Citation Nr: 1335145 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 07-06 509 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey THE ISSUES 1. Entitlement to service connection for a skin disorder, to include a sebaceous cyst. 2. Entitlement to service connection for a gastrointestinal disorder, to include as secondary to service connected PTSD. 3. Entitlement to service connection for a respiratory disorder, to include seasonal allergies and as secondary to service connected PTSD. 4. Entitlement to an initial rating in excess of 50 percent for PTSD. 5. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J.B. Freeman, Counsel INTRODUCTION The Veteran (appellant) served on active duty from May 1969 to May 1971. This case comes before the Board of Veterans' Appeals (Board) on appeal from May 2005 and April 2008 rating decisions of the Appeals Management Center Resource Unit in Bay Pines, Florida, and the Newark RO, respectively. The May 2005 rating decision granted service connection for major depression. The Veteran disagreed with the initial rating assigned and requested TDIU. In the October 2011 supplemental statement of the case, the service-connected psychiatric disorder was recharacterized as PTSD (formerly rated as major depression). The service connection issues arise from the April 2008 rating decision. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system and the "Veterans Benefits Management System" to insure a total review of the evidence. The Veteran testified before the undersigned at a November 2011 hearing at the Newark RO. A transcript is of record. The Board remanded these issues in a May 2012 decision, which also granted an earlier effective date for the grant of service connection for PTSD and denied service connection for residuals of a urinary tract infection. The Veteran filed a motion for reconsideration of the May 2012 denial of service connection for residuals of a urinary tract infection, which was denied by the Board in June 2013. The Veteran responded to the denial of reconsideration with the submission of additional evidence in August 2013 and a request that this be used in his "pending appeal" on the urinary tract infection. The May 2012 Board decision is final and more than 120 days has elapsed since its issuance. There is, therefore, no pending appeal as to the urinary tract infection claim. The Board REFERS a petition to reopen the claim of service connection for residuals of a urinary tract infection to the Agency of Original Jurisdiction (AOJ) for appropriate action. The issue of a respiratory disorder, to include seasonal allergies and as secondary to service connected PTSD is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's recurrent sebaceous cyst was not present during service, has not been persistent since service, and is not otherwise related to any incident of service. 2. The Veteran's gastroesophageal reflux disease was not present during service, has not been persistent since service, is not otherwise related to any incident of service and was neither caused nor aggravated by a service-connected disability. 3. Prior to June 9, 1998, the Veteran's PTSD was productive of totally incapacitating psychoneurotic symptoms. 4. On and after June 9, 1998, the Veteran's PTSD was not manifested by severe impairment of the ability to establish and maintain effective or favorable relationships with people, psychoneurotic symptoms of such severity and persistence that there is severe impairment in the ability to obtain or retain employment, impairment such that the attitudes of all contacts except the most intimate were so adversely affected as to result in virtual isolation in the community, or totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes or demonstrable inability to obtain or retain employment. 5. On and after June 9, 1998, the Veteran's PTSD was not manifested by occupational and social impairment with deficiencies in most areas. 6. On and after June 9, 1998, the Veteran has a single rating of 50 percent for PTSD. 7. On and after June 9, 1998, the Veteran is not unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for a skin disorder, to include a sebaceous cyst, are not met. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). 2. The criteria for service connection for a gastrointestinal disorder are not met. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2013). 3. Prior to June 9, 1998, the criteria for an initial rating of 100 percent for PTSD are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7 (2013), 4.132, Diagnostic Code (DC) 9411 (1996). 4. On and after June 9, 1998, the criteria for an initial rating of 50 percent for PTSD are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.130, DC 9411 (2013), 4.132, DC 9411 (1996). 5. On and after June 9, 1998, the criteria for assignment of a total disability rating based on individual unemployability are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 4.16 (1996, 2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions as to the Veteran's claims for service connection and an increased initial rating to include TDIU. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2013). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his 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 inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. As to the service connection claims, compliance with the first notice element requires notice of the five service connection elements: (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. See 38 U.S.C. § 5103(a); see also Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). A December 2006 letter fully satisfied the duty to notify provisions prior to initial adjudication of the Veteran's service connection claims in April 2008. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). As to the initial rating for PTSD, the Veteran's October 1995 initial claim was filed prior to the passage of the Veterans Claims Assistance Act of 2000 (VCAA) and its implementing regulations, which describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Adequate notice under the VCAA was provided in a June 2007 letter. Although this letter was not sent prior to initial adjudication of the Veteran's PTSD claim, this was not prejudicial to him, since he was subsequently provided adequate notice in June 2007, he has had years to respond with additional argument and evidence and the claim was readjudicated and an additional supplemental statement of the case (SSOC) was provided to the Veteran most recently in December 2012. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). Prior to initial adjudication of entitlement to a TDIU, a December 2006 letter satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). During the November 2011 Board hearing, to assist the Veteran, the undersigned asked questions to help direct the Veteran's testimony, and specifically advised the Veteran that additional evidence was needed to substantiate his service connection and increased ratings claims and elicited sources of evidence. The Board remanded this case in May 2012 in part based on the elicited information. These actions fulfilled the duties under 38 C.F.R. § 3.103 (2013). See Bryant v. Shinseki, 23 Vet. App. 488 (2010). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the file. Private medical records identified by the Veteran have been obtained, to the extent possible. The Veteran's Social Security Administration (SSA) records have been associated with the file. The Veteran has identified relevant records in the possession of New Bridge Services. The Board remanded this case in part in May 2012 to request that the Veteran either submit these records or provide an authorized release form to allow VA to obtain the records on his behalf. The Veteran did not submit the records or complete an authorized release form despite being specifically asked to do so in a May 2012 letter. Some New Bridge records had been obtained during prior development in 2000 and again in 2006, but the Board finds that the RO has made all reasonable attempts to obtain records after 2006 and that further development would be fruitless. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c); McLendon v. Nicholson, 20 Vet. App. 79, 81-82 (2006). If VA provides a claimant with an examination in a service connection claim, the examination must be adequate. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). The probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300 (2008). The Veteran was afforded a June 2012 VA medical examination to obtain an opinion as to whether his skin or gastrointestinal disabilities were the result of service or, for the gastrointestinal claim, another service-connected disability. The opinions were rendered by a medical professional following a thorough examination and interview of the Veteran and review of the claims file. The examiner obtained an accurate history and listened to the Veteran's assertions. The examiner laid a factual foundation and reasoned basis for the conclusions that were reached. Therefore, the Board finds that the examination is adequate. See Nieves-Rodriguez. As to the initial rating for PTSD and TDIU claim, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2013). The RO provided the Veteran an appropriate VA examination most recently in June 2012. The Veteran has not reported receiving any recent treatment specifically for this condition (other than at VA and the private treatment mentioned above, records of which are in the file), and there are no records suggesting an increase in disability has occurred as compared to the prior VA examination findings. There is no indication that there has been a material change in the severity of the Veteran's service-connected PTSD since he was last examined. 38 C.F.R. § 3.327(a). The examination report provides sufficient evidence to apply the both the prior and current versions of the ratings schedule and to determine that the schedular rating is adequate. The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007) (mere passage of time does not require VA to provide a new medical examination); see also VAOPGCPREC 11-95. The June 2012 VA examination report is thorough and supported by VA outpatient treatment records. The examination in this case is adequate upon which to base a decision. The Board is obligated by law to ensure that the RO complies with its directives; where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). The Board remanded these claims to the AMC in May 2012 to obtain outstanding records from the New Bridge Services in Pompton Plains, New Jersey, and to provide the Veteran with VA examinations for his service connection and initial rating claims. The AMC sent the Veteran a May 2012 letter asking for the New Bridge Services records or a completed authorized release form so that the AMC might obtain those records on his behalf. The Veteran did not submit the records or a release form. The Veteran also has a duty to assist and cooperate with VA in developing evidence; the duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The AMC executed the instruction to the extent possible. The Board also remanded to provide the Veteran with VA examinations to obtain medical opinions in regard to the service connection and initial rating and TDIU claims. Those examinations were conducted in June 2012 and the reports and opinions are adequate for ratings purposes, as discussed above. The Board finds that the RO complied substantially with May 2012 remand instructions. Further remand for additional development of the prior remand instructions is not warranted. See Stegall. The May 2012 grant of an earlier effective date for service connection for PTSD resulted in an initial ratings period extending back before the implementation of the current ratings criteria for PTSD and entitlement to a TDIU. The Veteran was not provided notice of these changes and the RO did not consider them in the first instance following the May 2012 decision. Formerly, where a granted benefit resulted in a change in law on which an appeal is to be considered, remand was necessary to afford the claimant adequate notice and develop evidence to substantiate the claim. See Hickson v. Shinseki, 23 Vet. App. 394, 400-01 (2010). The grounds for that practice have been revised to allow the Board to address law in the first instance without remand. See 38 C.F.R. § 20.903 (2013); see also 76 Fed. Reg. 17,548 (Mar. 30, 2011) (promulgating a final rule striking a requirement that the Board notify appellants and their representatives of its intent to consider a law not considered by the RO where consideration could result in denial of an appeal). As will be discussed below, consideration of the prior ratings criteria will result in a partial grant in the benefit sought on appeal. Additional remand and development cannot result in a benefit to the Veteran; hence, there is no prejudice to him in the Board's considering these revisions in the first instance. See Bernard v. Brown, 4 Vet. App. 384, 393-94 (1993). As discussed below, the Board grants an initial 100 percent rating prior to June 9, 1998 for PTSD, and denies an initial rating in excess of 50 percent on and after that date. This action triggers no additional notice or procedural obligations. See O'Connell v. Nicholson, 21 Vet. App. 89, 93 (2007). Service Connection The Veteran contends that he has skin and gastrointestinal disabilities as a result of service or as a result of his service connected PTSD. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110. Service connection connotes many factors but basically means that the evidence establishes that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisted such service, was aggravated therein. 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Veteran has been diagnosed with a sebaceous cyst and GERD. These are not chronic diseases listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) does not apply. Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed. Cir. 2013). The Board notes that the instant claims were filed prior to an October 2006 revision in 38 C.F.R. § 3.310. The prior version is more favorable to the Veteran and will be applied in this case. A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a) (2006). In addition, secondary service connection may also be granted for the degree of aggravation to a nonservice-connected disorder, which is proximately due to, or as the result of a service-connected disorder. 38 C.F.R. § 3.310(b) (2006); Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Board observes that lay evidence can be competent and sufficient to establish the elements of service connection where the lay observer is reporting personal sense impressions (knowledge derived from the five senses), in reporting what a medical professional has told him, or in reporting personal sense impressions which support a diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). Although the Veteran is competent to give evidence about what he experiences, he is not competent to diagnose any medical disorder or render an opinion as to the cause or etiology of any current disorder because he does not have the requisite medical knowledge or training. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997). a. Skin Disability The Veteran's treatment records show that he has had recurrent treatment for a sebaceous cyst since 2000. The record also reflects notations of acne vulgaris, rosacea and sebaceous gland inflammation. During his hearing before the undersigned, the Veteran clarified that, although he had other skin disorders, his claim was specifically for the sebaceous cyst. The current disability is well established. See Shedden. Upon entry into service, clinical evaluation of the Veteran's head, face, neck, scalp, were all normal, as reflected on the April 1969 report of medical examination at enlistment. On the report of medical history at enlistment, the Veteran denied having or had previously a skin disease. While in service, the Veteran visited sick call in April 1970 with complaints of a furuncle on the right shoulder. Physical examination of the Veteran revealed a cyst in the right deltoid area that was open but not draining. The right shoulder was soaked in warm water, a sterile dressing was applied, and he was placed on light duty thereafter. At his April 1971 separation from service medical examination, clinical evaluation of the Veteran's head, face, neck, scalp, were all normal. The in-service disease element is satisfied. See Shedden. The Board notes that a second set of service treatment records was submitted by the Veteran. Review of these records shows that the word "sebaceous" was handwritten onto typed reports mentioning a cyst on the right shoulder. These handwritten entries do not appear on the original service treatment records. The Veteran appears to have added these notations on the treatment records in an effort to highlight the in-service illness. These additions do not reflect a medical diagnosis either at the time or obtained later by the Veteran. These altered documents have no probative value. The Board finds that the current disability and in-service disease elements are met as to the skin disorder claim. See Shedden. The remaining question for direct service connection is whether the two are related. See id. The Veteran is generally competent to report the presence of a skin disorder. See Jandreau, 492 F.3d at 1377; see also Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (holding that a lay observer is competent to report the presence of visible varicose veins), rev'd on other grounds by Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). He is also competent to report that the symptoms in service and at the present are the same and that an observable skin disorder has been persistently present since service. See id. The Veteran's statements do claim that the symptoms in service are the same as his present symptoms, but he has not provided a consistent report of symptoms persistent since service. The Veteran filed an October 2005 statement in which he claimed that "medical records for physical disorder[s] exacerbated by stress" were not of record, mentioning skin ulcers and cysts. He stated further that the condition occurred in the military and was reoccurring at the present. His statements are vague as to frequency of reoccurring, i.e., monthly, annually, etc., or whether there was a significant break in time when the symptoms were not present. An April 1985 doctor's note indicates that the Veteran had been seen for seborea dermatitis. No other details were given. An undated letter from a dermatologist, Dr. D.Z., is of record. The letter indicates that the Veteran had some disorders of the skin which he had had since adolescence which continued and exacerbated through his military service. He had reoccurring sebaceous cysts, acne vulgaris, as well as acne rosacea, seborrheic dermatitis and inflammation of his sebaceous gland. The letter states that the conditions occurred during military service and reoccurred on a frequent and periodic basis. The Veteran's November 2011 testimony before the undersigned was that he incurred a sebaceous cyst on his right shoulder in service, and since that time, the cyst reoccurs on the neck and near the right shoulder. At a June 2012 VA examination, the Veteran indicated that he had a cyst on his right shoulder while in the military. He stated that it became ulcerated and required treatment, but resolved. He denied further cysts until 2000 when he developed a cyst on his neck. He was seen by a dermatologist and treated with antibiotics. The cyst has been chronic since 2000, but the Veteran denied any change in size, pain, or restricted neck motion. The Veteran reported that the cyst had been recurring since 2000. The record contains a March 2002 note from a dermatologist, Dr. Z., states that the Veteran was treated with antibiotics for an inflamed cyst on his right neck in June 2000, which supports the June 2012 history. The Board finds that the Veteran's lay statements are not entitled to significant probative value as to whether a nexus to service exists. Initially, the Veteran has not provided evidence that he has been told by a medical expert that the two are related. Although he is competent to describe the presence of lay observable symptoms of a skin disorder, his statements have varied as to whether there have been persistent lay observable symptoms since service. This contradiction tends to make his statements not credible. The Board finds that the Veteran's contentions are not credible lay evidence of nexus. See Jandreau. There is no other lay evidence regarding nexus of record. In light of the confusion in the Veteran's account, the Board affords his lay statements little probative value. The Board turns to the medical evidence of nexus. The June 2012 VA examination report contains a competent medical opinion that the furuncle during service and the current sebaceous cyst are not related. The examiner indicated that the furuncles and sebaceous cysts are distinct and different skin disorders. Because they are different skin disorders, the examiner concluded that the two were not likely related to one another. There is no other medical evidence regarding nexus of record. The Board finds that the preponderance of the evidence is against a relationship between the in-service furuncle and the current sebaceous cyst. The Board places great probative weight on the medical evidence that the two are distinct skin disorders. Although a lay observer can report the presence of skin disorders, the Veteran's statements are reduced in probative weight because of the decades between the original furuncle and the identification of the sebaceous cyst. Given the number of skin disorders which have been diagnosed from time to time, the Board finds that the Veteran could be easily confused regarding which was present during service and which was not. The Board concludes that service connection for a sebaceous cyst is not warranted on a direct basis. See Shedden. The Veteran also stated that the skin disorder was induced and exacerbated by stress and called it psychosomatic in his claim and Notice of Disagreement. As discussed below, there are repeated letters from the Veteran's regular individual therapy providers to the effect that the Veteran had somatic complaints, but none of the listed complaints include skin disorders. When describing his contentions at the hearing before the undersigned, the Veteran did not discuss a potential secondary relationship. The Board also notes that the Veteran regularly refers to "stress" in his life as encompassing such things as trying to care for his disabled mother, trying to obtain custody of his mother, financial stress, and other incidents of life which are not manifestations of his PTSD. The Board concludes that secondary service connection has not been properly raised by the Veteran's statements. As such, the Board finds that the preponderance of the evidence is against the Veteran's service connection for a skin disability claim. Consequently, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. b. Gastrointestinal Disability The Board finds that the Veteran's gastrointestinal disability was not present during service and is not the result of any incident of service. The Board also finds that the Veteran's gastrointestinal disability was not caused or aggravated by a service-connected disability. The Board concludes that service connection is not warranted on direct and secondary bases. The Veteran was seen at a June 2012 VA examination in connection with this claim. The examiner indicated that the Veteran bore a current diagnosis of gastroesophageal reflux disease (GERD). The current disability is established. See Shedden. The Veteran's May 2005 claim for a gastrointestinal disability indicates that the gastrointestinal disorder occurred originally in military service and was recurring at the present time. In his January 2009 substantive appeal, the Veteran contended that the gastrointestinal disability was psychosomatic and the result of a service-connected psychiatric disability. During his hearing before the undersigned, the Veteran testified that he received treatment for what he called "stomach distress" during service but only received antacids, which he believed would not be reflected in his service treatment records. He also reported finally receiving a diagnosis of acid reflux in 2002. The Veteran is competent to report stomach distress during service. See Jandreau. The Board finds, however, that he has not done so credibly. The Veteran's service treatment records do not contain mention of a gastrointestinal disorder. An April report of medical history indicates that the Veteran denied frequent indigestion at entrance to service. An April 1969 entrance to service physical examination report and an April 1971 separation from service physical examination report indicate that the Veteran's abdomen and viscera were clinically normal. The remaining service treatment records do not show complaints or treatment related to the gastrointestinal system. The Board is not persuaded by the Veteran's statement that his in-service "stomach distress" treatment was not written down. The absence of evidence may not generally be considered as substantive negative evidence. See McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006); see also Forshey v. Principi, 284 F.3d 1335, 1363 (Fed. Cir. 2002) (en banc) (Mayer, C.J., dissenting) (distinguishing between the existence of negative evidence and the absence of actual evidence and noting that "[t]he absence of actual evidence is not substantive 'negative evidence' "). The absence of an entry in a record may be evidence against the existence of a fact if it would ordinarily be recorded. See Fed. R. Evid. 803(7). The Veteran alleges that he sought treatment for "stomach distress" while serving aboard ship in the Navy. Although the Veteran has alleged that the treatment was so minor that it would not have been recorded, the Board notes that ordinary medical practice for a ship's doctor would be to record all visits to sickbay, the reason for the service member's visits and what the findings and resolution were. The Veteran's service treatment records appear to be complete. The fact that there is no record of treatment for stomach complaints is strong evidence that stomach complaints did not occur during service. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (stating that VA may use silence in the service treatment records as evidence contradictory to a veteran's assertions if the service treatment records appear to be complete and the injury, disease, or symptoms involved would ordinarily have been recorded had they occurred). The Veteran's private treatment records also indicate that the Veteran's reflux disease was not present during service and has not been persistent since that time. A September 1977 radiology summary is of record, indicating that the Veteran had been seen complaining of abdominal pain, severe, heartburn and gastrointestinal distress. Imaging was negative. He was given an antacid and referred to a gastrointestinal specialist. The Board notes that this record, dated more than six years after separation, is the earliest credible reference to heartburn and abdominal pain. In October 1978, the Veteran was seen again for chronic gastrointestinal pain and discomfort. The Veteran was placed on a bland diet and instructed to follow up with his own physician. An August 2002 gastroenterology report indicates the presence of recurrent reflux disease. The Veteran reported at that time that he had complaints of recurrent heartburn for the past ten years, dating to approximately 1992. He also reported upper abdominal discomfort periodically, unrelated to meals or bowel movements. A November 2002 gastroenterology consultation noted mild GERD. No estimation of the time of onset or earliest lay observable symptoms was provided. A second letter, dated May 2008, from the same gastroenterologist indicates that the Veteran had similar complaints reflux in 2008. The May 2008 letter also states that the Veteran had periods of exacerbation of reflux which seemed "to be primarily dietarily related." The June 2012 VA examination, the Veteran stated that he began having problems with frequent heartburn in 1995. The Veteran reported treatment through a gastroenterologist who prescribed medication. The Veteran reported that he had a previous endoscopy done in 2009 which was unremarkable. The examiner concluded that the GERD was not likely related to in-service treatment as he had no evaluation or treatment for the condition while in the military and had no history of confirmed treatment for GERD in the military. The Board has found the Veteran's account of in-service treatment not credible. Moreover, the Veteran has not provided a history of lay observable, persistent symptoms dating to service, only since 1992 at the earliest. There was no credible lay evidence of lay observable symptoms during or for years after separation from service. The examiner's reliance on service treatment records is appropriate in this case. The preponderance of the evidence of record does not establish that GERD was present during service or is related to some incident of service. The Veteran has not presented a credible account of seeking treatment for stomach distress during service. There is no other in-service injury or disease to which the GERD may be related. The earliest credible evidence to show gastrointestinal symptoms is dated more than six years after separation. The Veteran's statements during the course of medical treatment in August 2002 and during the course of the June 2012 VA examination indicate onset of lay observable symptoms in 1992 or 1995. The Veteran has not testified or provided a statement to the effect that he has had persistent GERD symptoms, such as heartburn, since service. The Board finds that the preponderance of the evidence is against a relationship between the current GERD disability and any incident of service. Service connection is not warranted on a direct basis. See Shedden. The Veteran has also contended that his GERD was either caused or aggravated by his service-connected psychiatric disability. The Veteran's testimony was to the effect that a Dr. M. may have provided an opinion that it was stress related. In review of the file, the record does not include such an opinion. At best, his statements are confirmed in a March 2011 letter from a psychiatrist, Dr. A.K., stated that the Veteran had come in complaining of many psychosomatic issues including "GI problems." The Board cannot tell from the context of this statement whether this statement represents a medical opinion or reports the Veteran's statements. The Veteran's underlying treatment notes do not discuss psychosomatic complaints. Other letters discussing potential psychosomatic complaints do not mention the presence of gastrointestinal symptoms. Similarly, the March 2011 letter lacks enough specificity for the Board to determine whether the psychiatrist is aware of the GERD diagnosis. The Board assigns little probative value to this letter. The Veteran has not reported how he, as a lay observer, could know that his GERD was either caused or aggravated by his psychiatric disability. The June 2012 VA examination report contains an opinion that the GERD was neither caused nor aggravated by the Veteran's PTSD. The examiner's rationale was that PTSD did not cause or aggravate GERD. The preponderance of the evidence is against a causal or aggravation relationship between the Veteran's GERD and his PTSD. The June 2012 VA opinion indicates that the general medical principle is that PTSD does not cause or aggravate GERD. The March 2011 statement from A.K. does not provide sufficient information for the Board to determine that the full extent and nature of the gastrointestinal complaints were known to A.K. The Board finds that the June 2012 VA opinion outweighs the Veteran's statements and the March 2011 opinion from A.K. The remaining evidence of record does not address a potential relationship between PTSD and GERD. The Board finds that the Veteran's GERD was neither caused nor aggravated by the Veteran's service-connected PTSD. In the absence of a causal or aggravation relationship, service connection is not warranted on a secondary basis. As such, the Board finds that the preponderance of the evidence is against the Veteran's service connection for a gastrointestinal disability claim. Consequently, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Increased Ratings The Veteran contends that he is entitled to an initial rating in excess of 50 percent and TDIU for his PTSD. For the reasons that follow, the Board concludes that an increased initial rating of 100 percent is warranted prior to June 9, 1998, but that an initial rating in excess of 50 percent and TDIU are not warranted on and after that date. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2013); 38 C.F.R. § 4.1 (2013). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2013). However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14 (2013). The Board awarded an effective date of service connection of October 4, 1995, for PTSD in a May 2012 decision. During the pendency of this claim, the criteria for rating psychiatric disabilities were revised (effective November 7, 1996). See 61 Fed. Reg. 52,695-52,702 (October 8, 1996) (codified at 38 C.F.R. §§ 4.125, 4.126, 4.130, Diagnostic Code 9411 (1997)). The Board will evaluate the Veteran's claim under the criteria in the VA Schedule for Rating Disabilities in effect at the time of his filing and under both the prior and current regulations on and after November 7, 1996, in order to ascertain which version would accord him the highest rating. See VAOPGCPREC 7-2003 (Nov. 19, 2003); VAOPGCPREC 3-2000 (Apr. 10, 2000); 38 U.S.C.A. § 5110(g) (West 2002 & Supp. 2013); 38 C.F.R. § 3.114 (2013). Prior to November 7, 1996, PTSD was evaluated under Diagnostic Code 9411, found in 38 C.F.R. § 4.132 (1996). Under the General Rating Formula for Psychoneurotic Disorders in place at that time, a 50 percent evaluation required that the Veteran's ability to establish or maintain effective or favorable relationships with people was considerably impaired, by reason of psychoneurotic symptoms the reliability, flexibility and efficiency levels were so reduced as to result in considerable industrial impairment. A 70 percent evaluation was assigned when the ability to establish and maintain effective or favorable relationships with people was severely impaired, and the psychoneurotic symptoms were of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. A 100 percent evaluation was assigned when the attitudes of all contacts except the most intimate were so adversely affected as to result in virtual isolation in the community, or when there were totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic, and explosions of aggressive energy resulting in profound retreat from mature behavior, or when the veteran was demonstrably unable to obtain or retain employment. 38 C.F.R. § 4.132 (1996). Note (1) to the General Rating Formula for Psychoneurotic Disorders as in effect prior to November 7, 1996, provided that social impairment per se will not be used as the sole basis for any specific percentage evaluation, but was of value only in substantiating the degree of disability based on all of the findings. 38 C.F.R. § 4.132 (1996). The terms "totally," "considerable" and "severe" in 38 C.F.R. § 4.132 were quantitative in nature. See Hood v. Brown, 4 Vet. App. 301, 303 (1993), vacated on other grounds 7 Vet. App. 553 (1995) (per curiam order). VA's Office of General Counsel issued a precedent opinion concluding that "considerable" was to be construed as "rather large in extent or degree." See VAOPGCPREC 9-93. The Board is bound by this interpretation of the term "considerable." See 38 U.S.C.A. § 7104(c). On and after November 7, 1996, PTSD has been rated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). Ratings are assigned according to the manifestation of particular symptoms. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact a veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. Under the provisions for rating psychiatric disorders, a 50 percent disability rating requires evidence of the following: 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. The criteria for a 70 percent rating are: 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.) The criteria for a 100 percent rating are: 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; 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board notes that the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including (if applicable) those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). See Mauerhan, supra. Within the DSM-IV, Global Assessment Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). While not determinative, a GAF score is highly probative as it relates directly to the veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). According to DSM-IV, a score of 61-70 illustrates "[s]ome 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." Id. A score of 51-60 represents "[m]oderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co-workers)." Id. A score of 41-50 illustrates "[s]erious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)." Id. Initial Rating for PTSD The Veteran filed a claim on October 4, 1995, indicating that he could not work due to his psychiatric disability. The claim indicates that he had depression and anxiety which began in April 1994. He reported seeking treatment at two facilities, from April to June 1995 at Wayne General Hospital and one week in June 1995 at St. Mary's Hospital. An intake note for Wayne General Hospital dated June 1, 1995 represents the first psychiatric treatment for the Veteran. He reported chronic feelings of hopelessness, helplessness, depression, losing 70 pounds over the past several months and losing his part-time job as a florist in March 1995. He reported a B.A. in Social Sciences. He also reported civil service jobs in the past at the post office, in welfare, and security. His mood was depressed and anxious with a flat affect. His insight, judgment, attention and memory were poor. He had concrete thinking, circumstantial speech and preoccupations with caring for his mother. He was also alert and oriented times three and denied suicidal and homicidal thoughts. After discharge, the Veteran began individual counseling. A June 14, 1995 counseling note shows that the Veteran was sweating and shaking and had to take many breaths to speak. The Veteran got disorganized and confused often. He had numerous outstanding tickets for traffic violations and was afraid of losing his license for a year. A June 15, 1995 counseling note shows that the Veteran had been taken to the emergency room by an ambulance who also took his mother for care. The Veteran was having a severe panic attack and exhaustion. The counselor indicated in the notes that the Veteran needed a partial care program but would not leave his mother alone for more than an hour or two. Records from St. Mary's showed a one week admission for severe depression, anhedonia, tearfulness, helplessness, hopelessness, poor appetite and sleep and a weight loss of 60 pounds in the previous six months. The Veteran had been attending individual therapy session and decompensated. Although the intake evaluation indicates that this was an involuntary commitment, he was admitted to the voluntary psychiatric unit. He was referred to the New Horizons program on discharge. The diagnosis was a single episode of major depression, severe, with dysthymia and schizoid features. A GAF score of 50 was assigned. A June 30, 1995, intake note for Wayne General Hospital states that the Veteran regained 25 pounds while hospitalized at St. Mary's and that his symptoms stabilized on a new course of medication. His educational/vocational functioning was described as poor, but also indicated that he had credits from courses at several schools and was accepted by another. The Veteran was acting as primary caregiver for his mother and denied other social contacts. The Veteran reported being on probation for credit card fraud. He described his problem as involving care for his mother and his need for assistance in caring for her. The note's author indicated that the Veteran was isolated from the outside world, had problems with activities of daily living and an inability to function with others due to poor social skills. On mental status exam, the Veteran was oriented times three, was casually dressed but somewhat disheveled. He had poor ADLs. His speech and thought processes were coherent and relevant. His thought content was preoccupied with caring for his mother. His affect was mildly flat and his mood euthymic. His insight, judgment, attention and memory were fair. He had no impairment of cognitive functioning. He denied suicidal or homicidal ideation. The Veteran was seen for an August 1995 psychiatric evaluation for depression by a psychiatrist at Wayne General Hospital. The Veteran reported that he lived with his mother, who had Alzheimer's dementia. He had one brother and his father had died a few years previously. The Veteran reported having a Bachelor's degree in science but had never worked in the field. He reported working a few jobs as a florist and that he was laid off in March 1995. On mental status exam, the Veteran was casually dressed, looked stated age, with fair personal hygiene. His speech was coherent and relevant. His mood was sad, with a congruent affect. He denied hallucinations. No delusional ideation was elicited. He denied homicidal and suicidal ideation, plan or intent at that time. He was oriented times three with intact memory, logical thought processes. His insight and judgment were fair. Individual therapy and partial care hospitalization were recommended. No GAF score was offered. Treatment notes from August and September 1995 show that the Veteran reported ongoing problems with his mother's care and that Adult Protective Services had placed her into a nursing home. He also was in contact with the Alzheimer's Association and the SSA during this period. The Veteran also had his driver's license confiscated and expected to lose the license for traffic violations. The Veteran's social and occupational functioning is not directly described. An October 1995 evaluation was conducted at Wayne General Hospital. The Veteran reported that he had been living off his mother's financial benefits and that her placement into a nursing home would leave him without a place to live. He claimed that he lost his job in March 1995 because he used credit cards belonging to his employer for personal use. He was charged for the crime but received probation. He also lost his driver's license due to numerous violations. On mental status exam, the Veteran was calm and cooperative. He was casually dressed and appeared to be of the stated age. He had good eye contact and was verbal, but spoke monotonously in a low tone and in brief sentences. There was no evidence of any mannerisms or stereotypical behavior during the interview. His mood was depressed and affect restricted. There was no evidence of looseness or flight of ideas. He denied phobias, obsessions or compulsions. He did report symptoms of panic disorder and anxiety. He denied agoraphobic symptoms. He was alert and oriented to person, place and time. He denied psychotic symptoms and no delusions were in evidence. There was no evidence of suicidal or homicidal ideation. His memory in the remote, recent and immediate past was well preserved. He was insightful and judgment was improving. He received a current GAF score of 40 and a 45 over the past year. The Veteran was appropriate for admission into a partial care day program five days a week. He was to be assigned to social enhancement and vocational groups. Records of participation in a partial care program are not of record. The RO granted pension benefits in January 1996 on the basis of his psychiatric disability, which the RO stated rendered him unable to secure and follow a substantially gainful employment. The Veteran underwent a February 1996 psychiatric evaluation in connection with a SSA disability claim. The Veteran reported working from 1988 to 1995 at a florist's greenhouse. He also worked at the same time as a meter reader for the local municipality. He reported being attacked working as a meter reader by a dog and injuring his neck and back in June 1995. The Veteran reported having a fear of going places after the dog attack. He reported the onset of anxiety attacks. On mental status examination, the Veteran was clean, tidy, and slightly overweight. He was dressed with good, casual clothing. He knew the day, month and year. He remembered three of three items in a few minutes. Abstracted analogies showed normal intelligence. He was logical and reality oriented. Mood was moderately depressed and stable. Affect was constricted and appropriate. Concentration was adequate for the interview. Orientation, memory, information, judgment, and insight were all adequate. He was able to sleep through the night with medication. He did all chores around the house. He takes care of bills and shopping. The Veteran liked reading, art, drawing, and building ship models. He had a couple of friends and converses with them occasionally. He did not date. The examiner indicated that the prognosis was fair. From observation, the Veteran seemed able to perform simple, repetitive chores. The Veteran participated in individual counseling at Wayne General Hospital from September 1997 to May 1998. The Veteran reopened treatment in August 1997 at the hospital complaining about depression, anxiety, living alone, and lack of direction in his life. He was seeking career and vocational counseling and indicated that he was unable to work. The Veteran underwent a September 1997 psychiatric evaluation. He reported being "mildly depressed" with unstable sleep, a decreased range of interests and poor concentration. The Veteran reported that he had been using medication. He was casually dressed and fairly groomed, appearing his stated age. He was easily engageable in interview. His mood was depressed with constricted affect. His rate of speech was normal. His thought processes were goal directed. He denied suicidal or homicidal ideation. He was preoccupied with feelings of hopelessness and helplessness. He did not show psychotic symptoms. His concentration was poor, short term memory fair. He recalled two items out of three. His fund of knowledge appeared to be intact. His insight was fair and he understood he had a psychological problem for which he needed treatment. His judgment was not impaired. Impulse control was good. The diagnosis was major depressive disorder, moderate, recurrent. A GAF score of 50 was assigned. The treatment records from September 1997 to May 1998 show that the Veteran was placed on various medication regimes until he had improvement in sleep and depression. He denied suicidal and homicidal ideation consistently. He did not have psychotic symptoms. His mood was consistently depressed. His affect was typically constricted. In October and November 1997 sessions, the Veteran considered himself able to function and not disabled. The November 1997 treatment note indicates that he was fighting to gain custody of his mother. The Veteran underwent another psychiatric evaluation in connection with a SSA disability claim in November 1997. The Veteran reported past employment as a meter reader and as a handyman/helper for a florist. He was receiving regular treatment and was on medication. The Veteran's responses on testing were characteristic of brooding, over sensitivity, and tending to flee interaction with others as unduly stressful. The Veteran's scores on memory, attention, and concentration testing indicated deficient functioning, which the examiner found consistent with an affective disorder. The Veteran had flat affect, avoidance of social interactions, anhedonia, lack of energy and feelings of fatigue, and difficulty sleeping. He reported having no friends and riding a bicycle 15 blocks every day to visit his mother in a nursing home. The Veteran reported to the examination by himself, using public transportation. Due to the timing of bus schedules, he arrived early and spent time at a nearby public library browsing through journals. He was appropriate in appearance with good grooming and hygiene. He was alert and oriented. He appeared to put maximum effort into all items presented. He was a good historian. His insight was adequate. He related fairly well to the examiner but lacked spontaneity and appeared rigid and over controlled. His conversations were goal oriented, with no circumstantial or tangential thinking noted. His affect was flat, suggestive of underlying depression. Based on the examination results, the examiner concluded that the Veteran was not able to function in a full time competitive work setting. The Veteran began seeking treatment from New Bridge in June 1998 and records in the claims file reflect treatment until May 2000. A June 1998 treatment note shows that the Veteran reported depression and anxiety and that medication and counseling helped. He spoke coherently and relevantly. He denied hallucinations. No delusions were expressed. He was oriented to time, place, and person. He did not have memory impairment. He had some insight and his judgment was fair. He was given a GAF score of 55/50. The Board notes that GAF scores reported in this manner refer first to the GAF score on the day of evaluation and second to the score during the previous year. October and November 1998 entries note that his depression was controlled, with improved functioning in November. The Veteran had some sleep disruption in January and February 1999, which resolved with a medication change. He was psychiatrically stable by April 1999. His medications were reduced in October 1999. By the end of the New Bridge treatment notes in May 2000, the Veteran denied anxiety and depression but did report some trouble sleeping. A July 2000 letter by a Dr. R. R.-F. from New Bridge was written to whom it may concern. The letter indicates that the Veteran had complaints of insomnia, poor attention and concentration, somatic complaints such as fatigue, muscle tension, headaches, heart palpitations, irritability, constant worry and phobias. He remained socially isolated. He was on medication and had weekly individual therapy sessions. A June 2001 reevaluation was conducted at New Bridge. This psychiatrist was the author of the 1998 to 2000 treatment notes discussed above. The Veteran had a history of recurrent anxiety and depression. There had been no hospitalizations since 1998. The Veteran had been stable on a medication, but switched due to difficulty swallowing the pills. On mental status examination, he was alert, calm, pleasant, and cooperative. His mood was euthymic. He was relevant, coherent and no cognitive impairment was observed. He was given a GAF score of 60/55. The same psychiatrist wrote a June 2001 letter on the Veteran's behalf. The doctor indicated that the Veteran had symptoms of insomnia, sleep cycle deprivation and interruption, sleep deprivation, social isolation, "unattentive" concentration and memory. The doctor also mentioned physical symptoms of fatigue, muscle tension, headaches, heart palpitations, irritability, excessive worry and phobias. The letter does not explain why these additional symptoms were not reported in the reevaluation or in the regular counseling notes from 1998 to 2000. A June 2001 VA examination report indicated that the Veteran had received treatment for depression and was currently on medication. The report noted a history of one psychiatric hospitalization. The Veteran had a history of suicidal ideation but no history of suicidal behavior. This history appears to refer to the 1995 hospitalizations. The Veteran reported intermittent depressed moods and poor sleep. He indicated that his concentration was okay. He denied feelings of helplessness, hopelessness and worthlessness. He was not irritable. He did not have hypervigilance. The Veteran reported that he was not working at the time, indicating past odd jobs like helping his brother. He stated that business was slow as the reason for his current unemployment. The Veteran reported that he never married, had no children, and lived alone. He had very little social contact. On mental states examination, the Veteran was dressed casually and was cooperative. His mood was neutral, affect blunted. His speech was normal. There were no perceptual problems. Thought process and content were normal. There were no suicidal or homicidal ideations. He was oriented to person, place, and time. Memory was one out of three. He was able to do serial 7's. His insight, judgment, and impulse control were fair. He denied recent stressful life events. The examiner diagnosed depression, not otherwise specified, and assigned a GAF score of 50, noting sporadic employment and isolative behavior. As to employability, the examiner repeated that the Veteran was unemployed because business was slow. The Veteran received another private evaluation in July 2001 from Dr. R. R.-F. The psychologist indicated that the Veteran had PTSD with a history of depression and panic disorder. The Veteran reported joining the Navy before age 18 and serving eleven months in combat in Vietnam. He reported completion of a college degree but never using the degree, working only at odd jobs. He was on Social Security disability benefits at that time and helped his landlord with transportation and his brother in construction. The psychologist indicated that he was isolated, having no friends and visiting his mother at a nursing home. The Veteran was alert and oriented times three. His speech was monotonic, clear, and coherent. He reported his mental state as stable with only some severe sleep disturbance. Otherwise, his panic and depressive symptoms had stabilized. His affect was constricted and mood was appropriate. There was no evidence of suicidal or homicidal ideation. His thinking was goal directed. There was no thought disorder apparent. Insight was fair. The psychologist administered a battery of tests, concluding that the Veteran's language, short, long and semantic memory, attention, concentration, reasoning, and judgment were largely unimpaired. His responses to reasoning items could be considered concrete. His responses to questions of judgment were "somewhat" unusual. His clock drawing response showed attention to the task and motivation to do well. A January 2002 letter from a Dr. L.A. at New Bridge indicated the Veteran had symptoms of depression, including insomnia, poor attention and concentration, withdrawal with somatic complaints like headaches, fatigue, tension and palpitations. He worried a lot and had phobias. He reported nightmares of being lost in the forest of the Philippines and of being attached by bandits from the jungle. He also had dreams of the ship, presumably the ship he was stationed aboard during service, being attacked by sampans. He also had a startled reaction whenever a car backfired. The Veteran was on medication and received weekly individual therapy. An October 2002 letter on the Veteran's behalf was prepared based on a September 2002 evaluation of the Veteran. The doctor indicated that the Veteran had a permanent loss of function and that the Veteran was totally disabled and unable to work in any job capacity at the time. The Veteran underwent another psychiatric evaluation in January 2003 to determine eligibility for continued SSA disability benefits. The Veteran reported receiving ongoing treatment for depression and anxiety. The Veteran had multiple medications. He had some medical problems relating to an accident in June 2002 involving a truck. The Veteran reported clerical work in the past and last working last year for the municipality in maintenance. The Veteran reported spending the average day working around the house. He reported writing poetry and song lyrics. He also built model ships. He might go out to eat with the landlord and tried to socialize as much as he could when the opportunities presented themselves. The Veteran was dressed appropriately, was helpful and cooperative. He could follow the topic of a conversation. On mood and affect, the Veteran's mood was not particularly bright or seriously depressed. The examiner indicated that the medication regime had been helpful and that serious depressive symptoms were in remission. The examiner concluded that the Veteran was dysthymic on a chronic basis. His speech was normal. There were no hallucinations. His thought processes were normal. There was no thought insertion or withdrawal and no evidence of paranoia or delusions. The Veteran was oriented to time, person, and place. There was no evidence of memory dysfunction. He had a reasonable fund of general information. The examiner assigned a GAF score of 62. The examiner questioned whether he could not find a job and whether vocational rehabilitation was appropriate. In January 2003, the SSA determined that the Veteran was no longer disabled due to psychiatric disability based on the March 2002 opinion by Dr. M.E. and the January 2003 psychiatric evaluation. The decision letter notes that the current medical evidence demonstrated that the Veteran had only mild restrictions in his activities of daily living, maintaining social functioning, and in maintaining the concentration, pace and persistence necessary to perform basic work activity. As a result of the SSA's determination that he was no longer disabled, the Veteran filed a July 2003 claim for non-service-connected VA pension benefits. He claimed that anxiety, depression and PTSD prevented him from working. He reported a college degree and computer related, electronic schooling. Another set of New Bridge treatment records dated between 2003 and 2006 have been associated with the claims file. These treatment records show that the Veteran is generally stable, alert and oriented times three, appropriate dressed and groomed, with intact insight and judgment, and good impulse control. GAF scores were assigned, with 65-70 in September 2003, 70-80 in October 2004, and 65-75 in November 2005. The Veteran was seen for an October 2004 VA examination in connection with the pension claim. At the time, he reported being depressed and feeling anxious over his mother's situation. She remained in a nursing home. He reported that his depression dated to 1995 when he lost his car to a moving violation and lost his job. He reported having computer skills, but has not been employed in this capacity. He claimed the hours for computer jobs were not suitable for him. He reported helping the landlord with chores in the duplex that he currently occupied. The Veteran reported sleep problems, depression, and anxiety related to legal issues trying to gain custody of his mother and financial problems. Concentration was reported as adequate. He claimed that he had been compliant with his medication. The anxiety symptoms reported were hyperventilation, tremors, and feeling hot and cold. The Veteran denied working since 1995 but also reported getting injured at work and filing a Worker's Compensation claim in 2002. On mental status exam, the Veteran was alert and oriented to time, person, and place. He was calm and cooperative. His speech was productive, coherent, and relevant. His mood was euthymic and affect appropriate. Form of thought was sequential. He denied auditory and visual hallucinations. He denied suicidal and homicidal thoughts. No delusions were elicited. Judgment and insight were fair. The examiner assigned a GAF score of 72. The Veteran underwent a December 2004 private evaluation from a Dr. A.K. The Veteran was alert and oriented times three, with a depressed mood and constricted affect. His cognitive function seemed to be fair. He seemed anxious but cooperative. The Veteran reported working different jobs in the past, mainly computers. The Veteran obtained a December 2004 private evaluation from a Dr. P.C., the report of which is dated January 2005. The Veteran reported that his only psychiatric hospitalization was in 1995. The Veteran was alert and oriented to time, place, and person. His memory for recent and past events was good. His speech was lucid and coherent and pressured from within. His thought trends focused on physical and mental symptoms and were concrete. His mood was anxious and depressed. Dr. P.C. did not provide a description of the impact of the Veteran's psychiatric symptoms on his level of social or occupational functioning, only indicating that the pain and anxiety/depression limited activity. The evaluation noted that the Veteran's hobbies and activities included building model ships, writing poetry and song lyrics, and floral work. The report states that the Veteran "works" part time as a florist. This was the Veteran's employment until March 1995. It is not clear whether the Veteran had obtained another job as a florist at that time. The report also indicates that the Veteran was unemployed as a construction worker. The Veteran obtained another private evaluation in January 2005 from a Dr. M.P. The doctor wrote a narrative report indicating that the Veteran had PTSD and major depression. The Veteran was dejected and anxious without psychotic thought process. He was oriented in all three spheres. His judgment and insight were within normal limits. He did not have suicidal thoughts. Following the grant of service connection in May 2005, the Veteran filed a September 2005 Notice of Disagreement. He did not offer a description of his symptoms at that time. He also completed a VA Form 21-8940, indicating that he wanted to file for TDIU. The Veteran indicated on the form that he was prevented from following a substantially gainful employment by his psychiatric disabilities. A psychiatrist from New Bridge, Dr. R.C., sent three letters in support of the Veteran's claim in short succession. A December 2005 letter indicates that the Veteran had been tried on numerous medication regimes, most of which were changed as the medication lost efficiency. He was then on Remeron. The letter notes that the severity of the Veteran's depression and anxiety waxes and wanes and that he continued to need pharmacologic intervention. No assessment of functioning was included. An April 2006 letter indicates that the Veteran has been on various medications which have lost efficiency over time. Due to waxing and waning symptoms, the Veteran was not able to hold a job. The Veteran reported that he tried to work a number of times, but was not able to keep jobs for long due to worsening mood symptoms. He endorsed being uncomfortable and increased anxiety in crowded places. He had limited interaction with few friends and acquaintances. A December 2006 letter indicates that the Veteran is diagnosed with major depressive disorder, recurrent, moderate in severity. No other information as to functional impairment was offered. The Veteran submitted lay statements from friends in July 2007. The statements from L.P. and N.P. are identical to each other, as are statements from D.S. and K.S. The statements differ only in the signatures. These statements do indicate that these four individuals have known the Veteran for either "a very long time," or "for an extended [period] of time." The statements indicate that the Veteran had been distressed and affected by his mother's condit5ion, that because he took time to care for his mother, he had not taken care of his personal needs and that the Veteran encountered stress and pressure during his Naval service. The Veteran underwent another evaluation from Dr. M.P. in July 2007. On mental status examination, the Veteran was alert and oriented in all three spheres with dejected, anxious mood. He had good insight and judgment with decline in concentration and memory. He denied any suicidal thoughts at that time. The Veteran obtained a July 2007 evaluation from a Dr. L.H. The doctor indicated that the Veteran asked for a letter describing his mental status to continue receiving service-connected compensation. The Veteran described his current daily routine of reading, watching TV, writing poetry, and interacting with his landlord. His other activity was pursuit of a lawsuit to regain custody of his mother. The doctor concluded that the Veteran was not capable of working in a competitive marketplace. No description of symptoms was offered. The Veteran obtained another letter in support of his claim from Dr. R.C. in July 2008. The Veteran was on medication for depression, anxiety, and PTSD. He reported that his agitation had mostly subsided. He had nightmares. He remained anxious and depressed about his situation, dreams, nightmares continued. The Veteran obtained another evaluation from Dr. A.K. in March 2011. The Veteran was complaining about psychosomatic issues such as respiratory problems with panic attacks and GI problems. He continued "to have difficulty functioning with no jobs or anything with difficulty maintaining any job" (emphasis in original). He continued to have PTSD symptoms and denied current issues at the time. The Veteran was seen for another VA examination in May 2011. The Veteran reported living independently for the last 17 years and driving independently to the exam. He reported obtaining a college degree in 1977. He had a sporadic work history and not working full-time for almost 20 years. He worked in the restaurant business with his brother, in security, in computers, but the jobs never lasted for an extended period of time. The Veteran reported experiencing difficulty relating to others. He denied working at all since 2001, when he quit working temporary, part-time jobs. The Veteran qualified for disability in 1998 and has been on disability since that time, due to PTSD symptoms. He reported going to New Bridge Services four times a year and receiving private psychiatric care. He reported trying a variety of medications and that the only medication that somewhat controlled and stabilized his symptoms was Paxil. The examiner concluded that the Veteran's symptoms were consistent with PTSD. The Veteran arrived on time for his scheduled appointment. He was alert, cooperative, dressed and groomed appropriately. Motor activity was calm. Mood and affect were indifferent, aloof, and restricted. Speech was normal. There was no evidence of perceptual impairment or any evidence of thought disorder. Thought content was appropriate to the examination. He denied both suicidal and homicidal ideation and was oriented to time, place, and person. Memory, concentration, abstract reasoning, judgment, impulse control, and insight were all intact. The Veteran tended to be extremely isolative. He enjoyed model ship building, poetry and song writing, reading, landscaping and floral design. The Veteran denied ever being arrested. The Veteran was fully independent with regard to all activities of daily living. The Veteran's PTSD was marked by recurring intrusive thoughts and flashbacks. He avoided thoughts and activities there were associated with his experience. He had decreased interest in formerly enjoyable activities. He felt detached and estranged from others and exhibited restricted affect. He had difficulty falling and staying asleep, exhibiting irritability, hypervigilance, and an exaggerated startle response. The examiner indicated that the Veteran's PTSD was of moderate severity, and assigned a GAF score of 51. The Veteran's symptoms would make work difficult, but the examiner concluded that the symptoms would not be enough to prevent him from being able to work. His functional impairments included impaired sleep, isolation, avoidance of recreation and leisure activities, heightened arousal, flashbacks and mood swings, with restricted affect and depression. The examiner noted the presence of schizotypal personality traits that, while not rising to the level of an Axis II diagnosis, contributed to isolative behavior. The Veteran testified in November 2011 before the undersigned. He asserted that he was prevented from working in gainful employment. He indicated that he had little social involvement apart from his landlord. He also denied panic attacks at the present, endorsing depression and anxiety. The Veteran claimed he had not worked a substantially gainful job in about 22 years, stating that he would get part-time jobs lasting only a few months. He also stated that his PTSD did not bother him until after his mother became ill in 1995. He also claimed that his PTSD was an impediment, along with other life problems, in getting involved in an intimate relationship. The Veteran also testified that, since his last job, he had not tried to look for work. He stated that there was not much available work. He reported having some experience working "in the forest" and that he could do that at present. He also testified that there were other jobs that he could get, but with his mother's issue and his physical matters, he had not taken the time to look for work. He also testified that he assumed that an employer would not hire him because of his psychiatric symptoms. The Veteran solicited another letter in support of his claim from Dr. R.C. in December 2011. R.C. described the Veteran's psychiatric disability history briefly. R.C. indicated that medications were used to fairly good effect, but that the effects of specific medications would not last long. He indicated that the "waxing and waning" of psychiatric symptoms prevented the Veteran from holding a job for long because the pressures and stresses of work resulted in worsening psychiatric symptoms. R.C. indicated that, over time, the Veteran has lost basic skills and trust in himself to do the things that he is expected to do including having the mental capacity to withstand the rigors and responsibilities of a job. The doctor concluded that the Veteran had made significant gains in control of his psychiatric symptoms, but his functional capacity remained generally limited to the barest minimum such as performance of household chores and non-complicated activities including pursuing disability benefits from the Navy. The Veteran was seen for another VA examination in June 2012 with the same examiner that conducted the May 2011 VA examination. The examiner reviewed the claims file and indicated that there was no change in the Veteran's disability from the May 2011 VA examination. The Veteran continued to "obsess" over his mother's care in a nursing home. He was otherwise estranged from living family members. He was isolated. He had never had a productive, intimate relationship. The Veteran claimed his SSA disability benefits were originally for his mental condition and then later his medical condition was added. He was not working at the time, but reported past employment in clerical, florist, and computer work. The Veteran saw a private psychiatrist every 12 weeks and was on medication. The Veteran reported that the medication was effective in reducing his anxiety, depression, and PTSD. The examiner noted evidence of progress and significant attenuation of symptoms secondary to successful medication management. The Veteran endorsed symptoms of PTSD. He had depressed mood, anxiety, suspiciousness. The examiner indicated that the Veteran had both difficulty in and an inability to establish and maintain effective work and social relationships. He had difficulty in adapting to stressful circumstances. The examiner noted schizotypal traits. The examiner indicated that, on further review, the Veteran's level of functioning was better than he previously found in May 2011 and assigned a GAF score of 54. The examiner indicated that the Veteran was "clearly able to sustain the demands of employment..." in any of the fields he had worked in the past. In light of the foregoing, the Board finds that the Veteran was unable to obtain or retain substantially gainful employment as of the date of service connection. The Veteran had multiple commitments for psychiatric symptoms in the months prior to October 4, 1995. The Veteran had lost 60 to 70 pounds when untreated for his psychiatric disability, recovering only during and after his hospitalizations. The Veteran was isolated from the outside world, had problems with daily living and had an inability to function due to poor social skills. The October 1995 Wayne General Hospital evaluation, which is the closest evaluation in time to the date of service connection, showed the need for intensive, partial hospital care five days a week. The Board finds that the Veteran had totally incapacitating psychoneurotic symptoms as of the date of service connection. The criteria for a 100 percent rating are met as of October 4, 1995. See 38 C.F.R. § 4.132, DC 9411. The record does, however, show that the Veteran improved during the course of medical care. The February 1996 SSA psychiatric evaluation and individual counseling records from Wayne General Hospital show ongoing social isolation and a belief on the Veteran's part that he was not disabled but in need of career and vocational counseling. The Veteran's self-care improved. The reports show moderately or mildly depressed mood with constricted affect. His concentration and memory were questioned. Medication had reduced his symptoms. The February 1996 SSA evaluation indicated that the Veteran would be able to perform simple, repetitive tasks. The Veteran's GAF score was raised from 40-45 in October 1995 to 50 in September 1997. On the other hand, a November 1997 SSA psychiatric evaluation concluded that the Veteran was not able to work in a competitive environment. The Board notes that the SSA evaluations of employability are somewhat cursory, providing detailed backgrounds but not rationales for the conclusions reached. New Bridge treatment records showed another improvement in GAF scores to 55/50 in June 1998. Treatment notes describe improved function in October and November 1998, with stable symptoms by April 1999 and reduced medications by October 1999. By June 2001, the Veteran had a GAF score of 60/55. GAF scores of 51-60 generally represent "moderate" symptoms, for example moderate difficulty in social or occupational functioning. DSM-IV, supra. This contrasts with GAF scores of 41-50, which indicate serious impairment, such as an inability to keep a job. Id. The psychiatrist assigning the improved GAF scores, Dr. R.C., also authored several letters on the Veteran's behalf to the effect that the Veteran had physical symptoms associated with his disability which do not appear in the regular treatment notes. Dr. R.C. also repeatedly stated that the Veteran's symptoms precluded employment, which is not consistent with the GAF scores he assigned. The letters from R.C. also describe the presence of psychosomatic complaints, such as muscle pain and tension headaches, which are not present in the regular treatment notes. Medical records generally describe the patient's complaints as to physical condition. Psychosomatic complaints are the sort of thing that would appear in regular treatment notes if they were present. They are not present in the Veteran's treatment notes in this case. The Board finds that the accounts of psychosomatic complaints are not credible. Moreover, the Veteran has separate medical diagnoses for many of his supposedly psychosomatic symptoms, including skin, respiratory, and gastrointestinal symptoms. The Board finds the preponderance of the evidence is against a finding that the Veteran has psychosomatic complaints. The Veteran also began reporting working odd jobs at the June 2001 VA examination. The Veteran continued to have very little social contact through January 2003 when a SSA psychiatric evaluation noted that the Veteran tried to socialize as much as he could, including with his landlord. The Veteran also reported working for the local municipality in 2002 in maintenance. Although the Veteran continued to have symptoms of psychiatric disorders, these were controlled on medication. The Board notes that there are several medical opinions in favor of the claim that are of little probative value. An October 2002 letter did not provide a description of the Veteran's symptoms or rationale for its opinion; instead, the doctor asserted his conclusion. Moreover, the doctor was director of a spine, orthopedic, and sports rehabilitation center. The doctor's specialty is not appropriate to the disability under consideration. In the absence of rationales, the Board affords this opinion little probative weight given the adequate opinions from psychologists, psychiatrists, and counselors. Similarly, July 2007 and March 2011 letters from Drs. L.H. and A.K., respectively, lack rationales for their conclusions that the Veteran was unable to obtain or maintain employment. The probative value of a medical opinion is based, in part, on whether the medical professional applied principles and methods reliably to the facts of the case. See Nieves-Rodriguez v. Shinseki, 22 Vet. App. 295, 300 (2008). In the absence of a rationale, the Board places little probative value on the July 2007 and March 2011 opinions. Given the existence of extensive, reasoned, and thorough opinions in the record, the Board must give greater weight to the remaining medical evidence. Another set of opinions lacks sufficient specificity to rate the Veteran's service-connected PTSD. July 2000, June 2001, January 2002, December 2005, and July 2008 letters from psychiatrists at New Bridge identify some symptoms, but do not quantify those symptoms, their frequency or degree, as necessary for rating under the prior version of DC 9411. See Hood, 4 Vet. App. at 303. The April 2006 letter from a New Bridge psychiatrist, Dr. R.C., indicates that the Veteran was not able to keep a job. In contrast, the December 2006 letter from Dr. R.C. described the Veteran's symptoms as recurrent and moderate in severity. December 2004, January 2005, July 2007, July 2008, March 2011 letters from Drs. A.K., M.P., L.H., and R.C. also lack quantification of symptoms, frequency or degree. Id. The Board places little probative value on these evaluations under the previous version of DC 9411. The Board finds that the preponderance of the evidence demonstrates that the Veteran's PTSD symptoms were no longer productive of virtual isolation in the community, totally incapacitating psychoneurotic symptoms, or demonstrable inability to obtain or retain employment as of June 9, 1998, the date of the June 1998 New Bridge treatment note showing an improved GAF score indicating "moderate," not serious or severe, symptoms. The Veteran continued to have few social contacts, but began working odd jobs and seeking out socialization opportunities. The Veteran's main manifestation of impairment was his isolation, which is not dispositive in the assignment of disability evaluation. See 38 C.F.R. § 4.132, DC 9411 at Note (1). The Veteran's other PTSD symptoms were much improved. He lived independently. He obtained several jobs, though they were not sustained for long periods of time. The July 2007 lay statements regarding the witnesses' long acquaintance with the Veteran may be taken as evidence that the Veteran was not virtually isolated from the community on and after June 9, 1998. His November 2011 testimony indicated that he thought that he could work some jobs but had not pursued employment for other reasons. He also testified that he assumed that an employer would not hire him with his disability, but an assumption is not competent lay evidence. See 38 C.F.R. § 3.159(a)(2). The Veteran also reported training in and working some jobs with computers during the period on appeal. He also obtained employment through his local municipality. The June 2012 VA examination report indicated that the Veteran would be able to sustain employment in clerical, florist, and computer work. The SSA determination that the Veteran had retained functional capacity also weighs against a finding of unemployability. The Veteran has not described his income level from any of these jobs, which prevents meaningful analysis of his compensation was substantially gainful. The Veteran's testimony before the undersigned was that he could not obtain substantially gainful employment and had been without such employment for 22 years, dating to approximately 1989. He also testified that his PTSD did not bother him until 1995. The remaining record does not explain why the Veteran was not substantially gainfully employed from 1989 to 1995 in the absence of PTSD. The Veteran was also charged with theft for misuse of an employer's credit card and lost his job in 1995, as described in his hospitalization records. The Veteran was also impeded by the loss of his driver's license and vehicle for moving violations. There is no indication of how his PTSD caused moving violations. These findings represent a significant improvement in overall functioning to the point where the preponderance of the evidence is against virtual isolation in the community, totally incapacitating psychoneurotic symptoms, or demonstrable inability to obtain or retain employment as of June 9, 1998. The Board concludes that a 100 percent rating is not warranted under the previous DC 9411 on or after June 9, 1998. The Board also finds that the weight of the lay and medical evidence demonstrates that Veteran's PTSD was not productive of severe impairment in the Veteran's ability to establish and maintain effective or favorable relationships or the ability to obtain or retain employment. The Veteran's PTSD symptoms came under control on and after June 9, 1998. The Veteran's anxiety and depression went into partial remission. The GAF scores indicate improvement in symptoms to a "moderate" level of impairment. The Veteran's mood was affected by depression and his affect constricted during this period; however, his panic attacks appear to have stopped, his anxiety and sleep improved, his behavior was appropriate, his speech coherent and relevant, and he was independent in activities of daily living. Although there are entries of anhedonia, the Veteran reported several hobbies and interests. The Veteran developed longstanding friendships as shown by the July 2007 lay statements on his behalf. The Board finds that the Veteran's weight of the lay and medical evidence demonstrates that that level of impairment from PTSD was not "severe" on and after June 9, 1998. The Board concludes that a 70 percent rating is not warranted on or after June 9, 1998, under the previous ratings criteria. See 38 C.F.R. § 4.132, DC 9411. The Board turns to the current version of the ratings criteria under 38 C.F.R. § 4.130, DC 9411. The weight of the lay and medical evidence demonstrates that the Veteran's PTSD was not productive of occupational and social impairment with deficiencies in most areas on and after June 9, 1998. The Veteran does not have deficiencies in judgment or thinking on and after June 9, 1998. The assessments since June 1998 characterize his judgment as fair to good. His insight has been intact throughout this period. The Veteran also completed some sort of training for computers. This is the only reported educational or vocational training in the period beginning on June 9, 1998. Thus, the preponderance of the evidence does not show deficiencies in school. The effect of the Veteran's PTSD on his family relations is difficult to determine but does not appear deficient during this period. The Veteran's father had died and his mother had already been institutionalized with dementia prior to the effective date of service connection. The Veteran never married nor had children of his own. The Veteran has been diligent in visiting his mother and maintaining a relationship with her, despite her condition. The record shows that the Veteran's only brother gave him odd jobs from time to time. Given the contact with his brother, the Board finds that the evidence preponderates against deficiencies in family relations. The Veteran did have deficiencies in mood, with persistent, though alleviated, symptoms on and after June 9, 1998. The Board acknowledges the Veteran's persistent depression affecting his mood. Given the lack of deficiencies in school, family relations, judgment and thinking, the Board finds that the Veteran's symptoms overall are not productive of deficiencies in most areas. See Vazquez-Claudio. A 70 percent rating is not warranted on and after June 9, 1998 under the current ratings criteria. See 38 C.F.R. § 4.130, DC 9411. Where entitlement to compensation 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. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Consistent with the facts found, the rating may be higher or lower for segments of the time under review on appeal, i.e., the rating may be "staged." Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has considered the possibility of staged ratings and has assigned a staged rating prior to June 9, 1998. The Board, however, concludes that the criteria for a rating in excess of 50 percent have at no time been met on or after June 9, 1998. Accordingly, further staged ratings are inapplicable. See id. As such, the Board finds that the preponderance of the evidence is against the Veteran's claim for an initial rating in excess of 50 percent on and after June 9, 1998, on a schedular basis. Consequently, the benefit-of-the-doubt rule does not apply, and the claim must be denied on and after June 9, 1998. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Extraschedular Considerations The Board has also considered whether a referral for extraschedular rating is warranted. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). 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. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule; therefore, the assigned schedular evaluation is adequate, and no referral is required. See VAOPGCPREC 6-96; see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993). The schedular evaluation for the Veteran's PTSD is not inadequate. The Veteran's PTSD has been characterized by such symptoms as depression, anxiety, sleep impairment, intrusive thoughts, impaired memory, difficulty trusting others, and lack of friends. These symptoms are very similar to the schedular rating criteria. In addition, the level of occupational and social impairment is explicitly part of the schedular rating criteria. The GAF scores are incorporated as part of the schedular rating criteria as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. Moreover, the Veteran's psychiatric symptomatology is contemplated by the schedular rating criteria, which rates by analogy psychiatric symptoms that are "like or similar to" those explicitly listed in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. The Veteran has also argued that he has various psychosomatic complaints. To the extent that he has sleep impairment and fatigue, these are anticipated in the ratings criteria. To the extent that he has skin and gastrointestinal complaints, the Board has separately denied service connection above and inclusion in the disability rating for PTSD is not appropriate. The Board has also separately remanded service connection for a respiratory disability below. To the extent that he has other complaints, such as muscle pain and tension headaches, the Board has found these not credible as they were not supported by contemporaneous treatment records despite his claims of seeking treatment for them. The Veteran disagrees with the assigned evaluation for his level of impairment. In other words, he does not have any symptoms from his service-connected disorder that are unusual or are different from those contemplated by the schedular criteria. The available schedular evaluations for that service-connected disability are adequate. Referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. Further inquiry into extraschedular consideration is moot. See Thun, supra. TDIU Total disability ratings for compensation may be assigned where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of a service-connected disabilities: Provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). For a veteran to prevail on a claim for a total compensation rating based on individual unemployability, the record must reflect some factor, which takes this case outside the norm. The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the appellant is capable of performing the physical and mental acts required by employment, not whether the appellant can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The Board's conclusion that a 100 percent schedular rating is warranted for PTSD prior to June 9, 1998, renders moot whether TDIU is warranted for the same period solely on the basis of PTSD. This analysis pertains only to the period on and after June 9, 1998. During the pendency of this claim, the criteria for TDIU were revised (effective November 7, 1996). These changes deleted 38 C.F.R. § 4.16(c) to reflect changes in the ratings criteria for psychiatric disabilities and the final rulemaking instituting the current 38 C.F.R. § 4.130. The reason for the revision was that, under 38 C.F.R. § 4.16(c), TDIU could not be considered where a 70 percent was in effect for a psychiatric disability as the 100 percent ratings criteria included unemployability. The Veteran is not in receipt of a 70 percent rating after June 9, 1998, and this revision is moot. On and after June 9, 1998, the Veteran is service-connected only for PTSD at a 50 percent disability rating. The Veteran does not meet the schedular criteria listed in 4.16(a) on and after June 9, 1998. However, it is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b). Rating boards should refer to the Director of the Compensation and Pension Service for extra-schedular consideration all cases of veterans who are unemployable by reason of service connected disabilities but who fail to meet the percentage requirements set forth in 38 C.F.R. § 4.16(a). The Veteran's service-connected disability, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. 38 C.F.R. § 4.16(b). The rating board did not refer this case for extra-schedular consideration. The Board has discussed the Veteran's employability in terms of the symptoms of his service-connected disability, employment history, educational and vocational attainment, social functioning and family functioning above. Although the Veteran has considerable impairment due to his PTSD, the preponderance of the evidence demonstrates that he retains the capacity to obtain and follow substantially gainful employment consistent with his past employment in clerical, floral, and computer work. The Board finds that the preponderance of the evidence demonstrates that the Veteran is not unemployable by reason of his service-connected disabilities even when considering the effect of his service-connected disabilities, employment history, educational and vocational attainment, and all other factors relevant to the question. Referral of this case for to the Director of the Compensation and Pension Service for extra-schedular consideration is not warranted. 38 C.F.R. § 4.16(b). The Board concluded that the schedular requirements for a TDIU have not been met. The Board also concludes that referral for an extraschedular TDIU is not warranted. In reaching these conclusions, the Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's TDIU claim on schedular and extraschedular bases, that doctrine is not applicable. See 38 U.S.C.A. 5107(b); 38 C.F.R. § 3.102. ORDER Service connection for a skin disorder, to include a sebaceous cyst, is denied. Service connection for a gastrointestinal disorder, to include as secondary to service connected PTSD, is denied. An initial rating of 100 percent for PTSD is granted prior to June 9, 1998. An initial rating in excess of 50 percent for PTSD is denied on and after June 9, 1998. Entitlement to a TDIU on and after June 9, 1998 is denied. REMAND The Board must remand the issue of service connection for a respiratory disorder, to include seasonal allergies and as secondary to service connected PTSD for a new VA examination. The Board previously remanded this issue for a VA examination and medical opinion in May 2012. Specifically, the Veteran contends that his respiratory disorder existed prior to service and became worse during his military service. He testified that he suffered with bronchitis as a child, which worsened in service due to stress and lack of sleep. See the November 2011 Board hearing transcript. Review of post service treatment records document the Veteran's complaints and treatment for respiratory disorders. His May 2005 claim for service connection states that he had been seen for restrictive lung disease. A May 2008 private medical statement indicates that the Veteran had a history of recurrent pharyngitis and bronchitis several times a year. A June 2008 private medical statement indicates that the Veteran had been treated for a history of frequent bronchitis. The statement also noted a possible restrictive lung defect, which may have been the result of poor effort during pulmonary function tests. A July 2008 private medical statement indicates that the Veteran has complained of recurrent episodes of nasal congestion with a runny nose or rhinorrhea, hay fever symptoms, seasonal allergy exacerbations, and acute bouts of sinusitis. He also reported to the private physician that his sinus problems date back to approximately 1970, while on active military duty. The Veteran was evaluated at a June 2012 VA examination following the Board's remand. The examiner addressed only seasonal allergies, not the additional recurrent problems, which rendered the examination report inadequate for ratings purposes. Even in addressing seasonal allergies, the examiner's opinion was inadequate for ratings purposes. The examiner asserted that the allergies were not at least as likely as not related to service without any type of rationale. The Board remands again to afford the Veteran an adequate VA examination and medical opinion. Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine to determine the nature and etiology of his respiratory disorder, to include seasonal allergies, pharyngitis, sinusitis, bronchitis, and restrictive lung disease. All necessary tests should be performed, and the examiner should identify all current respiratory disorders. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including his service treatment records, his post-service medical records, and the lay statements and assertions. Thereafter, the examiner should provide an opinion as to whether any current respiratory disorder clearly and unmistakably pre-existed service and, if so, whether the evidence is clear and unmistakable that it was not aggravated during, or as a result of, his service. If aggravation is found, the examiner should address whether the permanent increase in severity was due to the normal progression or the disorder or whether such worsening constituted chronic aggravation of the disorder due to service. (Note: aggravation connotes a permanent worsening above the base level of disability, not merely acute and transitory increases in symptoms or complaints.) For any respiratory disorder that did not exist prior to service, the examiner should opine as to whether it is at least as likely as not related to service or any event of service. The examiner should provide a clear and thorough rationale for the conclusion(s) reached and cite the evidence relied upon or rejected in forming an opinion. If the physician cannot respond without resorting to speculation, he/she should so indicate this and explain the reason why an opinion would be speculative. The claims file should be made available to the examiner in conjunction with the examination. 2. Then, the RO should readjudicate the claim on the merits. If the benefits sought are not granted, the Veteran and his representative should be furnished a supplemental statement of the case and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655 (2013). 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 Supp. 2013). ______________________________________________ K.J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals