Citation Nr: 1337340 Decision Date: 11/15/13 Archive Date: 11/26/13 DOCKET NO. 03-03 091A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for back disability. 2. Entitlement to an initial evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD)/anxiety disorder, not otherwise specified, with alcohol and cocaine dependence for the period prior to May 11, 2001, and in excess of 50 percent thereafter. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Peters, Associate Counsel INTRODUCTION The Veteran had active duty service from March 1968 to December 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In March 2009, the appellant testified at a Board videoconference hearing with respect to the following issues: entitlement to service connection for back disability; whether new and material evidence has been received to reopen a previously denied claim seeking service connection for dental disability due to trauma; entitlement to an effective date earlier than April 1, 2004, for the award of nonservice-connected pension benefits; and entitlement to an initial rating in excess of 30 percent for PTSD from March 29, 1999, and in excess of 50 percent from May 11, 2001. In an April 2009 decision, the Board granted an earlier effective date of July 23, 2001, for the award of nonservice-connected pension benefits. The remaining issues determined to be on appeal were remanded to the RO for additional evidentiary development and due process considerations. While the matter was in remand status, the appellant perfected a timely appeal of a July 2008 rating decision denying a total rating based on individual unemployability due to service-connected disability. In connection with his appeal, the appellant requested another Board videoconference hearing. In May 2012, the appellant testified at a second Board videoconference with respect to the issues on appeal. At the May 2012 Board hearing, the appellant was advised that because he had previously testified at a Board hearing before a different Veterans Law Judge in March 2009, his case would be assigned to a panel of three Veterans Law Judges and that both judges who conducted hearings would participate in making the decision in the appeal, in accordance with 38 C.F.R. § 20.707 (2013). He was offered the opportunity to appear at a Board hearing before the third panel member, but declined and asked that the panel proceed immediately with consideration of his appeal. See Arneson v. Shinseki, 24 Vet. App. 379, 386 (2011). The Board notes that although the RO bifurcated and separately adjudicated the issue of entitlement to a total rating based on individual unemployability in the July 2008 rating decision, the appellant has raised the issue of unemployability in connection with other claims, including the issue of entitlement to a higher initial rating for PTSD. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (holding that a claim for a total rating based on individual unemployability, either expressly raised by the appellant or reasonably raised by the record, is part of the claim for an increased rating). In the interests of clarity, however, the Board will list the issue separately in accordance with the actions of the RO. See Tyrues v. Shinseki, 23 Vet. App. 166, 176 (2009) (en banc) (indicating the bifurcation of a claim is generally within the Secretary's discretion). With respect to the appellant's claim for a higher initial rating for PTSD, the Board notes that in October 2011, the appellant testified before a Decision Review Officer (DRO) at the RO in connection with that issue. In a November 2011 Supplemental Statement of the Case, the DRO recharacterized the appellant's service-connected psychiatric disability as an anxiety disorder, not otherwise specified, with alcohol and cocaine dependence, and continued the 50 percent rating assigned from May 11, 2001. In light of the RO's actions, the Board has recharacterized the issue on appeal as set forth on the cover page of this decision. A review of the record shows that in March 2012, the appellant submitted a claim of service connection for ischemic heart disease. According to the appellant's Virtual VA file, in an April 2012 rating decision, the RO granted service connection for coronary artery disease, status post myocardial infarction, and assigned an initial 100 percent disability rating from March 13, 2012, and a 30 percent rating from July 1, 2012. The record currently available to the Board contains no indication that the appellant has disagreed with the initial rating or effective date assigned. Thus, those matters are not in appellate status. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or effective date assigned). In February and April 2011 letters to the appellant and his congressional representative, the RO indicated that VA's records showed the Veteran had multiple issues pending on appeal, including a claim of service connection for a skin condition. The Board, however, is unable to locate any such claim or issue in the claims folder. In August 2012, the Board referred this matter to the RO for clarification and any subsequent action deemed necessary. It does not appear that this was accomplished. It is again referred to the RO for any appropriate action. In August 2012, the Board remanded this appeal for further development. That development having been completed, the case has been returned to the Board for further appellate review at this time. The issue of entitlement to a TDIU 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 experienced a basketball injury in service which resulted in a lateral and oblique lumbar strain; the Veteran did not experience any further injury during service, including from any forklift accident. 2. The Veteran's current back disability did not originate in service or until many years thereafter, and is not otherwise related to service, including to the basketball injury in service. 3. Throughout the appeal period, the Veteran's psychiatric symptomatology was productive of social and occupational impairment with deficiencies in most areas, but not by total occupational and social impairment. . CONCLUSIONS OF LAW 1. Back disability was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1101, 1110, 1112, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2013). 2. The criteria for a 70 percent evaluation, but no higher, for PTSD/anxiety disorder not otherwise specified, with alcohol and cocaine dependence throughout the appeal period have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.7, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper notice from VA must inform the claimant of any information and medical or lay 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. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran's claim for increased evaluation of his psychiatric disability arises from an appeal of the initial evaluation following the grant of service connection. Once service connection is granted, the claim is substantiated, and additional notice is not required as any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The Board notes that VA has complied with the due process requirements of 38 U.S.C.A. §§ 5103A and 7105 (West 2002). With regard to the Veteran's claim of service connection for a back disorder, he was sent a letter in January 2009 that provided information as to what evidence was required to substantiate that claim and of the division of responsibilities between VA and a claimant in developing an appeal. The letter also explained what type of information and evidence was needed to establish a disability rating and effective date. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Moreover, his statements in support of the claim are of record, including testimony provided at hearings during the appeal. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records 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 claims herein decided. The August 2012 remand order instructed the Agency of Original Jurisdiction to obtain the Veteran's VA treatment records, and to schedule the Veteran for VA examinations of his back and psychiatric disorders. The Veteran's VA treatment records were obtained and associated with the claims files. Likewise, the Veteran underwent VA examinations for his psychiatric disability and lumbar spine disorders in October 2012. Those examinations are adequate for the purpose of adjudicating the claims at issue, as they provided the relevant clinical findings and medical opinions. Neither the Veteran nor his representative contend otherwise. Therefore, the Board finds that its remand order has been substantially complied with, and it may proceed to adjudicate the merits of this case with regards to those two issues herein decided. See Stegall v. West, 11 Vet. App. 268 (1998) (A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order.). For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist him in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Analysis Service Connection for Back disability Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty or for aggravation of a pre-existing injury or disease in the line of duty. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2013). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2013). Service connection for certain chronic diseases, including arthritis, may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. § 1112 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (2013). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a) (2013). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as opposed to merely isolated findings or a diagnosis including the word "chronic." When the fact of chronicity in service (or during any applicable presumptive period) is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran's service treatment records document that on his enlistment examination in January 1968, his lumbar spine was shown to be normal, though the doctor noted that the Veteran had scoliosis which was not considered disqualifying for service. The Veteran did not report back trouble of any kind at that time. In February 1969, prior to his service in the Republic of Vietnam, the Veteran was treated for back complaints and was diagnosed as having a lateral and oblique strain of the lumbar spine at that time. X-ray studies were noted as being negative or not taken at that time. No further treatment for that condition or for any other lumbar spine condition appears in the record. The Veteran underwent a separation examination in December 1969, at which time his lumbar spine was noted as being normal; there was no mention of scoliosis at that time. The Veteran denied back trouble of any kind in his report of medical history. The Board has extensively reviewed the Veteran's VA treatment records in the claims file. Those records document treatment for chronic low back pain, which is alternatively referred to as lumbago. Additionally, the Board notes that the Veteran has diagnoses of lumbar spine degenerative joint disease (DJD), degenerative disc disease (DDD), lumbar arthralgia, lumbar spondylosis, and lumbar facet arthropathy. The Board additionally notes that early mental health treatment records in 2001 indicate he had a lumbar spine strain, though it does not appear that an actual diagnosis of that condition was made by a non-psychiatric medical professional. The earliest notation of any lumbar spine problem was in 1999, when the Veteran reported low back pain since 1983 which was insidious in onset and which had lasted for more than 1 year. The Veteran was diagnosed as having somatic back pain, which was relieved at that time. In subsequent treatment records, the Veteran reported that he sustained a basketball injury in service, and then later experienced another injury in Vietnam when the brakes on a forklift he was driving failed and he was forced to jump out of that vehicle and land on his back. The treatment records show that the Veteran has not been consistent in describing the origin of his current back problems. He tended most often to indicate that his problems began after the forklift injury, but occasionally reported that the back pain began with the basketball injury. At other points, the Veteran would report a history of back pain that would place the onset as following his discharge from military service. At least one treatment record documents that he reported his back pain had progressively worsened since 1980, and that he has worn a back brace since 1985. The treatment records also show that at times, he alternately lists the onset of his back problems as either in 1971 or 1973 (in other words, after service), though he does claim that those dates represent the dates of the forklift incident or the basketball injury. The Veteran underwent a VA examination of his lumbar spine in October 2012. After examination of the claims file and the Veteran, the examiner diagnosed the Veteran as having lumbar DDD without radiculopathy or functional limitation. She concluded that the Veteran's current lumbar spine disorder was not causally related to the Veteran's service, to include the noted "back trouble" (lumbar strain) in February 1969, which was conservatively treated. She noted that such a back strain is a condition that involves the muscles and ligaments (soft tissues) of the spinal region, whereas lumbar DDD is a degenerative process involving the discs and vertebral bodies. The one (soft tissue damage) is not the cause of, or related to, the other (degenerative process). She further noted that the Veteran's pre-existing scoliosis that was identified on the enlistment examination was less likely than not aggravated by service, as scoliosis is a developmental condition that undergoes natural progression not worsened by service. On appeal, the Veteran has stated that he injured his back in military service and relates his lumbar spine disorder to either the basketball injury or to the forklift injury in service. He also has stated that he has suffered ongoing symptoms with his lumbar spine since discharge from service, to specifically include pain since leaving service. After review of the evidence, the Board finds that service connection for back disability is not warranted. The evidence shows that the Veteran currently has several degenerative back conditions, including DDD, DJD, facet arthropathy and lumbar spondylosis. With the exception of the 1999 diagnosis, however, the record does not show that the Veteran's current back disorders include lumbar strain. In this regard, the Board points out that the 1999 diagnosis of lumbar strain was made by a medical professional in the field of psychiatry, and not by an orthopedist or other medical professional who tends to treat disorders of the musculoskeletal or neurological systems. That is not to say that a psychiatrist (who would be a medical doctor), is necessarily unfamiliar with diseases of the orthopedic or neurological systems. The Board finds that a psychiatrist, however, would be expected to primarily limit himself or herself to treating psychiatric, and not orthopedic or neurological diseases. Moreover, the record shows that since that diagnosis, the Veteran was evaluated extensively by medical professionals specializing in the musculoskeletal and neurological systems, none of which diagnosed the Veteran's back problems as involving lumbar strain. The Board notes that the post-1999 diagnoses were often based on diagnostic studies. The Board consequently finds that, even considering the psychiatrist's opinion, the evidence as a whole shows that the Veteran's current back disorders do not include lumbar strain. The service treatment records show that the Veteran sustained a basketball injury in service, which resulted in a lumbar strain. The records for the remainder of service are silent for any further reference to lumbar strain. As already noted, the evidence as a whole does not show that the Veteran currently, or after service, has or had a lumbar strain disorder. The service treatment records are silent for any reference to any other back complaints or findings in service. The Veteran maintains that he injured the back again in a forklift incident. The Veteran did work in service in the military occupational specialty of "warehouse" with training as a "sub storage specialist," and likely worked with forklifts, but the service treatment records nevertheless do not mention any injuries associated with a forklift accident. Nor, again, do those records mention any back complaints (other than the earlier lumbar strain), regardless of any precipitating injury. The Veteran maintains that records were made of the forklift injury, but that he was given those medical records and told to hang onto them, but lost them instead. The Board finds his account highly unlikely, particularly given that he specifically denied any history of back problems at service separation. The Board would have expected that he would attempt to record such a history of a back injury if he had lost the records, and yet he did not. Moreover, the separation examination report showed that examination of his spine was normal. The Board points out that the mere absence in service treatment records of treatment for a claimed disability can not be used to assess a claimant's credibility. In this case, however, the Veteran specifically contends that he was treated in service for a particular accident, and for specific problems. The absence of any corroborating service treatment records, particularly where the service records appear to be complete, may be used to assess the Veteran's credibility. The Board finds that the absence of any mention of a forklift accident or resulting back problems in service, including at discharge, undermines the credibility of the Veteran's account. The Veteran maintains that he has experienced back problems continuously since service. The Board points out that the provisions of 38 C.F.R. § 3.303(b) allow for the use of continuity of symptoms (including from observations made by a claimant), but only where a chronic disease was noted as such in service. That is not the case in the current appeal. The only diagnosis of a back disorder was that pertaining to lumbar strain. Even if the lumbar strain were noted to be chronic in service, lumbar strain is not a "chronic" condition for the purposes of 38 C.F.R. § 3.303(b). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran currently does have back disorders which are "chronic" for that purpose, such as degenerative joint disease, and arguably degenerative disc disease, but those conditions were not noted in service, and therefore the provisions of 38 C.F.R. § 3.303(b) are not for application in this case. The Board notes that, in any event, the Veteran's account of his symptoms since service, including in the one year period following his discharge, lacks credibility. Despite voluminous medical records covering the years since service, the first mention by the Veteran of any back complaints is years after service. The Board finds it implausible that the Veteran would seek treatment for a variety of other ailments, and yet fail to mention significant back pain and other problems. Moreover, the Board points out that the Veteran has been inconsistent in his account of the origin of his back problems. At times he dates the problems to service (although he is also inconsistent as to which of the two claimed incidents in service led to his back problems), and at other times indicates that the back problems began after service. The Board finds that the absence of any mention of back problems when he clearly had access to health care and took advantage of such access for many years prior to first reporting back problems, along with his inconsistent account of when his back problems actually began, renders incredible his current account of back problems in the year after service and since that time. For the above reasons, the Board finds that service connection on a presumptive basis under 38 C.F.R. §§ 3.303(b), 3.307 or 3.309 is not appropriate. Essentially, the evidence of record demonstrates that the Veteran began seeking treatment for his back in 1999, at which time he reported an insidious onset of symptomatology in 1983, which was more than a decade after service. It was not until much later, and contemporaneous with the filing of his claim for compensation that the Veteran began to report that his symptomatology arose from service injuries, and had existed continuously since service. The Board finds the Veteran's initial account of the onset of back symptoms to be more credible than those provided in connection with his claim for compensation benefits, particularly as the Veteran's initial account was offered at a time when he was not concerned with receiving monetary compensation. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care); see also Caluza v. Brown, 7 Vet. App. 478, 511 (1995), aff'd per curium, 78 F.3d 604 (Fed. Cir. 1996) (when determining whether lay evidence is satisfactory, the Board may properly consider internal consistency, facial plausibility, consistency, with other evidence submitted on behalf of the Veteran, and demeanor of witness (if hearing held)); Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the Veteran). Turning to the evidence of a link between the current back disability and service, the only medical opinion evidence addressing this matter is against the claim. The October 2012 examiner considered the evidence showing a lower back strain in service, but concluded that the current lumbar spine condition was not the result of military service. She provided an explanation for her conclusion which involved comparing the type of injury sustained in service versus the different type currently manifested by the Veteran. The Board finds that the rationale offered is supported by the available medical records. The only opinion supportive of the claim is that of the Veteran himself. Although in some cases a claimant is competent to offer such an opinion, see Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009), this is not such a case. The case at hand involves the determination of the etiology of a set of disorders that are not readily apparent to the senses, and which typically are diagnosed with the assistance of diagnostic studies. In addition, this case involves determining whether a basketball injury occurring decades ago led eventually to a variety of degenerative back disorders. In the Board's opinion, the etiology questions involved in this case are clearly well beyond the expertise of a layperson, and instead require the expertise of a medical professional to answer. The Veteran is not competent to offer an opinion as to whether his current back disorders, which first manifested more than a decade after service, are related to a basketball injury in service for which the records show he did not seek treatment on more than a very limited basis. In any event, even assuming the Veteran is competent to offer an opinion concerning the relationship of his current back disorder to service, the Board finds that the probative value of that opinion would be outweighed by the October 2012 examiner's opinion. The October 2012 examiner clearly does have more education, training and experience in diagnosing and determining the origin of medical disorders than the Veteran. Moreover, her opinion is more consistent with the actual evidence of record. As already discussed, the Board finds the Veteran's account of back problems since the basketball injury in service (and his account of the forklift injury) to lack credibility. There is no other competent evidence of record which relates the Veteran's current lumbar spine arthritic conditions to his in-service basketball injury and strain. No competent evidence refutes the October 2012 examiner's findings or opinion, and the Board finds that opinion to be highly probative in this case. With regards to the scoliosis previously noted, the Board notes that no problems with the scoliosis-or even any diagnosis of such-has been referenced since the enlistment examination. Even assuming that the Veteran had scoliosis during service and up to the present, the October 2012 examiner concluded that any aggravation would be the result of the normal progression of that disease, and the Board notes that there is no evidence of any worsening of that condition either in service or at anytime throughout the balance of the Veteran's life. Accordingly, the Board finds that service connection for a back disability is not warranted on the basis of the evidence of record; the Board must deny that claim. See 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. In reaching the above conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Increased Evaluation for Psychiatric Disability 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 (West 2002); 38 C.F.R. § 4.1 (2013). Separate diagnostic codes identify the various disabilities. 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 (2013); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2013); 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 (2013); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (2013). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the claimant 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 Veteran filed his claim of service connection for PTSD on March 29, 1999. The Veteran's PTSD has been evaluated as 30 percent disabling from March 29, 1999 to May 10, 2001, and as 50 percent disabling beginning May 11, 2001. The Veteran's PTSD is evaluated under Diagnostic Code 9411. The Board notes that in a February 2013 rating action, the RO granted the Veteran a temporary total evaluation under the provisions of 38 C.F.R. § 4.29 (2013) for his PTSD; the temporary total evaluation was in effect from December 6, 2011 to May 1, 2012. The below analysis as to the proper rating assignable for the PTSD, although it covers the same period as does the temporary total evaluation, is done with the understanding that the temporary total evaluation for that period should not be disturbed, as there is a separate basis for the award of that evaluation, namely the provisions of 38 C.F.R. § 4.29. Under Diagnostic Code 9411, which is governed by a General Rating Formula for Mental Disorders, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders, Diagnostic Code 9411 (2013). 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; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); 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. One factor for consideration in evaluating mental disorders is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). A GAF score of 61 to 70 indicates some mild symptomatology (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect 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). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 31 to 40 reflect 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). Turning to the evidence in this case, the Board notes that the Veteran filed a claim for service connection on March 29, 1999. In his claim, the Veteran reported problems sleeping and being treated for anxiety and depression at VA. At that time, the Veteran was enrolled in a VA domiciliary program for homeless veterans. A discharge summary noted that, at discharge in June 1999, the Veteran had a GAF score of 55. The Veteran had previously sought treatment in Biloxi and was complaining of homelessness and unemployment at that time. The Veteran reported that he chose to become homeless to "re-invent himself." The Veteran had been in a drug treatment program in 1994, and was noted as having multiple types of substance abuse at that time. The Veteran reported a history of rage. On admission, he was alert, oriented and did not demonstrate any inappropriate behavior. He was noted as the same on discharge in June 1999, though he was discharged for being "irregular" and not following the program's rules. In a May 1999 psychiatric treatment record, it was noted that it was the Veteran's initial evaluation for one-on-one therapy. The Veteran was very guarded and irritable. He avoided eye contact and avoided answering questions by being vague. He was noted as being single without any children. He reported that he had a college degree in Criminal Justice, and that his employment history was one of brief stints of employment marked with continued conflict with his supervisors. The Veteran noted that his legal history included charges of assault and battery, disorderly conduct, possession of illegal drugs, and public drunkenness. He explained that he had no friends, stating he "never have been friends, just pretenders . . . no such things, nothing but an assumption." He reported a history of drug and alcohol abuse; he started using alcohol, marijuana and crack cocaine in the early 1980's and had recently stopped using those substances on admittance to the domiciliary program. The Veteran reported having problems with anger, anxiety, and depression. He had a history of violent outbursts, the most recent of which was a year before where he tried to stab his brother to death. It was noted that the Veteran was not appropriate for one-on-one treatment, as he was guarded and said he did not like being around people he did not know. He was also suspicious of VA staff, who "had their own personal agenda[s]." He was noted as very distrusting of others, and did not even want to engage the doctor in the conversation. The Veteran was not interested in discussing solutions for his difficulties or examining himself for a solution. He did, however, note interest in an inpatient drug/alcohol program. Treatment records during the domiciliary program frequently documented displays of anger by the Veteran at not being diagnosed with PTSD. Just after discharge from the domiciliary program, in a July 1999 treatment note, the Veteran reported having sleep impairment with bad dreams. His appetite was ok, and he was taking medications as prescribed. He noted that the medications helped to some degree, and that he had been drug and alcohol free since February 1999. He continued to have night sweats and anxiety attacks. On examination, the Veteran was noted as being single without any children, and living alone. He was oriented, but easily irritated. He expressed difficulty getting along with others. He reported that he had been unemployed for 3 to 4 years, despite having a degree in criminal justice. He was appropriately dressed, and displayed coherent and relevant speech. The examiner noted that the Veteran exhibited high irritability and desired to participate in an anger management group. In an addendum, the examiner noted that the Veteran stated everything irritated him and that he gets angry both physically and verbally. The Veteran also reported that he was a very light sleeper and did not want to be bothered; he avoided crowds of people. In November 1999, the Veteran underwent a VA psychiatric examination. The Veteran was noted as seeking treatment with VA initially in 1995 for his nerves; he also attended a homeless program from July to September 1999 with VA. He reported that he was using medication. Following discharge from service, the Veteran was noted as having several jobs with intervening periods of unemployment. He was last a janitor until 1996, and had been unemployed since that time. The Veteran reported that he experienced anxiety attacks and depression, and stated he did not get along with others. He had some paranoid ideations, poor sleep and felt tired all the time. His speech was noted as being coherent, relevant and sensible. He exhibited no speech or thought disorder, though he admitted to having intermittent visual hallucinations of flashing lights as well as bouts of paranoia. The Veteran's memory was intact and he was oriented. His insight and judgment were fair. He was diagnosed with minimal to moderate PTSD and assessed with a GAF score of 70. Treatment records on file show that in May 2000, the Veteran was assessed with a GAF score of 60; he was noted as being depressed, anxious, and looking worried. He reported that he was isolated and felt angry. He denied any suicidal or homicidal ideations at that time. In June 2000, he was assigned a GAF score of 50, and was reporting occasional nightmares. He was irritable and angry since his Vietnam service. He continued to deny suicidal or homicidal ideations at that time. He was assessed with a GAF score of 65 in August 2000 based on similar complaints. In November 2000, the Veteran attended a psychiatric evaluation. He reported 18 years of education and 48 months of technical training; he noted that he was unemployed and that his last job was unskilled labor. The Veteran gave an extensive legal history which included drug charges, assault, disorderly conduct, vagrancy, and public intoxication. He denied any current legal trouble and was not on probation or parole. The Veteran reported that he normally lived alone. He reported no serious conflicts with his family or other people within the last month. The Veteran reported having serious anxiety or tension, hallucinations, trouble understanding, concentrating or remembering, and trouble controlling violent behaviors. He denied any serious thoughts of suicide or having attempted suicide in the past month. From December 2000 to January 2001, the Veteran had inpatient psychiatric treatment with VA. In that discharge summary, the Veteran was noted as having chronic PTSD and an assigned GAF score of 51, with the highest GAF score in the past year as 51 and the lowest GAF score within the past year as 45. The Veteran was noted as being unemployed, and never married. He was noted as having predominant arousal symptoms of PTSD, including anger, insomnia, limited physiologic reactions to some reminders, avoidance, limited emotional expression, occasional imagery of Vietnam, and occasional nightmares. He also related periods of significant depression, which lasted a few days at most. He currently denied any significant decrease in hedonic capacity, though he had dysphoria, irritability, helplessness and passive suicidal ideations. He denied any active suicidal ideations or attempts. He had no history of mania or hypomania. He noted no lasting psychotic symptoms, though he gave an occasional feeling of being watched or followed. He had no significant history of déjà vu or olfactory hallucinations, though he did reference "occasional time lapses." On examination, the Veteran was alert and cooperative, with good eye contact. He was slightly anxious with a constricted but related affect. He had goal-directed thought processes without evidence of a fundamental thought disorder. His motor functioning was normal. He denied any current delusions, illusions, hallucinations, or suicidal or homicidal ideations. At discharge from the program, the Veteran was noted as denying suicidal or homicidal ideations. Throughout the program, he was noted as interacting appropriately with peers and staff. It was, however, noted that his symptoms of PTSD were chronic and severe in nature. On May 11, 2001, the Veteran underwent mental health treatment at VA via walk-in, to include medication refill. At that time, it was noted that the Veteran had problems with anger management and had a history of violent behavior, though his last episode of violence was an altercation with his brother some time ago. He reported that he was frequently depressed, though he denied suicidal ideations. He reported experiencing homicidal thoughts toward another brother the previous week, but "got over it." He had an exaggerated startle response. He indicated that he lived with a brother. He had a history of alcohol and substance abuse, but denied current use. On examination, the Veteran was appropriately dressed and groomed. He was alert, oriented, cooperative and pleasant. He presented with coherent thoughts, an irritable mood, a blunted affect and a normal rate and volume of speech. He was assessed with a GAF score of 50. In July 2001, the Veteran reported having a lack of any desire for sex. He reported that he was taking his medications as prescribed, but that he did not sleep restfully. He indicated that he was depressed, and had low energy. He reported that he had difficulties with concentration. He indicated that he was single without any close family or friends. He reported an increased startle reflex. On examination, the Veteran was neatly dressed in casual clothing and groomed. He was pleasant and cooperative with a normal rate and volume of speech. He was oriented. He was mildly agitated with an irritable and depressed mood/affect. He had logical and goal-directed thought processes. He noted having suicidal ideations from time to time but indicated that "they are just thoughts going through my head, that's all." He was noted as having paranoid thoughts off and on, but with no preoccupation or ideas of reference. He also did not have any obsessions, compulsions, or hallucinations, though he had nightmares of Vietnam. He indicated that he was very nervous all the time. He had fair insight and judgment and he was cognitively intact throughout the interview. He was diagnosed with PTSD, described as moderate, with depression; he was assessed with a GAF of 50. In October 2001, the Veteran underwent a general medical VA examination, which revealed the presence of anxiety and depression; he was recommended for psychiatric evaluation. In October 2001, the Veteran was seen for depression, suicidal thoughts and homicidal ideations. He was assessed with a GAF of 40. The Veteran reported being angry and irritable all the time, experiencing difficulty getting along with people, and becoming easily irritable and agitated. The examiner noted that he was superficially cooperative and appeared to have difficulty with moods and temper and would get irritable with questions. He reported variable sleep problems. He lived with his brother at that time, and reported that he was frequently at odds with him. On examination, the Veteran was alert, oriented and superficially cooperative. He had some ability of affect and potential for aggression, admitting to getting angry easily. He denied any active thoughts to hurt himself or others, auditory or visual hallucinations, or suspicions or paranoia. His memory was fair. His insight was borderline, judgment was questionable, and he had difficulty coping with his impulsive, aggressive thoughts and potential for aggression. His affect was mildly irritable and angry. The Board has reviewed the Veteran's remaining VA treatment records from 2002. Generally, those records demonstrate similar symptomatology findings. In 2002 the Veteran generally was assigned a GAF score of 50; it thereafter declined first to 45, and then to 43 for the balance of the records in the claims file. The lowest GAF score assessed appears was 41 in December 2004. In that treatment record, the Veteran denied side effects from his medications, and indicated that his medication had helped somewhat with insomnia, agitation, irritability, intrusive thoughts, flashbacks and nightmares, but that those symptoms were all still present. The Veteran had increased problems with intrusive thoughts. On examination, the Veteran's mood was depressed with a restricted affect. His speech was productive. He did not have any homicidal or suicidal ideations; he was not psychotic. He had normal attire and appearance and displayed socially acceptable behavior. Other records demonstrate continued problems with anger and anxiety, as well as continued social isolation. A May 2008 VA treatment record reflects that the Veteran reported that his medications had helped with his agitation, irritability, intrusive thoughts and flashbacks. On examination, the Veteran was acceptably dressed and groomed and was cooperative. He was alert and oriented. He had a normal gait, with productive speech. His affect and mood were flat and he had agitated psychomotor functioning. His anxiety was high. He had a logical and goal-directed thought process and content, without any suicidal or homicidal ideations, delusions, ideas of reference, preoccupations, obsessions or compulsions, or hallucinations or illusions. He had fair judgment and insight with a grossly intact cognitive level. He was assessed with a GAF score of 45. Many of the subsequent VA treatment records reflect this type of symptomatology and level of severity. Most notably, however, this treatment record is generally similar to the above-noted December 2004 record. In October 2008, the Veteran underwent a VA psychiatric examination. The examiner noted that the Veteran was receiving treatment from VA approximately every 4 months for his PTSD. She also noted that the Veteran was only hospitalized for a week in the 1990's, though he had stayed for four months at a domiciliary because he was homeless. She noted that the Veteran was currently taking several psychiatric medications, which alleviated, but did not eliminate, the Veteran's psychiatric symptoms. The Veteran noted that he had anhedonia and mild depression, which was daily and chronic. He noted that in 2000 he spent some time in jail for physically assaulting his brother, though he had not had legal problems since that time. The Veteran reported that he had never married, and had no children or a girlfriend; he indicated that he did not want a girlfriend. He reported last having a close interpersonal relationship in 1976. He had a sister and six brothers, and described the relationships with his siblings as satisfactory except for one of the brothers with whom he had chronic conflict. He had no friends or associates, lived by himself and preferred to be by himself. He indicated that he does not allow anyone to get emotionally close to him. He reported having limited activities and leisure pursuits. He denied any history of suicide attempts. With the exception of the incident with a brother, he had not had any episodes of violence. On examination, the Veteran was neatly groomed and cooperative, with unremarkable psychomotor activity and spontaneous speech. His affect was appropriate and his mood was mildly depressed. His attention was intact, though he was unable to do serial 7s or able to spell a word forward and backward. He was oriented. His thought process and content were unremarkable. He did not have any delusions, hallucinations, inappropriate behaviors, obsessive or ritualistic behaviors, panic attacks, or homicidal or suicidal thoughts. He had chronic sleep impairment, including nightly insomnia resulting in sleepiness during the daytime and necessitating naps. The examiner noted that the Veteran had maintained good impulse control since 2000, when he had an altercation with his brother. He was noted as being able to maintain minimal personal hygiene and did not have any problem with his activities of daily living. His remote and intermediate memory were normal, though his recent memory was mildly impaired. He was diagnosed with PTSD and assessed with a GAF score of 50. The examiner concluded that the Veteran's symptoms resulted in "reduced reliability and productivity." The Veteran underwent a psychiatric consultation at VA in January 2009. In that consult, the VA psychiatrist noted that the Veteran had a history of mood swings, irritability and a suicide attempt where he ran into a tree; he also had a history of trying to hurt his brother in 2000, when he beat him up. He also had a history of alcoholism and other substance abuse from the 1980's through 2000, when he went through a rehabilitation program at the Tuskegee VA Medical Center. The Veteran reported marked problems with anger, irritability and mood swings. On examination, the Veteran had fair concentration, low energy, good appetite, and middle insomnia. He was noted as being anxious. He was alert and oriented. His cognition was intact, and he was well-groomed. He was cooperative, with productive, goal-directed speech. His mood was irritable with an appropriate affect to his mood. His thought process was linear, with improved judgment and insight. His impulse control was also improved. He denied any suicidal or homicidal ideations, or hallucination or delusions. A depression screen reflected moderate depression. He was diagnosed with PTSD and assessed with a GAF score of 50. In August 2010, the Veteran underwent another VA psychiatric examination. The examiner noted that the Veteran continued to have group and individual therapy with VA, as well as anger management classes. His hospitalization history as well as legal history was unchanged. The Veteran was noted to use psychiatric medication with fair effectiveness. The Veteran denied any relationships outside of his family. He also denied any activities or leisure pursuits, or history of suicide attempts. He acknowledged that he had a history of getting into fights. The Veteran reported being sober from alcohol and crack cocaine for 2 months. On examination, the Veteran was clean, neatly groomed, appropriately and casually dressed. His speech was spontaneous and his psychomotor functioning was unremarkable. He was relaxed, friendly and cooperative, with a normal affect and an anxious mood. His attention was intact and he was able to perform serial 7's and able to spell a word both forward and backwards. He was oriented. His thought process and content were unremarkable. He denied any delusions, hallucinations, or homicidal or suicidal ideations. He did not demonstrate any inappropriate behavior, obsessive or ritualistic behaviors, or panic attacks. His impulse control was fair, though the examiner noted that he had episodes of violence with regards to getting into fights. He was able to maintain minimum personal hygiene and did not have any problem with his activities of daily living. His remote, recent and intermediate memories were normal. The examiner noted that the Veteran's PTSD symptoms were chronic, daily and severe. She additionally noted that the Veteran reported isolation, being withdrawn, and having hypervigilance, distrust, irritability, and no social relationships. He was diagnosed with PTSD, alcohol and crack cocaine abuse, and assessed with a GAF score of 60. She concluded that the Veteran's symptom severity was that of "reduced reliability and productivity due to PTSD symptoms," noting that irritability, distrust and anger could impair occupational and social activities. In April 2011, the Veteran sought treatment with VA, at which time he reported that he was "surviving." The previous week his mood "wasn't so good" and he cited "dealing with people, dealing with places to stay" as his stressors. He reported sleeping well over the week, though he reported a "blowout" after which things had calmed. On examination, the Veteran was clean. He was alert, oriented, and cooperative. His speech was normal. He had a mildly irritable mood with a blunted affect. His thought process was logical with normal abstract thinking. There was no evidence of psychotic symptoms. He had normal judgment and insight. There were no suicidal or homicidal ideations. He was diagnosed with PTSD, a mood disorder, alcohol dependence and a history of cocaine dependence in early remission. He was assigned a GAF score of 50. In August 2011, the Veteran underwent another VA psychiatric examination. At that time, the examiner diagnosed the Veteran with an anxiety disorder, noting that he met the criteria for a PTSD diagnosis, except in one category. She noted that the Veteran denied nightmares and intrusive distressing thoughts of service events, and that he only had occasional night sweats; she indicated that the latter was due to drug/alcohol dependence and not necessarily due to any combat trauma. She additionally noted that he startled to certain noises and had hypervigilance, but did not avoid places or situations or other conversations or activities because of combat stress/PTSD. She noted that this appeared to be an improvement from the past based, on his chart review. She also diagnosed alcohol and cocaine dependence, which she noted were the Veteran's way of coping primarily with his current life circumstance but also with his PTSD symptoms. The examiner indicated that the Veteran's symptom severity resulted in occupational and social impairment with reduced reliability and productivity. She noted that the Veteran was homeless, lived at the YMCA, and came to VA to use the computer and go to recreation therapy. He was participating in recreational therapy frequently for socialization, and reportedly got along well with fellow attendees. He denied having any friends, however, among fellow Veterans, and he rarely spoke to his family that time. The examiner noted that he was not working. The Veteran reported using several medications for his symptoms, and reported that his alcohol use varied. Regarding his cocaine use, the Veteran noted that he used crack cocaine up to 3 times in a week. On examination, the examiner noted that the Veteran had a depressed mood, suspiciousness, mild memory loss (such as forgetting names, directions or recent events), disturbances of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. She further noted that the Veteran had had distrust since Vietnam, though it was not to the point of paranoid ideation. She noted that he last acted out of anger 4 or 5 years ago, which was when he cussed and got irritable with his VA doctor; he vented and then walked out. He stated that was "the worse he has been [with respect to] irritability in the last year or so." He was socially withdrawn, \occasionally hopeless, and focused more on life circumstances and expressed that he was coping better with Vietnam issues now than in the past. The examiner noted that the Veteran's daily abuse of alcohol and drugs suggested problems with his cognitive capacity to manage his own money. The examiner further noted that the Veteran had a normal mood; he often smiled and laughed and was very pleasant with the examiner. He was tearful when talking about how life had treated him. The examiner described the Veteran's mood as variable. His speech was goal-directed, clear and logical. He was adequately groomed and dressed in casual, clean clothing. The Veteran had good intermediate memory, somewhat impaired short-term memory, and his long-term memory during the interview was suggestive of it being within normal limits. The examiner noted that the Veteran had difficulty with concentration that interfered with his memory, including forgetting what he planned to do, misplacing things and having to write things down. He performed backward serial 3s adequately, though backwards serial 7s he had difficulty with and had to be pressed to try. He adequately spelled a word forwards and backwards. The examiner indicated that the Veteran's performance on the tests was suggestive of mildly-impaired attention. The Veteran could show abstract thought by observation during the interview and was able to interpret a common proverb in an abstract-thought manner. During his May 2012 hearing, the Veteran testified that he self-medicated with drugs and alcohol to cope with his PTSD. He further stated that he does not get along with or trust people. He indicated that he avoids crowds and preferred being by himself rather than around other people. He stated that he is unable to provide himself an income, maintain a family, have children, or purchase things for himself because of his PTSD. The Board has reviewed the Veteran's Virtual VA efolder, which contains numerous VA treatment records regarding his mental health and his psychiatric disorder. The Board finds that generally those records reflect similar findings with regards to the records detailed above. A September 2012 treatment record noted that he was acceptably dressed and groomed. He was cooperative, alert, and oriented. His speech was productive, though he had agitated psychomotor functioning, a flat and dysphoric affect and mood, and was highly anxious. His thought process was logical and goal-directed and he did not have any delusions, ideas of reference, preoccupations, obsessions or compulsions, or hallucinations or illusions. He had grossly intact cognition, with fair judgment and insight. There were no suicidal ideations at that time. He was assessed with a GAF score of 48. The Veteran underwent a VA psychiatric examination in October 2012. The examiner diagnosed the Veteran with PTSD and noted that the last VA treatment records, in September 2012-noted above-showed a GAF score of 48. The Veteran denied having any current nightmares and only occasional intrusive thoughts, but did indicate a history of mood swings. He was also diagnosed with alcohol dependency. His GAF score was assessed as 60, with mild to moderate PTSD with social impairment. The examiner noted that the Veteran's PTSD symptoms included infrequent reexperiencing of his trauma, and his alcohol dependency included mood instability and excessive consumption of alcohol. The examiner indicated that his symptomatology was of the severity level demonstrating occupational and social impairment with reduced reliability and productivity. The Veteran "hit his fingers on his chair constantly during the exam, was frequently off track in the exam and showed poor social skills." He reported few social contacts due to his distrust of others, though he attended church. The Veteran reported suicidal and homicidal ideations without intent, and the examiner noted that he once drove his vehicle into a tree (in an apparent suicide attempt) but changed his mind at the last second. After he was prompted, the Veteran indicated that he had no more nightmares, but had intrusive thoughts once a week. On examination, the examiner noted the following symptomatology: depressed mood, anxiety, suspiciousness, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and suicidal ideations. The examiner additionally noted that the Veteran had suicidal and homicidal ideations without intent and a history of manic episodes. He concluded that there were no changes since his last two VA examinations in 2007 and 2010. The record shows that the RO obtained a VA medical opinion in January 2013 on the matter of the impact of the Veteran's PTSD on his employability. The examiner concluded that the Veteran's PTSD symptoms did not preclude him from obtaining and maintaining gainful employment from 1999 to the present. Based on the foregoing evidence, the Board finds that a 70 percent evaluation, but no more, is warranted throughout the entire appeal period. The Board notes that throughout the appeal period the Veteran reports and is noted as being angry with a high irritability level with a history of violent outbursts; while later evidence shows that the Veteran was able to control those symptoms, the Board finds that his symptomatology is demonstrable of an impaired impulse control throughout the appeal period. Moreover, the Veteran has a clear pattern of isolating himself. He has never married, has no children, routinely reports having no friends, and actively avoids people, including his family. The Board finds that the Veteran has an inability to establish and maintain effective relationships. He also appears to have difficulty in adapting to stressful circumstances and to have near-continuous depression throughout the appeal period which has affected his ability to function independently, appropriately and effectively. The Board additionally notes that beginning in 1999, the Veteran began experiencing passive suicidal thoughts, though he never actively demonstrated plan or intent. The Board further notes that he is shown to report hallucinations, though they do not appear to be chronic or persistent in nature. He also has expressed some instances of homicidal ideations, particularly toward one of his brothers. The Veteran has never acted on those ideations during the appeal period, although a year before filing for service connection it appears that the Veteran attempted to stab his brother during an altercation. Although the Board acknowledges the presence of both homicidal ideations and hallucinations during the appeal period, the Board does not find that those symptoms are persistent, chronic, or are generally consistent with the symptoms contemplated by the criteria for a total schedular rating, namely total occupational and social impairment. The Veteran's behavior throughout the appeal period is consistently noted as being appropriate. His thought processes and communication are routinely noted as being goal-directed and appropriate. There is no evidence of psychotic thinking beyond the occasional hallucinations that he reported early in the appeal period. There were no delusions noted or reported throughout the appeal period. Likewise, the Veteran was consistently alert and oriented throughout the appeal period. Throughout the appeal period, the Veteran was appropriately dressed and groomed. Nor was there any suggestion that the Veteran could not routinely perform adequate and appropriate activities of daily living, including the maintenance of minimal personal hygiene. Finally, the Veteran did not demonstrate significant memory loss during the appeal period, such as forgetting his own name or the names of his close relatives. The Board additionally notes that the assigned GAF scores varied widely throughout the appeal period, but generally fell around 43 to 45, with a low of 40 and a high of 70. The Veteran's symptomatology was also described as "severe" several times throughout the appeal period. In light of the above noted symptomatology, the Board finds that the disability picture for the Veteran's psychiatric disability, for the entire period involved in this appeal, more closely approximates that of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The disability picture does not, however, more nearly approximate that of total occupational and social impairment in this case, either for the entire appeal period, or for any discrete period involved in this case. In sum, the Veteran's psychiatric symptomatology includes occasional but not persistent hallucinations, with some episodes of paranoia but no psychotic thinking; some suicidal and homicidal ideations, with no evidence suggesting he is a persistent danger to himself or others; near-continuous depression affecting his ability to function independently, appropriately and effectively; impaired impulse control marked with anger, rage and some episodes of violence; difficulty adapting to stressful circumstances; and, an inability to establish and maintain effective relationships. His symptomatology is demonstrable of social and occupational impairment with deficiencies in most areas, but does not rise to the level of total social and occupational impairment. The Board notes that the Veteran apparently last worked in 1996, but finds that the evidence does not demonstrate that the Veteran's PTSD has resulted in "total occupational impairment," given the varied GAF scores assigned (some of which are inconsistent with total impairment). The Board also points out that the January 2013 reviewer determined that the PTSD, alone, did not preclude employment. The Board additionally notes that total social impairment is not present. Although the Veteran does tend to isolate himself and not have friends, he clearly is able to interact socially at least with other patients. The Board consequently finds that the criteria for a 100 percent evaluation, which requires total occupational and social impairment, are not met or approximated. Accordingly, the Board finds that a 70 percent disability evaluation, but no higher, for PTSD is warranted for the entire period involved in this case. See 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. The Board again points out that the above analysis does not serve to disturb the temporary total evaluation assigned for the period from December 6, 2011, to May 1, 2012. The Board must also determine whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Director, Compensation Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2013). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. Id. at 115-116. When either of those elements has been satisfied, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this case, the schedular evaluation is adequate. The criteria for evaluating PTSD do not list specific symptoms which must be met to qualify for a particular rating, but rather provide examples of the types and severity of symptoms which warrant the rating. The Veteran's symptoms consequently are contemplated by the schedular criteria, as the symptoms are evaluated by comparison of the typical symptoms and severity of symptoms contemplated by a particular rating. Each of the Veteran's reported and demonstrated psychiatric symptoms are either listed in the rating criteria, or are capable of being analogized to the examples listed for each rating. The Board points out that the rating criteria specifically contemplate social and industrial impairment. As the rating schedule is adequate to evaluate the disability, referral for extraschedular consideration is not in order. In so reaching these conclusions, the Board has appropriately applied the benefit-of-the-doubt doctrine in this case, where applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER Service connection for a lumbar spine disorder is denied. An initial 70 percent evaluation, but no higher, for PTSD throughout the appeal period is granted, subject to the regulations controlling the payment of monetary benefits. REMAND In light of the Board's award of a 70 percent evaluation for PTSD, the Veteran now meets the minimum schedular criteria for a TDIU. See 38 C.F.R. § 4.16(a). The Board therefore finds that a remand of that issue is necessary in order for the RO/AMC to consider entitlement on a schedular basis in the first instance. Accordingly, the case is REMANDED for the following action: Following any additional indicated development, the RO/AMC should review the claims file and readjudicate the Veteran's claim of entitlement to a TDIU. If the benefit sought on appeal remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). ____________________________ ______________________________ MARJORIE A. AUER THOMAS H. O'SHAY Veterans Law Judge, Acting Veterans Law Judge, Board of Veterans' Appeals Board of Veterans' Appeals ____________________________________ JAMES L. MARCH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs