Citation Nr: 1334358 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 98-12 274 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to an effective date earlier than April 5, 2002, for the grant of service connection for posttraumatic stress disorder (PTSD); to include an earlier effective date for the assignment of an increased disability rating for the service-connected PTSD (previously rated as dysthymia with generalized anxiety disorder). REPRESENTATION Appellant represented by: John F. Cameron, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Orfanoudis, Counsel INTRODUCTION The Veteran had active service from March 1966 to June 1969. His decorations include the Combat Action Ribbon and the Purple Heart Medal. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 1998 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO), in Montgomery, Alabama, that, in pertinent part, denied service connection for PTSD. In July 2000, the Veteran testified at a personal hearing over which a Veterans Law Judge of the Board presided while at the RO. A transcript of that hearing has been associated with the claims file. The provisions of 38 C.F.R. § 3.103(c)(2) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: the duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). During the above hearing, the Veterans Law Judge clarified the issues on appeal and inquired as to the etiology, continuity, and severity of the Veteran's asserted symptoms. The Veteran was offered an opportunity to ask the Veterans Law Judge questions regarding his claim. The Board, therefore, concludes that it has fulfilled its duty under Bryant. In an October 2003 decision, the Board awarded service connection for PTSD. In a January 2004 rating decision, the RO re-characterized the service connected psychiatric disability from dysthymia with generalized anxiety disorder to PTSD, and continued a 30 percent disability rating. In May 2005, the RO increased the disability rating of the Veteran's PTSD from 30 percent to 100 percent, effective April 5, 2002. In September 2007, the Board denied an effective date earlier than April 5, 2002, for the grant of service connection for PTSD; and denied entitlement to a disability rating in excess of 30 percent for a psychiatric disability for the period prior to April 5, 2002. The Veteran appealed the Board's September 2007 decision to the United States Court of Appeals for Veterans Claims (Court). In a January 2010 Memorandum Decision, the Court set aside the denial of entitlement to an effective date earlier than April 5, 2002, for the 100 disability rating for PTSD, and remanded the claim to the Board for further development in accordance with its decision. In December 2010, the Board denied an effective date earlier than April 5, 2002, for the award of a 100 percent disability rating for an acquired psychiatric disorder, variously characterized and to include PTSD. The Veteran appealed the Board's December 2010 decision to the Court. In a January 2013 Memorandum Decision, the Court set aside the denial of an effective date earlier than April 5, 2002, for the award of a 100 percent disability rating for an acquired psychiatric disorder, variously characterized and to include PTSD, and remanded the claim to the Board for further development in accordance with its decision. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issue on appeal. FINDINGS OF FACT 1. On January 8, 1998, the Veteran filed a claim of entitlement to service connection for PTSD. 2. On September 30, 2000, the competent and credible evidence first shows the Veteran met the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV) criteria for a diagnosis of PTSD. 3. From January 8, 1998, to September 29, 2000, the Veteran's psychiatric disorder was manifested primarily by some mild symptoms with some difficulty in social or occupational functioning , but generally functioning well with some meaningful interpersonal relationships. 4. From September 30, 2000, the Veteran's PTSD (previously rated as dysthymia with generalized anxiety disorder) has been manifested by total occupational impairment. CONCLUSIONS OF LAW 1. The criteria for an effective date of September 30, 2000, for the grant of service connection for PTSD have been met. 38 U.S.C.A. §§ 5103, 5107, 5110, 7104, 7105 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.151, 3.400 (2013). 2. The criteria for a disability rating greater than 30 percent for dysthymia with generalized anxiety disorder from January 8, 1998, to September 29, 2000, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1-4.14, 4.40, 4.130, Diagnostic Code 9411 (2013). 3. The criteria for a 100 percent disability rating for PTSD (previously rated as dysthymia with generalized anxiety disorder) from September 30, 2000, have been met. 38 U.S.C.A. §§ 1155, 5103, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1-4.14, 4.40, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012), 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013), requires VA to assist a claimant at the time that he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of what they must do to substantiate their claims. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that the claimant is to provide; and (3) that VA will attempt to obtain. See Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005). In addition, the notice requirements of the VCAA 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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. By letters dated in August 2001, February 2004, and March 2006 the Veteran was notified of the evidence not of record that was necessary to substantiate his claim. He was told what information that he needed to provide, and what information and evidence that VA would attempt to obtain. He was also provided with the requisite notice with respect to the Dingess requirements. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied. With regard to the aspect of this claim that specifically addresses the effective date of the initial grant of service connection, the underlying claim is a downstream issue of the effective date assigned following the award of service connection. As this has been substantiated, further VCAA notice is not required. See Hartman v. Nicholson, 483 F.3d 1311 (2006); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). For increased-compensation claims, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. See Vazquez-Flores v. Shinseki, 580 F. 3d 1270 (Fed. Cir. 2009); Wilson v. Mansfield, 506 F.3d 1055 (Fed. Cir. 2007). In this case, the Veteran was provided pertinent information in the above mentioned letters and other correspondence provided by the RO. Specifically, VA informed the Veteran of the necessity of providing, on his own or by VA, medical or lay evidence demonstrating a worsening or increase in severity of the respective disability, and the effect that the worsening has on his employment and daily life. The Veteran was informed that should an increase in disability be found, a disability rating would be determined by applying the relevant diagnostic codes; and examples of pertinent medical and lay evidence that he could submit relevant to establishing entitlement to increased compensation. The Veteran was also provided notice of the applicable relevant diagnostic code provisions. Next, the VCAA requires that VA make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. The Veteran's relevant service, VA, and private medical treatment records have been obtained. There is no indication of any additional, relevant records that the RO failed to obtain. The Veteran has been medically evaluated. In sum, the Board finds that the duty to assist and duty to notify provisions of the VCAA have been fulfilled and no further action is necessary under the mandates of the VCAA. Factual Background A review of the evidence of record reveals that a VA medical record dated in June 1970 shows that the Veteran was said to have sustained a rather severe psychological injury after being shot in the genital area. He was said to be severely distressed and depressed. He was also said to be 100 percent disabled because of his psychological reaction. His symptoms were said to include depression, including some suicidal thought, impotence, nightmares, emotional lability, bitterness, frustration, and lack of self esteem. The examiner indicated that his physical complaints were secondary to depression, and that the depression was secondary to the gunshot wound, and that they were all working in a vicious cycle. These findings were reiterated by a VA examiner later in June 1970. By rating action dated in October 1970, the Veteran was awarded service connection for depressive neurosis, wherein an initial 30 percent disability rating was assigned effective June 5, 1969; a 100 percent disability rating was assigned effective May 7, 1970; and a 30 percent disability rating was assigned effective July 1, 1970. A VA examination report dated in April 1981 shows that the Veteran was said to be friendly and cooperative. He denied auditory or visual hallucinations, and denied homicidal or suicidal ideations. Insight and judgment were fair. He was anxious, but coherent, relevant, and oriented in three spheres. The assessment was mild anxiety neurosis. He was said to be disabled in his industrial and social capacity. An accompanying psychiatric evaluation shows that the Veteran provided a history of not working since 1967. He admitted that he had not looked for a job in recent years, but that when he had looked for work in the past, he would get turned down because of his physical disabilities. He denied being treated as an inpatient for his psychiatric illness during the preceding four to five years. He admitted that he would still get a little depressed about world news, but there was no evidence of overt depressive symptoms or feelings of dysphoria. Affect was appropriate, and there was no evidence of psychotic thought process. Sleep patterns were within normal limits. Industrial disability was said to be minimally imposed by psychiatric illness; and social disability imposed by psychiatric illness was said to be negligible. The assessment was generalized anxiety disorder. A VA examination report dated in December 1991 shows that the Veteran reported that he had no psychiatric problems, and that his only prior visit to see a psychiatrist had been 15 years earlier. He reported being occasionally depressed but that it was not severe or anything that he could not work out. He described having an occasional flashback when hearing a loud noise or looking at the woods, but denied sleep disturbance or, nightmares. He stated that he was jumpy, but not irritable and that he would get along with others. Mental status examination revealed that he was casually dressed, made good eye contact, and was cooperative. Speech and thought processes were normal. Mood was euthymic and pleasant. He was not anxious or depressed during the interview. His affect was appropriate. He was oriented in all spheres. Insight and judgment were within normal limits. The Veteran added that he would socialize with his friends and family. He would occasionally cook or help with housework. He would hunt and fish, and occasionally go to church or walk. The examiner concluded that there was no diagnosis. The examiner added that the Veteran complained of mild anxiety and symptoms related to PTSD, but it was felt that he did not meet the diagnostic criteria for these conditions. On January 8, 1998, the Veteran's claim for an increased disability rating for his service-connected psychiatric disability was received. The Veteran also indicated that he wished to apply for service connection for PTSD. A VA psychiatric examination report dated in April 1998 shows that the Veteran indicated that he had constant thoughts of Vietnam and intense psychological stress when anyone spoke of Vietnam. He also reported difficulty around crowds and efforts to avoid conversations about Vietnam. He stated that he had detached feelings and only a few friends. He denied suicidal or homicidal ideation, as well as irritability or difficulty concentrating. He indicated that he sometimes had an exaggerated startle response. He stated that he was currently receiving no psychiatric treatment for PTSD or depression, and that he was currently unemployed due to his low back disability. Mental status examination revealed that he was casually dressed with a neat beard. He was cooperative throughout the examination and was alert and oriented. He exhibited good eye contact, and there was no abnormal mood activity. His speech was within normal limits. His thought processes were logical, coherent, and he showed no flight of ideas or looseness of association. He was able to focus, sustain, and shift attention. Thought content was negative for auditory or visual hallucinations, and there were no ideas of delusional thinking or of obsessions or compulsions. Memory was intact, and insight and judgment were fair. His mood was "okay," and his affect was within normal limits. The diagnoses were dysthymia and generalized anxiety disorder with features of PTSD. A Global Assessment of Functioning (GAF) score of 65 was assigned. The examiner indicated that the Veteran did not meet the criteria for PTSD under DSM-IV. In a May 1998 rating decision, the RO re-characterized the psychiatric disability as dysthymia, but denied an increased disability rating. The Veteran appealed the May 1998 rating decision. A VA outpatient treatment record dated in September 1998 shows that the Veteran was said to have had a history of PTSD, and that he had been wounded twice while in Vietnam. He reported a history of nightmares of Vietnam, difficulty sleeping, and irritability. He was given a provisional diagnosis of PTSD and referred to a PTSD program. During his July 2000 hearing, the Veteran testified that he would experience nightmares two to three times per week. He added that he would have suicidal ideations. He stated that he would not leave his house and avoided large crowds. He reported having a good relationship with his children. He also indicated that he would easily be startled by unexpected loud noises. He described having two or three close friends that he would see once a week. He also noted that he worked until October 1996 as a truck driver. A lay statement from the Veteran's spouse dated in July 2000 (first received by VA on April 26, 2002) shows that the Veteran was said to experience sleep disturbance, restlessness, withdrawal, avoidance of crowds, increased startle response, and nervousness. A private medical record from W. Pineda, M.D., dated September 30, 2000 (first received by VA on April 26, 2002), shows that the Veteran's psychiatrist indicated that he had reviewed the medical records and examined the Veteran. During the evaluation, the Veteran was said to have appeared ill at ease and somewhat depressed, but cooperative. He became increasingly anxious as he tried to recount his experiences in Vietnam, especially the incident when he was shot in the groin. He endorsed persistence of occasional passive suicidal ideation, extreme isolativeness, and spells of cognitive disturbance. It was noted that the Veteran had experienced exposure to gunfire, enemy attacks, and numerous dead bodies in Vietnam. In particular, he was shot in the groin in an enemy ambush. The Veteran was noted to have become visibly agitated while recalling this incident. Dr. Pineda indicated that the Veteran's medical records documented classic signs and symptoms of PTSD including recurrent flashbacks, avoidance of stimuli that would remind him of the traumatic event, paranoia, fear of others, sleep disturbances, social withdrawal, emotional numbing, and hypervigilance. The diagnoses were chronic PTSD, generalized anxiety disorder, dysthymic disorder, and agoraphobia. Dr. Pineda noted that the diagnoses were based upon review of the Veteran's medical records, lay statements, and psychiatric evaluations as well as the current examination. It was specifically noted that the Veteran met the criteria for a diagnosis of PTSD under DSM-IV. Dr. Pineda referenced the Veteran's June 1970 VA treatment records, but did not address subsequent VA treatment records. Dr. Pineda also opined that the Veteran had been totally disabled and unable to work due to these mental conditions since at least July 1996. On April 5, 2002, the Veteran's separate claim for entitlement to a total disability rating based upon individual unemployability (TDIU) was received. In October 2003, the Board granted service connection for PTSD. In implementing the Board's grant of service connection, in January 2004, the RO re-characterized the Veteran's psychiatric disability as PTSD (previously rated as dysthymia with generalized anxiety disorder). A VA mental disorders examination report dated in November 2004 shows that the Veteran reported not going to the outpatient psychiatric clinic and not taking any psychotropic medications. He added that he had never been admitted to any psychiatric unit, and that he was afraid to take any psychiatric medication. He reported getting along fairly well with his wife, with occasional irritation or agitation. He added that at times he would have nightmares and difficulty sleeping, with irritability the following day. He reported having two to three good friends, but that he would mostly stay at home. He stated that he hardly went to church and had given up fishing. Mental status examination revealed that he was cooperative and oriented in all spheres. He was mildly depressed and anxious. He had recurrent thoughts about the Vietnam War. He would get easily aroused and had difficulty to modulate his aggression, however, he was not suicidal or assaultive. Memory for recent and remote events was fair. He was able to concentrate well during the interview. The diagnosis was PTSD. A GAF of 60 was assigned. The examiner added that his depression may be part of his PTSD, and that it was also probably related to Vietnam and his back problems in combination. He examiner concluded that he was not able to work in gainful employment, and that the symptoms for this could not be separated out. By rating action dated in May 2005, the RO increased the disability rating of the Veteran's PTSD from 30 percent to 100 percent, effective April 5, 2002, the date of his claim for entitlement to a TDIU. Earlier Effective Date for the Grant of Service Connection for PTSD Except as otherwise provided, the effective date of an award of compensation based on an original claim will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.400 (2013). A specific claim in the form prescribed by VA must be filed in order for benefits to be paid to any individual under the laws administered by VA. 38 C.F.R. § 3.151(a) (2013). The term "claim" or "application" means a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief of entitlement, to a benefit. 38 C.F.R. § 3.1(p) (2013). "Date of receipt" generally means the date on which a claim, information or evidence was received by VA. 38 C.F.R. § 3.1(r) (2013). The applicable statutory and regulatory provisions require that VA look to all communications from the appellant that may be interpreted as applications or claims - formal and informal - for benefits. In particular, VA is required to identify and act on informal claims for benefits. 38 U.S.C.A. § 5110(b)(3); 38 C.F.R. §§ 3.1(p), 3.155(a); see Servello v. Derwinski, 3 Vet. App. 196, 198-200 (1992). An informal claim must identify the benefit sought. 38 C.F.R. § 3.155(a) (2013). As to when the Veteran's claim for service connection for PTSD was received by VA, review of the claims file clearly shows that on January 8, 1998, the Veteran's claim of entitlement to service connection for PTSD was received. Therefore, the Board finds that the date of the Veteran's claim of entitlement to service connection for PTSD was January 8, 1998. However, having decided that the Veteran's claim of service connection for PTSD arose from his January 8, 1998, statement, the next question for the Board to consider is when the record first shows he became entitled to service connection for PTSD because, the effective date of an award of compensation based on an original claim will be the date of receipt of the claim or the date entitlement arose, whichever is later. See 38 U.S.C.A. § 5110 ; 38 C.F.R. § 3.400. In this regard, the establishment of service connection for PTSD has unique evidentiary requirements. It generally requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., DSM-IV); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). See also Cohen v. Brown, 10 Vet. App. 128 (1997). During the pendency of this appeal, the regulations governing service connection for PTSD claims were amended. Under the revised regulations, if a Veteran's claimed stressor relates to a fear of hostile military or terrorist activity, then lay testimony may establish the occurrence of the claimed in-service stressor, absent clear and convincing evidence to the contrary. This lay evidence is sufficient only if the claimed stressor is consistent with the places, types, and circumstances of the Veteran's active military service, a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD, and that the symptoms are related to the claimed stressor. 38 C.F.R. § 3.304(f)(3) (2013). The first clinical evidence reflecting that the Veteran met the criteria for a diagnosis of PTSD was the September 30, 2000, private medical record from Dr. Pineda. While this evidence was not first received by VA until April 26, 2002, the Board finds that the date the Veteran met the DSM-IV criteria for PTSD was September 30, 2000. Dr. Pineda suggests that the Veteran exhibited symptoms of PTSD since 1970. To the extent he is suggesting the Veteran met the criteria for a diagnosis since that time, the Board does not find his opinion convincing. PTSD was first recognized as a distinct disability by VA on April 11, 1980, see 45 Fed. Reg. 26,326 (1980), and this change constituted a liberalizing VA issue. See VAOPGCPREC 26-97 (July 16, 1997); Green v. Brown, 10 Vet. App. 111 (1997). With regard to PTSD claims, VAOPGCPREC 26-97 held that "an effective date prior to the date of claim cannot be assigned under section 3.114 unless the claimant met all eligibility criteria for the liberalized benefit on April 11, 1980, the effective date of the regulatory amendment adding the diagnostic code for PTSD, and such eligibility existed continuously from that date to the date of claim or administrative determination of entitlement." As such, while the Veteran's depressive neurosis was said to be secondary to his period of active service, the Veteran was awarded service connection for such disability in 1970, and the severity of such symptoms were appropriately rated over time. The evidence of record, nonetheless, does not show that the Veteran met the criteria for a diagnosis of PTSD until September 30, 2000. In June 1970, the Veteran was found to have depressive neurosis. In April 1981, he was diagnosed with mild anxiety neurosis and generalized anxiety disorder. In December 1991, the was no psychiatric diagnosis and the VA examiner concluded that the Veteran did not meet the diagnostic criteria for PTSD. In April 1998, he was diagnosed with dysthymia and generalized anxiety disorder with features of PTSD, but the VA examiner reiterated that he did not meet the criteria for PTSD under DSM-IV. While the Veteran was given a provisional diagnosis of PTSD in September 1998, it was not indicated that he met the criteria for PTSD under DSM-IV at that time. The Board finds the contemporaneous examination and clinical reports more convincing than the opinion of Dr. Pineda. The 1991 and 1998 psychiatric evaluations included mental status interviews and specifically considered whether the Veteran met criteria for PTSD. While some symptoms of PTSD were noted, it was specified that all diagnostic criteria were not met. Dr. Pineda does not indicate why those evaluations were incorrect or reconcile them with his opinion. The Board finds by a clear preponderance of the evidence that PTSD was not clinically identified prior to September 30, 2000 and that this is the earliest date entitlement to the benefit arose. In light of the foregoing, the Board finds that an effective date of September 30, 2000, for the grant of service connection for PTSD is warranted. Disability Rating from January 8, 1998 As noted above, on January 8, 1998, the Veteran's claim for an increased disability rating for his service-connected nervous condition was received, as was his claim of service connection for PTSD. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. Id. It is necessary to rate the disability from the point of view of the Veteran working or seeking work, 38 C.F.R. § 4.2, and to resolve any reasonable doubt regarding the extent of the disability in the Veteran's favor. 38 C.F.R. § 4.3. If there is a question as to which disability rating to apply to the Veteran's disability, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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 (2013). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2013); Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the Veteran's entire history is reviewed when assigning a disability rating, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Additionally, in determining the present level of a disability for any increased rating claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Words such as "moderate," "moderately severe," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. 4.6 (2013). Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2013). It is possible for a Veteran to have separate and distinct manifestations from the same injury that would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); 38 C.F.R. § 4.14 (2012) (precluding the assignment of separate ratings for the same manifestations of a disability under different diagnoses). The Veteran's service-connected psychiatric disorder, to include PTSD, is rated pursuant to 38 C.F.R. § 4.130, which rates such disorders under the General Rating Formula for Mental Disorders, which provides that: A 100 percent disability rating is warranted if 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 self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. A 70 percent disability rating is warranted when 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 ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 50 percent disability rating 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; difficulty in establishing and maintaining effective work and social relationships. A 30 percent disability rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, 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, mild memory loss (such as forgetting names, directions, recent events). Id. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased disability rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing DSM-IV; 38 C.F.R. § 4.125 (2013). A GAF of 51 to 60 is defined as 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 GAF of 61 to 70 is defined as 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, has some meaningful interpersonal relationships. Having carefully considered the evidence of record for the period from January 8, 1998, to September 29, 2000, the Board finds that a disability rating greater than 30 percent is not warranted. In this regard, on VA examination in April 1998, the Veteran was cooperative, alert and oriented. Mood, affect, and speech were within normal limits. Thought processes were logical and coherent. There were no hallucinations, delusions, obsessions or compulsions. Memory was intact, and insight and judgment were fair. A GAF of 65 was assigned which is indicative of some mild symptoms or some difficulty in social and occupational functioning, but generally functioning pretty well. In September 1998, he was noted to have a history of nightmares, difficulty sleeping, and irritability, but no current assessment was provided. During his July 2000 hearing, the Veteran reported nightmares, suicidal thoughts, increased startle response, and avoidant behavior, but also described having a good relationship with his children and having two or three close friends that he would visit once a week. These symptoms were reiterated by the Veteran's spouse in her July 2000 letter that was received in April 2002. The competent medical evidence of record prior to September 30, 2000, reflects a disability that is manifested by some mild symptoms or some difficulty in social and occupational functioning, but generally functioning pretty well. The Veteran's GAF score does not reflect 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. As such, the schedular criteria for a disability rating greater than 30 percent have not been met prior to September 30, 2000. The Board recognizes that in his September 2000 letter, Dr. Pineda opined that the Veteran had been totally disabled and unable to work due to his mental conditions since at least July 1996. However, the Board finds that Dr. Pineda did not provide any explanation as to the reasons for assigning the stated date as the onset of total disability. Moreover, while Dr. Pineda commented of VA treatment records dated in 1970, subsequent VA examination reports records dated as recent as April 1998 showing mild disability were not referenced. As such, the Board finds Dr. Pineda's conclusion that the Veteran was totally disabled since July 1996 to be of limited probative value. The Veteran and his spouse are certainly competent to report that his symptoms are worse. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, in evaluating a claim for an increased schedular rating, VA must consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. The Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the appellant or his representative, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In this case, the Board finds no other provision upon which to assign a higher disability rating prior to September 30, 2000. The Board also finds that the Veteran's psychiatric disorder prior to September 30, 2000, does not warrant referral for extra-schedular consideration. In exceptional cases where schedular ratings are found to be inadequate, consideration of an extra-schedular disability rating is made. 38 C.F.R. § 3.321(b)(1). There is a three-step analysis for determining whether an extra-schedular disability rating is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id.; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. The Board finds that the evidence does not warrant referral of the Veteran's claim for extra-schedular consideration. The level of severity of the Veteran's psychiatric disorder prior to September 30, 2000, is adequately contemplated by the applicable diagnostic criteria. The criteria provide for a higher rating, but as has been thoroughly discussed above, the rating assigned herein is appropriate. The assigned disability rating compensates for social and occupational impairment for psychiatric symptomatology regardless of the precise symptoms. See Mauerhan. In view of the adequacy of the disability rating assigned under the applicable diagnostic criteria, consideration of the second step under Thun is not for application in this case. Accordingly, the claim will not be referred for extra-schedular consideration. As such, the preponderance of the evidence is against a disability rating higher than 30 percent for the Veteran's psychiatric disorder prior to September 30, 2000. Thus, the benefit-of-the doubt doctrine does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disability Rating from September 30, 2000 As noted above, the Veteran was found to meet the DSM-IV criteria for PTSD on September 30, 2000. A 100 percent disability rating for the PTSD has been in effect as of April 5, 2002. As such, the Board must examine whether a disability rating greater than 30 percent is warranted for the PTSD from September 30, 2000, to April 4, 2002. The September 2000 letter from Dr. Pineda reflects that the Veteran was increasingly anxious and endorsing persistent occasional passive suicidal ideation, extreme isolativeness, and spells of cognitive disturbance. He was noted to have recurrent flashbacks, avoidant behavior, paranoia, fear of others, sleep disturbance, social withdrawal, emotional numbing, and hypervigilance. Dr. Pineda concluded that the Veteran was presently severely restricted and unable to function at a productive level at work in any substantial gainful employment on a sustained basis due to the pervasive symptoms of chronic PTSD, generalized anxiety disorder, dysthymic disorder, and agoraphobia. The criteria for a 100 percent disability rating are met when the Veteran has total occupational and social impairment. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Veteran has been found to be unemployed and unable to engage in substantial gainful employment since the effective date of the grant of service connection for PTSD. Dr. Pineda concluded that the Veteran was totally disabled and unemployable due to PTSD. Resolving all doubt in the Veteran's favor, this evidence establishes total occupational impairment. Dr. Pineda has also found the Veteran to have almost no social relationships. It was indicated that he was isolated, paranoid, and exhibited agoraphobia. Elements of avoidant behavior have been established, and the Veteran was said not to engage in any social activities. Although the Veteran does not exhibit all of the symptomatology consistent with a 100 percent disability rating from September 30, 2000, through April 4, 2002, the evidence does show that he has total occupational and near total social impairment. This level of disability most closely approximates the criteria for a 100 percent disability rating. 38 C.F.R. §§ 4.7, 4.21. This level of disability has been present since the effective date of service connection for PTSD (September 30, 2000). A 100 percent disability rating is, therefore, granted effective from the date of service connection for PTSD. This is the maximum benefit available. ORDER An effective date of September 30, 2000, for the grant of service connection for PTSD is granted. A disability rating greater than 30 percent for service-connected dysthymia with generalized anxiety disorder from January 8, 1998, to September 29, 2000, is denied. A 100 percent disability rating for service-connected PTSD (previously rated as dysthymia with generalized anxiety disorder), from September 30, 2000, is granted, subject to the applicable criteria governing the payment of monetary benefits. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs