44. In this regard, the Board finds that the schedular evaluations in this case are not inadequate. Ratings in excess of those assigned are provided for certain manifestations of the service-connected PTSD. The record evidence shows that those manifestations (total occupational and social impairment) are not present from February 27, 2004 to September 30, 2005. The diagnostic criteria also adequately describe the severity and symptomatology of the Veteran's service-connected PTSD. Therefore, the Veteran's current rating appropriately contemplates the scope of his PTSD symptoms and referral for extraschedular consideration is not warranted. As previously noted, since February 24, 2005 a TDIU has been in effect. From February 27, 2004 through early February 2005, the Veteran was employed. Thus, entitlement to a TDIU has not been raised by the record during this period. October 1, 2005 to present The Board finds that the evidence supports the grant of a 100 percent rating from October 1, 2005, for PTSD. To warrant a 100 percent evaluation, the evidence must show that the Veteran's symptoms of his PTSD cause total occupational and social impairment. The evidence during this time period reflects the Veteran's overall symptoms, to include mood, anxiety, sleep disturbance, nightmares, anger, irritability, social isolation, and suicidal ideations, with an inability to maintain gainful employment and an inability to establish and maintain effective relationships. Here the Veteran's GAF scores ranged from 40 to 42. The decrease in GAF scores from 45 to 40 indicate a shift from serious symptoms to some impairment in reality testing or communication or major impairment in most areas. During this time period, the Veteran's medical records indicate that his condition was in a continuing decline. At his October 2005 VA examination, the examiner noted that his performance in employment and routine responsibilities of self care had been compromised, so much that he was unemployable. Further, his family role functioning had been adversely affected as evidenced by difficulty with interpersonal relationships. The examiner also noted problems with memory for the first time. In his 2007 SSA application, the Veteran noted his increasing isolation and that his pets are his only friends. In medical records from 2009 and 2010, the Veteran reported more dysphoria, anxiety, and paranoia, resulting in ever more social isolation and inability to work. Depression, anxiety, and suicidal ideation continued to be pervasive. The Veteran's appearance began to be noted as disheveled and unkempt in treatment records. Last, the Veteran's October 2010 VA examination report showed that he did not want to leave his property, he did not have friends, and had not worked since 2005. The Veteran's overall PTSD symptoms appeared to be unabated and the examiner opined that the Veteran was unemployable. The record shows that the Veteran began to have total occupational and social impairment at the time of the October 1, 2005 VA examination. It was at that time that it was noted that the Veteran's GAF score first dropped below 45 to 42 and that he was determined to be unemployable due to his PTSD, as supported by the Veteran's statements that he was no longer working. The Veteran is competent to testify as to the severity of the symptomatology associated with his service-connected PTSD during the time period in question and his reasons for and date of retirement. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran's statements are presumed credible because his complaints of symptoms and approximate last date of working have been consistent in both his lay testimony SSA records, and in what he reported to his treating providers in the medical evidence of record. The Veteran's impairment continued at this severity throughout the period in question as shown by his continuing decline in his subsequent VA treatment records and October 2010 VA examination. As the Veteran's symptoms during the time period in question prevent him from working, socializing, or even leaving his property, the Board finds that an evaluation of total occupational and social is appropriate. The evidence more nearly approximates a 100 percent rating effective October 1, 2005, for the Veteran's service-connected PTSD. 38 C.F.R. § 4.7; Gilbert, 1 Vet. App. at 49. The evidence of record does not warrant ratings in excess of those assigned for the Veteran's PTSD at any time during the appeal period. 38 U.S.C.A. § 5110 (West 2002 & Supp. 2012). See also Fenderson, 12 Vet. App. at 119. (CONTINUED ON NEXT PAGE) ORDER Entitlement to an initial evaluation in excess of 50 percent from December 28, 1993 to February 26, 2004, for PTSD is denied. Entitlement to an evaluation in excess of 70 percent from February 27, 2004 to September 30, 2005, for PTSD is denied. Entitlement to a 100 percent rating effective October 1, 2005, for PTSD is granted, subject to the laws and regulations governing the payment of monetary benefits. ____________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs