Citation Nr: 1336018 Decision Date: 11/06/13 Archive Date: 11/13/13 DOCKET NO. 09-30 477 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUE Entitlement to an initial rating for posttraumatic stress disorder (PTSD) in excess of 30 percent prior to September 15, 2009 and 50 percent thereafter. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Jonathan Tracy, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1967 to July 1969. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a December 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. In the December 2008 rating decision, the Veteran was awarded an evaluation of 30 percent for PTSD, effective August 28, 2008. In a May 2011 rating decision, the Veteran was awarded an increased rating of 50 percent for PTSD, effective September 15, 2009. After the Veteran has perfected his appeal, a subsequent rating decision awarding a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal. AB v. Brown, 6 Vet. App. 35 (1993). Accordingly, the issue is still properly before the Board. The issue of whether clear and unmistakable error was committed in the prior final rating decisions of November 1990 and November 2002 has been raised by the record, but has not been adjudicated by the RO. Therefore, the Board does not have jurisdiction over it, and it is referred to the RO for appropriate action. FINDING OF FACT Manifestation of the Veteran's service-connected PTSD includes occupational and social impairment with reduced reliability and productivity throughout the appeal period, but the disorder does not result in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. CONCLUSION OF LAW The criteria for an initial evaluation of 50 percent from August 28, 2008, but not higher, for PTSD has been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9413 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Notice 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. Pelegrini v. Principi, 18 Vet. App. 112 (2004). In rating cases, a claimant must be provided with information pertaining to the assignment of disability ratings (to include the criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The RO provided notice by letters dated in September 2008 and February 2009 and the claim was adjudicated most recently in April 2012. The content of the notice letters complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). With respect to the Dingess requirements, the letters included notice of the type of information and evidence needed to establish a disability rating, as well as notice of the type of evidence necessary to establish an effective date. Accordingly, the duty to notify has been fulfilled. VA is also required to make reasonable efforts to help a claimant obtain evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to a claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). In this instance, the claims file contains the Veteran's service treatment records, VA treatment records, private treatment records, and the Veteran's own assertions in support of his claim. The Board has reviewed the file for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim for which VA has a duty to obtain; therefore appellate review may proceed without prejudicing him. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board has also reviewed records on Virtual VA and the Veterans Benefits Management System (VBMS). In addition, the RO arranged for VA examinations in November 2008 and January 2011. The claims file was reviewed at both examinations. The Board finds that the examinations obtained in this case were adequate, as they provided findings relevant to the criteria for rating the Veteran's PTSD. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). VA has substantially complied with the notice and assistance requirements and the appellant is not prejudiced by a decision on the claim at this time. II. Legal Criteria, Factual Background, and Analysis A. Criteria of Disability Evaluations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). The pendency of the issue in this instance dates to the original rating decision granting service connection. Id. Consequently, the Board will evaluate the Veteran's psychiatric disorder as a claim for a higher evaluation of the original award. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). B. Increased Rating for PTSD The Veteran was assigned a 30 percent rating for PTSD, effective August 28, 2008 and a 50 percent rating effective September 15, 2009, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. Diagnostic Code 9411 provides that a 30 percent rating is warranted for occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to 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, or effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation, neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The Global Assessment of Functioning (GAF) scale is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). A GAF score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF score of 41 to 50 indicates serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of between 51 and 60 indicates that the Veteran has moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores ranging between 61 and 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. A GAF score of 71 to 80 indicates, if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). See DSM-IV. While the Rating Schedule indicates that the rating agency must be familiar with the DSM -IV, VA does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. Rather, GAF scores are but one factor to be considered in conjunction with all the other evidence of record. C. Analysis The Veteran is service-connected for PTSD and his stressor was combat in Vietnam. He was wounded in combat and received a Purple Heart. The Veteran filed this claim in September 2008 and his first PTSD VA examination was conducted in November 2008. The examiner reviewed the claims file and noted that there were no outpatient treatment records for any mental disorder. The Board notes that there was a diagnosis from a private physician in 2002. However, the Veteran did not pursue treatment at that time at the VA or elsewhere. At the examination, the Veteran reported "experiencing some symptoms of depression and stated that at times, he doesn't feel like getting out of bed and spends the day in pajamas. He stated that during these times, he doesn't interact with other people. He said that this has been going on for many years, but feels that it worsened in the last two years when helicopters started flying over his house, and he began having feelings that he was back in Vietnam. He said that he discussed these symptoms with his primary care physician in 2002, and his physician referred him to the VA. The Veteran reported that despite this, he decided not to follow through because he [did not] trust the VA due to prior bad experiences." The Veteran reported that he married his second wife in 1973. He shared that they get along well at times, but have difficulty at other times. He described needing "a lot of space. He indicated feeling that he needs to be alone at times to keep from fighting." The Veteran said that he has 4 children and reported that he is alienated from the 2 that were from his first marriage. He said that he interacts with his son but is not as close as he would like to be. He said that his daughter is a 24 year old college student and lives at home. He said they get along well at times, but they do sometimes fight. The Veteran reported that he "drinks 2 or 3 gallons of wine a week because it is relaxing" and helps him sleep. He also reported that "he does not have many friends that he spends time with outside of his family. He indicated that he used to have friends, but said something always seems to happen to ruin these friendships." The "Veteran said that 20 years ago, he threatened to kill himself, and his wife hid his gun... He said that he no longer owns a gun. He said that watching a war movie...triggered him to feel suicidal. He has had no suicide attempts." The Veteran reported having a history of violence. Specifically, he assaulted an officer when he was arrested 20 years ago for drunk and disorderly conduct. Upon examination, the Veteran's general appearance was described as clean. His psychomotor activity and speech were noted to be unremarkable. His affect was normal. His mood was described as anxious and dysphoric. The Veteran's attention was described as being intact. The Veteran was able to do serial 7's "easily" but was not able to spell a word forward and backward. His orientation was intact to person, time and place. His thought process and content were unremarkable. The Veteran reported not having delusions or hallucinations. The examiner noted that in terms of the Veteran's judgment, he understood the outcome of his behavior. His intelligence was noted to be average. In terms of his insight, the Veteran was noted to understand that he has a problem. The examiner reported that the Veteran has sleep impairment. The Veteran reported drinking wine to fall asleep. "He said that 2 or 3 times a week he tosses and turns for an hour. He indicated that he wakes up 3 or 4 times a night and is not sure why. He said that he is able to fall back asleep sometimes but not others. He said that he often checks all of the windows and door locks when he wakes up and sometimes checks to see if anyone is in his yard. He stated that he gets around 4 to 5 hours a night." The Veteran was reported to not have inappropriate behavior. He interpreted proverbs appropriately. The examiner reported that the Veteran does engage in obsessive/ritualistic behavior. The Veteran "washes and sanitizes his hands several times a day and at times spends 15 to 20 minutes washing his hands... He reported that when he carried bodies in Vietnam, he would often wash his hands over and over again to get rid of the smell. He said at times, he feels that this smell is on his hands and he [cannot] get it off." He denied that his hand washing significantly interfered with daily activities. The Veteran reported not suffering from panic attacks. He also reported not having homicidal or suicidal thoughts. The examiner noted that the Veteran had good impulse control. The Veteran was reported to have the ability to maintain minimum personal hygiene. The examiner also reported that the Veteran does not have a problem with activities of daily living. The Veteran's remote, recent, and immediate memory were all described as normal. The examiner reported that the Veteran suffers from persistent reexperiencing of the traumatic event by "recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions" and "recurrent distressing dreams of the event, acting or feeling as if the traumatic event were recurring." Also, the examiner reported that the Veteran engages in "efforts to avoid thoughts, feelings, or conversations associated with the trauma" and "efforts to avoid activities, places, or people that arouse recollections of the trauma." The Veteran has "markedly diminished interest or participation in significant activities" and has a "feeling of detachment or estrangement from others." The examiner also reported that the Veteran had persistent symptoms of increased arousal, including: "difficulty falling or staying asleep, irritability or outbursts of anger, hypervigilance, [and] exaggerated startle response." The examiner found that the Veteran's "disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning." The symptoms were described as chronic. The "Veteran indicated that he has thoughts about his combat experiences on a daily basis... He described the battle during which he volunteered to retrieve wounded soldiers as being the most pronounced memory and said at times it plays back in his mind and he feels he [cannot] find the 'stop button.' He stated that on some days this is so bad he feels he [cannot] interact with others and does not go to work and this has caused financial problems." He also reported being easily irritated and stated that he left many jobs because of this. The "Veteran said that he occasionally had periods during which his symptoms were less acute," but said that these did not last long. The Veteran reported that "when he was a pastor at his church, at times he would just go off on people and had to resign from his job 3 years ago because of not getting along with others. He said that [he has] had to resign from 3 churches for this reason. He indicated that he has had a hard time keeping jobs..." The Veteran reported that he owned his own business until the mid-1980's when he attended seminary. He worked in ministry for 25 years until he quit in order to open his water purification business. The examiner reported that the Veteran has problems related to occupational functioning due to "increased absenteeism" and "poor social interaction." The Veteran reported that when "his reexperiencing symptoms are acute, he stays in his room and feels unable to work. He reported that he does not interact with others during these times, including his wife. He stated that the last time this occurred[,] a few months ago[,] he missed over 2 weeks of work. The Veteran said that missing work because of his symptoms has been a financial burden to him and his family." The examiner diagnosed the Veteran with PTSD, alcohol dependence, and major depressive disorder. The Veteran was assigned a GAF score of 35. The examiner wrote that the GAF score was "based on serious PTSD, depression, and alcohol dependence symptoms and major impairment in several areas, including social, occupational, and interpersonal functioning. This Veteran's symptoms of PTSD have impacted several areas of his life, including his ability to work consistently. He reported that he has changed jobs several times since Vietnam because he is irritable and unable to get along with others." The examiner noted the Veteran's occupational and social impairment. Judgment is impacted by the Veteran's drinking heavily to sleep and relax. The examiner noted that the Veteran "appears to be unaware that this can have detrimental effects on his mental and physical health." His thinking is impacted by "having symptoms of intrusive thoughts that are severe and frequently prevent him from working and interacting with others." His family relations are impacted in that the Veteran and his wife "often argue and have a strained relationship." The Veteran's employment is impacted when "his reexperiencing symptoms are acute" and he "stays in his room and does not work, or talk to anyone." In terms of the Veteran's mood, he described isolating himself when experiencing PTSD symptoms and feeling increased depression. The examiner opined that the Veteran's prognosis for recovery was poor. However, the examiner noted that if the Veteran sought help, symptoms may improve. The Board also reviewed VA treatment records. On September 15, 2009, the Veteran reported that he continued to feel depressed. Panic attacks had increased to every other night. During some of these attacks he would vomit. On other occasions he would relive combat experiences. He also reported increased difficulty remaining on his job. Symptoms were managed with Citalopram, Quetianpine, and Buspirone. The Veteran's mood was depressed and affect was mildly dysthymic. He remained coherent and goal directed. He was described as constantly on guard and watchful of others. He also described feelings of numbness and detachment. He reported sleeping only about 2 hours a night and experiencing night sweats and chills. Hypervigilance and his checking behavior reportedly increased. He reported a history of intermittently thinking of suicide. He also reported visual hallucinations. He had begun attending outpatient treatment at that time. The Veteran was seen in April 2010. He reported being stressed out about several incidents that had recently occurred. He reported quitting his job due to stress. He was also seen in September 2010. He indicated that he was not in compliance with his medications. It was also noted that the Veteran did not continue with the individual counseling sessions which he had agreed to in April 2010. In October 2009, he had a GAF score of 65. He denied suicidal and homicidal ideation in March 2010 and had a GAF score of 45. He was given a negative suicide risk assessment in December 2010 and January 2011. His GAF score in November 2010 was 60, earlier in the month he had been at 50. In January 2011, the Veteran was provided a second PTSD VA examination. Prior to the examination, the Veteran completed a ten week outpatient psycho-educational program. The examiner noted that the Veteran's symptoms did not improve as a result of the treatment. The examiner also reported that the Veteran attended PTSD support groups. The Veteran reported that he was still married to his second wife. However, "he described strain on the marriage due to his PTSD symptoms and financial problems." He also reported that "he is unable to keep a job and is struggling to pay his bills." The Veteran again reported that he only maintains relationships with 2 of his 4 children - the 2 from his second marriage. However, the relationship with the 2 children was described as confrontational at times. The Veteran brought a letter from his wife to the examination. The letter indicated that his wife is often fearful of his "volatility and is increasingly concerned about his social withdrawal and inability to get along with others." The Veteran denied any close or intimate relationships other than with his wife. He listed no hobbies other than reading and watching television. Upon examination, the Veteran's general appearance was described as clean, neatly groomed, and appropriately dressed. His psychomotor activity was reported to be hyperactive. His speech was described as rapid. His affect was full and his mood was anxious. The Veteran was unable to complete the serial 7's and unable to spell a word forward and backward. His orientation was intact to person, place, and time. His thought process and content were described as unremarkable. The Veteran was reported to not suffer from delusions or hallucinations. However, in terms of his judgment, the examiner noted that the Veteran "does not understand [the]outcome of [his] behavior." The Veteran is reported to partially understand that he has a problem. The examiner reported that the Veteran does not have inappropriate behavior. The Veteran "described intermittent awakenings during the night, each night." He described experiencing heightened hypervigilance at night that interferes with sleep. The Veteran also reported "recurrent nightmares that are related to combat experiences." The Veteran interpreted proverbs appropriately. The examiner noted that the Veteran does not have any obsessive/ritualistic behavior. The Veteran "described panic-like symptoms when he awakens at night from a nightmare. [He] will awaken frightened, unable to breathe, heart pounding, with a sense of impending doom. These same symptoms occur when hearing helicopters when working as a security officer outside. The [symptoms] recede in several minutes." The Veteran did not report suicidal thoughts but "admitted to vague homicidal ideation at times with no gestures or realistic plan." The extent of his impulse control was described as poor. The examiner noted that the Veteran has the ability to "maintain minimum personal hygiene" and there was no problem with activities of daily living. His remote, recent, and immediate memory were described as normal. The examiner noted that the Veteran has "recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions" and "recurrent dreams of the event." The Veteran is reported to take "efforts to avoid thoughts, feelings, or conversations associated with the trauma" and to take "efforts to avoid activities, places, or people that arouse recollections of the trauma." Also, the Veteran is reported to take "markedly diminished interest or participation in significant activities" and "feeling detachment or estrangement from others." The Veteran also suffers from persistent symptoms of increased arousal as evidenced by difficulty falling or staying asleep; irritability or outbursts of anger; hypervigilance; and exaggerated startle response. These symptoms were described as chronic by the examiner and the Veteran reported experiencing no remissions. The examiner noted that the Veteran described symptoms similar to the ones described at the earlier VA examination: difficulty getting along with others, especially at work; social avoidance as a means of controlling anxiety; recurrent combat related nightmares at night; chronic sleep disturbance; hypervigilance, especially at night; exaggerated startle response to loud noises or noises resembling those associated with trauma; flashbacks when hearing helicopters that have resulted in him leaving work and barricading himself at home; drinking alcohol at night to soothe anxiety and facilitate sleep; irritability with wife and work supervisors; intense feeling of grief and guilt related to combat experiences; depressive episodes resulting in absenteeism from work; feelings of hopelessness; crying spells; and intrusive memories that significantly impact mood and interrupt concentration. The Veteran was given a quantitative psychometric assessment. The examiner reported that the results corresponded to a diagnosis of a moderate level of severity for his PTSD and the examiner noted that the results were "probably valid." The examiner also noted that the Veteran "demonstrates no cognitive impairments that would prevent him from managing funds. However his mood and lack of patience would make it difficult at times or he may impulsively make decisions based on mood." The Veteran reported working as a security officer and has had that position for 1 to 2 years. He reported missing 3 weeks of work in the last 12 months due to depression. He also reported working as a salesman after his previous VA examination but he "quit due to problems with [his] supervisor and [a] poor attendance record." The examiner noted that the Veteran's problems related to occupational functioning are "decreased concentration" and "poor social interaction." The examiner diagnosed the Veteran with PTSD and assigned a GAF score of 50. The examiner noted that the Veteran "has had three jobs since his last [examination]. During his last [examination], he was self employed. He had a business partner, running a water filter business. Due to severe depressive symptoms and conflict with [his] partner, he closed his business. He described staying in bed for weeks during this time, unable to make sales calls or respond to customer calls. Several months later, he got a job...as an outside salesman. [The Veteran] stated that conflict developed with his manager" and he had problems with absenteeism and tardiness. "He [has] also suffered from poor concentration (getting lost while driving) and flashbacks (while in his sales truck, a helicopter hovered overhead and he immediately drove home and hid in his house - leaving work without telling his manager). His manager recommended that he take a leave of absence so [the Veteran] just quit. Four months later, he got a job at...a security company.... [The Veteran] feels this job is quite tenuous as he has routine conflict with his manager, and continues to have intrusive thoughts and flashbacks that interfere with his ability to function at work." In discussing the Veteran's marriage, the examiner noted that the Veteran's wife "continues to be [the Veteran's] only support, yet she is increasingly unable to help [the Veteran] manage his moods and difficulties at work. She described [the Veteran's] increasing avoidance of her and others and the impact it is having on the marriage." The examiner also noted that the Veteran uses alcohol to self medicate anxiety. He remarked that his current consumption is less than it was several years ago. He also reported drinking on the job when he worked as a salesman after his business was closed. The examiner noted an increase in the Veteran's symptoms in the preceding few months, including: a flashback that resulted in the Veteran barricading himself at home; intrusive thoughts that impede concentration at work (getting lost while driving to work); chronic sleep disturbance; increased social avoidance; increased irritability; lack of consistent employment because of interpersonal problems and absenteeism; alcohol abuse; intense guilt and grief that result in significant depressive episodes; and hypervigilance at night. Also, the examiner noted that the Veteran's relationship with his wife appeared to be deteriorating. In the VA treatment records from March 2012, passive thoughts of death were noted but not suicidal or homicidal ideation. There was no evidence of psychosis found. The Veteran was reported to have good eye contact, to be cooperative, with speech coherent and goal directed. Affect was appropriate with mood dysthymic. The Veteran denied hallucinations, paranoid or grandiose ideations, and homicidal or suicidal thoughts. He was also oriented to person, place and time. The Board also considered the Veteran's assertions in support of his claim. The Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). He is also competent to report symptoms of his condition. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). However, the Veteran is not competent to provide a medical diagnosis. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The majority of the Veteran's lay statements were provided at the VA examinations. Most of the Veteran's statements, therefore, were considered in the medical opinions provided. However, the Veteran did make other statements. The Veteran indicated in his statement from June 2011, that he had no social contact with friends or relatives and that his work relationships were strained. He further stated that he was having increasing difficulty being able to work around others without episodes of unprovoked irritability and displays of uncontrolled violence. He also stated he has panic attacks every day usually at night. He explained that if a siren or a helicopter flies over it triggers panic attacks with flashbacks. He also described having periods of unprovoked violence at home and he indicated that he has damaged and broken things. He also described his recurrent employment problems: "I have a history of only staying employed at most one or two years at a time. I either get fired or [have an] outburst of anger and quit." He wrote that at times he becomes confused as to where he is and what is going on around him. He reported that this makes him fearful. He described himself as the most depressed that he has ever been and that he has to force himself out of bed. In his statement dated in April 2012, the Veteran reported having a verbal altercation with his supervisor at work to the point where she ran to her car to escape him. The Board notes that the Veteran has a documented history of difficulties with his supervisors and co-workers. The Veteran also reported experiencing hallucinations before going to bed and while checking the perimeter of his house. He described these hallucinations as shadows from trees, but he indicated that he sees the "real enemy" out there. He also reported having thoughts of suicide with plans which he has never carried through. He described having had thoughts of harming himself and others. The Veteran's wife submitted a letter in November 2011. She indicated that she felt the Veteran's symptoms were getting worse and that he has had difficulty keeping employment because of his symptoms. She gave details of his problems and the circumstances which lead to his leaving various jobs. The symptoms were reported as frequent anxiety and panic attacks along with nightmares and flashbacks. She also stated that the Veteran's relationship with family members and friends was at times distant and strained. Photographs were submitted with the statement showing walls the Veteran damaged while having a fit of rage. She also reported an altercation with a man in the stands when the family went to a baseball game. The Veteran had to be restrained. The Board also reviewed statements from the Veteran's co-workers that indicated that the Veteran would have problems getting along with co-workers and superiors and that he would respond to correction by kicking floor signs, slamming doors, and kicking walls. The Veteran had a hearing before the Decision Review Officer at the RO in April 2012 and the transcript has been associated with the claims file. The Veteran testified that he was currently employed in security work. He indicated he would have flashbacks at times when he hears a helicopter while patrolling the 'perimeter' but his supervisor allows him to go to a quiet place and do breathing exercises to bring him back to reality. He indicated he has had four jobs in the last five years. He also reported that being in the VA medical center treatment program made his symptoms worse as he had to recount his combat experiences. He indicated that he does not sleep in the same bedroom as his wife because he wakes up with panic attacks. His wife testified that there are days he becomes introverted and she stays away from him. He reported his flashbacks are becoming more frequent and that he has become overly cautious since his treatment. The RO rated the Veteran at 30 percent from August 28, 2008 to September 14, 2009, and 50 percent thereafter. Based on the evidence, the Board finds that Veteran is entitled to a rating of 50 percent back to the effective date of the grant of service connection for PTSD, but not higher. The Board concludes that the evidence supports a rating of 50 percent from August 28, 2008. The VA examiner at the first examination concluded that the Veteran's PTSD majorly impaired with several areas of the Veteran's life, including employment, social, and interpersonal functioning. He also had a GAF score of 35 at the first examination. While the evidence indicates that his GAF score has improved, the symptoms have largely remained the same. The Veteran's PTSD is manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as: hyper speech; panic attacks; impairment of memory; diminished judgment; disturbance of motivation and mood; avoidance behavior; hypervigilance; hyperarousal; difficulty in establishing and maintaining effective work and social relationships; and reexperiencing of traumatic events from Vietnam. The Veteran's VA examinations and VA treatment records showed that his symptoms do not meet the criteria for a 70 percent rating. Specifically, the Veteran denied suicidal and homicidal ideation at both VA examinations and in most of the VA outpatient records. In the Veteran's statements from April 2012 and June 2011, he indicated having suicidal thoughts. However, the Board does not give these statements credibility because the Veteran specifically denied suicidal thoughts when asked at VA examinations and he had negative suicidal risk evaluations as shown in the VA treatment records. In his more recent statements, the Veteran explained that he has been experiencing hallucinations. However, he always denied this at the VA examinations. When describing the hallucinations, he describes them as shadows from trees that he notices when he is experiencing hypervigilance at night. There was also no indication that the Veteran engages in obsessional rituals which interfere with routine activities. At the VA examinations, the only obsessional behavior the Veteran reported was frequently washing his hands and checking the locks at night. He denied that the hand-washing interfered with his daily activities. Also, there is no indication in the evidence that his hypervigilance in checking the locks and windows at night interferes with routine activities. The evidence only shows that the hypervigilance interrupts the Veteran's sleep, which is contemplated in the 50 percent rating criteria. Also, the Veteran's speech was not found to be intermittently illogical, obscure or irrelevant. At the first VA examination, his speech and thought process were noted to be unremarkable. His speech was described as "rapid" at the second examination, but his thought process and content were described as "unremarkable." The evidence does not indicate that the Veteran suffers from near-continuous panic or depression affecting his ability to function independently, appropriately and effectively. Various triggers are discussed in the evidence, namely helicopters and sirens. According to the examiners the Veteran suffers from depression and panic attacks. However, at the first examination, the Veteran reported not experiencing panic attacks. At the second examination, he reported suffering from panic attacks at night. He also described a time when he heard a helicopter and left work to race home to barricade himself inside. This instance stands out, and the impact of his symptoms is reported to be worse when his symptoms are acute, but he has been able to function. Also, he reported at his second VA examination that the symptoms receded after several minutes. His panic attacks and depression are not described as near-continuous. Despite employment problems, he is able to work for extended periods of time and both examiners concluded that the Veteran's symptoms do not interfere with his ability to perform daily activities. The Veteran does have a history of some violent outbursts. He described an indecent where he yelled at his female supervisor to the point where she ran away to her car. His wife described how he got into an altercation at a baseball game and broke part of the wall in their home. Also, he has a history of having confrontations with co-workers. However, the first examiner found that the Veteran had good impulse control. At the second examination, the extent of his impulse control was described as poor. While the Veteran is described as irritable and he has had examples of yelling at co-workers and supervisors, he has been able to go to work for extended periods of time and there are no reported acts of violence against anyone. The only instance of violence since the assault on the police officer more than 20 years ago, when he was intoxicated, was when he damaged the walls at his house and kicking signs and slamming doors at work. At both examinations, the Veteran was oriented to person, place and time. Therefore, there is no evidence that the Veteran has experienced spatial disorientation. Further, there is no evidence that the Veteran neglects personal appearance and hygiene. At both examinations and in the VA treatment records, the Veteran has always been described as clean and well groomed. He was also found to be able to maintain minimal personal hygiene at both examinations. The Board further finds that the manifestation of the Veteran's service-connected PTSD do not result in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The Veteran has worked for many years, albeit he has changed jobs several times due to problems with management and co-workers. He also has problems dealing with stress when supervisors attempt to correct him. However, he has been able to keep jobs for extended periods of time and to be offered new positions. His family relations have been strained, but they do exist. He has remained married and he does continue to have relationships with 2 of his children. Although his judgment was noted to be impaired at the second examination, there was no mention of this resulting in significant social or occupational impairment. The first examination report found that the Veteran's "disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning." The symptoms were described as impacting several areas of his life, including his ability to work consistently. He has changed jobs several times since Vietnam. His thinking has been impacted by "having symptoms of intrusive thoughts that are severe and frequently prevent him from working and interacting with others." However, while his symptoms have reduced his reliability and productivity, they have not resulted in deficiencies in most areas. While his symptoms were noted to have worsened at the second examination, his GAF score improved. Further, he can still function socially and occupationally. When he does experience acute symptoms, they recede after several minutes. In summary, the manifestations of the Veteran's service-connected PTSD include occupational and social impairment with reduced reliability and productivity throughout the appeal period, but the disorder does not result in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Based on the medical evidence, the Veteran is not entitled to a rating in excess of 50 percent. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the Veteran's claim for an initial evaluation in excess of 50 percent for anxiety disorder, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). D. Extraschedular Consideration The discussion above reflects that the rating criteria reasonably describes and contemplates the severity and symptomatology of the Veteran's service-connected PTSD. The Veteran's disability is manifested by impairment in social and occupational functioning; the rating criteria contemplate these impairments. Thus, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). ORDER An initial rating for PTSD of 50 percent is extended back to August 28, 2008. To this extent only, the appeal is granted. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs