Citation Nr: 1328375 Decision Date: 09/05/13 Archive Date: 09/16/13 DOCKET NO. 07-17 271A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an increased initial increased rating for posttraumatic stress disorder (PTSD), evaluated as 30 percent disabling, prior to April 17, 2010, as 50 percent disabling prior to August 31, 2012, and as 70 percent disabling thereafter. 2. Entitlement to an increased rating for service-connected diabetes mellitus, currently evaluated as 20 percent disabling. 3. Entitlement to an initial compensable evaluation for service-connected pterygium, cataracts of any type, retinopathy or maculopathy. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Stephen Eckerman, Counsel INTRODUCTION The Veteran served on active duty from June 1968 to April 1970. His awards include the Silver Star, a Bronze Star with "V" device, two Army Commendation Medals with "V" devices, and the Combat Infantryman's Badge. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2006 rating decision of the St. Petersburg, Florida, Department of Veterans Affairs (VA) Regional Office (RO) that granted service connection for PTSD and assigned a 30 percent disability rating, effective from December 29, 2004 (date of claim). The Veteran appealed the issue of entitlement to an increased initial evaluation. In March 2011, the RO granted the claim, to the extent that it increased the Veteran's rating for PTSD from 30 percent to 50 percent, and assigned an effective date for the 50 percent rating of April 17, 2010. In September 2012, the RO again granted the claim, to the extent that it increased the Veteran's evaluation to 70 percent, with an effective date of August 31, 2012. Since these increases did not constitute a full grant of the benefits sought, the increased initial evaluation issue remained in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). The Board remanded the claim for additional development in January 2010, and July 2011. The matter has been returned for final appellate consideration. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Travel Board hearing in September 2009. A transcript of that hearing is of record and associated with the claims folder. The issues of entitlement to an increased rating for service-connected diabetes mellitus, currently evaluated as 20 percent disabling, and entitlement to an initial compensable evaluation for service-connected pterygium, cataracts of any type, retinopathy or maculopathy, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Prior to April 17, 2010, the Veteran's PTSD is not shown to have resulted in occupational and social impairment with reduced reliability and productivity. 2. For the period from April 17, 2010 to August 31, 2012, the Veteran's PTSD is not shown to have resulted in occupational and social impairment with deficiencies in most areas. 3. As of August 31, 2012, the Veteran's service-connected PTSD is not shown to have been productive of total occupational and social impairment. CONCLUSIONS OF LAW 1. Prior to April 17, 2010, the criteria for an initial evaluation in excess of 30 percent for service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.130, Diagnostic Code 9411 (2012). 2. For the period from April 17, 2010 to August 31, 2012, the criteria for an evaluation in excess of 50 percent for service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.130, Diagnostic Code 9411 (2012). 3. As of August 31, 2012, the criteria for an evaluation in excess of 70 percent for service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Increased Initial Evaluation, PTSD Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, 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. The RO has evaluated the Veteran's PTSD under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. Under DC 9411, Under DC 9411, a 30 percent rating is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactory, with routine behavior, self care, and conversation normal), due to such symptoms as depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; or mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted where the disorder is manifested by 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. Id. A 70 percent rating is warranted where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: Suicidal ideations; obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted where there is total occupational and social impairment, due to such symptoms as: Gross impairment in thought processes or communication; persistent delusions or hallucinations; gross inappropriate behavior; persistent danger of hurting oneself 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. Id. The Global Assessment of Functioning (GAF) scale is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994). GAF scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). GAF scores ranging from 51 to 60 reflect more 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). GAF 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. See Quick Reference to the Diagnostic Criteria from DSM-IV at 47 (American Psychiatric Association 1994) ("QRDC DSM-IV"). Although some of the Veteran's recorded symptoms are not specifically provided for in the ratings schedule (e.g., such symptoms as nightmares), the symptoms listed at 38 C.F.R. § 4.130 are not an exclusive or exhaustive list of symptomatology which may be considered for a higher rating claim. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has similarly emphasized that the list of symptoms under a given rating is a nonexhaustive list, as indicated by the words "such as" that precede each list of symptoms. See Vazquez-Claudio v. Shinseki, ___F.3d___, No. 2012-7114, 2013 WL 1395804 (Fed. Cir. April 8, 2013). It 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. Id. at 4. Other language in the decision indicates that the phrase "others of similar severity, frequency, and duration," can be thought of as symptoms of like kind to those listed in the regulation for a given disability rating. Id. at 2. As discussed above, the appeal period is from December 29, 2004 to the present, see 38 C.F.R. § 3.400(b)(1) (2012), and the issue may be stated as whether the criteria for an evaluation in excess of 30 percent for PTSD have been met prior to April 17, 2010, whether the criteria for an evaluation in excess of 50 percent for PTSD have been met prior to August 31, 2012, whether the criteria for an evaluation in excess of 70 percent have been met thereafter. The Veteran is appealing the original assignment of a disability evaluation following an award of service connection. In such a case, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). A total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is in effect from August 31, 2012. In addition, a report from the Social Security Administration (SSA), dated in June 2002, shows that the SSA determined that the Veteran was disabled as of October 2001, with a primary diagnosis of multiple sclerosis. A. Prior to April 17, 2010 A report from S.F.R., Ph.D., dated in April 2005, notes that the Veteran has been treated since 2003, and that he has symptoms consistent with PTSD. A December 2005 report notes an Axis I diagnosis of PTSD, and that a GAF score of 60 was assigned. VA progress notes show that the Veteran received essentially ongoing treatment for psychiatric symptoms beginning in September 2005, at which time he denied a history of depression or anxiety, and indicated that he had a history of alcohol abuse, and drug abuse. On examination, he was AO (awake and oriented) times three (to person, place and time). Reports, dated in April 2006, note that he was AAO x 4 (awake, alert, and oriented to person, place, time and date), cooperative and appropriately groomed, and that the content of his speech was well-controlled, with no cursing, although he appeared agitated and reflected difficulty controlling his temper. An October 2006 report notes signs of depression, anxiety, and social withdrawal, as well as frequent and intrusive thoughts of Vietnam, and that the Veteran had problems communicating with his wife. A December 2006 report notes that he had just returned from a vacation to the mountains with his wife. Thereafter, the Veteran was repeatedly noted to be AO x 3, or AO x 4, and to have a normal mental examination. See e.g., reports, dated in January and December of 2006, February and July of 2007, October 2008, February, March and November of 2009. There are notations that his PTSD was stable. See e.g. reports, dated in February 2008, and June 2009. A November 2009 report notes that a depression screen was negative. Reports from the Vet Center, dated between 2005 and 2007, show that in September 2005, the Veteran to be agitated, hostile and sarcastic, with impaired memory and judgment. There were no delusions, disorganized thinking, or hallucinations. The Veteran complained of symptoms that included sleep disturbance, low energy, and suicidal thoughts in the past, with none recent. A January 2006 report, written by T.T.M., LCSW, notes that the Veteran was appropriately groomed, and that he was alert and oriented to person, place, time, and situation. He was able to attend and concentrate without distraction. Speech was clear and coherent with normal rate, tone and volume. Thought process was logical and goal-directed. There was no evidence of delusions or hallucinations. No tangentiality or circumstantiality was noted. Mood was good, with a congruent range of effect. The Veteran denied suicidal or homicidal ideation, intent or plans. Between 2006 and 2007, the Veteran attended a number of group therapy sessions. A January 2007 report shows complaints of nightmares and sleep difficulties. The evidence includes two statements from T.T.M., LCSW. In a June 2006 statement, Mr. M took issue, in large part, with the June 2005 VA examiner's conclusion that the Veteran does not have PTSD. He also argued that the June 2005 VA examination report was not probative, as it was not based on a review of the claims file, and that it was based on an erroneous and inadequate history. In a December 2006 statement, Mr. M asserts that the Veteran has total occupational and social impairment, memory loss, inability to establish and maintain effective and function work, social, or family relationships, deficits in thinking and judgment, disturbances in motivation and mood, 5-7 panic episodes per week, depression, impaired impulse control with unprovoked irritability with periods of violence and marked difficulty adapting to stressful situations, "even those one expects to meet while living in a complex society." A February 2007 report from a different social worker notes that the Veteran has been treated since January 2005, and that he has numerous symptoms, with regular and consistent individual and group therapy. His symptoms were noted to include difficulty sleeping, frequent outbursts of anger, anxiety, hypervigilance, difficulty in relationships, and isolating behavior. He was noted to be "severely impaired in his abilities to perform activities of daily living," and it was stated that his symptoms were chronic and were not expected to improve over time. A VA examination report, dated in June 2005, shows that the examiner stated that the Veteran's C-file had been reviewed. The Veteran reported the following: he had never received medication for control of his psychiatric symptoms. His symptoms included anxiety, avoidance of situations and experiences that reminded him of combat, and that he frequently thought about combat. He denied flashbacks, nightmares, hyperarousal, hypervigilance, mania, psychosis, and obsessive-compulsive disorder. He denied any problematic alcohol or substance abuse, and reported that he had been sober and not used any drugs for the past 14 years. His sleep was sometimes disturbed due to anxiety, but he frequently slept adequately throughout the night. The examiner noted that no new psychiatric symptoms had appeared in the past year. He had received psychiatric evaluations in the past, but he was not receiving any ongoing treatment except for bi-weekly treatment at the Vet Center for the past four to five months. He had never been hospitalized for psychiatric symptoms, and he has never attempted suicide. He was currently taking Prozac, and the predominant reason for this was his multiple sclerosis, although it had improved his anxiety somewhat. He had been married for the past 34 years and had a daughter. He endorsed having a good relationship with all of his family members. On examination, the Veteran was alert and oriented to all spheres. There was good grooming and eye contact. Speech had normal rate, tone, and volume, without loosening of associations, tangentiality, circumstantiality, or flight of ideas. Speech was logical, linear, and goal-directed. The Veteran denied any suicidal or psychotic thinking. There were no obvious delusional constructs. He complained that his mood was "frustrated." Affect was full-range. He appeared angry discussing his treatment at the Bay Pines VAMC. Cognition was intact. Insight and judgment were moderate. The Axis I diagnosis was anxiety disorder, not otherwise specified (NOS). A GAF score of 58 was assigned. The examiner stated that the Veteran did not meet the criteria for PTSD, that there were no impairments of thought process or communication, and that no other mental disorders were found A VA examination report, dated in June 2006, shows that the examiner stated that the Veteran's C-file had been reviewed. The Veteran complained of symptoms that included nightmares and flashbacks, with at least one nightmare per night. He also reported avoidance behaviors, and that he had been an isolationist his entire life. The examiner noted that he displayed hyperarousal with extreme irritability. The Veteran stated the following: he and his wife no longer slept in the same bed due to his violent nightmares. He slept no more than three hours at a time. His symptoms were triggered by television, and anti-war sentiments. His mood was good. He had vibrant energy, and he had a fun outlook on life. He had been doing much better since he began treatment at the Vet Center. He had a long history of IV (intravenous) drug abuse, but had not done any "hard drugs" since 1987. He had a history of alcoholism since age 16. He had a history of assaultive behavior, with the most recent assault over three years before. He stopped working in 2000 due to multiple sclerosis. He lived with his wife of 35 years, and said that she was "wonderful." He had one daughter, and had a good relationship with her, as well as his family. The examiner noted the following: the Veteran was completely independent in activities of daily living. He denied suicidal and homicidal intent or plan. On examination, the Veteran was mildly irritable with an affect of average range and intensity; it was appropriate to thought content. He was oriented times four (person, place, time, and date). Memory was intact. He was coherent, logical, and goal-directed. There was no FOI (flight of ideas), LOA (looseness of associations) or thought-blocking. He was not circumstantial or tangential. He was not reporting any current AH (audio hallucinations), VH (visual hallucinations), delusions. He was not suicidal or homicidal. Insight and judgment were fair. The Axis I diagnoses were combat-related PTSD, nicotine dependence, cannabis dependence, and polysubstance dependence in sustained full remission. He was assigned a GAF score of 65. The examiner characterized the Veteran's disability as "moderately disabling," stated that he was employable, and that he had a fair capacity for adjustment, noting that the Veteran had very significant medical illnesses. The Board finds that prior to April 17, 2010, an initial evaluation in excess of 30 percent is not warranted. The Veteran's symptoms are not sufficiently severe to have resulted in occupational and social impairment with reduced reliability and productivity. The totality of the evidence more closely resembles the criteria for not more than an initial 30 percent rating. The Veteran has reported that he has been married for well over 30 years, that he has a daughter, and that he has a good relationship with all of his family members. There is no demonstrated impairment of memory, or thought process, and no evidence to show the presence of hallucinations or delusions. He is not shown to be suicidal or homicidal. Insight and judgment have been characterized as "fair" and "moderate." The Veteran's GAF scores have ranged between 58 and 65, which indicates mild to moderate symptoms. See QRDC DSM-IV. The June 2006 VA examiner specifically characterized the Veteran's symptoms as moderate. The Board has considered the reports of the Vet Center social workers, who assert that the Veteran has total impairment due to his PTSD. However, none of these care providers cite to clinical findings to support this conclusion. Their determinations are also significantly at odds with the findings in the VA progress notes (which are far more extensive) and the demonstrated range of GAF scores. For example, contrary to statements in the Vet Center reports, the VA progress notes contain no evidence of impaired memory, or panic attacks. Similarly, while the February 2007 statement from the Vet Center social worker notes that the Veteran was "severely impaired in his abilities to perform activities of daily living," the June 2006 VA examiner stated that the Veteran was completely independent in activities of daily living. In addition, Mr. M's conclusions are not supported by the findings in his own report, dated in January 2006. Finally, the conclusions of the social workers from the Vet Center are afforded less probative value than the conclusions of the VA examiners, as the VA examiners are both shown to be physicians. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches). In summary, prior to April 17, 2010, there is insufficient evidence of such symptoms as flattened affect; irregular speech; difficulty in understanding complex commands; impairment of short- and long-term memory; and impaired abstract thinking, nor are the other PTSD symptoms shown to have resulted in such impairment. The Board therefore finds that the Veteran's symptoms are not of such severity to approximate, or more nearly approximate, the criteria for an initial evaluation in excess of 30 percent under DC 9411 prior to April 17, 2010. See 38 C.F.R. § 4.7. B. April 17, 2010 to August 31, 2012 The Veteran was examined on April 17, 2010. The examination report shows that the examiner stated that the Veteran's C- file had been reviewed. The Veteran was noted to be taking Fluoxetene for depression. The Veteran complained of symptoms that included depression, decreased energy and libido, feeling worthless, hopeless and helpless, poor sleep, concentration, intrusive thoughts, anxiety, anger, and a "horrible temper." He stated that he was smoking a great deal of marijuana every day for pain relief. He stated that he had spent a day in jail for fighting about one year before. He reported that he had been married 40 years "and for the most part they get along." He indicated that he did not have any social relationships, and that he liked to work in his garden and sit in his yard. The report states that there was no history of suicide attempts. On examination, the Veteran was cooperative, relaxed, attentive and friendly. Affect was constricted, and mood was depressed. Attention was intact. He was oriented to person, time and place. Thought process was unremarkable. There were no delusions, hallucinations, inappropriate behavior, or homicidal thoughts. There were suicidal thoughts without intent or plan. For judgment, it was noted that he understood the outcome of behavior. For insight, it was noted that he understood that he has a problem. Impulse control was poor. Effects on activities of daily living were characterized as "none" (dressing, undressing, bathing, self-feeding, grooming, and toileting), "moderate" (recreational activities, driving, traveling, shopping, and household chores), and "prevents" (sports and exercise). The Veteran was able to maintain personal hygiene. Remote memory was normal. Recent and immediate memory were mildly impaired. The examiner characterized the Veteran's symptoms as moderate, daily, and chronic. The Veteran reported that he had not been employed for 10 years, due to multiple sclerosis and other problems. The examiner noted that the Veteran himself did not relate his unemployability to his PTSD. The Axis I diagnoses were PTSD, cannabis dependence, and depression due to a GMC (general medical condition) (multiple sclerosis and pain). The examiner noted that the Veteran's physical conditions exacerbated his PTSD, and that he had increased feelings of being out of control. He had hyperarousal, intrusive thoughts and dreams, avoidance behavior, anxiety, depression, irritability, and major mood swings that interfered with social and occupational functioning. A GAF score of 48 was assigned. The examiner indicated that there was not total occupational and social impairment due to PTSD signs and symptoms, that PTSD signs and symptoms did not result in deficiencies in the areas of judgment, thinking, family relations, work, mood, or school, but that there was reduced reliability and productivity due to PTSD symptoms. The examiner concluded that the Veteran's PTSD had worsened due to his increasing medical problems. VA progress notes show that the Veteran received ongoing treatment for psychiatric symptoms. A July 2010 report notes that the Veteran complained of mild depression. There was no suicidal or homicidal ideation. Screens for depression, and PTSD, were negative. VA hospital reports show that in early February 2012, the Veteran was hospitalized for about one week following a suicide threat. He reported that his wife had kicked him out of the house two months before due to ongoing substance abuse, and that he had been living in the woods. His GAF score upon admission was 20. Upon discharge, he stated that he had reconciled with his wife, and that he would be returning home. He denied homicidal or suicidal ideation. He denied psychotic symptoms, or "any significant PTSD symptomatology." His GAF upon discharge was 49. Following his discharge from the VA hospital, the Veteran immediately entered a VA substance abuse treatment program. A February 13, 2012 report notes a GAF score of 62, with a low for the year of 20. A February 23, 2012 report notes a GAF score of 62, with a high for the past year of 62. Subsequent progress notes show that he continued to receive ongoing treatment for psychiatric symptoms, with findings through late August tending to show that he was alert and oriented times four, with normal speech and thought processes, cognition within normal limits, no hallucinations or delusions, and adequate grooming and hygiene. See e.g., reports, dated in March, May, June and August of 2012. In May 2012, the Veteran reported that his symptoms had decreased, and in July 2012, he reported that his symptoms had "much improved." The Board finds that prior to August 31, 2012, an evaluation in excess of 50 percent is not warranted. The Veteran's symptoms are not shown to be sufficiently severe to have resulted in occupational and social impairment with deficiencies in most areas. The preponderance of the evidence shows that the Veteran's PTSD more closely resembles the criteria for not more than a 50 percent rating. The findings as to such things as the Veteran's speech, thought processes, memory, and insight, and judgment, are not shown to be sufficiently severe to warrant an increased evaluation. Overall, other than upon admission for hospitalization in February 2012, his GAF scores have ranged between 48 and 62, which indicates mild to serious symptoms. The April 2010 VA examiner characterized the Veteran's symptoms as moderate, and the examiner indicated that that PTSD signs and symptoms did not result in deficiencies in the areas of judgment, thinking, family relations, work, mood, or school. Consideration has been given to the Veteran's one week hospitalization in February 2012, at which time his GAF score was 20 upon admission. However, this appears to have been no more than a temporary exacerbation of his condition, as opposed to a worsening of his underlying condition. Specifically, the Veteran was noted to be under the influence of narcotics at the time of his suicide threat, following being told to leave his home by his wife. See February 23, 2012 VA progress note (in which a VA physician characterized this suicide attempt as occurring in a "setting of amphetamine intoxication"). In addition, the Veteran's GAF score was 62 upon discharge six days later. He immediately went into a VA substance abuse treatment program, and he was assigned VA GAF scores of 62 on February 13th and February 23rd of 2012. The subsequently-dated VA progress notes, discussed supra, simply do not contain findings consistent with a 70 percent rating. The Board therefore finds that the Veteran's symptoms are not of such severity to approximate, or more nearly approximate, the criteria for an evaluation in excess of 50 percent under DC 9411 prior to August 31, 2012. See 38 C.F.R. § 4.7. C. As of August 31, 2012 The Veteran was examined on August 31, 2012. The examination report shows that the examiner stated that the Veteran's C-file had been reviewed. The report notes that the Veteran had been hospitalized for suicidal ideation in the context of intoxication (cannabis and amphetamines) for about one week in February 2012. The Veteran reported that his sleep had improved with medication, to about 7 hours per night. He reported symptoms that included isolating behavior, depressed mood, low energy, poor sleep, attention and concentration, and suicidal ideations without plan or intent. It was noted that the Veteran had received substance abuse treatment since February 2012. The Veteran stated that he was living with his wife of 42 years, and that his relationship was getting better. He stated that his relationship with his daughter was good, although they did not talk a lot. He said that he had no friends, and that in general he did not get along with others because he could not trust people. The report indicates that the Veteran had difficulty falling or staying asleep, and irritability or outbursts of anger, that were of moderate intensity. The examiner indicated that the Veteran's symptoms included depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, impairment of long and short-term memory, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, inability to establish and maintain effective relationships, and suicidal ideation. On examination, the Veteran was clean and neatly groomed and appropriately dressed. He was awake and oriented times four, with a full range of affect. Speech rate and tone, and thought content and progression, were unremarkable. The report indicates that there was no flight of ideas, looseness of associations, hallucinations, or delusions. Memory, and attention and concentration, were within normal limits. The Veteran denied current homicidal or suicidal ideation. Insight and judgment were good. The Axis I diagnoses were chronic PTSD, and polysubstance dependence in early remission since February 2012. He was assigned a GAF score of 50. The examiner indicated that the Veteran's symptoms were productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The examiner noted that the Veteran's symptoms interfere with his sleep and concentration, and that they will interfere with his ability to learn new tasks at work. His symptoms of suspiciousness, irritability, and avoidance behaviors will significantly interfere with his ability to establish and maintain effective relationships at work. He was not able to effectively deal with stressful circumstances to include worklike settings. His ability to understand and follow instructions, to retain instructions, to sustain concentration to perform simple tasks, and to sustain concentration to task persistence and pace, were all considered moderately impaired. His ability to respond appropriately to coworkers, supervisors, or the general public, and to respond appropriately to changes in the work setting, were considered to be markedly impaired. A VA progress note, dated August 31, 2012, shows that the Veteran received substance abuse treatment. The report states that the Veteran's mood was stable, and that there were no complaints of, or evidence of, depressive symptoms. The report states that his anxiety and PTSD continued to be much-improved on his current medication. The Veteran reported that he slept well, with only occasional nightmares or bad dreams. There were no complaints of, or evidence of, any other anxiety or PTSD symptoms. There were no complaints of hopelessness, irritability, or hallucinations. There was no evidence of manic or psychotic symptoms. The Veteran denied any suicidal or homicidal ideation, intent, or plan. The assessment was that he was presently stable. The Board finds that as of August 31, 2012, an evaluation in excess of 70 percent is not warranted. The VA examination report shows that the Veteran stated that he was living with his wife of 42 years, and that his relationship was getting better. He endorsed having a good relationship with his daughter, although they did not talk a lot. His speech and thought content, were unremarkable. There were no flight of ideas, looseness of associations, hallucinations, or delusions. Memory, attention, and concentration, were within normal limits. The Veteran denied current homicidal or suicidal ideation. Insight and judgment were good. He said that he had no friends, and that in general he did not get along with others because he could not trust people. During the time period in issue, the Veteran was assigned one GAF score, of 50. This is evidence of serious symptoms. See QRDC DSM-IV. However, the VA examiner noted that two of his symptoms, difficulty falling or staying asleep, and irritability or outbursts of anger, were of no more than moderate intensity. The examiner indicated that the Veteran's symptoms were productive of occupational and social impairment with deficiencies in most areas, and this indicates that the criteria for no more than a 70 percent evaluation have been met. See 38 C.F.R. § 4.130, General Rating Formula. The only other relevant evidence is the August 2012 VA progress note which states that the Veteran's PTSD continued to be "much-improved" on his current medication. The Veteran reported that he slept well, with only occasional nightmares or bad dreams. There were no complaints of, or evidence of, any other anxiety or PTSD symptoms. Finally, there is no evidence of gross impairment in thought processes or communication, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name, nor are the Veteran's psychiatric symptoms otherwise shown to have resulted in total occupational and social impairment. In summary, the evidence does not show that the Veteran has psychiatric symptoms that are so severe as to warrant a 100 percent rating, and the claim must be denied. D. Conclusion In deciding this claim, the Board acknowledges that the Veteran is competent to report symptoms of his psychiatric disability. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465 (1994). Additionally, he is credible in his reports of symptoms and their effect on his activities. He is not however competent to identify a specific level of disability of his disability according to the appropriate diagnostic code. Such competent evidence concerning the nature and extent of the Veteran's service- connected psychiatric disability has been provided by VA medical professionals who have examined him. The medical findings directly address the criteria under which this disability is evaluated. The Board finds these records to be the only competent and probative evidence of record, and therefore is accorded greater weight than the Veteran's subjective complaints of increased symptomatology. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). Consideration has also been given to whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Under Secretary for Benefits 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) (2012); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the veteran or reasonably raised by the record). In determining whether an extra-schedular evaluation is for consideration, the Board must first consider whether there is an exceptional or unusual disability picture, which occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a Veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must next consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-16. When those two elements are met, the appeal must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1) (2012); Thun, 22 Vet. App. at 116. The schedular evaluation in this case is not inadequate. An evaluation in excess of 70 percent is provided for certain manifestations of the service-connected PTSD disability, but the evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's disability, as the criteria assess the level of occupational and social impairment attributable to the Veteran's symptoms, and the level of functioning. As the Board finds that the Veteran's disability picture is contemplated by the rating schedule, the inquiry ends and the Board need not consider whether the disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Accordingly, referral for consideration of an extra- schedular rating is not warranted. In deciding the Veteran's claim, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119, 126 (1999), and Hart v. Mansfield, 21 Vet. App. 505 (2007), and whether the Veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. As noted above, the Board does not find evidence that the Veteran's evaluations should be increased for any other separate period based on the facts found during the whole appeal period. The evidence of record supports the conclusion that the Veteran is not entitled to increased compensation during any time within the appeal period. The Board therefore finds that the evidence is insufficient to show that the Veteran had a worsening of the disability on appeal such that an increased initial evaluation is warranted. In reaching this decision, the Board considered the benefit- of-the-doubt rule; however, as the preponderance of the evidence is against the appellant's claim, such rule is not for application. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). II. The Veterans Claims Assistance Act of 2000 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 notification obligations in this case were accomplished by way of letters from the RO to the Veteran dated in December 2006, and February 2007. Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Board notes that this appeal involves a claim for an initial increased evaluation for PTSD. Thus, although two VCAA notices were issued, where, as here, 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 was intended to serve has been fulfilled; no additional § 5103(a) notice is required. Dingess, 19 Vet. App. at 491. The RO also provided assistance to the appellant as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. It appears that all known and available post-service records relevant to the issue on appeal have been obtained and are associated with the Veteran's claims file. The RO has obtained the Veteran's VA and non-VA medical records, and SSA records. The Veteran has been afforded three VA examinations. Simply stated, the Board finds that the post- service medical record provides evidence against this claim. In January 2010, and July 2011, the Board remanded this claim. In January 2010, the Board directed that the Veteran be scheduled for a VA psychiatric examination. In April 2010, this was done. In July 2011, the Board directed that the Tampa Vet Center be contacted and that an attempt be made to obtain all of the treatment notes related to the Veteran's individual and group psychotherapy since January 2005. This has been done. The Board also directed that the Veteran be afforded another examination, and in August 2012, this was done. Concerning these examinations, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Here, the VA examination reports show that the examiners reviewed the Veteran's medical history, recorded his current complaints, conducted an appropriate examination, provided the appropriate findings, and rendered diagnoses that are consistent with the remainder of the evidence of record. In September 2009, the Veteran was provided an opportunity to set forth his contentions during a hearing before the undersigned at the RO. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the U.S. Court of Appeals for Veterans Claims recently held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the September 2009 hearing, the undersigned identified the issue on appeal. Also, information was solicited regarding the severity of his disability. The testimony did not reflect that there were any outstanding medical records available that would support his claim. Therefore, not only was the issue "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim" were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, the hearing discussion did not reveal any evidence that might be available that had not been submitted. As such, the Board finds that, consistent with Bryant, the undersigned has complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claim based on the current record. The Board concludes, therefore, that decisions on the merits at this time do not violate the VCAA, nor prejudice the appellant under Bernard v. Brown, 4 Vet. App. 384 (1993). Based on the foregoing, the Board finds that the Veteran has not been prejudiced by a failure of VA in its duty to assist, and that any violation of the duty to assist could be no more than harmless error. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). ORDER Prior to April 17, 2010, a rating in excess of 30 percent for service-connected PTSD is denied. For the period from April 17, 2010 to August 31, 2012, a rating in excess of 50 percent for service-connected PTSD is denied. As of August 31, 2012, a rating in excess of 70 percent for service-connected PTSD is denied. REMAND With regard to the claims of entitlement to an increased rating for service-connected diabetes mellitus, currently evaluated as 20 percent disabling, and entitlement to an initial compensable evaluation for service-connected pterygium, cataracts of any type, retinopathy or maculopathy, in March 2012, the RO denied the claim for an increased rating for diabetes mellitus, and granted service connection for "pterygium, cataracts of any type, retinopathy or maculopathy." In May 2012, the Veteran filed a timely notice of disagreement (NOD) as to the denial of the increased rating claim, and the issue of an initial compensable evaluation for his eye disability. A statement of the case has not yet been issued as to these claims. Because a timely NOD was filed to the March 2012 rating decision, the RO must now provide the Veteran with a statement of the case on these issues. See Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following action: Issue a statement of the case with respect to the issues of entitlement to an increased rating for service- connected diabetes mellitus, currently evaluated as 20 percent disabling, and entitlement to an initial compensable evaluation for service-connected pterygium, cataracts of any type, retinopathy or maculopathy. The Veteran should be advised that he may perfect his appeal of these issues by filing a Substantive Appeal within 60 days of the issuance of the Statement of the Case. See 38 C.F.R. § 20.302(b). The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2012). ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs