Citation Nr: 1334119 Decision Date: 10/28/13 Archive Date: 11/06/13 DOCKET NO. 08-13 528 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUE Entitlement to a higher initial disability rating for posttraumatic stress disorder (PTSD) in excess of 50 percent from December 19, 2002, to July 5, 2004. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Shauna M. Watkins, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1964 to January 1966. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas, which granted a 10 percent disability rating for PTSD, effective December 19, 2002. In an October 2004 rating decision, the Decision Review Officer (DRO) increased the disability rating to 30 percent disabling, effective December 19, 2002, and assigned a 50 percent disability rating effective July 6, 2004. Because these awards are not the maximum benefit allowed by law and regulation, the appeal continues to the Board for further appellate review. See AB v. Brown, 6 Vet. App. 35 (1993) (holding that on a claim for an original or increased rating, the claimant will generally be presumed to be seeking the maximum benefit allowed by law and regulation, and it follows that such a claim remains in controversy, even if partially granted, where less than the maximum benefit available is awarded). In May 2011, the Veteran testified at a Board hearing held before the undersigned Acting Veterans Law Judge in San Antonio, Texas. A copy of the transcript is of record. In an August 2012 decision, the Board increased the disability rating for the service-connected PTSD to 50 percent, effective from December 19, 2002, to July 5, 2004. The Board then denied the Veteran's claim of entitlement to a higher initial disability rating for PTSD in excess of 50 percent from December 19, 2002, to July 5, 2004. The Veteran appealed the denial to the United States Court of Appeals for Veterans Claims (Court). In a March 2013 Joint Motion for Remand of BVA Decision on Appeal (Joint Motion), the parties asked that the Board's August 2012 decision be vacated and the matter be remanded to the Board for readjudication and disposition consistent with the Joint Motion. The Court granted the Joint Motion and vacated the August 2012 Board decision, remanding the case to the Board for readjudication and disposition consistent with that motion. Since the most recent adjudication of this claim, additional evidence has been added to the record. However, the Veteran waived his right to have the RO initially consider this evidence in a statement dated in June 2013. 38 C.F.R. §§ 20.800, 20.1304 (2013). The Veteran's Virtual VA paperless claims file has been reviewed in preparing this decision, along with his paper claims file. In the August 2012 decision, the Board also remanded the issue of entitlement to a higher initial disability rating for PTSD in excess of 50 percent from July 6, 2004, to the RO via the Appeals Management Center (AMC) in Washington, DC. To date, the AMC has not issued a Supplemental Statement of the Case (SSOC) as directed by the Board in its remand nor has the issue been recertified t to the Board. Therefore, this issue is not currently before the Board. FINDING OF FACT From December 19, 2002 to July 5, 2004, the most probative evidence of records shows that the service-connected PTSD more nearly approximated occupational and social impairment with reduced reliability and productivity due to his psychiatric symptomatology. CONCLUSION OF LAW From December 19, 2002, to July 5, 2004, the criteria for an initial disability rating in excess of 50 percent rating for the service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.21, 4.126, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and, (3) inform the claimant about the information and evidence the claimant is expected to provide. In addition, the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of; and, (5) effective date of the disability. The Court held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection was awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The claim on appeal arises from the Veteran's disagreement with the initial 10 percent disability rating assigned after the grant of service connection. The courts have held, and VA's General Counsel has agreed, that where an underlying claim for service connection has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional VCAA notice or address prejudice from absent VCAA notice. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003. Furthermore, the Board finds that even if VA had an obligation to provide notice under 38 U.S.C.A. § 5103(a) and failed to do so, this notice problem does not constitute prejudicial error in this case because the record reflects that a reasonable person could be expected to understand what was needed to substantiate the claim after reading the rating decision, the statement of the case, and the supplemental statement of the case. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009). In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2013) requires that the Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the May 2011 Board hearing, the Veteran was assisted at the hearing by an accredited representative and that representative and the Acting VLJ asked questions to draw out the state of the Veteran's PTSD at all times during the appeal. No pertinent evidence that might have been overlooked and that might substantiate the claim was identified by the Veteran or the representative. The hearing focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. Therefore, the Board finds that, consistent with Bryant, the Acting VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Regarding the duty to assist, VA must make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In connection with the claim on appeal, the pertinent evidence of record dated since December 19, 2002 (the effective date of service connection) includes the Veteran's service treatment records, VA outpatient treatment records from March 2004 to May 2004, September 2003 Vet Center quarterly report, December 2003 Vet Center quarterly report, and March 2003 VA examination report through QTC Medical Services (QTC). The QTC examiner reviewed the Veteran's medical history, recorded pertinent examination findings, and provided conclusions with supportive rationale. The Board notes that the QTC examination report is probative with regard to the nature and severity of the Veteran's PTSD during the appeal period. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The claims file does not present evidence that the Veteran is currently receiving disability benefits from the Social Security Administration (SSA) for the disability currently on appeal. Therefore, the Board does not need to make an attempt to obtain these records. The Board does not have notice of any additional relevant evidence that is available but has not been obtained. For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claim on appeal. The evidence of record provides sufficient information to adequately evaluate the claim, all obtainable evidence identified by the Veteran relative to the claim has been obtained and associated with the claims file, and the Board is not aware of the existence of any additional relevant evidence which was not obtained. Therefore, no further assistance to the Veteran with the development of evidence is required. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). Disability Rating Legal Criteria Disability evaluations are determined by the application of the schedule of ratings which is based on average impairment of earning capacity. See U.S.C.A. § 1155 (West 2002). Separate diagnostic codes identify the various disabilities. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's disability. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). When entitlement to compensation has been established and a higher initial evaluation is at issue, the level of disability at the time entitlement arose is of primary concern. Consideration must also be given to a longitudinal picture of the Veteran's disability to determine if the assignment of separate ratings for separate periods of time, a practice known as "staged" ratings, is warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2013). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim on appeal. In evaluating the evidence in any given appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). In this regard, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Evans v. West, 12 Vet. App. 22, 30 (1998). Rating PTSD from December 19, 2002, to July 5, 2004 In a December 2003 notice of disagreement, via a VA Form 21-4138, the Veteran reported his belief that he should be rated at 50 percent as supported by a September 2003 Vet Center quarterly report and VA outpatient treatment records. Pursuant to the rating criteria, PTSD is evaluated under a general rating formula for mental disorders. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Veteran is currently rated as 50 percent disabling from December 19, 2002, to July 5, 2004. A 50 percent disability evaluation is assigned where the evidence demonstrates 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 in short-term and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired abstract thinking; disturbances of motivation and mood; and, difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability evaluation 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, inability to establish and maintain effective relationships. Id. A 100 percent disability evaluation is assigned where the evidence shows 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; 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. 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. 38 C.F.R. § 4.126(a) (2013). 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. Id. The rating agency shall also consider the extent of social impairment, but not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The Global Assessment of Functioning (GAF) Scale reflects the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the DSM-IV; see also Carpenter v. Brown, 8 Vet. App. 240, 242-44 (1995). Throughout the appeal period, the Veteran's GAF scores have ranged from 40 to 65. A GAF score of 31 to 40 is indicative of some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant), or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. A score of 41 to 50 is defined as serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A score of 51 to 60 indicates 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). A score of 61 to 70 is defined as some mild symptomatology (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, with some meaningful interpersonal relationships. Id. The Board notes that in Mauerhan v. Principi, 16 Vet. App. 436 (2002), the Court held that the symptoms listed in the Rating Schedule "are not intended to constitute an exhaustive list, but rather are to serve as example of the type and degree of the symptoms, or their effects, that would justify a particular rating." See Mauerhan, 16 Vet. App. at 442. The Court also held in Mauerhan that "the evidence considered in determining the level of impairment under [section] 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment." Id., at 443. Similarly, in a recent decision, the Federal Circuit focused on this language from the rating criteria for mental health disabilities: "[o]ccupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood" - the criteria for the 70 percent rating. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Federal Circuit held that: [I]n the context of a 70 percent rating, § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas. Therefore, to the extent that the Veterans Court implied that the listed 'areas' were irrelevant to the 70 percent disability determination, this was error. Although the [V]eteran's symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the [V]eteran's level of impairment in 'most areas.' At the end of this opinion, the Federal Circuit stated that, "Entitlement to a 70 percent disability rating requires sufficient symptoms of the kind listed in the 70 percent requirements, or others of similar severity, frequency or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). With the above criteria in mind, the Board notes that service connection for PTSD was granted, effective December 19, 2002, and assigned a 50 percent rating. Since that time, the first pertinent documentation of the Veteran's PTSD in the record was at a March 2003 VA QTC examination. At the examination, the Veteran described the following PTSD symptoms: lack of sleep; nightmares; depression; concentration problems; extreme anger; and, isolation. The Veteran reported that his lack of sleep and nightmares caused him to have "a lot of difficulties performing everyday duties." The Veteran denied any hospitalizations for his PTSD. He described his current marriage as fair, as his wife found him to be a cold and selfish person. The Veteran indicated that he would also lose his concentration when he was working because of thoughts about the past. The Veteran stated that he does not want to go out or do anything, and that he often feels sad. The examiner determined that the Veteran was able to establish and maintain effective work, but had difficulty with social relationships. He had no difficulty in performing his activities of daily living. The Veteran did not post any threat of persistent danger or injury to himself or others. The examiner found that the Veteran was mentally capable of managing his benefit payments in his own best interests, and was able to handle his money and bills. Specifically, the Veteran had flattened affect (rather constricted). His thought process was coherent, logical, and relevant. He was friendly, cooperative, and attentive to the examiner. He was oriented to person, place, time, and situation. The examiner found the Veteran's concentration, immediate memory, short-term memory, recent memory, and judgment to be good. His insight was intact. His mood was abnormal (rather depressed). The Veteran's PTSD was not manifested by the following symptoms: panic attacks; delusions; hallucinations; obsessional rituals; impaired judgment; impaired abstract thinking; and suicidal ideation. The examiner assigned the Veteran a GAF score of 65. The September 2003 Vet Center quarterly report revealed that the third quarter of 2003 had been characterized by continued use of internalization of feelings and numbing for the Veteran. The Veteran strived to control his anger and maintain composure, but experienced trouble sleeping, intrusive thoughts, and flashbacks. It was further noted the Veteran had been experiencing depression, trouble with memory, and organization of thought. The physician indicated that the Veteran was a member of the PTSD Support Group, but was not always able to attend because of his tendency to isolate himself. The physician found that the Veteran continued to have chronic PTSD and was struggling to deal with his depressive symptoms. The physician determined that the Veteran's GAF scores for the previous year (i.e., 2002) were 47 to 48 and his present scores were 43 to 45. The GAF scores were based on the Veteran's subjective symptoms as reported to the physician. The December 2003 Vet Center quarterly report revealed that the fourth quarter of 2003 was a "very difficult an[d] challenging quarter" for the Veteran. The Veteran experienced increased intrusive thoughts and flashbacks. The Veteran was not always able to attend the PTSD Support Group due to his tendency to isolate. He was more comfortable in situations with few people or when he was alone. The Veteran had recently decreased some of his community level activities. The Veteran's PTSD symptoms included: anger and depression; loss of sex drive; noted impairment in his short-term memory and organization of thoughts; and, an increasing level of isolation. The physician found that the Veteran had been experiencing a decreased ability to deal with community-based stressors and issues; rather than become enraged, he instead was becoming isolated, which fueled his depression. The physician determined that the Veteran's GAF scores for the previous year (i.e., 2002) were 45 to 48 and his present scores were 40 to 43. The GAF scores were based on the Veteran's subjective symptoms as reported to the physician. Subsequently, pursuant to a March 2004 VA outpatient treatment session, the Veteran reported working part-time and complained of a lack of concentration. He stated that his PTSD was causing him marital problems. His psychiatric symptoms included: frequent nightmares; concentration problems; intrusive thoughts related to in-service trauma; survivor guilt; avoidance of thoughts or conversations related to the war in Iraq; and restlessness. The Veteran stated that he was easily angered, and that this symptom was causing him marital problems, although the Veteran was currently married. The Veteran stated that he was working part-time at an administrative court job. The physician found the Veteran to be clean and well-shaven. His affect was appropriate and his mood was dysphoric. He was logical, coherent, and relevant. His content of thought was free of hallucinations, delusions, suicidal ideas, and homicidal ideas. The Veteran's memory was intact, and he was oriented to person, place, and time. His judgment was good and his insight was fair. Following the March 2004 treatment session, the physician assessed the Veteran with "moderately high" levels of anxiety and chronic PTSD. A GAF score was not assigned. In applying the aforementioned law to the facts of the case, the Board finds that the most probative evidence of record from December 19, 2002, to July 5, 2004, does not show the Veteran manifested PTSD symptoms that equaled or more nearly approximated occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood - to warrant a higher 70 percent initial rating. 38 C.F.R. § 4.130, Diagnostic Code 9411. Instead, the Board finds that the most probative evidence of record shows that the Veteran's service-connected PTSD was moderately disabling throughout the appeal period, which warrants the currently assigned 50 percent rating, but not higher. Id. Specifically, regarding occupational impairment, throughout the entire appeal period, the Veteran has been employed at least part time. At his VA QTC examination, the Veteran reported that his lack of sleep and nightmares caused him to have "a lot of difficulties performing everyday duties." The Veteran also indicated that he would lose his concentration when he was working because of thoughts about the past. However, at no time during the appeal period in question has the Veteran argued that he could not seek employment or was unemployed due to his service-connected PTSD. Moreover, in contrast to the Veteran's statements, the QTC VA examiner found that the Veteran's concentration, immediate memory, short-term memory, and recent memory were good. Furthermore, the VA QTC examiner determined that the Veteran was able to establish and maintain effective work. This medical opinion is not contradicted by any other medical opinion of record for this time period. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). Regarding the social impairment, although the Veteran stated at the VA QTC examination that he does not want to go out or do anything, the record demonstrates that, during the appeal period, he regularly attended a VA PTSD Support Group. The VA QTC examiner also determined that the Veteran had difficulty with social relationships; however, the record demonstrates that the Veteran has been married to the same woman throughout the appeal period despite having some problems. The VA QTC examination also found that the Veteran had no difficulty in performing his activities of daily living. This medical opinion is not contradicted by any other medical opinion of record for this time period. See Colvin, supra. In the December 2003 Vet Center report, the Veteran had recently decreased some, but not all, of his community level activities. In that report, the Veteran also stated that he felt more comfortable being alone or with just a few people. Regarding deficiencies in judgment, thinking, or mood, at the VA QTC examination, the examiner found the Veteran's mood to be abnormal (rather depressed) and his affect to be flat; however, the examiner also determined that the Veteran's insight was intact and his judgment was good. His thought process was coherent, logical, and relevant. He was oriented to person, place, time, and situation. The examiner found that the Veteran did not have impaired judgment or impaired abstract thinking. In both of the Vet Center reports, the physician noted the Veteran's subjective complaints of depression and impairment in his thought organization; however, no objective findings were made on these complaints in either report and therefore the Board does not afford find these findings probative. See Black v. Brown, 5 Vet. App. 177, 180 (1995) (holding that a medical opinion is inadequate when it is unsupported by clinical evidence). Similarly, in March 2004, the VA physician, following an examination of the Veteran, found the Veteran's mood to be dysphoric. However, the examiner also found the Veteran to be logical, coherent, and relevant. His content of thought was free of hallucinations, delusions, suicidal ideas, and homicidal ideas. Moreover, the Veteran's judgment was good, his insight was fair and he was oriented to person, time, and place. The Board finds that the aforementioned evidence which shows that the Veteran is working at least part time and married as well as shows that he has no difficulty in performing his activities of daily living; insight to be intact or fair; his judgment to be good; his thought process to be coherent, logical, coherent, and/or relevant; his being oriented to person, place, time, and situation; his not having impaired judgment or abstract thinking; and his thoughts to be free of hallucinations, delusions, suicidal ideas, and homicidal ideas does not establish occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, to warrant a higher 70 percent rating despite the objective evidence of an abnormal mood (depressed) and a flat affect and the subjective complaints regarding poor sleep, difficulty concentrating, intrusive thoughts, depression, anger, decreased community activities, and being more comfortable being alone. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board further finds that the Veteran's GAF scores throughout the appeal period support the conclusion that the Veteran's PTSD was moderate, at most, during his appeal period. As previously stated, his GAF scores have ranged from 40 to 65, indicating mild to major impairment. However, the Board notes that the most severe GAF scores were assigned to the Veteran by Vet Center medical providers. These GAF scores were based on the Veteran's reported history and not his objective symptoms at the treatment visits. Therefore, the Board does not find them to be probative evidence as to the severity of his PTSD. See Black, supra. In contrast, the GAF score of 65, indicating mild symptoms, was obtained at the Veteran's VA QTC examination and was assigned following an examination of the Veteran and based on his objective PTSD symptoms. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion."). The Board notes in this regard that the assignment of an evaluation under the Schedule is the responsibility of the finder of fact and not the examiner. The adjudicator is charged with interpreting the competent and credible evidence of record as whole and reconciling such to accurately reflect the disability. Moore v. Shinseki, 555 F.3d 1369, 1373 (Fed. Cir. 2009); 38 C.F.R. § 4.2. While medical opinions regarding the extent of functional impairment and GAF scores are evidence to be considered, the ultimate factual determination lies with the adjudicator. As an adjudicator may not substitute his or her own opinion for medical judgment, Colvin, a medical opinion cannot subvert the responsibility of the fact finder. Applying Moore to the facts of this case, the Board places greater probative value on the GAF score of 65 assigned by the VA QTC examiner and less value on the Vet Center GAF scores. Id. In applying the GAF score of 65, the Board finds that the Veteran's PTSD was moderately, at most, disabling during the appeal period in question, which warrants his current 50 percent rating. 38 C.F.R. § 4.130, Diagnostic Code 9411. In applying Mauerhan v. Principi, 16 Vet. App. 436 (2002), the Board notes that, during the appeal period, the Veteran did not display any of the enumerated symptoms for the 70 percent disability rating. 38 C.F.R. § 4.130, Diagnostic Code 9411. In contrast, the Veteran's service-connected PTSD was manifested by the majority of the enumerated symptoms for the 50 percent disability rating. Id. Similarly, the most probative evidence of record shows that the Veteran's service-connected PTSD was mildly to moderately disabling throughout the appeal period, which warrants a 50 percent rating. Id. This finding is supported by the GAF scores of record. This finding is also supported by the March 2004 physician who assessed the Veteran with "moderately high" levels of anxiety and chronic PTSD. At no time during the period in question has a physician examined the Veteran and found his PTSD to be so severe in nature, to warrant a higher 70 percent rating. 38 C.F.R. § 4.130, Diagnostic Code 9411. In summary, having reviewed the record evidence as a whole, the Board finds that the criteria for an initial rating greater than 50 percent during the period in question for the Veteran's service-connected PTSD have not been met. 38 C.F.R. § 4.130, Diagnostic Code 9411; Fenderson, supra. From December 19, 2002, to July 5, 2004, a higher schedular rating of 100 percent is also not warranted, as that rating requires evidence of total occupational and social impairment. Specifically, the Board notes that the Veteran was employed at least part time throughout the entire appeal period. At no time during the appeal period in question, has the Veteran argued that he could not seek employment or was unemployed due to his service-connected PTSD. This evidence does not establish total occupational impairment due to the service-connected PTSD. Additionally, throughout the appeal period, the Veteran has been married to the same woman and has regularly attended a VA PTSD Support Group. The evidence of record established that the Veteran had social impairment, but the evidence does not demonstrate that the Veteran had total social impairment during the period in question. Total occupational and social impairment was also not documented at the QTC examination or in the treatment records. The March 2003 QTC examiner found that the Veteran was able to pay his bills, manage his money, and carry out his activities of his daily living, and the treatment records do not provide contrary evidence. This evidence does not support total occupational and social impairment from December 19, 2002, to July 5, 2004. Thus, the Board finds that the Veteran is also not entitled to a higher initial disability rating of 100 percent for his service-connected PTSD during the appeal period. 38 C.F.R. § 4.130, Diagnostic Code 9411; Fenderson, supra. The Board has considered all other potentially applicable provisions of 38 C.F.R. Parts 3 and 4 (2013), as required by the Court in Schafrath. However, after careful review of the available diagnostic codes and the lay and medical evidence of record, the Board finds there are no other diagnostic codes that provide a basis to assign an initial evaluation higher than the 50 percent rating during the appeal period. The Board notes that in adjudicating a claim, the competence and credibility of the Veteran must be considered. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board acknowledges that the Veteran is competent to give evidence about what he observes or experiences. For example, he is competent to report that he experiences certain symptoms, such as memory loss and concentration problems, and he is credible in this regard. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). The Veteran's competent and credible belief that his disability is worse than the assigned rating, however, is outweighed by the competent and credible medical examinations that evaluated the true extent of impairment based on objective data coupled with the lay complaints. The physicians have the training and expertise necessary to administer the appropriate tests for a determination on the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the physical examination findings. See Black v. Brown, 10 Vet. App. 297, 284 (1997) (in evaluating the probative value of medical statements, the Board looks at factors such as the individual knowledge and skill in analyzing the medical data). The Board has also considered the doctrine of reasonable doubt. However, as the most probative evidence of record is against the Veteran's claim for a rating in excess of 50 percent for PTSD from December 19, 2002, to July 5, 2004, the Board finds that this doctrine is not for application. 38 U.S.C.A. § 5107(b); see also, e.g., Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extra-Schedular and TDIU Consideration In exceptional cases an extra-schedular rating may be provided. 38 C.F.R. § 3.321 (2013). The threshold factor for extra-schedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step - a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. Turning to the first step of the extra-schedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's PTSD from December 19, 2002, to July 5, 2004, is specifically contemplated by the schedular rating criteria, and no referral for extra-schedular consideration is required. The schedular rating criteria, Diagnostic Code 9411, specifically provides for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's PTSD has more nearly approximated a manifestation of occupational and social impairment with reduced reliability and productivity due to his psychiatric symptomatology during the appeal period. The schedular rating criteria specifically include occupational and social impairment, as indicated by reduced reliability and productivity, and as caused by specific psychiatric symptoms. The schedular rating criteria also include analogous symptoms that are "like or similar to" listed schedular rating criteria. Mauerhan, 16 Vet. App at 442; see also 38 C.F.R. § 4.21 (2013). Additionally, the Board has considered GAF scores, which are incorporated through the DSM-IV as part of the schedular rating criteria, as reflective of the degree of severity of psychiatric symptoms or overall functional impairment caused by PTSD. For these reasons, the Board finds that the schedular rating criteria is adequate to rate the Veteran's PTSD from December 19, 2002, to July 5, 2004, and referral for consideration of an extra-schedular evaluation is not warranted. In adjudicating the current appeal for a higher evaluation, the Board has not overlooked the Court's holding in Rice v. Shinseki, 22 Vet. App. 447 (2009) (per curiam) (holding that claims for higher evaluations also include a claim for a total rating based on individual unemployability (TDIU) when the Veteran claims he or she is unable to work due to a service connected disability). However, the Board finds that Rice is not applicable to the current appeal because the record shows that the Veteran was working at least part-time and he has never claimed that his PTSD prevents him from obtaining and/or maintaining employment during this appeal period. Therefore, the Board finds that the current decision need not consider whether the Veteran meets the criteria for a TDIU for the appeal period in question. ORDER The claim of entitlement to an initial disability rating in excess of 50 percent for the service-connected PTSD from December 19, 2002, to July 5, 2004, is denied. ____________________________________________ NEIL T. WERNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs